Guidance for Influenza in Long-Term Care Facilities

Transcription

1 Guidance for Influenza in Long-Term Care Facilities DSHS Region 2/3 Epidemiology Team January 2018

2 1. Introduction Every year, the flu affects people around the world, regardless of age. However, residents and staff of long-term care facilities have been identified as a group of people at higher risk for developing flu-related complications. Therefore, this toolkit was created to help long-term care facilities prepare for influenza cases and prevent the spread of the influenza virus to residents, visitors, and staff. The contents of the toolkit are listed below. What is Influenza? Page 2 Reporting Criteria for Flu Page 4 Flu Detection Page 5 Flu Surveillance Page 6 Control Measures for Residents Page 7 Control Measures for Staff Page 9 Outbreak Control Page 10 References Page 13 APPENDIX A EDUCATIONAL MATERIALS Page 14 1

3 2. What is Influenza? Definition Influenza (flu) is a contagious respiratory virus that can cause mild to severe illness. Flu season typically occurs during the fall and winter. The peak varies but has occurred anywhere from late November through March. However, flu can occur all year round. Types of Flu There are 4 types of flu: A, B, C and D. Influenza A and B cause illness in humans and cause seasonal epidemics almost every winter in the United States; however, flu infection can occur year round. Current Influenza A subtypes found in humans are H1N1 and H3N2. Influenza B does not include subtypes, but are broken down by two lineages: B/Yamagata and B/Victoria. Influenza C infections generally cause mild respiratory symptoms and are not known to cause epidemics. Influenza D primarily infects cattle. Signs and Symptoms Symptoms may include fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle and body aches, headaches, fatigue, and some may experience vomiting or diarrhea. How Flu Spreads The virus infects the nose, throat and lungs. Flu virus spreads mainly by droplets from an infected person when they cough, sneeze, or talk. These droplets can land in the mouth or nose of the person in close proximity. The flu can also be spread by touching your own face, eyes, or nose after coming into direct contact with surfaces or an object that is contaminated with the virus. Incubation Period Incubation period is 1 to 4 days, typically 2 days. This refers to how long it takes from when the person is exposed to the virus until the person has symptoms. 2

4 Contagiousness Period of contagiousness is typically 1 day before symptom onset and up to 5-7 days after symptoms begin. Individuals with a weakened immune system, including children, might be contagious for a longer period of time. High Risks and Complications People who are high risk for the flu include: individuals aged 65 years and older, people of any age with certain chronic conditions, pregnant woman, and children. Health complications due to the flu may lead to hospitalization or death. Complications include bacterial pneumonia, ear infections, sinus infections, and dehydration. For individuals with chronic illness, flu can further complicate pre-existing medical conditions such as congestive heart failure, asthma, or diabetes. Flu Vaccine The best way to protect against the flu is to get the flu vaccine each year. The flu vaccine begins working once the antibodies develop in the body two weeks after receiving the vaccination. Centers for Disease Control and Prevention (CDC) recommends injectable vaccines. Both trivalent and quadrivalent flu vaccines are available. Trivalent vaccines include 2 Flu A strains and 1 B strain. Quadrivalent includes 2 A strains and 2 B strains. 3

5 3. Reporting Criteria for Flu Deaths Influenza-associated pediatric mortality cases are reportable within one working day. Influenza Novel or variant influenza is reportable immediately. Variant flu strain does not typically infect humans. Outbreaks Outbreaks associated with influenza or influenza-like illness (ILI) should be reported immediately to the health department and to the Department of Aging and Disability Services (DADS). Influenza-like illness is characterized by a fever greater than or equal to 100 F plus a cough and/or a sore throat in the absence of a known cause other than influenza. A confirmed or suspected influenza outbreak in a long term care facility is defined as: Three or more cases of ILI among residents or healthcare workers who are in close proximity with each other (e.g., same area of the facility) within 72 hours; OR At least one confirmed influenza case along with one or more cases of ILI and/or influenza among residents or staff in the facility; OR A sudden increase of cases over the normal number seen at this facility each year. If you are experiencing an outbreak of flu in your facility, you are required to notify your health department per the Texas Administrative Code (TAC) Chapter 97, Title 25. Find the health department for your county here: 4

6 4. Flu Detection Positive test results from one or more ill persons with suspected influenza can support decisions to promptly implement prevention and control measures for influenza outbreaks. A number of flu tests are available to detect the influenza virus in respiratory specimens. The most commonly used is the rapid influenza diagnostics test (RIDT). RIDTs produce results within minutes, but are not as accurate as other flu tests as they can result in false negatives or false positives. Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and other molecular assays can identify the presence of influenza viral RNA in respiratory specimens. RT-PCR testing can determine the flu type such as H1N1 or H3N2, which RIDTs are not able to do. The likelihood of a false positive or false negative result for RT-PCR testing is low. This method of testing can help determine the strain that is circulating in an outbreak. Molecular assays such as RT-PCR are particularly useful to identify influenza virus infection as a cause of respiratory outbreaks in institutions (e.g., nursing homes, chronic care facilities, and hospitals). For RT-PCR testing, nasopharyngeal swabs in viral transport media (VTM) are the preferred type of specimen. Nasal and throat swabs in VTM and nasopharyngeal nasal aspirates in VTM from intubated patients are also accepted as specimens for RT-PCR testing. Some public health department laboratories have the capability of testing for influenza RT-PCR during an outbreak. Please contact your health department for more information. 5

7 5. Flu Surveillance Implementation Period At the beginning of influenza season, implement active influenza surveillance and control measures such as offering influenza vaccination to residents and/or staff as well as cough etiquette education. Implement additional control measures as needed once influenza cases have been identified in the community. Offer Vaccine Offer and provide influenza vaccine to residents and staff. Keep logs of resident and employee influenza and pneumococcal vaccination status. Implement Resident Surveillance and Education Conduct respiratory surveillance using McGeer criteria by keeping an infection log for residents. The log should include which McGeer criteria are met as well as which isolation precautions are implemented. Regularly monitor the infection log for an increase in respiratory illnesses and type of respiratory illness. Consider daily monitoring during influenza season. Educate physicians and staff about McGeer criteria. Implement Surveillance for Staff Absenteeism Keep a log of staff absences which includes reason for absence. Consult with Physicians for Testing Consult with the Medical Director or physicians regarding the need for testing residents for respiratory illnesses. Ensure they have appropriate testing recommendations for the current influenza season. Community Surveillance Contact the health department to receive influenza reports in order to know the status of influenza activity in the community. Put up signage for visitors to self-report respiratory symptoms. Restrict visitors based on influenza activity in the community as well as the facility. 6

8 6. Control Measures for Residents Influenza vaccine Vaccinate residents once the influenza vaccine is available each flu season. Educate residents and visitors Teach residents the symptoms of influenza and ask them to notify staff if they or a visitor are having symptoms. Mask if ill If a resident has respiratory symptoms, ask him/her to wear a facemask (surgical or procedure) when not in his/her room. Show him/her how to wear the mask correctly. Teach him/her why it s important to wear the mask. Teach him/her to throw the mask away if dirty or broken/damaged and to replace it with a new one. Exclude from group activities Residents who show symptoms of respiratory illness should be excluded from group activities to minimize the spread of illness. Recommend ill residents stay in their rooms as much as possible, even during meal time. Implement standard and droplet precautions If influenza is suspected or confirmed, the resident should be placed on droplet precautions until 7 days after illness onset or 24 hours after resolution of fever, whichever is longer. Staff should wear a facemask (surgical or procedure) for droplet precautions when caring for the resident. Residents with influenza may continue to shed the virus while on antiviral treatment; therefore, infection control measures to reduce transmission including but not limited to following standard and droplet precautions, should continue while the resident is taking antiviral medications. 7

9 Hand hygiene Teach everyone in facility how to sanitize and wash hands correctly. Get everyone involved. Teach residents to remind each other and the staff who care for them to do hand hygiene. Treatment Some influenza tests are not 100% accurate in detecting influenza. Treatment for influenza should not wait for lab confirmation. In order to be effective, treatment should be provided as soon as possible, preferably within 48 hours of symptom onset. Even if 48 hours has passed, initiating treatment may still be helpful. Physicians should follow CDC treatment recommendations for the current influenza season. 8

10 7. Control Measures for Staff The flu control measures for staff listed below should be implemented, regardless of the existence of an outbreak. Staff includes anyone who works in the facility such as physicians, nursing, housekeeping, and nutrition services. Influenza vaccine Offer influenza vaccine to staff once influenza vaccine is available each year. Educate staff Teach staff the symptoms of influenza so that they can detect illness in residents, visitors, and themselves. Ensure staff understand the components of droplet precautions and when to implement droplet precautions. Teach staff how to properly don and doff a facemask. Teach staff to screen visitors for respiratory symptoms. Exclude visitors or mask visitors based on facility policies. Staff should teach visitors how to wear a mask correctly. Educate physicians and staff about McGreer criteria, influenza test recommendations, and the current season s treatment recommendations. Stay home if ill Educate staff on CDC recommendations and facility policies regarding when they should stay home when ill. Also include the duration recommended by CDC. Exclude those with influenza like illness symptoms from work until at least 24 hours after they no longer have a fever. Hand washing Teach everyone in facility how to sanitize and wash hands correctly. Get everyone involved. Teach residents to remind each other and the staff who care for them to do hand hygiene. 9

11 8. Outbreak Control A confirmed or suspected influenza outbreak in a long term care facility includes: a sudden increase of cases over the normal background rate, OR three or more cases of ILI among residents or staff who are in close proximity of each other (e.g., same area of the facility) within 72 hours, OR two or more cases of ILI and/or influenza among residents when there is at least one confirmed influenza case. See the checklist below for control measures to implement. Additional control measures may be recommended by the health department. Report the outbreak to: The health department The Department of Aging and Disability Services (DADS) Re-educate staff on influenza detection and control measures, as listed in sections 6-8 of this toolkit. Monitor Residents and Staff for Flu Symptoms Monitor all residents for signs and symptoms of the flu. Recommend treatment with antivirals at the first sign of illness. Follow isolation precautions listed below. Monitor all staff for signs and symptoms of the flu. Recommend treatment with antivirals at the first sign of illness. Exclude ill staff from work until 24 hours after fever has resolved without the use of fever-reducing medications. Continue to regularly monitor personnel absenteeism due to respiratory symptoms and exclude those with influenza like illness symptoms from work per the guidance above. Continue monitoring until 7 days after the last case of flu. 10

12 Isolation Precautions When a resident is suspected or confirmed to have influenza, implement Standard and Droplet precautions for seven days after onset or until the resident is symptom-free for 24 hours, whichever is longer. Standard and droplet precautions should be continued even if the resident initiates antiviral therapy. Isolate or cohort ill residents with the same Flu Type in same room and/or wing. Avoid new admissions or transfers to wards with symptomatic residents. Resident and Community Education Re-educate residents on the signs/symptoms of flu and to report to the nurse or physician if they have any of the signs/symptoms. Post signage in entrance ways regarding flu illnesses and restrict ill visitors and staff from entering the facility. Utilize Educational Materials in Appendix A as needed. Flu Vaccine Offer flu vaccine to unvaccinated residents and staff who do not have medical contraindications. Chemoprophylaxis Treatment The facility should promptly initiate antiviral treatment to all residents (as a chemoprophylaxis/preventative) regardless of vaccination status. Nonvaccinated staff are recommended to receive antivirals. Chemoprophylaxis protocol should be continued for a minimum of two weeks and should continue 7 days after the last influenza case is detected (whichever is longer). 11

13 Administer influenza antiviral medications for treatment when influenza is detected. It is best to administer within 48 hours of onset. The recommended dosing and duration of antiviral treatment can be found on the CDC website: Cohorting of Staff Restrict staff movement between wards/buildings/wings especially between ill and non-ill residents. Limit the exposure of non-essential staff to ill residents (i.e. nursing can deliver dietary trays instead of nutrition services staff). Floating staff should work in either areas with ill residents or areas with well residents, but not both. Limit Group Activities Limit the number of large group activities in the facility and consider serving all meals in resident rooms with disposable trays, plates, and utensils, if possible, when the outbreak is widespread (involving multiple units of the facility). 12

14 9. References For more information on flu: 1. CDC About Flu 2. CDC s Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities 3. Texas Department of State Health Services Flu website 4. Stone, Nimalie D., et al. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infection Control and Hospital Epidemiology, vol. 33, no. 10, 2012, pp JSTOR, JSTOR, 13

15 APPENDIX A EDUCATIONAL MATERIALS 14

16 Contagious respiratory virus that causes cough, sore throat, fever, runny nose, muscle aches, and tiredness. Droplets from someone else s uncovered cough or sneeze enters the body through the mouth or nose. Touching the eyes can also cause people to get sick. Get the flu vaccine every year. Wash your hands. Stay away from others if you are sick. Request loved ones to not visit while you are sick. Wear a mask if you have any respiratory symptoms. Contact your facility administrator or your local health department for more information on the flu.

17 Perform hand hygiene before and after patient contact or contact with the patient s environment. Teach residents and visitors how to correctly use hand sanitizer and wash their hands with soap and water. Include important moments for performing hand hygiene. Implement respiratory etiquette by masking those with respiratory symptoms. Place residents on droplet precautions if flu is suspected. Notify infection prevention staff if flu is suspected. Stay home if you are sick.

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20 SAFETY TIPS: Are you wearing your mask correctly? Pull the mask apart so it opens all the way. Put the mask over your nose and squeeze so that it stays there. It will not stay on the nose if it s inside out. The soft filter should be inside, not outside. Make sure the bottom of the mask covers your chin. If you wear glasses, put your glasses on last.

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