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1 Region of Waterloo Public Health Infectious Disease and Tuberculosis Control Program (TTY ) This document is available in accessible formats upon request. Created September 2014

2 Contact Information For further information and consultation with Region of Waterloo Public Health: Phone numbers 1. Monday to Friday (8:30 a.m. to 4:30 p.m.) Respiratory Information Line ext After hours, weekends, and statutory holidays (24/7) Service First Call Centre (TTY ) Website 1. Partners and professionals (drop down menu) 2. Resources for Partners and Professionals 3. Resources for Health Care Providers 4. Includes Respiratory Outbreak Manual, tools, links, and forms 1

3 TABLE OF CONTENTS 1.0 Purpose Resources Acronyms 2.0 Preparedness Seasonal Checklist 3.0 Policy Development Policy Checklist Medical Directives 4.0 Immunization Resident Staff TB Screening 5.0 Surveillance and Reporting When to Call Public Health Outbreak Definitions Outbreak Quick Reference 6.0 Specimen Collection Nasopharyngeal swabs 7.0 Outbreak Control Routine Droplet Contact Precautions Additional IPAC Measures Health Care Worker Illness Confirmed Flu A and B Outbreaks Influenza Vaccination Antiviral Medication 8.0 Movement of Residents During An Outbreak Visitors Activities Medical/Dental Appointments Transfer Between Facilities Transfer from Hospital 9.0 Movement of Staff, Students and Volunteers Declaring the Outbreak Over 32 2

4 Appendices Medical Directive Writing Package 33 Sample Daily Surveillance Tool Fact Sheet: Herpes Zoster (Shingles) Common Viral Causes of Respiratory Outbreaks Resource List and Links from Regional Infection Control Network (RICN) Reportable Disease List 3

5 1.0 PURPOSE OF THE GUIDE The purpose of this guide is to provide clarity and key information for facilities and health care workers regarding the management of respiratory illness and outbreak control in long-term care homes, retirement homes and other residential facilities. This resource was created by Region of Waterloo Public Health in response to questions and inquiries from local health care partners. The guide is intended to supplement the information provided in the Ministry of Health and Long-Term Care s Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes and to integrate with other existing provincial and federal guidelines for the control of respiratory outbreaks. Scope The information in this document is not intended to replace federal or provincial guidelines, but is to serve as a supplemental reference tool for residential facilities for the prevention, identification and management of respiratory outbreaks within Waterloo Region. These guidelines are designed to address seasonal respiratory infections that are primarily spread by large droplets, as well as contact with fomites. This guide does not intend to address infections with known airborne spread such as measles or tuberculosis or a pandemic influenza event. Specific guidelines should be followed as laid out by the Provincial Infectious Diseases Protocol (2013). Resources The information contained in this document provides a collaboration of opinions from several resources including: 1. Ministry of Health and Long Term Care (MOHLTC) 2. Association of Medical Microbiology and Infectious Disease Canada (AMMI) 3. National Advisory Committee on Immunization (NACI) 4. Ontario Hospital Association (OHA) 5. Ontario Public Health Standards, Infectious Diseases Protocol, Public Health Ontario, Provincial Infectious Diseases Advisory committee (PIDAC) 4

6 Acronyms ARI - Acute Respiratory Illness HAI - Hospital acquired infection HCW - Health Care Worker ICP - Infection Control Practitioner IPAC - Infection Prevention and Control ILI - Influenza-Like Illness MOHLTC - Ministry of Health and Long Term Care MMR - Measles, Mumps, Rubella vaccine NACI - National advisory on Canadian Immunization NP/NPS - Nasopharyngeal swab OB - Outbreak OHS - Occupational Health Services OHA - Ontario Hospital Association PHO - Public Health Ontario PPE - Personal Protective Equipment PIDAC - Provincial Infectious Disease Advisory Committee RSV - Respiratory Syncytial Virus SDM - Substitute decision maker TB - Tuberculosis Tdap - Tetanus, diphtheria, acellular pertussis vaccine TST - Tuberculosis skin test UIIP - Universal Influenza Immunization Program URTI - Upper Respiratory Illness WWICN - Waterloo-Wellington Regional Infection Control Network 5

7 2.0 Preparedness Respiratory Outbreak Preparedness Seasonal Checklist Immunization, education, surveillance and outbreak control interventions require co-ordinated efforts throughout the year. The following seasonal checklist will assist facilities in organizing outbreak prevention and control activities in preparation for respiratory season. 6

8 Respiratory Outbreak Preparedness - Seasonal Checklist Intervention Facility Checklist Date/Initial SPRING Ensure healthy workplace policies and procedures are up-todate Review and update the following policies: o Health Care Worker (HCW) immunization and exclusion policies o Additional precautions and droplet and contact precautions o Collection of nasopharyngeal swabs Update Medical Directives for upcoming season: o Specimen collection nasopharyngeal swabs o Immunization of residents o Management of anaphylaxis o Immunization of staff/volunteers o Antiviral administration Consider mandatory annual influenza vaccination as a condition of continued employment Register for annual Public Health Spring Forum SUMMER Ministry Requirements Immunization Surveillance Retirement homes prepare Universal Influenza Immunization Program (UIIP) prequalification submissions in early summer Plan dates for influenza vaccine clinics during early fall for all staff involved in resident care areas Post signage to promote self-monitoring of acute respiratory infections Plan communication strategy to inform leaders, residents, staff and visitors, should an outbreak occur 7

9 Infection Prevention and Control Ensure all staff and volunteers are knowledgeable in routine and additional precautions Equipment Locate and check expiry date on nasopharyngeal lab kits - discard any expired kits Ensure equipment is accessible and has been checked for expiry date: o PPE ( gloves, gowns, masks, eye protection) o Outbreak signage order if needed (include where to order) o Alcohol-based rub Communicate to staff location of non-expired PPE and lab kits for upcoming flu season Education Perform/arrange annual IPAC and/or influenza education sessions for staff and residents? Plan influenza and influenza immunization education/training of health care providers/residents/visitors for Fall Remind HCWs of facility policies regarding antiviral use and work restrictions for non-immunized staff FALL Immunization Consent Schedule staff influenza vaccine clinics during early fall for all staff working in resident care areas Ensure up-to-date consent for immunization and antiviral administration for all residents Staff influenza vaccine consent form should include consent to release of immunization status in the event of an outbreak Preparedness Obtain medical directive for antiviral medication for all residents. Make arrangements with supplying pharmacy. 8

10 Education Equipment Immunization Attend annual Public Health Fall Forum Obtain new nasopharyngeal specimen collection kits at Fall Forum Immunize all eligible residents, health care providers and staff with annual influenza vaccine Ensure list of unimmunized staff is maintained Surveillance Conduct targeted active surveillance of respiratory symptoms of residents and staff WINTER Immunization Ongoing immunization of all new eligible residents and staff Requirements Submit immunization rates of residents and staff to public health Surveillance Consider outbreak status of other facilities if staff and residents are attending other facilities 9

11 3.0 POLICY DEVELOPMENT Long-term Care homes are mandated to implement an infection prevention and control program in accordance with the Long Term Care Home Act, This program must adhere to requirements set out in subsection 86(1) of the act, which addresses program structure, surveillance and preparedness. Retirement homes must adhere to the care and safety requirements of the Retirement Home Act, The act states that an infection prevention and control program must be in place within the home. As well, the home must comply with all public health requirements and safety standards (60.4-2). Administrative control is advised to ensure best practices are being carried out by health care workers. Formal policies and procedures can ensure that homes meet legislative requirements and that staff deal effectively with the transmission risks associated with infectious diseases. Facility Policy Checklist The following checklist includes important topics that should be addressed by facilities in written policies: Immunization of residents to address seasonal influenza, TB screening and other vaccine preventable diseases Healthy workplace policy to enable all HCW to remain home while ill with an acute respiratory illness (ARI) Exclusion policy for staff and volunteers who choose not to receive influenza immunization or take antiviral drugs during a respiratory outbreak Sufficient staffing levels to enable compliance with infection prevention and control (IPAC) policies Policies to support mandatory staff training in routine practices, droplet/contact precautions and hand hygiene Authorization for any regulated health care professional to initiate the appropriate additional precautions at the onset of respiratory symptoms 10

12 Authorization that permits discontinuation of additional precautions in consultation with the ICP or designate IPAC policies addressing disease transmission, hand hygiene, principles of routine and additional precautions, assessment of risk for exposures, indication for personal protective equipment (PPE) Mandatory reporting to the local the Medical Officer of Health (Public Health) when a resident has a new respiratory infection following recent travel or contact with an ill person with a recent travel history Mandatory reporting of ARI clusters to the local Medical Officer of Health Medical Directives The Regulated Health Professions Act (2000) requires that medical directives be in place when performing a controlled act to a resident or staff member. Controlled acts may include: Administration of a substance (i.e. immunization) Performing a procedure below the dermis (i.e. NP swab) Prescribing or dispensing a drug (i.e. Fluviral) An annual review of directives will ensure that changes to vaccines and recommendations are addressed. Please see appendix Region of Waterloo Medical Directive Writing Package for detailed guidance on directive writing. 11

13 4.0 Immunization Resident Immunization The following immunizations are recommended for residents: a) Annual Influenza vaccine b) Pneumococcal vaccine (upon admission) c) Tetanus/Diphtheria vaccine every ten years d) Acellular Pertussis vaccine (one lifetime dose for all adults <64 years of age) Two additional immunizations are not publicly funded, but are recommended for older individuals. Some residents will have benefits that may cover the cost of the vaccines if these vaccines are prescribed by a physician. Consult ROWPH for more information. a) Herpes zoster (shingles) vaccine (for those >60 years of age) b) Pneumococcal Conjugate - 13 vaccine Staff Immunization a) Annual staff influenza immunization is highly recommended. Some facilities may require staff to be immunized as a condition of employment. Facilities should maintain a list of unimmunized staff for outbreak purposes. The National Advisory Committee on Immunization (NACI) considers the provision of influenza vaccine to be an essential component of the standard of care for all health care workers (HCWs) for the protection of their patients. This includes any person, paid or unpaid, who provides services, works, volunteers or trains in a health care setting HCWs who have direct patient contact should consider it their responsibility to provide the highest standard of care, which includes annual influenza vaccination. In the absence of contraindications, refusal of HCWs who have direct patient contact to be immunized against influenza implies failure in their duty of care to patients. NACI (Canada Communicable Disease Report, 2013) b) Influenza immunization should be easily accessible and promoted in the workplace 12

14 c) All health care workers should be up to date with their immunizations in accordance with the most current Publicly Funded Immunization Schedule for Ontario. As of July, 2014 the following immunizations are included: Measles, Mumps, Rubella (MMR) vaccine Varicella vaccine, or serological proof of immunity (for staff < 50 of age) Hepatitis B vaccine, followed by serology to document immune status Acellular Pertussis vaccine Tetanus/Diphtheria vaccine In addition, health care worker immunization policies that are consistent with the Ontario Hospital Association/Ontario Medical Association Joint Influenza Surveillance Protocol for Ontario Hospitals should be in place. This protocol applies to all persons carrying on activities in the home including students, volunteers and contract workers: a) An Ontario personal immunization record or physician/provider documentation is the only accepted proof of influenza immunization b) Medical contraindication to influenza vaccine or refusal should be documented in the individual s Occupational Health Services file c) On-site vaccination clinics are recommended d) For long-term care homes, influenza vaccine coverage rates should be reported to Public Health annually in December (recommended for retirement homes) e) Staff that are not vaccinated against influenza and also refuse chemoprophylaxis during an outbreak, should not provide direct patient care or carry on activities where they have a potential to acquire or transmit the virus Tuberculosis Screening The Long-Term Care Homes Act, 2007 and the Retirement Home Act, 2010 require that all residents admitted to a nursing home or retirement home be screened for active TB. This screening should be completed within 90 days prior to admission, or within 14 days after admission. In February 2014, updated screening recommendations for LTC/Retirement Home residents and staff were released. The Canadian Tuberculosis Standards (7 th Edition) recommend a chest x-ray for TB screening of residents > 65 years of age. TB skin testing is no longer considered a reliable TB screening tool for those over 65 years of age. Individuals less than 65 years of age may continue to be screened using TB skin testing. 13

15 Effective November 1, 2014, residents admitted to a long-term care or retirement home setting must have a valid chest x-ray with specific views (posterior-anterior and lateral) completed within 90 days prior to admission, or within 14 days after admission. For all residents, regardless of age, a medical assessment to rule out symptoms of active TB is also recommended. Summary of TB Screening Recommendations **Recommended screening should be completed within 90 days prior to admission or within 14 days after admission** Residents <65 years of age >65 years of age Staff All health care workers Screening Recommendations Medical assessment physical assessment and symptom review for symptoms of active TB disease Baseline two-step TB skin test (TST) for all new admissions Referral for chest x-ray is TB skin test is positive Medical assessment physical assessment and symptom review for symptoms of active TB disease Baseline chest x-ray (posterior-anterior and lateral views) for all new admissions A copy of the report must be provided to the home Screening Recommendations Baseline two-step TB skin test at time of employment Annual TSTs are generally not recommended for low risk health care settings 14

16 5.0 Surveillance and Reporting Surveillance systems are the key to early outbreak detection. ROWPH recommends the following components as a part of an effective surveillance program: 1. Routine monitoring of staff and residents for the following symptoms (especially during respiratory season): UPPER RESPIRATORY TRACT INFECTION (2 or more symptoms) Runny nose or sneezing Nasal congestion/runny nose/sneezing Sore throat/hoarseness/difficulty swallowing Dry cough INFLUENZA LIKE ILLNESS (2 or more symptoms) Fever >38 C Chills Headache Myalgia/malaise Loss of appetite Sore throat New or worsening cough Note: ** For both upper respiratory tract infection and Influenza, fever may or may not be present in the elderly. **Symptoms must be new or worse than normal and consideration that symptoms may be caused by other illness must be made (i.e. allergies). Different respiratory viruses often cause similar acute respiratory symptoms. Refer to appendix Common Viral Causes of Respiratory Outbreaks to understand common viral causes of respiratory outbreaks: 2. A mechanism for recording surveillance data (electronic or paper). See Appendices for Sample Daily Surveillance Tool 3. Close monitoring to identify trends/clusters of illness in staff and/or residents 4. Alert infection control lead for the facility to presence of illness 5. Initiate formal line list when illness is identified and meets case definition 6. Alert Public Health to increased respiratory illness When there are residents meeting case definition (2 or more respiratory symptoms), a respiratory outbreak should be considered. Respiratory outbreaks are classified as under investigation/suspect, probable or as confirmed outbreaks. The following factors are considered before an outbreak is officially declared: 15

17 Number of cases Number and nature of symptoms for each case Timing of symptom onset Location of each case within the facility Laboratory results Medical history of each case Staff illness When to Contact Public Health Whenever there are two cases of acute respiratory tract illness within 48 hours, Public Health should be called at ext An outbreak should be suspected and specimen collection may be recommended to determine the causative pathogens. Early reporting of suspected outbreaks is key to preventing further transmission of illness to those most vulnerable. 16

18 Outbreak Definitions Each respiratory outbreak requires its own outbreak definition. The outbreak definition should be developed for each individual outbreak based on its characteristics, reviewed during the course of the outbreak, and modified if necessary to ensure that the majority of cases are captured by the definition. The following chart summarizes the outbreak definitions published by the MOHLTC Infectious Disease Protocol (2013): Upper Respiratory (URTI)/ Influenza-Like Illness (ILI) Influenza. Suspect Outbreak Two cases of acute respiratory illness that meet case definition of URTI/ILI From one unit Onset of symptoms within 48 hours More than one unit has a case of acute respiratory illness within 48 hours One lab-confirmed case of Influenza occurs Two cases of acute respiratory tract illness occurs within 48 hours in one unit More than one unit having a case of acute respiratory illness within 48 hours Confirmed Outbreak Two cases of acute respiratory tract illness within 48 hours From one unit Onset of symptoms within 48 hours One of which is labconfirmed Three cases of acute respiratory illness From one unit Onset of symptoms within 48 hours More than two units having a case of acute respiratory illness within 48 hours Two or more cases with influenza like illness From one unit Onset of symptoms within 48 hours One of which is labconfirmed as Influenza 17

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20 6.0 Specimen collection A nasopharyngeal (NP) swab is: A tool used for surveillance and screening of respiratory illnesses Criteria for obtaining a swab: Determination to swab resident has been made in collaboration with Public Health Resident meets case definition (i.e. demonstrates onset of 2 symptoms) Onset of symptoms within the previous 48 hours Medical directive or physicians order to collect swab Contraindications: Refusal or is un-cooperative Any condition that would interfere with the collection of the specimen (i.e. nasal fracture, nasal polyps, nasal surgery, trauma, swelling) Suspected or confirmed basal skull fracture Common Problems to avoid: Always discard expired testing vials (pink liquid) Ensure staff know where NP swabs are located at all times and keep accessible Keep separate from other specimens in fridge Ensure specimen is labelled with 2 patient identifiers 19

21 How to Collect a Nasopharyngeal Swab Specimens should be collected as early in the illness as possible. Respiratory virus collection kits are distributed each season by Public Health. A visual of the procedure is included in the kits. 1. Check expiry date of the testing vial containing pink liquid. 2. Position the client with the head of the bed raised at a 45 angle. 3. Wash your hands. Put on mask, gown, gloves and protective eyewear. 4. Measure the distance from the tip of the nose to the tip of the earlobe and mark the length with your finger while the swab is still in the package. 5. Tilt the head as the picture on the following page shows. Insert the swab, keeping near the septum. You will know when you reach the nasopharynx when you meet resistance. Rotate the swab at least three to five times when you have reached the nasopharynx. 6. Immediately place the swab in the tube containing pink liquid and snap swab off at perforations and place in vial. Make sure it is closed tight. 7. Label the vial with two patient identifiers (e.g. patient name, date of birth). Place it in the clear plastic biohazard bag provided. Peel off the blue strip to seal. Place the requisition in the front pouch. Complete a Public Health and local lab requisition. 8. Refrigerate and Public Health will arrange pick up for transport to London Public Health Lab. Label for Public Health Pick-Up. To view a video about performing a nasopharyngeal swab, enter the address below or click to be linked to the web page: 20

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23 7.0 Outbreak Control Most respiratory viruses are spread through droplet transmission. Droplet transmission refers to large droplets that are generated from the respiratory tract of the source patient during coughing or sneezing. Certain procedures such as suctioning or bronchoscopy may also produce these droplets. These droplets do not remain suspended in the air but can be propelled a short distance away (up to two meters). They can be inhaled onto the nasal or oral mucosa of a new host who happens to be within two meters of the source patient. Many respiratory viruses remain viable (alive and able to produce infection) when the droplets settle on the objects or surfaces in the immediate environment of the ill source. Viruses such as influenza, respiratory syncytial virus (RSV), rhinovirus and others survive long enough on surfaces to be picked up on the hands of other residents or staff. The virus can then be inoculated into the eyes or nasal/oral mucosa of the new host if they rub their eyes or nose, or touch their mouth. See also: MOHLTC PIDAC document Routine Practices and Additional Precautions in All Health Care Settings, 3rd edition Routine Droplet Contact Precautions HAND WASHING/ HAND HYGIENE Hand hygiene is the most important measure in preventing the spread of infection. Hand hygiene is performed using alcohol-based hand rub and soap and water Staff must avoid touching their face or mucous membranes (including rubbing eyes, etc.) with their hands Hand hygiene should be performed: o Before direct contact with a resident o After any direct contact with a resident and before direct contact with the next resident o Before performing invasive procedures o After contact with blood, body fluids, secretions and excretions (including respiratory droplets) o Before touching food o After contact with contaminated items (e.g., oxygen tubing, masks, used tissues or other items handled by the resident). o Before putting on and taking off PPE o After contact with items in the resident s environment Click here for the video: Four Moments of Hand Hygiene 22

24 GLOVES Worn when there is a risk of contact with body fluids or contaminated surfaces or objects New pair of gloves should be donned before entering the resident s room Remove gloves before leaving the room Gloves should be changed between dirty and cleaner procedures on the same resident Gloves are not a replacement for hand hygiene Gloves cannot be reused or washed MASKS (use fluid resistant Procedure/ Surgical masks) EYE PROTECTION Safety goggles, goggles, or face shields (doesn t include personal eye glasses): Wear within 2 metres of the resident Masks must cover the nose and mouth of the care-giver Masks must be changed if they become wet or contaminated by secretions (see manufacturers recommendations) Masks must be removed /discarded and hands washed before staff cares for another resident or leave the room Masks should be only handled by strings/ties/loops to prevent contamination of hands Fit tested N95 masks should be used for suspected or confirmed airborne diseases (e.g. tuberculosis) Wear within 2 metres of the resident Wear when potential for coughing, splattering, or spraying of blood or body fluids, secretions or excretions during direct care or contact Remove carefully: grasping side arms of eye wear to reduce contamination of hands Wash hands immediately after removing eye protection If re-used, cleanse and disinfect eye protection per manufacturer s instructions using a minimum low level disinfectant GOWNS Long sleeved gowns should be worn to protect forearms and clothing from splashing and soiling with body substances if likely in the course of providing care for that resident Gowns must be removed before leaving the resident s room or dedicated bed space Homes are responsible for training staff in the proper donning and doffing of PPE to ensure staff are not contaminating themselves or their equipment during the process of putting on (donning) or removing (doffing) their PPE CLEANING OF ENVIRONMENT and EQUIPMENT All horizontal and frequently touched surfaces (hand rails, door knobs, light switches, tables, elevator buttons, etc.) should be cleaned daily or more often if soiled Correct cleaning technique must be used (proper concentration of disinfectants applied with clean cloths) Soiled patient care equipment should be handled properly to prevent contamination of skin or clothing Equipment should be cleaned and disinfected prior to use and between residents (blood pressure cuffs, stethoscopes, etc.) Please click on the following links to view videos for Putting on and Removing PPE. 23

25 Additional Infection Control Measures during an Outbreak Influenza Case management Isolate residents meeting case of residents definition for 5 days or until symptoms have resolved (whichever is shorter) Ill residents should be cared for by immunized staff or staff on antiviral medication Restrict residents to unit Antiviral medication (see section 10.0) Signage Post signage at all entrances to facility, all affected units and rooms with isolated residents Communication Daily update symptoms of residents/staff on line list and add new cases Daily follow-up with Public Health to review line list and other issues Public Health will fax the Outbreak Summary with any updated changes at end of day URTI/ILI Isolate all ill residents meeting case definition for 5 days or until symptoms have resolved (whichever is shorter) Cohort staff to minimize movement between outbreak and non-outbreak areas Restrict residents to unit Post signage at all entrances to facility, all affected units and rooms with isolated residents Daily update symptoms of residents/staff on line list and add new cases Daily follow-up with Public Health to review line list and other issues Public Health will fax the Outbreak Summary with any updated changes at end of day Health Care Worker Illness Respiratory viruses (including influenza) that cause common cold-like symptoms in healthy adults can cause severe lower respiratory tract infections in the frail elderly and residents with co-morbid conditions. Health care providers with acute respiratory symptoms who work with clients/patients/residents can both initiate and prolong an outbreak. Staff must report any of the following respiratory symptoms to their manager or workplace contact to determine what accommodations should be made: URTI SYMPTOMS Fever New/worsening cough Headache Sore throat Sneezing ILI SYMPTOMS New/worsening shortness of breath Chills Myalgia Nasal congestion Runny nose 24

26 If influenza is suspected, the staff person MUST remain off work until the period of peak symptoms have resolved and or five days have passed since symptom onset (whichever is sooner) Staff should not work if ill If staff member was ill due to a bacterial illness, they may return to work 24 hours after starting appropriate treatment Any symptoms should be reported to the supervisor Staff working with mild respiratory symptoms should wear a mask Outbreak Management for Confirmed Influenza A & B Outbreaks Influenza Vaccination Vaccination is the cornerstone for the prevention of influenza. It is recommended that all health care workers receive annual influenza immunization to protect the vulnerable populations for whom they care. Antiviral prophylaxis should not replace yearly influenza immunization. Antiviral Medication In addition to immunization, and other outbreak control measures, the use of antiviral medication is recommended to manage facility outbreaks of Influenza A or B. Decisions regarding influenza antiviral prophylaxis and treatment should be made in consultation with Public Health. The cost of antiviral medication will be reimbursed by the Ontario Drug Benefit Program if the outbreak has been confirmed by the local Medical Officer of Health (Public Health). An outbreak preparedness plan should include consent and advance orders for antiviral medications for residents. Special consideration must be given regarding treatment doses for adults with renal impairment. Treatment decisions for staff, including obtaining prescriptions for antiviral medication, are the responsibility of his/her health care provider. In addition to these recommendations, any staff member that has symptoms of ILI should not work for five days, regardless if antivirals were started. 25

27 It is expected, that with the use of antiviral medication and in conjunction with other outbreak control measures, influenza outbreaks will become controlled. If new cases of ILI continue to occur hours after initiating antiviral use, Public Health should be consulted. Additional laboratory testing of new cases or sensitivity testing may be required if resistance or another organism is suspected. The following situations should be considered when antivirals are ineffective: 1. New cases could be caused by another agent other than influenza 2. There may be compliance issues 3. The outbreak strain of influenza may be resistant to antiviral medication For more information, yearly updates on antiviral medication recommendations are published at 26

28 Summary of Antiviral Recommendations for Residents and Staff RESIDENTS Resident with swab positive for influenza A or B RECOMMENDATION If Symptomatic <48 hours: give treatment dose for 5 days If symptomatic >48 hours: consult with ROWPH Symptomatic resident <48 hours, untested Symptomatic resident >48 hours, untested Asymptomatic resident who received influenza vaccine >2 weeks ago Asymptomatic resident who did not receive influenza vaccine this year Resident on antiviral prophylaxis who becomes symptomatic STAFF Immunized >2 weeks prior to start of outbreak Immunized <2 weeks prior to outbreak or during outbreak Asymptomatic and unimmunized staff Antiviral treatment dose Consult with MOH Provide antiviral prophylaxis dose for duration of the outbreak Provide immunization if not contraindicated Provide antiviral prophylaxis dose for duration of the outbreak Continue on the antiviral, but change to treatment dose No antiviral necessary RECOMMENDATION If circulating strain is not well matched by the vaccine, provide antiviral prophylaxis dose for duration of outbreak Take antiviral prophylaxis for two weeks after vaccination or until the outbreak is declared over (whichever comes first) Provide antiviral prophylaxis dose for the duration of the outbreak Allow staff to work as soon as antiviral prophylaxis is started 27

29 8.0 Movement of Residents during an Outbreak The following section provides guidelines for most frequently asked questions about resident movement during outbreaks. Frequent consultation is required with Public Health as each outbreak is unique and changes over time. Visitors: Ill visitors should not enter the facility during an outbreak except for compassionate reasons Visitation by all others should not be restricted, except under the direction of Public Health Visitors who choose to enter the facility during an outbreak should: o Perform hand hygiene upon arrival and just before leaving the resident s room o Visit only one resident and exit the home immediately after the visit o Be educated in and wear appropriate PPE when visiting a resident in isolation o During influenza outbreaks, visitors should be immunized or be taking appropriate antiviral medication Activities: Family gatherings consult Public Health Internal Activities well residents from non-outbreak units may attend. Option: hold separate activities on outbreak unit for non-isolated residents Hairdressing well residents from non-outbreak units may attend. Well residents from OB unit may attend at very end of day Pastoral Visitation Should visit OB unit(s) last, followed by isolated residents very last. Medical/Dental Appointments: Non-urgent rebook for after outbreak is declared over Urgent o Inform receiving hospital ICP and admitting unit of outbreak o Inform transport staff of outbreak o If ill, resident should wear a mask during transport 28

30 Transfer of Residents between LTCHs/Retirement Homes: If facility is in URTI outbreak, consult Public Health Transfers during Influenza and ILI outbreaks are generally not recommended Transfer of Residents from Hospitals The return of residents to a long-term care/retirement home during outbreaks is generally restricted to protect susceptible individuals from being exposed to respiratory infections. Returns to long-term care homes/retirement homes are not, however, prohibited and must be carefully considered with respect to resident safety, quality of life and system capacity. Frequent consultation is required with Public Health as each outbreak is unique and changes over time. The following factors are considered by Public Health when making decisions about returning residents to facilities: Status of the outbreak (severity of illness, is it active or controlled?) Will the resident return to an affected unit? Does the facility have the capacity to provide the required medical care to the resident? If an influenza outbreak is declared, is the resident protected from influenza by vaccination or antiviral medication? Has the resident or substitute decision maker been given information about the return to the facility? Is the resident s physician in agreement with the transfer? What type of accommodation does the resident require and is this available at the outbreak facility? 29

31 Waterloo-Wellington Hospital Transfer Process Guidelines Patient seen in ER - not admitted Patient to go to a new care setting with an outbreak in progress Patient from a care setting in outbreak returning to the care setting Patient is medically stable and appropriate for transfer Patient can be returned to previous care setting. Public Health consult is NOT required for transfer Hospital to arrange transfer with care setting Patient is medically stable and appropriate for discharge Consult with Public Health required: Waterloo Public Health Wellington Public Health: ext.4752 or ext 4752 after hours If discharge to the new care setting is not appropriate, a daily call to Public Health is required for reassessment If discharge to new care setting is appropriate: Speak with patient/sdm. Ensure informed consent is obtained Hospital to arrange discharge with new care setting Patient is medically stable and appropriate for discharge. Consult with Public Health to determine if patient is part of the outbreak. Waterloo Public Health Wellington Public Health : ext.4752 or ext 4752, after hours If patient is part of the outbreak patient can be transfered back to care setting (note: may require prophylactic treatment prior to transfer). Hospital to arrange transfer with previous care setting If not part of outbreak and transfer is appropriate: Speak with patient/sdm ensure informed consent is obtained Hospital to arrange transfer to previous care setting (Note: may require prophylatic treatment prior to transfer) If transfer to the previous care setting not appropriate, a daily call is required to Public Health for reassessment 30

32 9.0 Movement of Staff, Students & Volunteers (SSV) Ill SSV exclude from work for 5 days from onset of symptoms or until symptoms are resolved, whichever is shorter. Influenza Outbreaks Immunized SSV no restrictions on ability to work at other facilities Unimmunized SSV receiving appropriate antiviral medication may return to work after first dose Unimmunized SSV not receiving appropriate antiviral medication may not work at outbreak facility/unit. Must wait 3 days from last day worked at outbreak facility/unit prior to working in a non-outbreak facility/unit Non-Influenza Outbreaks Staff should wait a minimum of 3 days, depending on the incubation period of the infecting pathogen (if known) from last day worked at outbreak facility/unit prior to working in non-outbreak facility/unit External Agency Staff/Services (in addition to above) Visit to outbreak facility/unit should be last visit of the day. If this is not possible (e.g., providing morning care): o Visit outbreak area and isolated residents last o Staff must wear appropriate PPE when visiting isolated residents o If uniform contaminated, must be changed before next visit 31

33 10. Declaring the Outbreak Over An outbreak is declared over when the facility has identified no new cases of infection, (resident or staff) for a period of time determined by Public Health Typically, viral respiratory outbreaks are declared over when there are no new cases for 8 days from the onset of symptoms of the last resident case It is necessary to wait eight days to allow for one period of communicability (five days), plus one incubation period (three days) This timeframe may be altered by Public Health, depended on the causative organism When an outbreak is declared over by Public Health, an Outbreak Over letter is provided to the facility 32

34 Insert Medical Directive Writing Package (Printed Separately)

35 Sample Daily Surveillance Tool Date: Patient Unit: Page of To be completed by ward/unit staff each day Monitor each new onset for 5 days until symptoms resolves Each shift to update this form Any new onset of symptoms of fever, cough/shortness of breath, vomiting, diarrhea and/or pneumonia in patients must be reported to the attending physician immediately and a message for Infection Prevention & Control must be left NAME/ DOB ROOM DATE OF ONSET & MONITORING FEVER >38 C HEADACHE GENERAL ACHES COUGH /SOB NASAL CONGESTION SOB HYPOXIA (O2 Sat <92%) VOMITING DIARRHEA DROPLET PRECAUTIONS (YES OR NO) ACTION (S) swabbed (A) assessed by Dr (T) treatment INITIAL Vaccine: Vaccine: Vaccine: Vaccine: Vaccine: Adapted Best Practices for Surveillance of Health Care-associated Infections in Patient and Resident Populations July 2014

36 Common Viral Causes of Respiratory Outbreaks VIRUS EPIDEMIOLOGY INCUBATION SYMPTOMS DIAGNOSTICS TREATMENT³ ²Adenovirus Fall/winter 1-10 days Rhinitis, pharyngitis, tonsillitis, cough, conjunctivitis, fever Viral culture, or rapid respiratory viral culture Symptomatic treatment only ¹Corona virus (multiple strains) Worldwide occurrence in winter in temperate climates 2-5 days, most infectious in early days of illness Rhinitis, cough, sore throat or fever, lower respiratory symptoms ²Enterovirus Summer and fall 3-6 days Fever, rhinitis, sneezing, cough, skin rash, mouth blisters, myalgia ²Human Metapneumovirus Annual late winter/early spring, coincides with RSV season, sporadic infection year round 3-5 days Coryza, rhinitis, cough, fever, pharyngitis, earache Molecular assays, serology, Viral culture, rapid respiratory viral culture Rapid antigen detection, rapid respiratory viral culture, multiplex respiratory viral PCR No proven antiviral therapy Potential antiviral treatment susceptible to ribavirin in vitro, no controlled clinical studies yet ¹Influenza A&B ²Parainfluenza (strains I, II, III, IV) Winter/early spring Spring, early summer and fall hours Fever, myalgia, headache, rhinitis, cough, fatigue, 2-4 days Fever, rhinitis and cough Rapid antigen detection, rapid respiratory viral culture, Influenza A/B PCR, multiplex respiratory viral PCR Rapid antigen detection, rapid respiratory viral culture, multiplex respiratory viral PCR For treatment and prophylaxis, use Oseltamivir (Tamiflu ), or Zanamivir (Relenza ) Symptomatic treatment only

37 VIRUS EPIDEMIOLOGY INCUBATION SYMPTOMS DIAGNOSTICS TREATMENT³ ¹Respiratory Syncytial Virus (RSV) Late winter/early spring ¹Rhinovirus Throughout year with peek in autumn and spring 2-8 days Rhinitis, sneezing, cough, pharyngitis, headache, fever and sometimes otitis media hours Rhinitis, headache, cough, sneezing, sore throat, malaise Rapid antigen detection, rapid respiratory viral culture, multiplex respiratory viral PCR Rapid antigen detection, rapid respiratory viral culture, multiplex respiratory viral PCR Potential antiviral treatment susceptible to ribavirin in vitro, no controlled clinical studies yet Symptomatic treatment only ¹Canadian Lung Association, ²Center for Disease Control and Prevention, ³ Public Health Ontario

38 Appendix: Resource list and links from the RICN