Influenza-Like Illness in Long-Term Care Facilities Toolkit Contents

Influenza-Like Illness in Long-Term Care Facilities
CD Guidelines for Reporting Influenza-Like Illness
Long-Term Care Facility Outbreak Management
Respiratory Outbreak Prevention
Additional Resources
Other References (Included)
Influenza-Like Illness Line List
From NYC Department of Health and Mental Hygiene: Nasopharyngeal
Specimen Collection for Viral Respiratory Pathogens: A Guide for Providers
State Flu 2012-2013 Clinical Guidelines
Lane County Public Health, Communicable Disease Program
CD Guidelines for Reporting Influenza-Like Illness
Are there two or more cases of influenza-like illness (cough, fever, sore
throat, etc.)?
Has at least one been
laboratory confirmed?
Continue observation for
influenza-like illness and
maintain prevention
strategies. Seek laboratory
confirmation if applicable.
Call Communicable Disease at LCPH
to report:
Phone: (541) 682-4041
After Hours: (541) 998-4227
Facility Activities:
Investigate ill residents/staff
and record data using the
Influenza-Like Illness Line List
(See: Additional Resources)
Continue daily surveillance of
the facility and update the ILI
Line List
Fax the updated ILI Line List to
LCPH daily:
Fax: (541) 682-2455
Implement infection control
measures (See: LTCF Outbreak
Determine vaccination status of
Communicate outbreak
situation to staff and residents
as appropriate
Treat and/or implement
prophylaxis to ill residents/staff
as appropriate
County Activities:
Determine if an
investigation is warranted
Determine cause and course
of the outbreak
Implement control
Document control of the
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Lane County Public Health, Communicable Disease Program
Long-Term Care Facility Outbreak Management
During flu season and periods of increased flu activity in the community,
daily active surveillance for influenza-like illness should occur among all
staff, new and current residents, and visitors.
With a confirmed respiratory illness daily active surveillance should occur
until at least one week after the last confirmed case occurred.
Ill staff and visitors should be asked not to enter the facility.
Even when it is not flu season testing should occur when any resident has
symptoms of influenza-like illness, especially when two more residents
develop ILI within 72 hours of each other.
Consider collecting vitals on all residents up to three times a day during
outbreak situations.
Determine the causative agent by performing tests on respiratory
specimens (i.e. nasal swabs, throat swabs, nasopharyngeal swab, or
nasopharyngeal or nasal aspirates).
Implement Standard and Droplet Precautions for Ill Residents
Perform hand hygiene before and after touching residents or their
Wear gloves if hand contact with respiratory secretions or contaminated
surfaces will occur. Change gloves and perform hand hygiene after each
resident encounter.
Implement droplet precautions for residents with suspected or confirmed
ILI for seven days after illness onset or until any fever and respiratory
symptom has been gone for twenty-four hours.
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Lane County Public Health, Communicable Disease Program
Implement droplet precautions by placing ill residents in private rooms or
cohorting the ill, wearing facemasks upon entering resident’s rooms, and
asking ill residents to wear facemasks upon transport.
Administer Antiviral Treatment or Prophylaxis
All LTCF residents who have a suspected or confirmed ILI should receive
antiviral treatment immediately, whether laboratory confirmation has been
received or not.
Once a respiratory outbreak has been established all eligible residents in
the entire facility should receive antiviral chemoprophylaxis whether they
have been vaccinated or not.
Chemoprophylaxis may be considered for unvaccinated staff that provides
care to residents at high risk for complications.
Reduce Transmission
Limit communal events, including closing the dining room for meal times.
Place signs at the main entrance and throughout the facility alerting
individuals to report ILI symptoms and encouraging visitors to visit at
another time.
Place hygiene materials throughout the facility, including gloves, masks,
and hand sanitizer.
Communicate properly with staff about suspected or confirmed ILI
residents, as well as updates about an outbreak situation as appropriate.
Ask that ill staff, new residents, and visitors refrain from entering the
facility until 24 hours after fever and ILI symptoms have ceased.
Keep track of any new cases, ED visits, hospitals admissions, and/or deaths
in the ILI Line List and update LCPH on a daily basis.
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Lane County Public Health, Communicable Disease Program
Respiratory Outbreak Prevention
Ensure that all eligible health care personnel and residents are vaccinated
annually against influenza.
Consider implementing an annual on-site influenza vaccine clinic for both
residents and staff.
Consider paying for, or reimbursing, staff vaccination to reduce staff illness,
absenteeism, and transmission of respiratory illnesses.
Determine new staff and resident admissions vaccination status and offer
immunization if unvaccinated.
Have data about resident and staff vaccination status available regardless
of whether or not there is a respiratory outbreak.
Non-Pharmaceutical Interventions
Ask that any visitors exhibiting influenza-like illness symptoms save their
visit for another time, regardless of whether or not it is flu season.
Ensure that residents and staff are practicing proper hand hygiene before
eating or touching the eyes, nose, and mouth and after coming in contact
with respiratory secretions.
Ensure that residents and staff are covering their nose and mouth with
their elbows or a tissue, and throwing the tissue away afterwards.
Keep tissues and proper hand hygiene items in resident’s rooms as well as
throughout the facility.
Clean and disinfect surfaces and objects that may be contaminated with flulike germs routinely.
Consider enforcing flexible sick leave policies, as appropriate, to ensure that
staff do not come to work when they are ill.
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Lane County Public Health, Communicable Disease Program
Ensure that each resident’s primary care provider’s contact information is
readily available in the event that a spontaneous outbreak may occur and
antivirals need to be prescribed.
If instead, a facility physician is assigned, contact them for antiviral
treatment/prophylaxis for residents.
Remain up-to-date on seasonal flu information from the CDC, Oregon State
Public Health, as well as the community and LCPH.
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Lane County Public Health, Communicable Disease Program
Additional Resources
Oregon State Public Health: Influenza and Influenza-like Illness Outbreaks in
Center for Disease Control: Healthcare-associated Infections in Long-Term Care
Center for Disease Control: Prevention Strategies for Seasonal Influenza in
Healthcare Settings:
Center for Disease Control: Hand Hygiene in Healthcare Settings poster:
Oregon Public Health Division: Disease Reporting for Clinicians poster:
Oregon Public Health Division: Disease Reporting for Laboratories poster:
Lane County Public Health: Communicable Disease Program:
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Lane County Public Health, Communicable Disease Program
Oregon State Public Health: Reported Outbreaks in Long-term Care Facilities
Center for Disease Control: Seasonal Influenza: Cover Your Cough posters:
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Facility contact:
Investigator's name:
Facility type (LTCF, etc.)
Total No. Residents
Total No. Staff
Fever >=
100 F (1=
Resident or Unit/ yes)*highest Cough throat
Age Sex staff?
Rm recorded temp (1=yes) (1=yes)
For ILI/Influenza only
Onset date
ED visit?
for influenza? influenza?
Died? (1=yes) (1=yes)
Other lab
results (expl.: Comments (e.g. other symptoms,
"adenovirus treated or prohylaxed
w/antivirals, etc.)
A Guide For Providers
Suction apparatus (Luken’s trap, syringe, or bulb)
• Sterile suction catheter (e.g., #8 French)
• Sterile saline
• Viral transport medium tube
1. Attach catheter to suction apparatus.
1. Bend shaft to follow curve of nasopharynx.
2. Instill several drops of sterile saline into
each nostril.
2. Insert swab through nostril to posterior
nasopharynx (same distance as from nostrils to
external opening of ear).
3. Place catheter through nostril to posterior
nasopharynx (same distance as from nostrils to
external opening of ear).
Nasopharyngeal swab (flexible shaft)
with rayon tip
• Viral transport medium tube
3. Rotate swab a few times to obtain infected
4. Apply gentle suction. Using rotating motion,
slowly withdraw catheter.
4. For an optimal sample, repeat procedure
using other nostril.
5. For an optimal sample, repeat procedure using
other nostril.
5. Place swab in transport medium.
6. With the viral transport medium, rinse secretions
through the catheter into the collection container.
6. Bend or cut shaft to completely seal
transport tube.
1. Send specimen to lab immediately (testing sensitivity decreases over time).
2. Cool specimen to 2o - 4oC (36o - 40oF) during storage and transport.
Incline patient’s head as shown.
Michael R. Bloomberg, Mayor
Thomas R. Frieden, MD, MPH, Commissioner
DIS1914201 – 1.06
Flu 2012-13 Clinical Guidelines
Updated 10/7/2013
Definition of Influenza-Like Illness: fever > 100 F (37.8 C) plus cough and/or sore throat in absence of a known cause
Infection Control Guidance:
- hand hygiene (patient and staff)
- respiratory hygiene (i.e. tissue, handkerchief, sneeze into sleeve)
- surgical mask (patient and any staff within 6 feet)
- staff surgical mask, gown, gloves, and eye protection in private inpt or outpt exam room
- staff N-95 respirator, gown, gloves, an eye protection for any respiratory procedures
Testing Options:
Rapid Influenza A&B (low sensitivity 40-70% but high specificity ~90% – more accurate in kids > adults)
If negative, cannot rule out influenza virus infection; If positive, likely a true positive
Real-time RT-PCR test – most accurate & sensitive, order if/when:
a. All hospitalized patients
b. Negative Rapid when high community flu activity (and desired lab confirmation)
c. Positive Rapid when low community prevalence (i.e. considering false positive)
d. Close exposure to pigs, poultry, other animals with possibility of novel flu virus
Treatment Overview
Antivirals recommended as early as possible for any patient with confirmed or suspected influenza who:
- Is hospitalized, or has severe, complicated, or progressive illness (if suspected flu, treat CAP w/ abx plus antivirals)
- Is at higher risk for influenza complications as follows:
Children younger than 2 years old (see note below)
Adults 65 years and older;
Medical conditions of chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic,
hematological (including sickle cell disease), neurological and neurodevelopmental conditions (including disorders of the
brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual
disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury); or
metabolic disorders (including diabetes mellitus);
Immunosuppression, including that caused by medications or by HIV infection;
Women who are pregnant or post-partum (within two weeks after delivery);
Persons younger than 19 years of age who are receiving long-term aspirin therapy;
American Indians and Alaskan Natives;
Persons who are morbidly obese (body-mass index ≥40);
Residents of nursing homes and other chronic-care facilities.
Antiviral treatment also can be considered for any previously healthy, non-high risk, symptomatic outpatient with confirmed or suspected
influenza based upon clinical judgment, if treatment can be initiated within 48 hours of illness onset.
(5 days)
Post-Exposure Chemoprophylaxis
(7 days post exposure)
Oseltamivir (Tamiflu)
75-mg capsule twice per day
75-mg capsule once per day
< 1 yr
3 mg/kg/dose twice daily
Not FDA Approved*
> 1 yr
< 15 kg
30 mg twice daily
30 mg once daily
> 1 yr
>15 to 23 kg
45 mg twice daily
45 mg once per day
> 1 yr
>23 kg to 40 kg
60 mg twice daily
60 mg once per day
> 1 yr
> 40 kg
75 mg twice daily
75 mg once per day
Zanamivir (Relenza)**
10 mg (two 5-mg inhalations) twice daily
10 mg (two 5-mg inhalations) once daily
Children (≥7 years or older for treatment, ≥5 years for chemoprophylaxis)
10 mg (two 5-mg inhalations) twice daily
10 mg (two 5-mg inhalations) once daily
*use in children ≥3 months and <1 yr old approved under EUA during the 2009 H1N1 pandemic; If child ≥3 months and <1 yr old, dose is 3 mg/kg/dose once per day.
**Relenza not recommended for treatment or prophylaxis in patients with asthma or COPD due to risk of serious bronchospasm
Flu 2012-13 Clinical Guidelines
Updated 10/7/2013
Chemoprophylaxis (post-exposure vs. pre-exposure): antivirals are ~70% to 90% effective in preventing influenza and are useful adjuncts to influenza vaccination.
1. Persons at higher risk of influenza complications (see list), and
- Influenza exposure without a vaccination history
- Influenza exposure during first two weeks following vaccination
2. Immunosuppressed persons after exposure to influenza (regardless of vaccination)
3. Residents of institutions during confirmed or suspected influenza outbreaks
- for control of outbreaks in long-term care facilities (e.g. elderly nursing homes) and hospitals, CDC recommends antiviral chemoprophylaxis for a minimum of 2
weeks, and continuing up to 1 week after the last known case was identified (and t/c PEP of unvax staff)
*post-exposure chemoprophylaxis not generally recommended if > 48 hours since last contact with infectious person
Duration of Isolation Precautions:
- patients should stay out of school, work, or public until fever free x 24hrs without fever-reducing medicines
- healthcare personnel should be excluded from work until fever free x 24hrs without the use of fever-reducing medicines
Pregnancy & Up to Two Weeks Postpartum (including following pregnancy loss)
- treat pregnant women with influenza-like illness ASAP with antiviral medications (best within 48hrs but still give later)
- Oseltamivir (Tamiflu) preferred for treatment because of systemic activity (Pregnancy Category C)
- benefits of treatment (& fever reduction) likely outweigh theoretical risks of antiviral use
- drug of choice for chemoprophylaxis is less clear (alternative is early treatment based on signs and symptoms)
Flu Vaccination
(an A/California/7/2009(H1N1)-like virus; an A/Victoria/361/2011 (H3N2)-like virus; a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage)
All persons aged 6 months and older should be vaccinated annually.
High Risk persons for influenza-related complications should continue to be a focus when vaccine supply limited:
o are aged 6 months--4 years (59 months)
o are aged 50 years and older
o have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic,
hematologic, or metabolic disorders (including diabetes mellitus)
o are immunosuppressed (including immunosuppression caused by medications or HIV)
o are or will be pregnant during the influenza season
o are aged 6 months--18 years and receiving long-term aspirin therapy
o are residents of nursing homes and other chronic-care facilities
o are American Indians/Alaska Natives
o are morbidly obese (body-mass index 40 or greater)
o are health-care personnel
o are household contacts and caregivers of children aged younger than 5 years and adults aged 50 years and older,
with particular emphasis on vaccinating contacts of children aged younger than 6 months
o are household contacts and caregivers of persons with medical conditions that put them at higher risk for severe
complications from influenza.
Children Ages 6mths- 8 Years Needing TWO Doses (spaced > 4weeks apart):
first ever flu vaccination or did not receive a total of 2 or more doses of seasonal influenza vaccine since July 1, 2010
Live Seasonal Flu Vaccine (LAIV) - approved for ages 2- 49 years who do NOT have the following Contraindications:
- persons with a history of hypersensitivity, including anaphylaxis, to any of the components of LAIV or to eggs
- children aged younger than 2 years (because of an increased risk for hospitalization and wheezing observed in clinical trials)
- children aged 2--4 years with history of a wheezing episode during the preceding 12 months
- persons with asthma
- persons aged 50 years and older
- have chronic pulmonary, cardiovascular (except hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
- adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV)
- children or adolescents aged 6 months--18 years receiving aspirin or other salicylates
- pregnant women
*A moderate or severe illness with or without fever is a precaution for use of LAIV
** LAIV should not be administered to close contacts of immunosuppressed persons who require a protected environment
Inactive Seasonal Flu Vaccine (TIV) Contraindications:
-People who had a severe allergic reaction to eggs (h/o mild reaction to egg—that is, one which only involved hives—may receive TIV with addl precautions.
-People who have ever had a severe allergic reaction to influenza vaccine.
-People with a history of Guillain–Barré Syndrome that occurred after receiving influenza vaccine and who are not at risk for severe illness from influenza
-People under 65 years of age should not receive the high-dose flu shot.
-People who are under 18 years old or over 64 years old should not receive the intradermal flu shot.
- Persons with moderate to severe acute febrile illness usually should not be vaccinated until their symptoms have abated.