Conjunctivitis

Recommendations

1. For healthcare personnel with suspected or confirmed infectious conjunctivitis, including epidemic keratoconjunctivitis, exclude from work for the duration of their symptoms.

Background

Conjunctivitis, often called "pink eye," can result from many causes, including pathogens, allergens, contact lens use, chemicals, and other medical conditions.1 Infectious pathogens that can cause conjunctivitis include viruses, bacteria, and fungi. Although many types of bacterial conjunctivitis may be spread person to person, transmission in healthcare settings is not typical. Viral conjunctivitis, however, is highly contagious and caused by a variety of viruses, including adenoviruses, rubella virus, rubeola virus, herpesviruses, and picornaviruses, with adenoviruses being amongst the most common causes.

Epidemic keratoconjunctivitis (EKC) is a more severe type of viral conjunctivitis caused by adenovirus serotypes, such as 8, 37, and 6412. EKC is a primary cause of healthcare-associated outbreaks of conjunctivitis, with several outbreaks historically reported in ophthalmology clinics3456. Healthcare personnel (HCP) have been linked to the spread of adenoviruses that cause EKC in healthcare settings and may have transferred the virus to patients or others via their hands or shared medical equipment. 46Adenoviruses are resistant to many common disinfectants and can remain infectious for long periods on environmental surfaces78and medical equipment.

Prevention of transmission of pathogens that cause conjunctivitis, including adenoviruses, in healthcare settings involves (a) using infection prevention and control practices as recommended by CDC9, (b) cleaning and disinfecting surfaces and reusable medical equipment in accordance with CDC recommendations10, (c) promptly responding to individual or clusters of cases, and (d) excluding potentially infectious HCP from work.

Occupational exposures

In healthcare settings, most viruses that cause conjunctivitis (e.g., adenoviruses) can be spread through hand- or medical device-to-eye contact when they are contaminated with the infectious pathogen. Hands and medical equipment can become contaminated when they contact infectious tears, eye discharge, fecal matter, or respiratory secretions, and then can serve as a vector for transmission to HCP14. Some viruses that cause conjunctivitis (e.g., adenovirus, herpesviruses) can also spread through deposition of respiratory, oral, or nasal secretions from an infected source person onto the mucous membranes of a susceptible host. Additionally, community and household exposures can result in HCP bringing viruses that cause conjunctivitis into the work setting and exposing coworkers and patients.

Clinical features

Signs and symptoms of conjunctivitis can include:

• Pink or red color in the white of the eye(s)
• Swelling of the conjunctiva (the thin layer that lines the white part of the eye and the inside of the eyelid) and/or eyelids
• Increased tear production
• Feeling like a foreign body is in the eye(s) or an urge to rub the eye(s)
• Itching, irritation, and/or burning
• Discharge (pus or mucus)
• Crusting of eyelids or lashes, especially in the morning
• Contact lenses that feel uncomfortable and/or do not stay in place on the eye

Depending on the cause of conjunctivitis, other symptoms may also occur. Bacterial conjunctivitis is more commonly associated with purulent discharge from the eye, while viral conjunctivitis can occur with symptoms of a respiratory infection and usually begins in one eye and may spread to the other eye within days. Most cases of viral conjunctivitis are mild and will resolve within 1-2 weeks11. EKC can last longer, up to 3 weeks, and a person is typically contagious from a few days before symptom onset to approximately 14 days after symptom onset, although they may be contagious for longer12.

While EKC usually only causes temporary symptoms, prolonged infections can result in corneal scarring, vision loss, and blindness, as well as other eye-related complications1.

Testing and diagnosis

When an infectious conjunctivitis is suspected, HCP are not commonly tested for the specific pathogen causing their symptoms. The diagnosis is usually based on clinical findings. However, testing is sometimes performed for specific pathogens when relevant to the health or treatment of HCP, prevention measures, or understanding the cause of an outbreak. When conjunctivitis is the only presenting symptom, adenovirus infection can be diagnosed by performing polymerase chain reaction (PCR) on a sample from a conjunctival swab. Although molecular assays (e.g., PCR) tend to be more readily used, other methods for testing for adenoviruses are available, such as isolation in cell culture and antigen detection.

Postexposure prophylaxis

There is no known effective postexposure prophylaxis (PEP) for HCP exposed to adenoviruses. In addition, there is no specific treatment for people with an adenovirus infection, other than supportive care, as most adenovirus infections are mild and do not require medical care13.

Work restrictions for HCP with EKC

Historically, HCP have been restricted from patient care and the patient care environment for the duration of their symptoms when they have infectious conjunctivitis, including EKC14. However, varying approaches to work restrictions for HCP with adenoviral EKC have been taken in recent years, with some reports34515161718 restricting these HCP from work for at least the duration of viral shedding (approximately 2 weeks), for duration of symptoms, or using a test-based return-to-work criteria.

Halting transmission of adenoviruses that cause EKC in healthcare involves a multifaceted approach, including strategies such as isolating symptomatic patients and restricting symptomatic HCP from work, strict adherence to recommended hand hygiene practices, and cleaning shared medical equipment and commonly touched surfaces. Hence, the reported effectiveness of individual HCP work restriction strategies is confounded by the use of concurrent additional infection control strategies. Among facilities reporting outbreaks of adenovirus EKC that included HCP, those that excluded symptomatic HCP with EKC from work for the duration of symptoms519, and those that excluded HCP with EKC from work for a minimum of 14-15 days31720212223 were all eventually successful in halting transmissions when using a multifaceted approach. As EKC symptoms can last for approximately 1-3 weeks12, both HCP work restriction strategies could result in similar durations of work restrictions.

One report of an EKC outbreak in a Neonatal Intensive Care Unit15 noted ongoing transmission despite implementation of appropriate infection control measures and restricting symptomatic HCP with EKC from work. The authors noted that transmission only halted after screening asymptomatic HCP for adenovirus conjunctival infection and restricting them from work. The possible contribution of asymptomatic adenovirus conjunctival infection to transmission in healthcare settings is unknown, and routinely screening for and restricting HCP with asymptomatic adenovirus conjunctival disease from work to halt transmissions is not typically performed.

Outbreaks of EKC

Outbreaks of EKC in healthcare settings pose challenges for healthcare facilities, including implementation of rapid outbreak control while continuing to provide a safe work and patient or resident care environment12. Outbreak reporting to the local or state health department may be required, depending on the jurisdiction, and can be important, as community setting outbreak control may also be needed, as well as assistance in the healthcare setting with managing the outbreak.

Strategies for the prevention and control of EKC outbreaks are described on the CDC website. 24