Influenza Preparedness 2018-2019ReqPrev&DetIPCNs · Respiratory Outbreaks –2017/2018 Season...

Influenza Preparedness

2018-2019

Prevention and Detection of Outbreaks

Niamh McDonnell, Infection Prevention and Control Nurse

Managing an Outbreak of Influenza

Key Infection Prevention and Control Measures

Patricia Coughlan Infection Prevention and Control Nurse

Influenza Preparedness 2018-2019

Prevention and Detection of Influenza

Outbreaks

Aide Memoir 2018-2019 Season

Outline

• Guidelines & Documentation circulated• Prerequisites – Planning & Education• Requirements for prevention - Actions

– Residents and Staff Vaccination– Records– What supplies are needed?– Monitoring of staff illness

• Requirements for detection - Actions

– Recognition• Case definition of influenza like illness• Definition of influenza like illness outbreak

– Reporting– Guidelines

www.hpsc.ie

Respiratory Outbreaks – 2017/2018

Season

Outbreaks

• 223 influenza/acute respiratory infection (ARI) outbreaks notified to HPSC,

• 198 associated with Influenza

• 156 of these were reported in residential care facilities or other residential care settings

• 36 of these outbreaks were reported in acute hospitals

• 44 outbreaks notified in Cork and Kerry - NH (14), CH(6), MH( 3), DS (1) Other (1)

Morbidity & Mortality

• 4680- confirmed influenza hospitalised cases – highest age specific rate in those 65yrs and older with a median age of 63 yrs

• 188 critical care admissions – 83 of these were over 65, 30 were 55-64 years of age

• 222 deaths were notified to HPSC – median age 81 yrs

Influenza Surveillance in Ireland – Weekly Report Influenza Week 20

(14th – 20th May 2018)

Be Prepared - Planning & Education

• Written policies on immunisation, IPC and Outbreak Management related to influenza

• Education for staff at induction and on going to include influenza

• Staff should

• receive education re Influenza (signs & symptoms) and the essential role of vaccination

• have a high index of suspicion for influenza during flu season

• be able to recognise and report potential cases and clusters

• be familiar with and have access to recommended PPE

• have access to details for their local Infection Prevention & Control staff (where available) and local Department of Public Health

• Nominate a senior manager to co-ordinate all actions and communication in the event of a suspected or actual outbreak to Public Health

The Aide Memoir

Requirements for prevention (1)• Resident Vaccination

– Has flu vaccine been offered to all residents throughout the flu season i.e. from September to the end of April?

– Ideal time for flu vaccination is Sept/Oct.

– If residents are not vaccinated at this time, the vaccine can be given until the end of April.

• In Disability Services vaccination is strongly recommended for children with any condition that can compromise respiratory function especially those attending special schools and day centres.

Requirements for prevention (2)

Resident Vaccination – Respites & Admissions

• Is advice re flu vaccination provided to respite admissions

from September to the end of April?

• Ideally flu vaccination should be given 2 weeks prior to

admission

• Are all new /respite residents vaccinated, ideally 2 weeks

prior to admission?

• If not vaccinated, is vaccine offered as soon as possible

after admission?

Application form

for Respite Care in

Cork Community

Hospitals

To protect long term

care residents and

prevent outbreaks

Planned Respite Care

Nursing Transfer Letter


Nursing Care Plan


Involving Residents & Families

• Used in St Finbarrs Hospital and other locations

• Letter sent in Sept • Requesting not to visit units

if they have flu like illness in the preceding 2 days

• Asking cooperation with visiting restrictions where a unit is experiencing symptoms of flu

• Encourage to use the hand hygiene facilities

• Advised re respiratory hygiene & cough etiquette


Staff Vaccination

• Was flu vaccination promoted amongst staff at the start of the flu season?

Records

• Is a record of staff vaccination available?

• Is a record of resident seasonal flu vaccination available?

• Is a record of resident pneumococcal vaccination available?• Where?

Sample Resident Records

Sample Staff Records



Supplies

• Is there a supply of 2 viral swabs available to take a throat swab in the event of an outbreak on the advice of Department of Public Health?

• List of sites where swabs are is held by DPH , if used will be replaced by post

• Discard pack from 2017/2018 Season

• Is there ready quick access to antiviral medication (Tamiflu) through the normal channels/pharmacy provider if needed in the event of an outbreak?

• Are sufficient supplies of surgical face masks (with ties) and eye protection of the correct standard available?

MASK FACE TYPE II DISPOSABLE

FACE MASK TIE ON

MASK SURGICAL TYPE IIR

DISPOSABLE

FLUID RESISTANT/ANTI-FOG WITH

VISOR

Requirements for prevention

(5)

Surveillance –Monitoring

• Is staff absenteeism monitored for influenza

like illness (ILI) and for unusual patterns i.e.

– more than expected staff absent

– 3 or more cases of ILI in a 72 hour period

Managing an Outbreak of InfluenzaKey Infection Prevention and Control Measures

Patricia Coughlan, Cork & Kerry Disability Services



Case Definition of Influenza Like Illness (ILI)

Sudden onset of symptoms

And

At least one of the following four systemic symptoms:

• Fever or feverishness

• Malaise

• Headache

• Myalgia (muscle pains)

And

At least one of the following three respiratory symptoms:

• Cough

• Sore throat

• Shortness of breath


Influenza in the Elderly

• In older adults, symptoms may initially be very subtle and

difficult to recognise. Elderly residents may present only

with

– cough, fatigue and confusion.

– fever response may be more blunted.

– Influenza may present in the elderly patient as an exacerbation

of an underlying condition

• If an increased number of residents become unwell over

a short period of time with respiratory illness, influenza

should be suspected.


Three or more cases (amongst residents and/or staff) of

influenza like illness (ILI) or influenza or respiratory illness

• within the same 72 hour period in the RCF,

• which meet the same clinical case definition and

• where an epidemiological link can be established.

Definition of Influenza/Influenza like

illness (ILI) Outbreak


Detection of Influenza outbreak (1-4)

• Inform the local medical team/attending GP for an appropriate diagnosis to be made

• If cases are confirmed the GP confirming the suspected outbreak notifies the Department of Public Health at 021-49 27601 / 066 7184542

• Department of Public Health will

• undertake a risk assessment and

• establish an outbreak control team if deemed appropriate

• advise on • appropriate clinical specimens to be taken

• Decide re antiviral treatment and chemoprophylaxis


Viral Swabs

• Pre-addressed postage box to the “National Virus Reference Lab”

• 2 Viral swabs • Instructions for Throat Swab to test for Influenza

• NVRL Request form with “Respiratory Viral Suite”

• Results sent to Dept Public Health


Instructions for Taking a Viral Throat Swab

• Clean hands, clean gloves

• Rub the swab over the tonsillar fossa or any area with visible exudate

• Avoid touching the tongue or mouth with the swab

• Carefully place the swab into the bottle and snap off the excess stick , secure the green cap on the bottle

• Remove gloves, clean hands

• Complete the form and add details to swab bottle – name, DOB, clinical details, date & time swab was taken.

• If postage is delayed store in a cool dry place, ideally in a fridge at 4°C



• Inform your Infection Prevention & Control Nurse where available

• Agree a communication strategy

– Nominate a person to act as liaison with the Dept of Public Health and the Infection Prevention & Control Nurse



• In addition to Standard Precautions, implement

Droplet Precautions as advised – See Section 3 and

Section 6 of the Infection Prevention and Control

Guidelines, HSE South, 2017

• www.hse.ie/infectioncontrol

• Refer to “Checklist for Residential Care Facilities on

the Prevention, Detection and Control of Influenza-like

Illness and Influenza Outbreaks, 2018/2019”


If possible cases of influenza are identified:

• Make a list of residents and staff with symptoms (use a template):• Name/DOB

• Date of first symptoms (onset)

• Symptoms - fever, cough, fatigue

• Vaccination status

• Consider• Layout of the facility (location of cases) and possible links between affected

residents

• Timeline – 3 affected within 72 hours

• If there is more than one GP attending the facility, ensure all are aware of other potential affected residents/staff.


Accurate information is essential as this will guide

Public Health response



www.hse.ie/infectioncontol

Under Resources – Influenza Button


Infection Control Measures (1)

• In addition to Standard Precautions, implement Droplet Precautions immediately for symptomatic cases in healthcare settings

• do not wait for laboratory results

• Patient Placement in RCF

• Place patient in a single room or cohort with similar patients

• Maintain a distance ≥ 1 metre between infectious patient and others

• Wear surgical masks within 1 metre of care

• Limit patient movement


Infection Prevention and Control

Precautions

Standard Precautions • Hand Hygiene

• Respiratory Hygiene and Cough Etiquette

• Patient Placement

• Protective Clothing

• Cleaning of the Environment

• Care of Client Care Equipment

• Care with Laundry

• Dealing with spills of body fluids safely

• Care and disposal of sharps

• Dealing with needle stick injury or blood or body fluid exposures

• Staff Health, hygiene and staff immunisations

• Healthcare risk waste

PLUS - Droplet Precautions

• Additional Protective Clothing

• Patient Placement

• Cleaning of the Environment

• Care of Client Care Equipment


PPE for routine care for suspected or confirmed

influenza case.

1. Surgical mask.

2. Wear gloves/apron/gown/goggles if risk of

contact with blood, body fluids, mucous

membranes or non-intact skin anticipated as

per Standard Precautions

PPE for an aerosol generating procedure (AGP) and

if remaining in or entering the patient’s room

within one hour after cessation of the AGP:

1. FFP2 or FFP3 respirator (correctly fitted),

goggles, long sleeved disposable gown, gloves.

2. AGP – intubation, tracheostomy insertion,

ventilation

Nebulisation is no longer considered an AGP but

patients receiving nebulisation should be placed in

a single room.


Sequence* for Donning PPE

1. Gown / Apron first

2. Mask

3. Goggles or face shield (if required)

4. Gloves

*Combination of PPE will affect sequence – be practical


How to Don a Mask

• Place over nose, mouth and chin

• Fit flexible nose piece over nose bridge

• Secure on head with ties or elastic

• Adjust to fit

INFO RE PPE ON CONTRACT


Sequence for Removing PPE

• Remove Gloves first – and perform hand hygiene

• Face shield or goggles (if required)

• Gown

• MaskRemember the outside aspect of PPE is considered contaminated


Removing a Mask

� Untie the bottom, then top,

tie

� Remove from face

� Discard

� Hand Hygiene



Management of admissions/transfers during an

outbreak

• Transfers

– to acute facility - inform the ambulance/admitting

facility/infection control team in advance of the

outbreak

– admission of new residents to RCF not generally

recommended

– Non –urgent transfers to another facility generally not

recommended.



Includes

1. Transfer of Resident diagnosed with ILI from Acute services back to a RCF – criteria to be met outlined

2. Transfer of resident hospitalised for reasons not related to ILI to a RCF experiencing an outbreak – based on assessment of risk of exposure

3. Transfer of patient with close contacting to case(s) of influenza to a RCF –criteria to be met outlined

4. Duration of Precautions for RCF residents with respiratory viral infections – risk factor for prolonged shedding outlined


Additional measures within the facility

• Restrict movement between affected and unaffected areas

• Consider rescheduling non urgent appointments

• Limit visitors as much as possible

• Excluded symptomatic visitors & all children

• Essential Visitors –

• Instruct to use hand hygiene facilities

• Visit one resident only and exit immediately after visiting

• Appropriate signage


Link with Section 18 Admissions, Transfers &

Discharges www.hse.ie/infectioncontrol


Respiratory Hygiene & Cough Etiquette

CHECK NEW POSTERS

• Should be in place at

all time

• Emphasise during

influenza season

• Signage, provide

facilities

• Consider visitors,

residents

What is it ?

• Element of Standard Precautions (2007)

Advising

• Control of respiratory secretions

• Hand hygiene after contact with respiratory secretions

• Spatial separation >3 ft of persons with respiratory infection

• Visual cue to remind people



• Environmental cleaning and disinfection– Clean with detergent and water

– Disinfect with 1,000ppm available chlorine• Or Combined cleaner & disinfectant

– Rinse and dry

• Emphasis on frequently touched surfaces and surfaces in close proximity to the affected residents

• Dedicate care equipment or clean and disinfect between affected residents



• In relation to staff recommended that

– Staff/volunteer absenteeism is monitor

– All staff aware of action to take if ill

– Ill staff should stay away from work for at least 5 days and until they are well enough to return – written policy in place

– Limit staff movement especially if areas are unaffected within the facility

– Vaccinated staff to work in affected area

– Asymptomatic unvaccinated staff should wait one incubation period (3 days) prior to working in a non-outbreak facility.

– Asymptomatic vaccinated staff have no restrictions working at other facilities



• On-going surveillance of ill pts/staff & maintain line list

• On-going communication with Dept Public Health, Infection Prevention Control

Nurse

• Appropriate signage for visitors

• Duration of precautions – 7 days following symptom onset or longer as advised

– Precautions required whilst people are symptomatic

– Advise should be sought regarding those who residents with risk factors

• An influenza outbreak is declared ‘over’ eight days after the onset of symptoms in

the last new case


Key Messages

• Vaccination of healthcare staff, patients, residents and visitors remains the

cornerstone of flu prevention strategies

• Be prepared

� Record of staff and resident flu vaccination

� Record of pneumococcal vaccine

� Supplies of the correct standard available – PPE, swabs,

� Know who to contact – Dept. Public Health, Infection Prevention & Control

� Know how to access antiviral drugs

� Continuous surveillance for ILI amongst residents and staff

• PREPARATION IS KEY – BE WINTER READY!


Web resources

• Health Protection Surveillance Centre Advice on

Aerosol Generating Procedures.

• https://www.hpsc.ie/a-

z/respiratory/influenza/seasonalinfluenza/infecti

oncontroladvice/File,3625,en.pdf

• Cork Kerry Community Healthcare Guidelines &

Resources

• https://www.hse.ie/eng/about/who/healthwellb

eing/infectcont/sth/resources/influenza.html


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