Prevention and Control of Influenza in California Long- Term Care Facilities. Overview. Influenza and Influenza-Like Illness 10/18/2012

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1 Prevention and Control of Influenza in California Long- Term Care Facilities Infection Prevention Training October, 2012 Becky Siiteri, RN, MPH Healthcare-Associated Infections Program California Department of Public Health LTC IP Training, October, 2012 Overview Influenza Definitions & Epidemiology Symptoms, Incubation, Communicability Transmission CA Influenza Vaccination Requirements Influenza Prevention Program Surveillance and Diagnosis Antiviral Treatment and Prophylaxis Summary References and Websites Influenza and Influenza-Like Illness The Flu-at-a-glance Respiratory illness caused by influenza type A or type B viruses Other respiratory viruses, some bacteria cause similar influenza-like illnesses (ILI) Annually, typically in winter, Oct - April Significant cause of morbidity and mortality, especially in the elderly 1

2 Influenza Definitions Influenza-Like Illness (ILI): Documented fever and cough and/or sore throat in absence of another cause Outbreak: Sudden increase of ILI cases over normal background rate or any resident tests positive for influenza One case of confirmed influenza by any testing method is considered an outbreak Disease Burden in Elderly People 65 years of age account for an estimated 90% of seasonal flu-related deaths and > 60% of seasonal flu-related hospitalizations* Number of Laboratory-confirmed Preliminary Influenza Outbreaks Reported to the California Department of Public Health, by Setting Season (N=58) 2

3 Influenza Symptoms in LTC Residents Acute onset of fever, 100*F (37.8*C) New onset of cough and/or sore throat Nasal congestion Malaise, fatigue, chills Muscle aches, itchy eyes, headache Change in respiratory status (cough, sputum production, breathing rate) Change in mental status or appetite Incubation and Communicability Time from first exposure to onset of symptoms 1 4 (average 2) days Most infectious during the first 3 days of illness Virus can shed beginning the day before and for > 7 days after symptom onset Transmission Primarily spread from person-to-person by large droplets of respiratory secretions from infected person May also occur by direct or indirect (person-object-person) contact Virus survives for hours on nonporous surfaces and 8 12 hours on porous surfaces 3

4 Transmission Airborne transmission may occur Inhalation of small droplets expelled into the air when infected person is coughing or during aerosol-generating procedures Degree it contributes to influenza transmission is uncertain and not adequately studied Influenza Prevention Annual vaccination is the most effective intervention to prevent influenza transmission. Cox, N. and K. Subbarao, Influenza. Lancet, (9186): p Influenza Prevention Higher vaccination levels among HCP have been associated with lower risk of LTCFassociated influenza cases Influenza outbreaks in LTCF have been attributed to low vaccination rates among HCP Higher influenza vaccination levels among HCP can reduce ILI and deaths in LTCF 4

5 Influenza Vaccination Misconceptions You can get the flu from the vaccine Virus in flu shot is dead Vaccine prevents against 3 most serious viral strains predicted to be circulating Flu vaccines can cause serious health problems Vaccines proven to be safe and effective Most common side effect is soreness at site You are young & healthy so don t need flu shot 2009, 2010 young people were group most affected Senate Bill 739 Require all health care facilities Offer free vaccines to all employees Maintain vaccination records of employees Require signed Declination forms Require proof of vaccination Institute respiratory hygiene & cough etiquette protocols Develop & implement isolation procedures Senate Bill 1318 Bill was vetoed 9/30/2012 Veto message from Governor Brown Encouraged all HCP to be vaccinated Support national goal 90% HCP vaccinated by 2020 Healthcare facilities to adopt their current county influenza vaccination policy 5

6 CA HCP Vaccination Forms Current influenza data collection forms: Consent to be Vaccinated Vaccination Declination Vaccination Received Elsewhere rentreportingforms.aspx Influenza Prevention Program Annual review of CDC and CDPH influenza vaccination recommendations uenza-recommendations-ltcf-v pdf Well-defined influenza policies & procedures Reviewed by Infection Control Committee Influenza Prevention Program Designate Influenza Vaccination Week Vaccinate all HCP and residents Encourage visitors to be vaccinated Encourage HCP to vaccinate family members 6

7 Influenza Prevention Program Post free influenza education materials throughout facility Influenza Prevention Program Respiratory Hygiene &Cough Etiquette Post alerts instructing HCP, residents and visitors to report respiratory symptoms Provide tissues and masks to residents who are coughing or sneezing Encourage coughing persons to stay at least 3 feet away from others Ensure hand washing supplies are readily available Influenza Prevention Program Post signs notifying visitors Adults with respiratory symptoms should not visit for 5 days Symptomatic children should not visit for 10 days following onset of illness Provide visitors with written information about the precautions implemented Ensure visitor hand hygiene supplies are available 7

8 Influenza Surveillance Develop HCP working when ill and sick leave policies Instruct HCP to self-report symptoms Monitor staff absenteeism Exclude HCP with fever 100ºF (37.8ºC) and other respiratory symptoms from work until at least 24 hours after fever resolved (without use of fever-reducing medicines) Influenza Surveillance Instruct HCP and visitors to report resident influenza symptoms Develop line lists of symptomatic residents and HCP Conduct daily surveillance until at least 1 week after last confirmed case occurred Influenza Outbreak Reporting Report all suspected and confirmed outbreaks to LTCF Medical & Nursing Directors Local Public Health Department (LHD) Licensing & Certification (L&C) district office 8

9 Laboratory Diagnosis A true diagnosis of influenza cannot be based on symptoms alone When a cluster of cases of acute respiratory illness occurs, establish the diagnosis through laboratory testing Laboratory Diagnosis Collect nasopharyngeal swab specimens from 3 4 residents and/or HCP Submit specimens for influenza viral culture and/or PCR testing Contact LPHD for specimen collection and submission process information For further diagnostic information consult: Laboratory Diagnosis Rapid diagnostic tests can detect influenza viruses within 15 minutes Negative result does not rule out flu May be helpful in determining if antiviral drug therapy should be implemented to prevent outbreak from spreading For further information /rapidlab.htm 9

10 Antiviral Treatment and Chemoprophylaxis Two FDA-approved influenza antiviral medications are recommended for use during the influenza season Oseltamivir (Tamiflu ) and zanamivir (Relenza ) CDC recommends these antiviral medications be considered for use during an influenza outbreak Antiviral Treatment and Chemoprophylaxis Antivirals should be started as soon as possible for residents with suspected or confirmed influenza Clinical judgment should be important component of resident treatment decisions Implement Standard and Droplet Precautions for resident/s with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility caresettings.htm 10

11 Confine first symptomatic resident and exposed roommate/s to room, restrict from group activities, serve meals in their rooms If other residents become symptomatic, cancel group activities, serve all meals in resident s rooms If symptomatic resident is in semi-private room, maintain separation of at least 3 feet and draw curtains Avoid rotating staff between units Until no new cases identified for one week If residents are ill on specific wards do not move residents to other units Limit admitting new and returning residents If admissions necessary, ensure new or returning residents do not have Acute respiratory illness Not transferring from facility with outbreak Admit new or returning asymptomatic residents to unaffected units 11

12 Place mask on ill residents during transport Instruct residents to cover their cough or use tissues when coughing and sneezing Assist residents with hand hygiene Before leaving and entering rooms After contact with respiratory secretions and contaminated tissues Communicate information about symptomatic resident with appropriate staff before transfer Notify transporting personnel and receiving facility of outbreak Assess potential transfers for Influenza vaccination history Symptoms of respiratory symptoms Assign staff to one unit, restrict floating Perform hand hygiene Before and after resident contact Contact with potential infectious material or contaminated surfaces Before putting on and after removing personal protective equipment, including gloves 12

13 Hand hygiene can be performed by Washing with soap and water Alcohol-based hand rubs If hands soiled, use soap and water Wear gown and gloves Providing care to symptomatic resident In contact with contaminated surfaces Change gown and gloves after each encounter with symptomatic resident Current facemask recommendation Wear mask when entering resident s room with suspected or confirmed influenza Remove mask upon leaving resident s room; dispose in waste receptacle Facility should consider allowing use of fitted N95 respirators based on HCP preference for added protection Visitor restrictions during outbreak Consider restricting all children If visitation necessary instruct symptomatic visitors to: Wear a surgical mask Cough and sneeze into a tissue Sanitize hands before entering room, before and after resident contact, upon leaving room trol/resphygiene.htm 13

14 Environmental cleaning Routine cleaning and disinfection procedures Routine procedures with soiled linen and dietary trays Frequent cleaning of commonly touched surfaces Summary Influenza Recommendations Vaccinate all residents and HCP against influenza as soon as vaccine available Ensure standing orders are in place for residents to receive influenza and pneumococcal vaccinations Educate all HCP, residents and visitors about importance of vaccinations Summary Influenza Recommendations Implement use of Declination and Vaccinated Elsewhere forms Implement respiratory hygiene/cough etiquette procedures and visitor precautions/restrictions Implement daily active surveillance for symptomatic residents and HCP 14

15 Summary Influenza Recommendations Confirm diagnosis by laboratory testing Annually review and update infection control and outbreak management policies and procedures Provide influenza education and information for HCP, residents and visitors Report all influenza outbreaks to LHD and L & C district office Consider use of antiviral medications during outbreaks References and Websites Recommendations for the Prevention and Control of Influenza in CA LTCFs LTCF-v pdf Prevention and Control of Influenza with Vaccines, Recommendations of the Advisory Committee on Immunization Practices (ACIP), Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities CDC recommendations for infection control for influenza in healthcare facilities are available at Using Antiviral Medications to Control Influenza Outbreaks in Institutions: Centers for Disease Control and Prevention, National Immunization Program. Prevention and Control of Vaccine-Preventable Diseases in Long-Term Care Facilities. Bradley SF, The Long-Term--Care Committee of the Society for Healthcare Epidemiology of America. Prevention of influenza in long-term care facilities. Infect Control Hosp Epidemiology, 1999;20: Centers for Disease Control and Prevention: Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities. Immunization Branch of the California Department of Health Services Influenza Information: and the Influenza Pandemic Response Plan. Questions? Long-Term Care (LTC)» Guidelines and Information for Long-Term Care Facilities (LTCF)» Includes NEW SURVEY 15