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Influenza: How to Prevent or Minimize Outbreaks

Through Oct. 13, influenza activity remained low across the United States. However, the Centers for Disease Control and Prevention (CDC) expects flu outbreaks to increase in the coming months. Avoiding and minimizing flu outbreaks not only protects residents and staff, it protects the facility as well given the laser focus on infection prevention and control that state surveyors have had during the first year of the Long-term Care Survey Process (LTCSP).


Directors of nursing services (DNSs) can work with the interdisciplinary team, residents, and families to reduce the risk of influenza transmission and minimize any outbreaks that occur. Limiting transmission requires a bundled approach, including the following steps:


Keep immunizing throughout flu season


The CDC recommends that providers give influenza vaccines to residents and staff as soon as they become available and try to complete all immunizations by the end of October, says Evelyn Cook, associate director for the Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina at Chapel Hill.


“Ideally, you should begin your campaign in the middle of the summer and ratchet it up in August and September,” says Cook. “However, you certainly can give the vaccine throughout the entire flu season, offering it, for example, to new residents and new staff. Most providers offer it to new residents, but when you are hiring staff during the typical influenza season, offering the influenza vaccine should be part of their orientation as well.” Note: See Misconceptions About Seasonal Flu and Flu Vaccines here. Find the CDC’s free e-learning module on vaccine administration skills within the course “Immunization: You Call the Shots.”


Conduct active surveillance


Providers should keep track of when influenza activity begins in their community and even within their state if family members routinely come to visit from across the state, says Cook. To assist with these tracking efforts, the CDC page Weekly U.S. Influenza Surveillance Report provides both national and regional data and also has an interactive ILINet State Activity Indicator Map, which allows facilities to click on their state to access state-specific and sometimes even county-specific data, as well as state Department of Health influenza resources.


The CDC recommends that providers test residents who exhibit influenza-like illness even outside the typical flu season period of Oct. 1 – March 31, says Cook. “However, from the very beginning of flu season, you should do active surveillance of residents, staff, and visitors. Monitor very diligently for signs and symptoms, and immediately test any residents who have those symptoms.” Note: Review flu signs and symptoms here. Learn about preferred testing methods in the Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities. Find additional resources here.


Make sure staff know when to stay home


“Often, long-term care staff don’t understand when they should not come to work when they do not feel well. Most staff feel badly if they have to call off work, or they feel like they need to work for various reasons. Facilities should have a strong employee education program on the importance of not working when staff are obviously ill or have certain symptoms,” says Cook. “Facilities should have policies in place that outline employee work restrictions, and they should have a designated staff member (usually the infection preventionist) with authority to ask staff to go home if they come to work obviously ill.”


On the survey side, F880 (infection prevention and control) in Appendix PP of the State Operations Manual states that providers must develop and implement written policies and procedures for infection control that “prohibit staff with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.”


Consider limiting visitors during heavy flu activity


Many providers are concerned that limiting visitors could infringe on resident rights, acknowledges Cook. “However, you definitely should consider limiting the number of visitors to reduce the risk of an outbreak in your facility, especially when visitors are symptomatic. The CDC even recommends that you have signs posted at the entrance to your facility reminding individuals that they should not visit if they’re sick and, if they do have a cough, to make sure they cover that cough when they come into the facility.” Note: Find Cover Your Cough flyers and posters in multiple languages here.


F563 (right to receive/deny visitors) in Appendix PP supports the CDC’s position. The following excerpt explains that visitor access to residents is “subject to reasonable clinical and safety restrictions,” including:


“Restrictions placed to prevent community-associated infection or communicable disease transmission to the resident. A resident’s risk factors for infection (e.g., immunocompromised condition) or current health state (e.g., end-of-life care) should be considered when restricting visitors. In general, visitors with signs and symptoms of a transmissible infection (e.g., a visitor is febrile and exhibiting signs and symptoms of an influenza-like illness) should defer visitation until he or she is no longer potentially infectious (e.g., 24 hours after resolution of fever without antipyretic medication). If deferral cannot occur such as the case of end-of-life, the visitor should follow respiratory hygiene/cough etiquette as well as other infection prevention and control practices such as appropriate hand hygiene.”


Promote alcohol-based hand rub


Since nursing facilities are often the residents’ home, some DNSs and administrators can be hesitant to put up alcohol-based hand-rub dispensers at readily accessible locations because they feel like the dispensers give the facility an institutional appearance, says Cook. “However, that is probably one of the biggest mistakes that can be made because, as we all know, hand hygiene in general is the No. 1 way to prevent transmission of infection, and use of alcohol-based hand rubs is preferentially recommended by the CDC, except when hands are visibly soiled.”


Providers will need to consider potential safety concerns (e.g., for residents with mental impairments). “But generally, making alcohol-based hand-rub dispensers more readily accessible to staff and visitors can go a long way in preventing not only influenza but transmission of other organisms,” says Cook. “Having visitors use alcohol-based hand rubs upon entry into the facility should be year-round practice,” she adds. “But certainly you should heighten awareness of the need to perform hand hygiene during influenza season.”


Know what counts as an outbreak


“All it takes is two residents to have an outbreak. Once you have one resident with laboratory-confirmed influenza and you have one more resident with influenza-like symptoms within 72 hours, the CDC considers that to be an outbreak,” says Cook. “If you have that situation, then the CDC’s Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities has very clear, specific, stepwise guidelines about what steps should be taken.”


Key steps to take once DNSs have identified an outbreak include the following:


Implement droplet precautions


Once a provider has those two cases that constitute an outbreak, the CDC recommends that, in addition to standard precautions, droplet precautions be implemented with all residents who are symptomatic, says Cook. “A critical component of droplet precautions is that residents who are symptomatic should remain in their room as much as possible. The best practice is to put them in a private room, and they should stay in their room at least for seven days after illness onset or until the respiratory symptoms and fever have been resolved for 24 hours, whichever one is longer. But seven days is the baseline minimum.”


In the examples of how to treat residents with dignity and respect, F550 (resident rights) in Appendix PP specifically cites transmission-based isolation precautions as one of the two exceptions for the need to refrain from “restricting residents from use of common areas open to the general public such as lobbies and restrooms.”


So community or joint activities should be limited for those ill residents, stresses Cook. “However, if they do come out of their room, they should wear a mask, and healthcare personnel should wear a mask going into their room.”


Start all residents on immediate antiviral chemoprophylaxis


Sometimes an outbreak is enhanced because the facility took the attitude, “We will just prophylaxis residents on this hall or the ones who have had contact with the ill resident,” points out Cook. “However, there is a lot of socialization in long-term care facilities. Residents often don’t stay in their rooms like they do in acute-care hospitals, and staff may go from one unit to the next—possibly enhancing the risk of transmission. The CDC recommends that all non-ill residents receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined. Priority should be given to residents living in the same unit or floor as the ill resident.”


Don’t wait to contact your local public health department


“As soon as you recognize that you have those two cases that constitute an outbreak, pick up the phone and call your local health department,” advises Cook. In some states, reporting an influenza outbreak to the local health department is required. “For example, in North Carolina, it’s part of our communicable disease rules,” she notes.


“But more importantly, the local health department can really help you,” says Cook. “Fear of punitive repercussions makes some providers slow to contact public health, but they are there to help—and they have expertise that you should take advantage of.”


F880 in Appendix PP requires that infection control policies and procedures include “which communicable diseases are reportable to local/state public health authorities” and, in the event of an outbreak, requires that facilities “comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks.”


Find additional educational resources


“A strong infection prevention and control program is key, and you have to have someone oversee the program to make sure that interventions are put in place to keep your residents and employees safe,” says Cook.


Providers in many states may be able to access state-based infection prevention and control training to help them develop a strong program. For example, in North Carolina, SPICE offers long-term care webinars (the webinar slides and recordings are available free nationwide); a twice-yearly, three-day Infection Control in Long-term Care course available to in-state and out-of-state providers; and an Ask SPICE page that in-state providers can use to get answers to infection control questions. “We get a lot of questions during flu season, and we help to the degree that we can,” says Cook.


Note: Appendix PP offers guidance that can help providers appropriately implement transmission-based precautions from a survey compliance perspective. In addition to F550, F563, and F880, key F-tags include F583 (personal privacy/confidentiality of records) and F603 (free from involuntary seclusion).


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