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Influenza in LongTerm Care Settings


staff home sick! If it occurs in the next year or two, there will be a scramble for vaccine ... new staff roles: videos, manuals... Determine sources, gather ... – PowerPoint PPT presentation

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Title: Influenza in LongTerm Care Settings

Influenza in Long-Term Care Settings
Influenza in Long-Term Care Settings
Stefan Gravenstein, MD, MPH, CMD Professor of
Medicine John Franklin Chair of Geriatrics
  • Stefan Gravenstein, MD, MPH
  • Eastern Virginia Medical School

Eastern Virginia Medical School, Norfolk,
Virginia and, Clinical Director, NH-QIOSC Quality
Partners of Rhode Island
Pretest (True or False)
  • Influenza is easily spread by touching
    contaminated door knobs
  • Vaccine always prevents influenza
  • You can get influenza from vaccine
  • Influenza vaccine is made from influenza virus
    grown in live chicken eggs
  • Influenza can be prevented by wearing a mask
  • The Avian flu pandemic will spread to us in the
    next year or two

  • Understand
  • how influenza spreads
  • the consequences of influenza
  • Learn how to
  • Keep from getting influenza
  • How to reduce influenza transmissibility
  • About outbreak control strategies
  • Pandemic influenza, and how to prepare as part of
    infection control in long-term care settings

Influenza is a Contagious Disease
  • Influenza occurs normally in aquatic birds
  • Waterfowl are the natural reservoir
  • Epidemic and pandemic influenza must spread from
    person to person
  • Influenza is spread by droplet aerosol
  • Coughing and sneezing are the most efficient way
    to spread influenza

Wartime and Influenza 1918
  • Grouping people close together
  • For extended periods
  • Whether sick or well
  • Global travel

Influenza Transmission
  • Depends on
  • hang time
  • Amount of virus in each droplet
  • Number of droplets inhaled
  • Immunity in person inhaling infected droplets
  • Number of droplets inhaled relates to distance
    from source of infected person coughing or
  • Clothing, bedding, hands, knobs make inefficient
    sources for influenza transmission

Influenza in LTC
  • We looked at 104 cases of influenza in a large
    LTC facility. Attack rate was
  • 18 overall
  • 14 in those living in rooms alone
  • 21 in those paired, but only one was able to
    leave on their own
  • 35 in those paired but both stuck there
  • 75 in those paired, married, living in the same
  • Limit spread by spacing ill from not ill
  • 6 feet or more would be ideal

Wheres Influenza in LTC from?
  • Most staff are not vaccinated (
  • Almost all residents are (90)
  • Most resident cases get infected by staff
  • Best and most cost-effective approach to reduce
    influenza in nursing homes is to vaccinate staff
    (more than 80 to make this work reliably)
  • Visitors
  • Can also bring in influenza. Less than 10
  • Reduce visitors during influenza season

Policies for Influenza Reduction
  • Before influenza arrives Vaccination
  • Vaccinate staff (aim for 80)
  • Those with direct patient contact and children
    are the highest priority
  • Those with children will likely get influenza
    from their children
  • Vaccinate residents (aim for 97)
  • Offer vaccine for frequent visitors (sitters,
    family, temps)
  • Once Influenza is there change environmental
  • Reduce group activities and mixing between wards
  • Separate ill from not ill screen visitors
  • Send ill staff home for at least a week unless
    getting antiviral (treat with Tamiflu or Relenza
    for five days)
  • Antivirals (chemoprophylaxis exposed residents)

DIAGNOSIS Is it a cold or the FLU?
Influenza The Way To Think About It
Cytokine response
  • Influenza infection is localized within the
    respiratory tract, but the release of cytokines
    produces a systemic response
  • Systemic symptoms caused by cytokines include
    myalgia, malaise, and fever
  • People with less cytokine are less symptomatic
  • Old people produce less cytokine
  • Old people have fewer symptoms
  • Less fever
  • Less myalgia

Vaccination, even poor match, reduces fever
Radziusauskiene D, Ambrozaitis A, Gravenstein S,
et al, 2002.
Influenza Vaccine Reduces Pneumonia, Cardiac, and
Cerebrovascular Disease in Older Patients
Percent Reduction
Year 1 All Patients
Year 2 Patients ³65 y
Nichol KL, et al. N Engl J Med.
Zanamivir vs. rimantadineDistribution of
Influenza Cases
Influenza Treatments
  • Adamantanes, rimantadine (Fluvirin, ) and
    amantadine (Symmetrel, )
  • Effective against influenza A, but not B, and not
    in 2006!
  • Resistance develops rapidly
  • Zanamivir (Relenza, inhaled, ) and oseltamivir
    (Tamiflu, ) are neuraminidase inhibitors,
  • Effective against influenza A and B
  • Resistance is rare (.3 in Japan for oseltamivir
    0 as of yet for zanamivir)
  • All treatments begin in 48 hours of onset, for 5
    days, twice daily (less for renal insufficiency
    except zanamivir)
  • Chemoprophylaxis is
  • half the dose for 10 to 14 days (7 days past the
    last new case in the building)

Other approaches
  • Hand washing
  • Covering your mouth
  • The Artic Hut experiment
  • Facial tissues
  • Antiviral facial tissues
  • Masks for general use
  • Cough into sleeve, not hand
  • Segregation
  • The roommate story
  • Hang time
  • Doors as barriers
  • Surfaces steel, Formica and pillow cases

Pandemic Planning
Projected Illness and Resource Utilization in the
Estimates do not account for impact of new
interventions unavailable last century
Department of Health and Human Services, Pandemic
Influenza Plan
Pandemic What to Anticipate
  • No idea!
  • Dont know when it will arrive, only that it will
  • Dont know the severity
  • Might be mild, seasonal epidemic (Category 1)
  • Might be severe, Spanish Flu (Category 4 or 5)
  • 1-3 million dead, 20-50 of population ill
  • Society would shut down food delivery, utilities
    and telephone, grocery stores, schools,
    transportation, etc. likely for many weeks (12?)
    staff home sick!
  • If it occurs in the next year or two, there will
    be a scramble for vaccine
  • LTC residents and staff likely low on the
    priority list

Strategic National Stockpile Goals
HHS stockpile contains 4 million doses against
A/H5N1/Vietnam-2004 strain First FDA A/H5 vaccine
approved 4/17/07, for ages 18-64 years of
age Federal stockpile already has 31 million
courses stockpile enough for 25 of US Source
Adapted from HHS Pandemic Planning Update II
6/26/06 Implementation Plan for the National
Strategy for Pandemic Influenza
Pandemic Influenza Special Considerations
  • Pandemic influenza, when it arrives will it has
    the potential to be the equivalent of a
    long-lasting disaster (think hurricane, but for
    2-3 months)
  • Disaster preparedness plans is an appropriate
    context for LTC facilities
  • Water, canned foods, hygiene and cleaning
    supplies, infection control supplies,
    incontinence products, blankets, sleeping bags,
    tents, battery-operated radio and lanterns,
    flashlights, body bags
  • Consider storage for stockpile, pharmacy

How to Plan
  • Consider what would be essential if no supplier
    is available for critical services for 6-8 weeks
  • Think incrementally--the first two weeks then
    for four weeks, etc.
  • Part of an all-hazards disaster plan
  • Infection control, staffing, communications,
    supply lines
  • Internal assessment of current preparedness
  • Staff knowledge
  • Infection control and airborne disease, vendor
    agreements, other critical operations (e.g.,
    food, pharmacy)
  • How would staff function with 40 absenteeism?

How to Plan What about?
  • Hands-on care
  • Incontinence, transfers, repositioning, feeding
  • Contingency for volunteers (family, retired,
    community, non-clinical, housekeepers, sales)
  • Pilot concept locally
  • Training materials for new staff roles videos,
  • Determine sources, gather

How to Plan What about?
  • Absenteeism 30-40?
  • Due to employee illness, family illness, school
    closures and child care, fear of workplace
  • Prioritize care by acuity and resident self-help
  • Onsite housing for staff and family?
  • Hands-on care
  • Incontinence, transfers, repositioning, feeding
  • Contingency for volunteers (family, retired,
    community, non-clinical, housekeepers, sales)
  • Pilot concept locally
  • Training materials for new staff roles videos,
  • Determine sources, gather
  • Develop regulatory exceptions at state and
    federal levels

How to Plan What about?
  • Medications
  • Can doses be skipped or drugs held?
  • triage plan for high and low priority medicines
    by resident, sharing medications,
    physician/pharmacy advice access (to extend
  • Develop regulatory exceptions at state and
    federal levels
  • Scope of practice, documentation
  • Antiviral priorities
  • Staff vs. residents (utilitarian vs. libertarian
  • Vaccine priorities
  • Who gets first incoming doses
  • Refrigeration, expiration dates
  • Needles, syringes and similar supplies

First Steps
  • Check out
  • http//
  • 24 major planning steps, with 54 subordinate
  • HCANJ, AHCA, OHCA efforts and recommendations
  • Multidisciplinary team/planning committee to
    address disaster and pandemic planning
  • Develop contacts with local, regional and state
    emergency preparedness groups, including
    bioterrorism/communicable disease coordinators
  • Areas hospital contacts to strategize
    hospitalization and facility resource sharing
  • Develop a written pandemic influenza plan,
    incorporating local/regional/state plans
Steps Pandemic Plan Elements
  • Surveillance residents, staff, visitors
  • Communications
  • Education personnel, residents, family members
  • Infection control for managing residents, staff
    and visitors with pandemic influenza
  • Occupational health for dealing with staff
    absences and other issues
  • Vaccine and antiviral use
  • Surge capacity

Surge Capacity
  • Contingency staffing (prioritizing critical from
    non-essential services by resident health status,
    functional limitations, disabilities and
    essential facility operations)
  • Estimate how many supplies needed in stockpile
    (masks, gloves, hand hygiene, IV pumps, etc.)
  • Address likely supply shortages, and alternative
    channels for procuring needed resources.
  • Strategies to help increase hospital bed capacity
    in community
  • Managing need for post mortem care, disposition
    of deceased
  • Area in facility that might be used as a
    temporary morgue

  • If LTC is not represented at the planning steps
    for the community, others will make the decisions
  • How to handle quarantine
  • Where to send supplies, food and how much
  • How to allocate beds and services
  • How to reallocate staff
  • Dont wait to be contacted engage
  • Reach across state lines
  • Let law enforcement know

Summary of the Community Mitigation Strategy by
Pandemic Severity
Posttest (True or False)
  • Influenza is spread by small droplet aerosol
  • Epidemic and pandemic influenza is spread from
  • Vaccines really dont work, can give you the
  • My doctor can look down my throat and diagnose
    (or exclude) influenza just by looking!
  • Influenza always causes a cough/sneeze and a
  • Tamiflu and Relenza can treat influenza if it is
    started within the first 2 days of symptom onset
  • Separating residents for meals and activities can
    reduce spread of influenza between them
  • Pandemic planning includes training outside of
    scope of practice

  • Influenza causes respiratory disease
  • Influenza is spread between people via air
  • Separating ill people from others reduces spread
  • Influenza is contagious from a few days (in
    young) to up to a week or more (in old)
  • Vaccination can prevent influenza or reduce
    symptoms from influenza
  • Vaccinated people spread influenza to others less
    easily because they dont make as much virus, and
    dont cough and sneeze
  • Pandemic planning is important locally, and
    should be part of larger disaster preparedness

Please, Lord, enough already!
  • Lynn Wagner, Sheperdstown, W.Va
  • Influenza research teams
  • Wisconsin
  • Paul Drinka, UW-Madison Wisconsin Veterans Home
  • Pete Shult, Wisconsin Department of Health
  • Vilnius University
  • Arvydas Ambrozaitis
  • Daiva Radziusauskiene
  • Eastern Virginia Medical School
  • Rex Biedenbender, Yuping Deng, Stacy Kouskoris,
    Jerianne Meyers, Norine Kuhn, Dean Howard, Noleen
    Guillaume, Barbara Stebler and Rick Drake