HEALTH ADVISORY: UPDATED INTERIM INFECTION CONTROL GUIDANCE FOR PREVENTING AND CONTROLLING INFLUENZA TRANSMISSION IN LONG TERM CARE FACILITIES

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1 Richard F. Daines, M.D. Commissioner James W. Clyne Executive Deputy Commissioner December 17, 2009 To: Nursing Homes, Local Health Departments From: NYSDOH Bureau of Healthcare Associated Infections HEALTH ADVISORY: UPDATED INTERIM INFECTION CONTROL GUIDANCE FOR PREVENTING AND CONTROLLING INFLUENZA TRANSMISSION IN LONG TERM CARE FACILITIES Please distribute immediately to all staff and all patient units. This advisory was first released on November 27, The advisory has been revised to reflect updated recommendations on 2009 H1N1 vaccination. Information that has been updated or revised is highlighted. This document has been developed to provide interim guidance to long term care (LTC) facilities for the infection prevention and control of residents with influenza-like illness (ILI) including those confirmed to be due to any influenza virus, including seasonal influenza A (H1N1), seasonal influenza A (H3N2), seasonal influenza B, or 2009 H1N1 influenza infection. The goal of this interim guidance is twofold: To minimize the introduction of influenza into a LTC facility and to stop transmission of influenza within a LTC facility. Key points in this advisory include: Identification of presentations meeting the standard definition of influenza-like illness (ILI) should raise the suspicion for infection with influenza virus. However, since long term care (LTC) facility residents are at high risk for disease and may have abnormal immune systems, particular attention should be paid to deviation from a given patient s baseline status. For the influenza season, a nosocomial outbreak is defined as a single resident with confirmed influenza that was acquired nosocomially, OR two or more residents and/or staff with ILI or confirmed influenza on the same unit within 7 days. This differs from previous influenza seasons.

2 Vaccine for seasonal influenza and 2009 H1N1 influenza should be made available for all those wishing to be vaccinated, including staff, residents, and visitors. The most important step in prevention of nosocomial outbreaks is early recognition and action, including screening and excluding ill visitors and staff, placing residents on the proper transmission based precautions, and initiating antiviral treatment and prophylaxis. Exclusion of ill staff should continue until the individual is afebrile off antipyretic medications for at least 24 hours. Visitor policies should be enforced widely, including the exclusion of any ill visitor and frequent hand hygiene for all visitors while in the facility. Local testing, specifically rapid methodologies, may not assist with diagnosis. Confirmatory testing for nosocomial outbreaks is available through public health. Treatment decisions will often need to be made in the absence of testing results, and a negative rapid test does not rule-out 2009 H1N1 infection. Treatment choice should be based on local surveillance and national antiviral resistance data. Currently, 2009 H1N1 is the predominate influenza agent circulating, and oseltamivir is the drug of choice for treatment and prophylaxis. All efforts should be made to minimize movement of ill residents within a facility. If movement is necessary, precautions should be taken to prevent illness spread to other residents and staff. Per Centers for Disease Control and Prevention guidelines, residents with suspected and confirmed 2009 H1N1 influenza infection should be placed in Standard and Droplet precautions. N95 respirators are recommended for routine care of these patients. Patients should remain in precautions for at least 7 days from illness onset or until the patient is afebrile off antipyretic medications for at least 24 hours, whichever is longer. Aerosol-generating procedures performed on residents with suspected and confirmed 2009 H1N1 influenza infection should be conducted using Airborne Precautions in an airborne infection isolation room (AIIR) if available. Upon identification of an outbreak, prophylaxis is recommended for all residents and any exposed staff who themselves are at high risk of influenza-related complications. Facilities may chose to offer prophylaxis in a step-wise fashion to affected units, after consultation with Health Department staff. Nosocomial outbreaks should be reported to the New York State Department of Health via the Nosocomial Outbreak Reporting Application (NORA) system located on the Health Provider Network (HPN) and by telephone to the local health department (LHD). 2

3 Major changes from previous advisories on 2009 H1N1 influenza include: The definition of a nosocomial outbreak for purposes of response and reporting is changed to: A single resident with confirmed influenza that was acquired nosocomially, OR two or more residents and/or staff with ILI or confirmed influenza on the same unit within 7 days. Vaccine for 2009 H1N1 influenza is no longer prioritized for specific groups only. Vaccine should be made available for all those wishing to be vaccinated, including staff, residents, and visitors. Exclusion of ill staff should continue until the individual is afebrile off antipyretic medications for at least 24 hours. Exclusion for 7 days is no longer necessary. In accordance with CDC guidelines, N95 respirators are recommended for routine care of residents with suspected and confirmed 2009 H1N1 influenza infection. In accordance with CDC and others guidance, nebulized treatments are no longer considered aerosol-generating procedures and do not require Airborne Precautions. Post-exposure prophylaxis for healthcare workers (HCWs) is recommended only if exposed AND the HCWs themselves are at high risk of influenza-related complications. Background and Epidemiology: Human-to-human transmission of 2009 H1N1 influenza virus appears to be primarily through large respiratory droplets generated when infected persons cough or sneeze; these large droplets can then settle on the mucosal surfaces of the upper respiratory tract of susceptible persons who are near (e.g. within about 6 feet). Transmission may also occur through indirect contact with respiratory secretions, such as touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth. Evidence suggests that the incubation period for seasonal influenza and 2009 H1N1 influenza is up to 7 days. Individuals may be infectious from 1 day before symptoms start to up to 7 days after symptoms start. The epidemiology of seasonal and 2009 H1N1 influenza has differed with respect to LTC facilities. Annually, seasonal influenza spreads through LTC facilities and older populations as well as through communities and younger populations. During the spring 2009 outbreak, the spread of 2009 H1N1 influenza was predominantly in the community setting and among younger (e.g., school age and young adult) populations. Thus far this fall, the NYSDOH has identified 4 confirmed outbreaks of 2009 H1N1 in LTC facilities. Most have been single cases or illness predominantly among facility staff. The clinical picture to date of 2009 H1N1 influenza is one of relatively mild disease; however, some will experience severe disease. While the risk of contracting 2009 H1N1 influenza infection is higher in younger people, the risk of complications due to 2009 H1N1 influenza infection remains higher in elderly patients. 3

4 Because of their underlying health status, residents of LTC facilities and other chronic care facilities with influenza are at high risk for developing serious complications or dying. The clinical picture of influenza in a LTC resident may not be typical, and resources for influenza transmission prevention may be limited. LTC facilities will face these and other challenges when identifying and providing care to residents infected with influenza. It is critical that LTC facility staff, residents and visitors follow the appropriate infection control (IC) precautions in order to prevent or minimize the introduction and transmission of influenza in the LTC setting. Table of Contents Section Topic Page 1. Definitions 4 2. Vaccination 5 3. Early Detection of ILI in Residents, Staff and Visitors 5 4. Laboratory Testing for Influenza 7 5. Antiviral Treatment 8 6. Standard and Transmission Based Precautions for Residents with 10 Confirmed or Suspected Influenza 7. Placement, Movement and Transfer of Residents with Confirmed or 13 Suspected Influenza 8. Additional Infection Control Strategies Post Exposure Management of Residents & Staff Case Reporting References Definitions A. Influenza-like Illness (ILI) in LTC Residents The following criteria for ILI in LTC residents can be used to determine the need for applying the infection prevention and control measures found in this guidance: An illness characterized by fever 37.8 C ( 100 F) and cough and/or sore throat in the absence of another known cause. 4

5 Providers should be aware that patients 65 years of age and older may display atypical symptoms, such as joint pain, muscle aches, and generalized weakness. Particular attention should be paid to deviation from a given patient s baseline status. For example, if a patient develops cough plus hypothermia or temperature instability rather than fever, or a patient with a tracheotomy develops increased secretions or need for suctioning, strong consideration of influenza as an etiologic agent should be made. B. Suspected Influenza in Health Care Workers (HCWs) and Visitors The following criteria for ILI in HCWs and visitors can be used to determine the need for applying the infection prevention and control measures found in this guidance: An illness characterized by fever 37.8 C ( 100 F) and cough and/or sore throat in the absence of another cause. C. Cluster or Outbreak in a LTC Facility For the purposes of this document and the influenza season, the NYSDOH is defining an outbreak as: A single resident with confirmed influenza that was acquired nosocomially in the LTC facility, OR Two or more residents and/or staff with ILI or confirmed influenza on the same unit within seven days 2. Vaccination Vaccination is the primary measure to prevent influenza, limit influenza transmission, and prevent influenza-associated complications in LTC residents and HCWs. On December 10, 2009, Governor Patterson announced that health care providers may make the H1N1 flu vaccine available to all New Yorkers who want the vaccine, including those who are not in priority groups established by the federal Centers for Disease Control and Prevention (CDC). LTC personnel (e.g., all paid and unpaid workers who have contact with residents and visitors, including volunteer workers) and all residents of LTC facilities are recommended to receive annual influenza vaccination and the monovalent 2009 H1N1 influenza vaccine according to 5

6 current national recommendations (see and 3. Early Detection of ILI in Residents, Staff and Visitors A. Residents LTC facilities should have an established mechanism to conduct year-round passive screening of all residents for symptoms of ILI. When community-level spread of influenza is occurring, consider facility-wide active screening of all residents for symptoms of ILI at least daily. B. Staff Staff should perform self-assessment for symptoms of ILI and should not work if they are experiencing an ILI. Staff should be educated regarding the importance of: Ceasing patient care activities immediately and going home if they develop symptoms of ILI while on duty Staying home until feeling better and afebrile off antipyretic medications for at least 24 hours Reporting their illness to their supervisor or the administrator responsible for occupational health so that appropriate measures, including a post-exposure investigation if indicated, can be conducted (See Section Nine: Post-Exposure Management) Facilities should strongly consider developing liberal, non-punitive sick leave policies for personnel who are excluded due to ILI or must care for family members with ILI. C. Visitors At a minimum, signage (in multiple languages, as appropriate) should be posted at all entrances to the facility reminding visitors NOT to enter if they are having symptoms of ILI, and passive screening of visitors for respiratory symptoms (e.g., staff observation of visitors for signs of illness, requesting ill visitors to self-report to facility staff, etc.) should be performed. Ill visitors must be excluded, and should not be allowed to visit while masked or maintaining distance from residents. Consider making exceptions to visitor restriction in extenuating circumstances (such as end of life care). Consider designating a person on each floor, wing, or unit (such as a charge 6

7 nurse) who can make these exceptions. Facilities may wish to work with their Family Councils to best convey the policy to all members of the LTC facility community. Hand hygiene stations with appropriate signage should be placed at all entrances and throughout the facility, and visitors should be encouraged to perform hand hygiene regularly. When community-level spread of novel influenza A (H1N1) is occurring, consider the following additional visitor screening strategies: Send a letter to residents families reminding them not to visit while ill Use Family Council meetings as a venue to reinforce not visiting when ill Limit entry into the building by visitors to a single door to facilitate surveillance for symptoms of ILI Depending on illness activity in the facility or community, consider active screening of visitors via interview or paper screening form Restrict visitation of children 4. Laboratory Testing Screening Residents with ILI for Influenza Facilities should establish plans for routine testing of respiratory specimens from patients with ILI at an appropriate hospital or commercial laboratory. Orders for testing should include: Rapid antigen test (RAT) for influenza A or B Viral culture for influenza and other respiratory viruses (If available) PCR-based testing for influenza (seasonal and/or 2009 H1N1) RAT continues to be the single most useful test in screening patients with ILI for influenza infection. However, the reliability of RAT results is limited, depending on which influenza virus is involved and the level of circulating virus in the community. RAT is not a sensitive test for 2009 H1N1 influenza and a negative RAT does not rule-out 2009 H1N1 influenza disease. Nasopharyngeal swabs are the specimen of choice for influenza. Specimens from resident(s) with suspected ILI should be collected while the patient is symptomatic and prior to initiation of antimicrobial therapy, and submitted to an appropriate laboratory. Confirmatory Testing Molecular testing for 2009 H1N1 influenza and confirmation of seasonal influenza subtypes is available at public health laboratories. Prior to shipment, testing requests must be coordinated 7

8 with the NYSDOH Regional Epidemiologist or New York City Department of Health and Mental Hygiene (NYCDOHMH) Influenza Coordinator (See Section 10: Case Reporting). Other than in NYC, local health department approval is no longer needed to submit specimens for confirmatory testing. Specimens may be sent for further testing at a public health laboratory in the following circumstances: RAT positive for influenza A or B Single case of suspected nosocomial transmission, regardless of RAT results Cluster of ILI regardless of RAT results Facilities should request that clinical laboratories save patient specimens for possible forwarding to a public health laboratory. It is the facility s and laboratory s responsibility to ensure specimens are properly preserved and packaged so that appropriate testing can be conducted. 5. Antiviral Treatment Clinical decisions regarding antiviral treatment of residents with suspected 2009 H1N1 influenza should NOT be based solely on influenza rapid antigen test results. Confirmatory testing for 2009 H1N1 influenza requires technology that is not widely available and not timely enough to assist with clinical management and infection control response. Thus, decisions regarding treatment, prophylaxis and transmission prevention must be made without confirmatory data. All LTC residents are considered at high risk for complications of influenza. Therefore, antiviral treatment is recommended for all LTC residents with confirmed or suspected influenza virus infection. Antiviral treatment should be initiated as soon as possible (ideally within 48 hours) after the onset of symptoms. Treatment can be initiated at any point, but is most effective earlier in the course of illness. Recommended duration of treatment is 5 days. Health care providers will need to make decisions about which antiviral medication to use for treatment by taking into consideration the influenza activity in New York State and the antiviral susceptibility patterns of the circulating strains. Thus far, 2009 H1N1 influenza virus is the predominant influenza strain identified in NYS this season. However, given the lower risk of 8

9 elderly persons becoming infected with 2009 H1N1 influenza, seasonal influenza strains may begin to appear in LTC facilities. Healthcare providers should review weekly their regional and state influenza virus surveillance data to determine which types (influenza A or B) and subtypes of influenza A virus (2009 H1N1, seasonal H1N1, or seasonal H3N2) are currently circulating in the area. Current information on influenza surveillance data in New York State is available at: The following recommendations are based on antiviral susceptibility patterns current as of November Oseltamivir or zanamivir should be used to treat individuals with 2009 H1N1 influenza, influenza A (H3N2), or influenza B. Zanamivir should be used to treat individuals with seasonal influenza A (H1N1). o Rimantadine can be used for patients who cannot receive zanamivir (e.g., patient is <7 years old, has chronic underlying pulmonary disease, or cannot use the zanamivir inhalation device) or if zanamivir is unavailable. o Amantadine can be substituted for rimantadine if rimantadine is unavailable. Zanamivir or a combination of oseltamivir and rimantadine will provide effective treatment against all possible circulating influenza viruses. Therefore, either of these regimens should be used if: o The patient s subtype information is not available and multiple influenza strains are circulating including seasonal influenza A (H1N1), or o Influenza surveillance information is not available or unknown. Note that zanamivir is not recommended for patients with underlying pulmonary disease, such as asthma or chronic obstructive pulmonary disease. Some experts recommend the use of increased (doubled) doses of oseltamivir for some severely ill patients, although there are no published data on its effectiveness. Dosages of some antiviral medications may need to be adjusted for persons age 65 years and older, persons with impaired renal function, or persons with liver disease. Clinicians should consult the package insert of each antiviral medication for additional dosing information, contraindications/warnings/precautions, and adverse effects. Dosage recommendations are available at 9

10 Interim recommendations for the selection of antiviral medications using viral surveillance data Influenza virus(es) in the community 2009 H1N1 influenza and/or Influenza A (H3N2) and/or Influenza B Seasonal influenza A (H1N1) Multiple influenza types/subtypes, including seasonal H1N1, are circulating or Surveillance data unknown or not available Preferred Medication(s) Oseltamivir OR Zanamivir Zanamivir OR Rimantidine Zanamivir OR Combination oseltamivir and rimantidine Comments If rapid influenza diagnostic testing is positive for influenza B, treatment with either oseltamivir or zanamivir is appropriate, regardless of other circulating strains in the community. Zanamivir should be used with caution in residents with underlying pulmonary disease, such as asthma or chronic obstructive pulmonary disease (See ntiviral/sideeffects.htm) 6. Standard and Transmission Based Precautions for Residents with Confirmed or Suspected Influenza Current CDC Guidance and OSHA Enforcement On October 14, 2009, the Centers for Disease Control and Prevention (CDC) issued revised guidance on infection control measures for healthcare settings. The guidance titled Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare settings, Including Protection of Healthcare Personnel can be found at: The NYSDOH appreciates the approach taken by CDC recognizing the importance of multiple interventions, using a hierarchy of controls that includes basic infection control measures, such as respiratory and hand hygiene, rapid identification and isolation of ill patients, excluding sick employees and visitors, and emphasizing that vaccination of healthcare workers is the most effective prevention measure. CDC recommends the use of N-95 respirators to protect health care workers against transmission of the 2009 H1N1 influenza. CDC has established a legally-enforceable standard of care with 10

11 which health care facilities must comply. The Occupational Safety and Health Administration (OSHA) is planning to enforce these CDC recommendations under the General Duty Clause and General Industry Respiratory Protection Standard. The NYSDOH recommends that health care facilities and organizations follow the CDC guidelines including demonstrating a good faith effort to provide N95 respirators for health care workers caring for residents with suspected or confirmed 2009 H1N1 infection. At the same time, NYSDOH recognizes that N95 supply shortages are already being reported in NYS and could worsen during the influenza season as health care facilities expand their use of N95s. The CDC guidance acknowledges the potential problem of limited supplies and allows facilities to prioritize N95s to the highest risk situations. The recommendations below are intended to help health care providers comply with CDC guidance while ensuring, to the extent possible, that N95 respirators are available to protect workers in situations of highest risk and that health care workers are provided with effective personal protective equipment while caring for residents with suspected H1N1 infection. It is important to keep the following points in mind while implementing the CDC guidelines: 1. The interim guidelines apply only to residents with suspected or confirmed 2009 H1N1 influenza during the season. 2. There is a hierarchy of critical control measures of which use of personal protective equipment is merely one component. Health care settings and providers need to implement all components to the extent possible. 3. CDC recommends the use of fit tested N95 respirators for all contact with patients with suspected or confirmed 2009 H1N1 influenza, but clearly acknowledges that there are insufficient supplies to meet this need. If supplies are insufficient, health care facilities may operate in prioritized use mode throughout the season. The following are suggested items for consideration when in prioritized use mode: a. NYSDOH agrees that the health care workers at highest risk are those performing aerosol-generating procedures (including bronchoscopy, endotracheal intubation and extubation, open suctioning of airways and cardiopulmonary resuscitation) on patients with suspected or confirmed 2009 H1N1 influenza, or when providing care to patients with other infections that are known to be transmitted via the airborne route (e.g., Mycobacterium tuberculosis). b. Each facility needs to assess its current supply of respirators, project future need (through at least May 2010, when the current influenza season is expected to end), seek additional supplies if warranted, document in writing their good faith efforts to obtain additional supplies and determine how to maximize the use of available respirators. Supplies of respirators for the high-risk use scenarios outlined above should be stockpiled in advance to assure they are sufficient if additional supplies cannot be obtained for the rest of this influenza season. 11

12 c. If a facility recognizes that it will not have sufficient supplies of N95 respirators during this influenza season to fully comply with the CDC guidelines, a policy should be developed for how the facility will approach prioritization of available supplies, considering the various options that the CDC provides in its revised guidance, including a prioritized use scheme (see Table 2 in the CDC guidance) or allowing reuse or extended use of disposable N95s as described by CDC. The NYSDOH strongly recommends that facilities adopt their prioritization policies early, in order to assure sufficient supplies for high-risk use throughout the influenza season. d. Out of an abundance of caution, the NYSDOH has previously recommended nebulizer treatments be considered aerosol-generating procedures. To be consistent with the CDC guidance, the NYSDOH no longer considers nebulizer treatments to be an aerosol-generating procedure. Transmission-based Precautions for seasonal influenza and 2009 H1N1 influenza during Prioritized Use Mode Follow STANDARD precautions plus N95 respirators or surgical mask (according to the facility s prioritization policy) for the routine care of residents with ILI. Standard precautions involve the use of gloves, eye protection (goggles or face shield) and gowns when soiling or exposure to blood, body fluids, secretions, or excretions is anticipated. Respirators/masks should be worn when within 6 feet of the affected individual. For aerosol-generating medical procedures (AGMPs) such as bronchoscopy, intubation and extubation, and open tracheal suctioning, gloves, eye protection (goggles or face shield), gowns and N95 respiratory protection are recommended. AGMPs should ideally be performed using Airborne Precautions. Airborne precautions involve the use of an airborne infection isolation room (AIIR) with a closed door; wearing a properly-fitted N-95 or higher rated respirator; and limiting the number of people in the room to only those necessary. Many LTCFs lack an AIIR or private procedure/examination room, and may not be able to isolate residents in private rooms. In this setting, the minimum requirements for performing AGMPs in a resident's room include: Using properly fit-tested N-95 or higher rated respirators by all staff in the room; Maintaining a distance of at least 6 feet between other residents in the room; Using a privacy curtain between the residents; Limiting the number of people in the room to only those necessary; Keeping the door to the room closed during the procedure; and Performing low-level disinfection of surfaces in the room used for AGMP immediately following the procedure. 12

13 Ensure that proper signage is posted on the symptomatic resident s room door indicating the precautions required. Transmission based precautions must be continued for a minimum of seven days or until 24 hours after symptoms have resolved, whichever is longer. 7. Placement, Movement and Transfer of Residents with Confirmed or Suspected Influenza A. Room Assignments Confine ill resident(s) in a single room with the door closed, if possible. When it is not possible to place an ill resident in a single room, the following alternatives can be considered: o Confine ill resident(s) in their own room; o Keep the privacy curtains drawn to create a barrier between an ill resident and other residents in the same room; o Arrange rooms to permit the maximum amount of space between beds (a minimum of 6 feet is preferred). Consider rearranging beds so that residents are not face-to-face; Explain to ill residents and their visitors about restrictions on the resident s movement; Consider roommates of the symptomatic individual to be exposed contacts. Monitor their health, and do not move them to rooms containing unexposed residents until they are deemed non-infectious and/or not incubating; For a single case of ILI, consider closing the resident s unit to any admissions or transfers. If an outbreak is identified (single confirmed or 2 or more ILI cases within 7 days), it is recommended the affected unit(s) be closed to any admissions or transfers. Assign dedicated staff to and discontinue staff floating to and from the affected unit(s); Do not cohort residents without a confirmed diagnosis, to avoid the risk of infection with multiple viruses or influenza subtypes; Do not reopen the affected unit(s) until all residents are deemed non-infectious (recovered and/or not infectious/not incubating), at least 7 days from onset of the final case. B. Movement of Residents with ILI or Confirmed Influenza Within the LTC Facility Every effort should be made to maintain all residents on affected units in their rooms and to limit their movements within the facility. When feasible, essential services should be provided at the bedside and nonessential services (e.g. social activities) should be postponed. If ILI or influenza is widespread within a facility, strong consideration should be given to postponement of all group social activities, including communal meals, at least until the outbreak subsides. Whenever possible, perform individual activities in residents rooms. 13

14 When it is necessary that a potentially infectious resident be moved from his/her room: Inform transporters/escorts of the resident s infectious status and provide instructions as necessary Inform the receiving unit of the resident s influenza status and the need to maintain droplet precautions Keep the resident masked with a surgical mask if he/she can tolerate a mask. N95 respirators need not be worn by ill patients during transport. If the resident cannot tolerate a mask: o Transporter may wear a mask o Instruct resident in respiratory etiquette and social distancing o Transporter will make an effort to keep the resident at a distance of 6 feet from others along the route Plan route from resident care unit to receiving unit utilizing the least crowded, most spacious areas of the facility If elevators are part of the route, and the resident is able to wear a mask and to comply with instructions, consider whether elevator can be emptied and used by the resident and escort only. If the resident is not able to tolerate a mask and/or is unable to comply with instructions, use an unoccupied elevator to transport the resident. If the resident is not able to comply with instructions (e.g. cannot keep a mask on, cannot cover cough or maintain social distance), consider transporting the resident in a wheelchair accompanied by a staff member who is familiar with the resident. Ensure that before the resident leaves his/her room: o Mask will be in place (if possible) o Resident s hands will be washed o Resident will be supplied with tissues and a means of disposing of them (e.g., paper bag) o Resident may be provided with hand sanitizer as appropriate C. Transfer of Residents with ILI or Confirmed Influenza from LTC to Acute Care Transfer of persons with known or suspected 2009 H1N1 influenza from a LTC to an acute care facility or emergency room should be based on clinical status and NOT on the need for isolation. Prior to transfer, inform the transporters and the receiving facility of the resident s diagnosis and of appropriate infection control measures, encourage/assist the resident to perform hand hygiene, and provide tissues and a means of used tissue disposal for residents who are able to perform respiratory hygiene. At the time of transfer, mask residents who can tolerate wearing a surgical face mask and, when residents cannot be masked, inform transporters and receiving facility in advance of the transport. 14

15 D. Admission/Transfer of a Patient with ILI or Confirmed Influenza into the LTC Facility Consider postponing the admission/transfer of a symptomatic resident until 7 days after the onset of their illness, or 24 hours after resolution of symptoms, whichever is longer. When admission of a symptomatic resident cannot be postponed, establish good communication with the referring entity regarding the health status of the expected resident. Admit any symptomatic resident or a resident with confirmed influenza infection directly into Droplet precautions, and maintain precautions until 7 days after the onset of their illness, or 24 hours after resolution of symptoms, whichever is longer. Asymptomatic patients who have not completed their precautions should be admitted under Droplet precautions for the remainder of their precautions. Asymptomatic patients who have completed their precautions or those with a negative test for influenza by PCR testing or have an alternative diagnosis established may be transferred as usual using Standard Precautions. Residents admitted during times of widespread influenza activity in the community or from a facility with a known outbreak of ILI or influenza should be preemptively placed in Droplet precautions and monitored for symptoms for up to 7 days. E. Outside Appointments/Activities for Residents with ILI or Confirmed Influenza Every effort should be made to keep residents who are infectious from leaving the LTC facility. LTC staff, the resident s medical/dental provider, and/or family should determine whether attendance at the appointment or social event is necessary. The following should be considered: Whether the appointment or event can be postponed. Ability of the resident to tolerate wearing a face mask, comply with social distancing, and perform hand hygiene and respiratory etiquette. A medical transport vehicle should be considered for infectious residents for whom medical appointments are necessary and who are unable to comply with infection control instructions. The degree to which the presence of the symptomatic individual may jeopardize the health of others at the event/appointment and whether adequate safeguards can be in place to prevent transmission. The effect of postponing or missing the social event on the physical or psychological health of the resident and whether an alternate situation can be arranged. 15

16 If a decision is made that the symptomatic resident should attend a medical or dental appointment (e.g. dialysis): Inform staff at the receiving office/facility of the resident s infectious status and inform office/facility staff of appropriate infection control measures. Arrange for appropriate transport/escort, inform escort of the resident s infectious status, and instruct escort in appropriate infection control measures. If feasible, teach the resident the importance of applicable infection control measures and evaluate resident s ability to comply. If tolerated, the patient should wear a surgical mask during transport and when in the office/facility. Ensure that the resident s hands are washed prior to transport. Provide necessary hygienic materials (hand sanitizer, tissues, bag for used tissue disposal). In the rare event that a potentially infectious resident must attend a social event ( e.g., funeral) the resident s family should be responsible for ensuring that the time resident spends at the event is limited, and that social distancing, respiratory etiquette (including masking, when feasible), and hand hygiene are maintained. If influenza activity is widespread in the community, consider cancelling social group outings into the community, social events with community participants, and nonessential appointments in the community. 8. Additional Infection Control Strategies A. Visitors See Section Three (Early Detection of ILI in Residents, Staff and Visitors) for guidance on evaluating visitors for symptoms of ILI. Facilities may wish to limit the number of visitors per resident to no more than 2 visitors at a time. Additionally, facilities may choose to exclude visitors who are <12 or <18 years of age. Consider limiting visitors to residents on Droplet precautions to persons who are necessary for the resident's emotional well-being and care. Visitors who have been in contact with a resident before and during his or her illness are a possible source of infection. Therefore, schedule and control visits to allow for appropriate screening for acute respiratory illness before entering the LTC facility and educate the visitor on appropriate use of personal protective equipment and other precautions (e.g., hand hygiene, limiting surfaces touched) while in the resident's room. Visitors should be given the equipment and supplies necessary to comply with Standard and other transmission based precautions. 16

17 Visitors should be instructed to limit their movement within the facility. B. Hand Hygiene All persons in the facility should practice good hand hygiene at all times. Signage with clear instructions for residents, staff, visitors, contractors, volunteers, etc. to perform hand hygiene should be posted at all entrances and throughout the facility, especially at areas of social gathering (e.g., dining hall). Alcohol-based hand sanitizer should be readily available at the entrances and exits of the facility, residential units, dining areas and at point-of-care in the resident s room. Observe staff compliance with facility s hand hygiene policy. Conduct staff re-education on appropriate hand hygiene as needed. Teach and encourage residents to perform frequent hand hygiene. If residents are unable to perform hand hygiene, they should be routinely and frequently assisted with hand hygiene. C. Respiratory Hygiene/Cough Etiquette Teach residents and staff how to perform respiratory hygiene practices (coughing into sleeve, using tissues and safely disposing of used tissues, etc.). Residents with ILI should wear a mask (if tolerated) when other residents or visitors are present. D. Education Provide in-service education for staff about the importance of influenza vaccination, signs and symptoms of influenza, proper use of personal protective equipment, and the need to strictly adhere to all infection control measures to prevent and control transmission. Education should be repeated regularly and as needed. E. Environmental Cleaning and Disinfection Environmental infection control should focus on regular daily cleaning for most surfaces and targeted use of disinfectants for surfaces touched frequently by hands. Use sanitizer wipes or cloths moistened with disinfectant to wipe electronic items (e.g., phones, computers, remote controls) that are touched often. 17

18 When illness is identified in a facility or is increasing in a community, ensure that all resident care areas are cleaned and disinfected more often than usual, especially on units with ill residents. See for US EPA and NYSDEC registered disinfectant products effective against influenza viruses F. Equipment Cleaning/Disinfection To the extent possible, all resident care equipment (e.g. stethoscopes, thermometers, blood pressure cuffs, glucometers) should be dedicated to residents with ILI or confirmed influenza. If individually dedicated equipment is not possible, clean and disinfect before reuse with another resident as per the manufacturer s recommendations. Note: Avoid use of equipment that recirculates air (i.e., fans). 9. Post-Exposure Management of Residents and Staff A. Post-Exposure Follow up of a HCW with ILI or Confirmed Influenza Determine if the HCW worked while ill, including locations and/or units. If the HCW worked while infectious (from 1 day prior to symptom onset until exclusion from work due to illness), identify all residents cared for by the ill HCW and all exposed coworkers. Consider post-exposure prophylaxis (PEP) for all exposed residents and any coworkers who are at high risk for complications of influenza (See Section Nine/E). Ill HCWs with household members at high risk for influenza complications should consult with their private physician on the need for prophylaxis of household contacts. Ill HCWs should not return to work until 24 hours after symptoms have improved and fever has abated without antipyretics. Maintain the facility on heightened surveillance for ILI in exposed residents and HCWs, especially those not indicated for PEP. Consider suspending floating of any exposed HCWs. 18

19 B. Post-Exposure Follow up of a Resident with ILI or Confirmed Influenza Determine when the resident was infectious and when he or she was placed on Droplet precautions. Identify all HCWs who cared for the resident during the infectious period, before the resident was placed on isolation precautions or without donning proper personal protective equipment (PPE). Identify other residents who may have been exposed to the ill resident during the infectious period and before the resident was isolated. Consider PEP for exposed HCWs at high risk for complications of influenza and any exposed residents. C. Antiviral Chemoprophylaxis Single Resident with ILI, not Confirmed Influenza PEP is recommended for all LTC residents who had close, unprotected contact with the person with ILI. PEP should be considered for all LTC residents of the affected unit. PEP should be considered for any staff who are at high risk for influenza complications [Adults 65 years of age and older; persons with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus); Immunosuppression, including that caused by medications or by HIV; Pregnant women] who had close, unprotected contact with the person with ILI. Single Resident with Confirmed Influenza OR Multiple Residents/Staff with ILI PEP is recommended for all LTC residents of the affected unit and residents who had close, unprotected contact with the person with ILI. PEP should be considered for all LTC residents in the facility, depending on staff and resident movement and exposure to social settings prior to initiation of Droplet precautions. PEP is recommended for any staff who are at high risk for influenza complications (See Section Five), who had close, unprotected contact with the person with ILI. For units housing the most vulnerable patient populations (e.g., in a subacute unit of a LTC facility), PEP should be considered for all exposed healthcare workers (HCW) regardless of personal risk status. When making decisions regarding PEP, providers should take into account the resident s infectious period. The infectious period for persons infected with the influenza virus is defined as one day before, until 7 days after the person s onset of illness or 24 hours following fever abatement off antipyretic medications (whichever is longer). If contact occurred with a case whose illness started more than 7 days before the contact, then PEP may not be indicated. 19

20 Chemoprophylaxis should be initiated as soon as possible following the exposure and should continue for 14 days following the last known exposure to ILI or influenza virus. Choice of antiviral medication(s) for chemoprophylaxis should be made according to available testing results and knowledge of influenza virus subtype(s) circulating in the community (see Section Five Antiviral Treatment). Often, clinical decisions regarding antiviral PEP must be made without confirmatory laboratory data. Once available, confirmatory results can be used to modify initial PEP recommendations. If surveillance indicates that new cases continue to occur, chemoprophylaxis should be continued for an additional 7 days after the date of onset of the most recent case of ILI. D. Vaccination If influenza is identified or ILI is increased in the facility, or influenza activity is widespread in the community, re-offer influenza vaccine (both seasonal and 2009 H1N1, if available) to unvaccinated residents and staff as per CDC/ACIP recommendations E. Persons at high risk of influenza-related complications Until further information is available, the same groups at increased risk of seasonal influenzarelated complications are considered to be at increased risk for 2009 H1N1 influenza-related complications and include the following: Children <5 years, but especially children younger than 2 years old. Persons with the following underlying medical conditions: o Chronic pulmonary disease, including asthma; o Chronic cardiovascular (except isolated hypertension), renal, or hepatic disease; o Hematological disorders, including sickle cell disease; o Metabolic disorders, including diabetes; o Neurologic or neuromuscular disorders that increase the risk for aspiration or compromise the handling of respiratory secretions (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders); or o Immunocompromising conditions, including HIV infection, leukemia, lymphoma, Hodgkin s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome; those receiving immunosuppressive chemotherapy (including corticosteroids); those who have received an organ or bone marrow transplant; and those who have central nervous system fluid leaks. Persons <19 years who are receiving long-term aspirin therapy for diseases such as rheumatoid arthritis or Kawasaki disease. Pregnant women and women up to 2 weeks postpartum (including following pregnancy loss). Residents of nursing homes and other chronic-care facilities. 20

21 Adults 65 years. (Note: while elderly persons have had overall lower rates of illness with 2009 H1N1 influenza virus than normally seen during seasonal influenza epidemics, their risk of hospitalizations and death if they become infected is elevated.) 10. Case Reporting LTC facilities must report to the NYSDOH any instance of nosocomial transmission of influenza. For the purposes of this season, this includes: 1. A single nosocomial case of confirmed influenza in a resident. 2. Two or more residents and/or staff with ILI or confirmed influenza on the same unit within 7 days. Reports should be submitted via the Nosocomial Outbreak Reporting Application (NORA) system located on the Health Provider Network (HPN) at LTC reporters should ensure they have access to the HPN and the NORA system. Those who do not have access or are unsure should contact their facility s HPN Coordinator for assistance. Outbreaks of ILI and/or influenza also need to be reported by telephone to the local health department (LHD). The appropriate NYSDOH Regional Epidemiology office or NYCDOHMH office will follow up with the facility making the report. For questions regarding nosocomial reporting, please contact the appropriate NYSDOH Regional Epidemiology office as listed on the following website: or the NYCDOHMH Influenza Surveillance Coordinator at (212) or (212) To reach the NYSDOH after hours, call In addition to the reporting criteria above, physicians should report immediately by telephone to the LHD any LTC resident(s) meeting the following criteria: Death in an adult or pediatric resident involving an unexplained acute respiratory febrile illness. Death in a resident suspected or confirmed to be related to 2009 H1N1 Death in a pediatric resident suspected or confirmed to be related to any type of influenza (2009 H1N1 influenza or seasonal influenza). 21

22 11. References New York State Department of Health: Health Provider Network (HPN) Novel H1N1 Influenza Response webpage found at: Centers for Disease Control: Influenza Clinical and Public Health Guidance webpage found at: and World Health Organization: Pandemic H1N Global Alert and Response webpage found at: Public Health Agency of Canada: H1N1 Flu Virus Interim Guidance: Infection Prevention and Control Measures for Health Care Workers in Long Term Care Facilities. Found at: 22