Infection Prevention & Control Guidelines for the Management of Influenza and Respiratory Viral Illness CDHB Infection Prevention & Control Service Updated May 2018
Table of Contents 1. Purpose... 3 2. Scope... 3 3. Respiratory Hygiene / Cough Etiquette... 3 4. Definition of Influenza like Illness... 3 5. Laboratory Testing for Influenza like Illness... 4 6. Seasonal Influenza... 4 6.1 General Information... 4 6.2 IPC Measures for Influenza (all clinical areas)... 4 7. Other Respiratory Viral Illness (Influenza like illness - ILI)... 6 7.1 General Information... 6 7.2 IPC Measures for Other Respiratory Viral Illness in general wards... 7 7.2 IPC Measures for Other Respiratory Viral Illness in high risk areas for vulnerable patients... 7 8. Antiviral chemotherapy... 8 9. Management of staff exposure... 9 10. Outbreaks... 9 11. Surveillance... 9 12. References... 9 Appendix A. Inpatient Influenza Flowchart... 11 Appendix B. Management of Respiratory Viral Illness Flowchart... 12 Appendix C. Laboratory Instructions for Respiratory Viral Testing... 13 Appendix D. Patient Information Sheet... 14 Authorised By: CDHB Infection Prevention & Control Committee Page 2 of 15 v4.issue Date: 05-04-18
Infection Prevention & Control Influenza & Respiratory Viral Illness Guidelines These guidelines describe the infection prevention and control (IPC) measures which must be taken to minimise transmission of influenza and other respiratory viral illnesses within CDHB healthcare facilities. The IPC measures for the management of influenza differ from other respiratory viruses and therefore these guidelines describe these in separate sections. 1. Purpose Provide guidance to staff on the precautions and other measures necessary to minimise the risk of transmission of influenza and other respiratory viral illnesses. 2. Scope All staff involved in the care of patients with possible or confirmed influenza or other respiratory viral illness. 3. Respiratory Hygiene / Cough Etiquette Respiratory hygiene must be practised at all times. Educate patients in the importance of respiratory hygiene. Cover your mouth and nose with a tissue when coughing or sneezing Use in the nearest waste receptacle to dispose of the tissue after use Perform hand hygiene Staff who have signs and symptoms of respiratory illness must NOT.. Care for patients for 72 hours after onset of symptoms Should stay off work for at least 24 hours after resolution of fever (without the use of fever-reducing medicine.) 4. Definition of Influenza like Illness Acute upper respiratory tract infection characterised by abrupt onset and two of the following: fever, chills, headache, myalgia Children and elderly patients may not present with classical symptoms Elderly may only present with cough symptoms and/or confusion without a fever Influenza presents in infancy and childhood as a wide variety of clinical syndromes including vomiting and diarrhoea. Authorised By: CDHB Infection Prevention & Control Committee Page 3 of 15 v4.issue Date: 05-04-18
5. Laboratory Testing for Influenza like Illness All inpatients or those admitted with a diagnosis of suspected influenza should have respiratory viral swabs taken. Refer to Appendix C or the Influenza Instructions for Respiratory Viral Testing 6. Seasonal Influenza 6.1 General Information Influenza viruses are spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a person). Transmission via large-particle droplets requires close contact between source and recipient persons, as larger droplets generally travel only a short distance (1 metre or less) through the air. Contact with respiratory-droplet contaminated surfaces is another possible source of transmission. Airborne transmission (via small-particle residue [5μm or less] of evaporated droplets that might remain suspended in the air for long periods of time) is also thought to be possible particularly during and after aerosol generating activities, although data supporting airborne transmission is limited. The typical incubation period for influenza is 1 4 days (average: 2 days). Adults can be infectious from the day before symptoms begin until approximately 7 days after illness onset. Young children might shed the virus several days before illness onset, and children can be infectious for 10 days or more after onset of symptoms. Severely immune-compromised persons can shed virus for weeks or months. Patients may be transferred or discharged to other care facilities including long term care with appropriate infection prevention and control measures in place. The CDHB IPC community liaison team is available for advice and/or to facilitate discharges to the long term care sector. 6.2 IPC Measures for Influenza (all clinical areas) Patient Management All patients with suspected or confirmed influenza must be cared for with Standard and Droplet Precautions A nasopharyngeal swab must be taken for respiratory viral PCR testing. Hand hygiene is performed as per The 5 Moments for Hand Hygiene. Either alcohol-based hand rub or liquid soap and water may be used for hand hygiene. A surgical mask should be worn when entering the patient s room/bedspace. Remove the mask when leaving the patient s room and dispose of the mask into hazardous waste. Perform hand hygiene. Aprons and gloves are worn if required as part of Standard Precautions e.g. risk of direct hand or body exposure to blood or body fluids. If worn, gloves and aprons are changed between each patient. In a cohort situation, staff may wear a mask when caring for more than one patient unless the mask becomes wet when it must be changed. Authorised By: CDHB Infection Prevention & Control Committee Page 4 of 15 v4.issue Date: 05-04-18
If patient movement or transport is necessary, have the patient wear a surgical mask if possible. Provide the patient with a Patient Influenza Information fact sheet (Appendix D) Patient to use a dedicated shower or patient to shower last prior to cleaning. Patients to use dedicated toilet facilities where possible. Do not use nebulisers in multibed rooms. If required, nebulisers can be used in a single room with the door closed whilst in use. An N95 mask must be worn by the HCW while in the room. HCWs must wear a N95 mask (particulate respirator) for high-risk aerosol generating procedures. High risk aerosol generating procedures: - intubation/extubation - Suctioning - cough inducing procedures - bronchoscopy - respiratory autopsy or surgery involving high speed devices - CPR Bed Management (Patient Placement) Refer also Appendix A flow chart Patient with suspected or confirmed influenza to be nursed in a single room o Where there are no single rooms available, patient may be nursed in a multibed room with privacy curtains drawn between bed heads (1 metre) if there is no additional risk to the patient management o Patient must not receive nebulisers in a multi-bed room Multiple suspected or confirmed influenza patients may be cohorted together but privacy curtains must still be drawn between bed heads (1 metre) to prevent cross infection of different influenza strains. A Droplet Precautions sign must be used and be visible Duration of Precautions for Confirmed Influenza Patients who have been prescribed anti-viral treatment (Tamiflu) shall remain in Droplet Precautions for 72 hours from commencement of treatment. Maintain Droplet Precautions for 5 days after commencing treatment for children aged 5 years and under and other patient groups who may have a low immune response e.g. critical care patients. Precautions should be continued greater than these times while the patient remains symptomatic. For those not given anti-viral treatment maintain Droplet Precautions for seven days from onset of illness. NB: Non-symptomatic patients (Contacts) prescribed prophylactic Tamiflu do not require isolation or Droplet Precautions unless they become symptomatic Management of Contacts Authorised By: CDHB Infection Prevention & Control Committee Page 5 of 15 v4.issue Date: 05-04-18
A Contact is any patient who is exposed to a suspected or confirmed influenza case prior to the use of Droplet Precautions. This is typically other patients who have been sharing the same multi-bed room with a suspected or confirmed influenza patient Contacts do NOT require Droplet Precautions or isolation unless they subsequently develop signs and symptoms of influenza, even if prescribed prophylactic Tamiflu If the index case is confirmed positive, contacts should be assessed by their clinical team and if deemed clinically indicated prescribed prophylactic Tamiflu (Appendix A). The multi-bed room shall remain open to further admissions. However avoid admitting those patients from the following vulnerable groups o those with chronic respiratory conditions o pregnant women, especially those in 2nd or 3rd trimester o the morbidly obese o those with immunosuppressive conditions e.g. cancer, transplant, immunosuppressive medication or HIV o those with other chronic illnesses such as cardiac disease, diabetes mellitus, chronic metabolic diseases, renal failure, chronic liver disease, chronic neurological disease Refer Management of healthcare workers for non-immunised staff contacts Cleaning Full terminal cleaning is not required following discharge of a suspected or confirmed influenza patient but staff undertaking a routine discharge clean should ensure the following environmental surfaces and touch points are addressed: o Bed mattress, frame and rails o All horizontal surfaces including locker and bed table o Frequently touched fixtures e.g. handles, call bells, knobs and rails Bed space curtains/screens do not require changing unless visibly soiled or the patient was nursed in Contact Precautions Visitor restrictions and information It is recommended the following people do not visit: o Infants (under 1 year). o Visitors with Influenza-like symptoms. o Pregnant women o Others susceptible to infection Visitors are required to wash their hands or use alcohol-based hand rub prior to leaving the room at the end of the visit. Visitors are not required to wear masks however social distancing should be advised (1-2 metre separation). 7. Other Respiratory Viral Illness (Influenza like illness - ILI) 7.1 General Information ILI may be caused by a number of viruses other than the influenza viruses A swab sent for respiratory viral testing will be tested for up to 16 different viruses Authorised By: CDHB Infection Prevention & Control Committee Page 6 of 15 v4.issue Date: 05-04-18
In the healthcare setting, the principal mode of transmission of other respiratory viruses is via the healthcare worker s hands, following contact with the patient and their environment The use of hand hygiene and respiratory hygiene / cough etiquette will limit the transmission of ILI in general wards and departments It is important to use Standard and Droplet Precautions for all patients until influenza is confirmed or ruled out. For laboratory or clinically confirmed influenza refer to 6.2 Infection Prevention and Control Measures for Influenza. If the viral laboratory testing is negative for influenza but positive for another respiratory virus, implement IPC measures described in this document for either general wards or high risk clinical areas 7.2 IPC Measures for Other Respiratory Viral Illness in general wards Standard Precautions are used for all respiratory viral illnesses in the general wards, with the exception of Influenza. The use of Standard Precautions, including respiratory etiquette and good hand hygiene will limit the transmission of other respiratory viruses in general wards and departments. Wear a surgical /droplet mask when in close contact with a patient coughing or sneezing as part of Standard Precautions, to prevent contact with respiratory droplets on the face. If the patient is being nursed in a multi bed room and has significant respiratory symptoms, such as coughing and sneezing, protect other patients in adjacent beds by drawing the privacy curtains half way between bed heads (1 metre). As with all respiratory illnesses, education and encouragement to the patient about respiratory etiquette is important to limit the spread of the virus in the environment. 7.2 IPC Measures for Other Respiratory Viral Illness in high risk areas for vulnerable patients In patients from vulnerable groups all respiratory viruses may cause severe disease, therefore requiring a different approach than the general population Use Contact and Droplet Precautions for patients in vulnerable groups who are being investigated for a respiratory viral illness until a laboratory result is obtained. Refer to section 6 for IPC measures for influenza Refer to the table on Page 8 for a list of other respiratory viral disease and the IPC measures required Prolonged shedding with respiratory viruses can occur in immunocompromised individuals. Therefore it is not recommended that re-testing of patients is used as an indicator to remove the patient from isolation. Please consider the patient s symptoms or lack of symptoms as an indicator and consult the IPC Service if any queries. Vulnerable groups of patients include: o those with chronic respiratory conditions o pregnant women, especially those in 2nd or 3rd trimester Authorised By: CDHB Infection Prevention & Control Committee Page 7 of 15 v4.issue Date: 05-04-18
o the morbidly obese o those with immunosuppressive conditions e.g. cancer, transplant, immunosuppressive medication or HIV The wards and departments specifically caring for vulnerable groups of patients are: o Intensive Care Unit o Neonatal Intensive Care Unit o Bone Marrow Transplant Unit o Children s Haematology Oncology Centre o Paediatric inpatient wards o Ward 25 o Ward 26 o Burwood Spinal Unit o Care of the Elderly wards Virus name Isolation requirements Personal Protective Equipment (PPE) required Influenza A and B Droplet Precautions Surgical/procedural mask RSV (Respiratory Syncytial virus) Parainfluenza virus (1-4 ) Human Metapneumovirus (HMPV) Contact Precautions Contact Precautions Contact Precautions Apron/gown and gloves (consider a mask as part of Standard Precautions) Apron/gown and gloves (consider a mask as part of Standard Precautions) Apron/gown and gloves (consider a mask as part of Standard Precautions) Rhinovirus Droplet Precautions Surgical/procedural mask Adenovirus (respiratory) Contact & Droplet Precautions Apron/gown and gloves Surgical/procedural mask Enterovirus (respiratory) Contact Precautions Apron or Gown and Gloves Mycoplasma pneumoniae Droplet Precautions Surgical/procedural mask Bocavirus Contact Precautions Apron/gown and gloves Parechovirus Contact Precautions Apron/gown and gloves Coronavirus Contact Precautions Apron/gown and gloves 8. Antiviral chemotherapy Antiviral drugs are only available for influenza viruses. Tamiflu (Oseltamivir) is prescribed via the hospital pharmacy Tamiflu: Authorised By: CDHB Infection Prevention & Control Committee Page 8 of 15 v4.issue Date: 05-04-18
o is an important line of defence in the prevention of seasonal influenza. o can be used either to treat influenza or prevent influenza (prophylaxis). o as a prophylaxis should be considered for exposed patient contacts of confirmed influenza cases. o should not be considered a substitute for influenza vaccination. Tamiflu is prescribed as follows: o 75mgs BD for 5 days for treatment of influenza cases o 75mgs daily for 10 days for prophylaxis o Refer to the Pink Book for other dosage requirements e.g. renal impairment 9. Management of staff exposure Seasonal influenza vaccination for healthcare workers is the internationally recognised best practice for protection of patients and staff against influenza. These are offered free of charge each year throughout the CDHB during the annual staff vaccination campaign Staff are advised to NOT self-diagnose by sending a viral swab to the laboratory Unvaccinated staff members who are exposed to influenza should contact their GP for further advice. 10. Outbreaks If influenza or other respiratory virus outbreak is suspected, the following measures should be taken to limit transmission: Contact the Infection Prevention & Control Service Restrict staff movement from areas of the facility having outbreaks Implement Outbreak Response as per Outbreak Management Guideline (refer CDHB IPC policy) Infection Prevention Control Manual 11. Surveillance Surveillance of inpatients with influenza and other significant respiratory viruses is undertaken by the Infection Prevention & Control Service. 12. References NZ Ministry of Health Influenza. National Influenza Strategy Group (NISG), Accessed at: www.influenza.org.nz. CDHB Infection Prevention & Control Policies and Procedures CDHB Intranet, Infection Control website Satinderpal K et al. Influenza in the Older Adult-Indications for the use of vaccine and antiviral therapy. Geriatrics Jan 2001; 56 (1). http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm Muthuri et al. (2014). Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a metaanalysis of individual participant data. Authorised By: CDHB Infection Prevention & Control Committee Page 9 of 15 v4.issue Date: 05-04-18
Authorised by the CDHB Infection Control Committee Date: 9 th June 2014 Version 2-May 2015 Minor changes to wording Reported respiratory viruses and isolation requirements for vulnerable groups table updated Version 3 May 2016 Changes to Occupational Health section Addition of two more vulnerable groups Version 4 April 2018 Minor changes to wording Version 5 May 2018 Minor changes to wording Authorised By: CDHB Infection Prevention & Control Committee Page 10 of 15 v4.issue Date: 05-04-18
Appendix A. Inpatient Influenza Flowchart CHDB Infection Prevention and Control Intranet Guideline Influenza and other Respiratory Virus Guidelines 2014 Appendix A Inpatient Influenza Flowchart - Management for Seasonal Suspected or Confirmed Influenza Patient All suspected cases to have a nasopharyngeal swab sent for Respiratory PCR testing Refer to Appendix B for the management of patients with other respiratory viral illnesses. Cough and sneeze etiquette/respiratory hygiene to be observed at all times. Educate patients in the importance of respiratory hygiene. Suspected or Confirmed Influenza Patient Patient should be placed in single room (IP&C Policy) Management of Contacts Contacts are patients exposed to the case (in the same room for more than 1 hour) prior to implementation of Droplet Precautions Contacts do NOT require isolation precautions unless they become symptomatic Contacts to be prescribed prophylactic Tamiflu as per clinical team assessment if Index case confirmed positive for Influenza Single room available (Preferred option) Single room not available (nursed in multi-bed room) NO Droplet Precautions for 7 days after onset of illness Droplet Precautions (Blue Sign) Prescribed anti-viral treatment YES Droplet Precautions for 72hrs following start of Tx (Children 5 years for 5 days) Patient bed space placed in Droplet Precautions (Blue Sign) Bed privacy curtains pulled between bed heads (1 metre) to minimise droplet spread from coughing to adjacent patients Dedicated shower OR patient to shower last Dedicated toilet where possible Patient to wear surgical mask when mobilising to shower or toilet Nebulisers MUST NOT be used in multi-bed room Multiple case (suspected or confirmed) may be cohorted in a multi bed room. The period of viral shedding may be extended in immune compromised and/or ICU patients Refer also IP&C Guideline Flow Chart for Use of Nebulisers Authorised By: CDHB Infection Prevention & Control Committee Page 1 of 1 Issue Date: April 2014 Authorised By: CDHB Infection Prevention & Control Committee Page 11 of 15 v4.issue Date: 05-04-18
Appendix B. Management of Respiratory Viral Illness Flowchart Appendix B Management for Suspected or Confirmed Respiratory Viral Illness All suspected cases to have a nasopharyngeal swab sent for Respiratory PCR testing Refer to Appendix A for the management of patients with influenza Cough and sneeze etiquette/respiratory hygiene to be observed at all times. Educate patients in the importance of respiratory and hand hygiene. Suspected or Confirmed Respiratory Viral Illness Patient should be placed in Droplet Precautions until viral testing results are obtained Single Room (IPC Policy) If no single bed available Refer Appendix A for bed space isolation precautions Management of Contacts Contacts do NOT require isolation precautions unless they become symptomatic Other Respiratory Virus Influenza Confirmed refer Appendix A Vulnerable Clinical Areas Patient not in Vulnerable Patient in Vulnerable Clinical Clinical Area Area ICU NICU BMTU CHOC Paediatric Inpatient Wards Standard Precautions Contact/Droplet Precautions Ward 25, 26 (See Table Page 8, Section 7.2) Burwood spinal Unit Care of the Elderly wards Authorised By: CDHB Infection Prevention & Control Committee Page 12 of 15 v4.issue Date: 05-04-18
Appendix C. Laboratory Instructions for Respiratory Viral Testing Authorised By: CDHB Infection Prevention & Control Committee Page 13 of 15 v4.issue Date: 05-04-18
Appendix D. Patient Information Sheet (Available on IPC Intranet site) Authorised By: CDHB Infection Prevention & Control Committee Page 14 of 15 v4.issue Date: 05-04-18
Authorised By: CDHB Infection Prevention & Control Committee Page 15 of 15 v4.issue Date: 05-04-18