Report to/rapport au: Ottawa Board of Health Conseil de santé d Ottawa. Monday, January 21, 2013/ le lundi 21 janvier, 2013

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1 Report to/rapport au: Ottawa Board of Health Conseil de santé d Ottawa Monday, January 21, 2013/ le lundi 21 janvier, 2013 Submitted by/soumis par : Dr./Dr Isra Levy, Medical Officer of Health/Médecin chef en santé publique Contact Person / Personne ressource: Siobhan Kearns, Manager/Gestionnaire Environment, Health Protection & Outbreak Management / Direction de l'environnement, de la protection de la santé et de la gestion des éclosions Ottawa Public Health/Santé publique Ottawa , ext./poste 23483, siobhan.kearns@ottawa.ca and Dr. Carolyn Pim Associate Medical Officer of Health/ Médecin adjointe en santé publique Ottawa Public Health/Santé publique Ottawa , ext./poste 23484, carolyn.pim@ottawa.ca CITY WIDE / À L ÉCHELLE DE LA VILLE UACS2013-OPH-EHP-0001 SUBJECT: OBJET : UPDATE ON OTTAWA PUBLIC HEALTH S OUTBREAK MANAGEMENT STRATEGY FOR LONG-TERM CARE FACILTIES RAPPORT SUR LA STRATÉGIE DE SANTÉ PUBLIQUE OTTAWA EN MATIÈRE DE GESTION DES ÉCLOSIONS POUR LES ÉTABLISSEMENTS DE SOINS DE LONGUE DURÉE REPORT RECOMMENDATIONS That the Board of Health for the City of Ottawa Health Unit receive this report for information. RECOMMANDATIONS DU RAPPORT Que le Conseil de santé de la circonscription sanitaire de la ville d Ottawa prenne connaissance du présent rapport à titre d information. EXECUTIVE SUMMARY Ottawa Public Health (OPH) has developed a multi-year strategy to manage outbreaks in the City s long-term care homes (LTCHs). Over the past year, OPH has worked with partners to implement this strategy and this report provides an update on progress to date. The strategy aims to reduce the number of outbreaks in LTCHs, reduce the time between the onset of illness and the first contact with OPH, and mitigate negative

2 impacts of an outbreak by decreasing the duration and number of residents affected. The strategy also includes measures that support LTCHs in the implementation of infection prevention and control best practices and effective outbreak management. In the 2011/2012 season, 52 outbreaks in LTCHs involved nearly 300 staff and 700 residents, were associated with 8 hospitalizations and may have contributed to 15 deaths among residents. In 2012, OPH provided two half-day Outbreak Management Forums for LTCH front-line staff; developed and disseminated infection prevention and control and outbreak management resources for staff in LTCHs; built stronger links with LTCHs; and provided LTCHs with a consistent OPH point of contact for infection prevention and control and outbreak management issues. In 2013, OPH will continue to strengthen knowledge exchange between OPH and LTCHs, as well as complete facility profiles for each of the 28 LTCHs in Ottawa to assist OPH in assessing the specific needs of each institution and in developing infection prevention and control and outbreak management resources. RÉSUMÉ Santé publique Ottawa (SPO) a adopté une stratégie pluriannuelle pour gérer les éclosions dans les établissements de soins de longue durée (ESLD) de la Ville. L année passée, SPO a travaillé avec des partenaires à la mise en œuvre de cette stratégie et ce rapport décrit les progrès réalisés à ce jour. La stratégie vise à réduire le nombre d'éclosions dans les ESLD réduire l'intervalle entre la manifestation de la maladie et le premier contact avec SPO et atténuer les effets négatifs d'une éclosion en diminuant sa durée et le nombre de résidents touchés. La stratégie comprend également des mesures pour soutenir les efforts des ESLD pour appliquer des pratiques exemplaires en matière de prévention et de contrôle des maladies infectieuses et de gestion efficace des éclosions. Pour la saison de , 52 éclosions dans les ESLD ont touché près de 300 employés et 700 résidents; elles ont entraîné huit hospitalisations; et elles peuvent avoir causé le décès de quinze résidents. En 2012, SPO a organisé deux forums d'une demi-journée sur la gestion des éclosions pour le personnel de première ligne des ESLD produit et diffusé aux employés des ESLD de la documentation et des outils entourant la prévention et le contrôle des maladies infectieuses et la gestion des éclosions a renforcé ses liens avec les ESLD et a fourni aux ESLD un contact de référence pour les questions de prévention et de contrôle des maladies infectieuses et de gestion des éclosions. En 2013, SPO poursuivra ses efforts pour renforcer l'échange de connaissances entre SPO et les ESLD et mettra la dernière main aux profils de chacun des 28 ESLD d'ottawa pour l aider à évaluer les besoins particuliers de chacun des établissements et produire de la documentation sur la prévention et le contrôle des maladies infectieuses et la gestion des éclosions.

3 BACKGROUND There are 28 Long- Term Care Homes (LTCH) in Ottawa, which provide care to over 4700 residents, most of whom are elderly and many of whom have chronic health conditions that make them vulnerable to complications from infectious diseases. Four LTCHs are managed by the City of Ottawa, some are privately run and still others are part of larger organizations. All LTCHs, regardless of the funding or management model, are regulated by the Ministry of Health and Long-Term Care and must follow the same provincial guidelines with respect to infection prevention and control, which includes the management of outbreaks. Outbreaks of infectious disease in these settings constitute a threat to health of residents and others, as well as a significant burden on the health care system. On June 20, 2011, the Ottawa Board of Health received a verbal presentation on Ottawa Public Health s Outbreak Management Strategy. This strategy, which focuses on infectious disease outbreaks in LTCHs is designed to reduce the frequency, duration and health impacts of outbreaks and to support the implementation of infection prevention and control measures in Ottawa s 28 LTCHs. The impetus for the multi-year strategy began with concerns about the impacts that outbreaks were having on the transfer of residents from acute care facilities back to their respective LTCHs. Transfers from hospitals back to LTCHs experiencing outbreaks are discouraged due to the risk that returning residents may acquire the outbreakrelated infection. This situation has been identified by acute care hospitals in the past as contributing significantly to bed shortages in these institutions. An outbreak is declared when a disease occurs in excess of its expected frequency, or when cases are clustered in space, time or in a particular population. Outbreaks have significant health impact and economic cost, particularly in LTCHs. What may be a mild illness in a healthy individual can lead to serious consequences, including death, in the frail elderly. There is also a significant economic burden associated with outbreaks in institutional settings including costs for staff overtime and sick leave; costs for prophylactic drugs (if required); lost revenue associated with unused beds due to admission restrictions; additional costs associated with care of sick residents (e.g., gloves gowns, masks, eye protection, food tray service, etc.); and increased cleaning costs. Approximately 60 outbreaks occur in Ottawa LTCHs every year (Table 1). In the 2011/2012 season, 52 outbreaks, including enteric and respiratory, in LTCHs involved nearly 300 staff and 700 residents, were associated with 8 hospitalizations and may have contributed to 15 deaths among residents.

4 Table 1: Number of resident and staff cases during an outbreak in Ottawa Long- Term Care Homes 2005/ /2012 season* Outbreak type 2005/ / / / / / /2012 Respiratory n= Residents Staff Total cases Hospitalizations** Deaths (allcause)** Enteric n= Residents Staff Total Hospitalizations** Deaths (allcause)** * Source: Ontario Ministry of Health and Long-Term Care, integrated Public Health Information System (iphis), extracted Oct 17, 2012 & OPH Institutional outbreak log ** Hospitalizations and death counts only apply to residents The Long-Term Care Interest Group of the Community and Hospital Infection Control Association of Canada has developed a tool to help institutions estimate the financial burden of outbreaks. Using this tool, OPH estimates that a typical non-influenza respiratory outbreak lasting 13 days on a 24 bed unit within an institution costs $10,000 to $20,000. These calculations do not include external health care costs (e.g. laboratory, hospitalization and public health costs), or wider societal costs due to loss of productivity. The cost and number of outbreaks that occur in any given year is dependent on variables that cannot always be controlled or anticipated by public health. For example, the virulence and transmissibility of a typical respiratory or enteric virus can change over time, so that there may be a greater number of outbreaks with many more cases of illness from one year to the next, even though the causative agents are the same. Year to year variability can also occur when the circulating influenza strains in the community do not match the strains provided in the current vaccine, resulting in decreased effectiveness of the vaccine and thus more infections and outbreaks due to influenza. There are, however, strategies that can help mitigate the impact of outbreaks in LTCHs in our community; these are highlighted in the Discussion section below. Summary of outbreaks On average, outbreaks in Ottawa LTCHs last about two weeks, although occasionally outbreaks can last longer (Table 2). The capacity for a LTCH to manage an outbreak is variable, and depends on many factors including staff capacity, staff turnover and infection prevention and control knowledge, as well as the physical resources and building design. As LTCHs in Ottawa do not all have similar capacities to manage

5 outbreaks, OPH customizes its assistance to the specific needs and challenges of each institution. Table 2: Median Duration and range in days of Outbreaks in Ottawa Long-Term Care Homes 2005/ /2012 season Outbreak type 2005/ / / / / / / 2012 Respiratory 15 (6-53) 18 (7-53) 16 (9-67) 17 (5-45) 17 (7-57) 15 (5-50) 17 (6-31) Enteric 18 (10-24) 13 (4-39) 13 (3-36) 17 (6-50) 15 (5-50) ) 16 (6-28) In a typical outbreak season, most outbreaks in LTCHs are caused by common respiratory or enteric (gastrointestinal) viruses. The identification of a causative agent, whenever possible, (whether it is a virus, bacteria, or a parasite) is important as control measures can be modified to reflect the specific characteristics of the infection. In a large proportion of outbreaks in LTCHs, however, the causative agent is not identified. This is often due to laboratory testing limitations or difficulty in obtaining specimens for testing. In general, there is a wider variety of causative agents identified for respiratory outbreaks (Document 1 - Figure 1) than in enteric outbreaks (Document 1 - Figure 2). Ottawa Public Health s Role in Outbreak Management Outbreaks of infectious diseases in institutions are reportable to public health under legislated authority of the Health Protection and Promotion Act. OPH immediately follows up on reports of outbreaks. The Ontario Public Health Standards require health units to assist institutions, including LTCHs, retirement homes and acute care facilities with outbreak management. This includes the detection and investigation of outbreaks and the implementation of control measures. OPH also manages outbreaks in other settings including child care centres, schools and the community. However, the focus of this Outbreak Management Strategy is on outbreaks in LTCHs. OPH works with LTCHs to manage outbreaks, with both parties contributing time, resources and expertise. Each outbreak is unique due to a number of variables such as the strain of influenza in the community as well as the physical layout of the facility. This requires a degree of flexibility in the approach taken to investigate and control the outbreak. The sooner an outbreak is identified, the sooner appropriate control measures can be identified and implemented to limit the transmission of the infection. Therefore, timely notification of an outbreak to OPH is an important factor in outbreak management. While outbreaks in LTCHs are usually reported to OPH within a few days of the onset of symptoms in the first ill resident, occasionally reporting of an outbreak is delayed. Longer reporting times may indicate that a LTCH is having difficulty identifying or appreciating the significance of common symptoms among residents. Alternately, longer notification periods may be due to the amount of time it takes to the meet the outbreak case definition, rather than a delay in reporting the outbreak.

6 DISCUSSION The goals of the multi-year strategy (September 2011-August 2014) are to: reduce the number of outbreaks in LTCH reduce the time between the onset of illness and the first contact with OPH mitigate the burden and negative impacts of an outbreak by decreasing the duration and number of residents affected support LTCHs in the implementation of infection prevention and control best practices and effective outbreak management measures To accomplish these goals, OPH s Outbreak Management Program has committed staff resources to develop and implement five broad components of the strategy. The progress to date on these components includes: 1. Capacity assessment/gap analysis: Developed a capacity assessment tool to create a facility profile for each of the 28 LTCHs in Ottawa. This will assist OPH in assessing the specific needs of each institution and in developing infection prevention and control and outbreak management resources. 2. Educational Support: Developed and disseminated infection prevention and control and outbreak management resources for staff in LTCHs. These comprise written materials, presentations and web-based resources: o An Outbreak 101 presentation. o An outbreak management resource guide that reviews all aspects of outbreak management. o A LTCH Outbreak Tool Kit with additional resources to provide frontline staff with all the physical resources (e.g. laboratory specimen kits, forms, signage) that are necessary to manage an outbreak. This resource will be particularly useful on the weekend or on statutory holidays when regular staff, who are more familiar with outbreak management practices, are not available. The tool kit is currently being disseminated to each LTCH along with a short educational presentation to staff on its contents and how it should be used. Provided educational opportunities including two half-day Outbreak Management Forums for LTCH front-line staff. Additional staff education is planned for Stakeholder engagement: Built stronger links with LTCH stakeholders by ensuring that each institution has an assigned OPH public health nurse and public health inspector to support them during outbreaks and to attend infection prevention and control meetings, as required under the Long-Term Care Homes Act (2009). This will also provide LTCHs with a consistent OPH point of contact for infection prevention and control and outbreak management issues. Used a structured questionnaire to survey each LTCH to solicit information and interest in the formation of a long-term care liaison group. The group

7 will be hosted by OPH to provide a venue for the discussion of relevant infection prevention and control and outbreak management issues affecting LTCHs. The survey was administered to all LTCHs in the fall of 2012 and will be analysed in early Designed a tool for LTCHs to assist with decisions about transferring patients between LTCHs and acute care facilities during outbreaks. This will allow better transfer decisions thus facilitating smoother and more efficient transfers of residents back to their LTCHs during the outbreak season (Document 2). 4. Surveillance and reporting: Developed a plan to communicate outbreak surveillance information in real time to pertinent community partners, including the Community Care Access Centre that is responsible for admissions and transfers to LTCHs. Having real time access to outbreak information will assist partner organizations in optimising timely and efficient transfers of patients between institutions and will eliminate unnecessary backlogs of transfers. 5. Program evaluation: OPH s staff will implement an evaluation plan to assess the effectiveness of the Strategy. Challenges to Implementing the Strategy Although OPH has successfully implemented many activities related to the Strategy, the Outbreak Management Program has experienced several significant challenges that have caused some delays. In its first year of implementation, the Outbreak Management Team played a pivotal role in OPH s response to a large scale community infection control lapse and in the management of a significant community outbreak of Salmonella that affected children in a child care centre and many Ottawa public schools. As a result of these events, some of the LTCHs capacity assessments and facility profiles were not completed until fall Next Steps OPH s Outbreak Management Program will take further action on the five components of the Outbreak Management Strategy and report back in LEGAL IMPLICATIONS There are no legal impediments to receiving the information in this report. FINANCIAL IMPLICATIONS There are no financial implications associated with this report. TECHNOLOGY IMPLICATIONS There are no technology implications associated with this report. BOARD OF HEALTH STRATEGIC PRIORITES The recommendations in this report support the Board of Health Strategic Priority B5: Reduce health risks related to preventable infectious and non-infectious diseases.

8 TERM OF COUNCIL PRIORITIES The recommendations in this report support the Term of Council Priorities under Healthy & Caring Communities. SUPPORTING DOCUMENTATION Supporting Document 1 Outbreaks in Ottawa Supporting Document 2 Admissions and Transfers from an Acute Care Facility to a Long-Term Care Home or Retirement Home during an Outbreak DOCUMENTS À L APPUI Document à l appui 1 éclosions à Ottawa Document à l appui 2 Admissions et transferts d un établissement de soins actifs à un établissement de soins de longue durée ou à une maison de retraite pendant une éclosion DISPOSITION Ottawa Public Health staff will carry out the activities stated in this report and report back in 2014 on the progress of this strategy.