Influenza in LongTerm Care Settings

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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
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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

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Objectives

• 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

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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

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Wartime and Influenza 1918

• Grouping people close together
• For extended periods
• Whether sick or well
• Global travel
• PANDEMICS

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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
  sneezing
• Clothing, bedding, hands, knobs make inefficient
  sources for influenza transmission

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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
  room
• Limit spread by spacing ill from not ill
• 6 feet or more would be ideal

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Wheres Influenza in LTC from?

• STAFF
• 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
  vaccinated
• Reduce visitors during influenza season

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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
• Vaccinate? And STEP UP SURVEILLANCE
• 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)

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DIAGNOSIS Is it a cold or the FLU?
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Influenza The Way To Think About It
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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

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Vaccination, even poor match, reduces fever
(inflammation)
Radziusauskiene D, Ambrozaitis A, Gravenstein S,
et al, 2002.
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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.
20033481322-1332.
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Zanamivir vs. rimantadineDistribution of
Influenza Cases
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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)

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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

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Pandemic Planning
http//www.pandemicflu.gov/plan/community/commitig
ation.html
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Projected Illness and Resource Utilization in the
US
Estimates do not account for impact of new
interventions unavailable last century
Department of Health and Human Services, Pandemic
Influenza Plan
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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

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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
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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

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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?

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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,
  manuals
• Determine sources, gather

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How to Plan What about?

• Absenteeism 30-40?
• Due to employee illness, family illness, school
  closures and child care, fear of workplace
  infection
• 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,
  manuals
• Determine sources, gather
• Develop regulatory exceptions at state and
  federal levels

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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
  ethics)
• Vaccine priorities
• Who gets first incoming doses
• Refrigeration, expiration dates
• Needles, syringes and similar supplies

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First Steps

• Check out
• http//pandemicflu.gov/plan/healthcare/longtermcar
  echecklist.html
• 24 major planning steps, with 54 subordinate
  tasks
• 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

www.hhs.gov/pandemicflu/plan/
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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

wws/hhs.gov/pandemicflu/plan/sup10.html
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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

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Participate!

• 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

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Summary of the Community Mitigation Strategy by
Pandemic Severity
http//www.pandemicflu.gov/plan/community/commitig
ation.html
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Posttest (True or False)

• Influenza is spread by small droplet aerosol
• Epidemic and pandemic influenza is spread from
  person-to-person
• Vaccines really dont work, can give you the
  flu!
• My doctor can look down my throat and diagnose
  (or exclude) influenza just by looking!
• Influenza always causes a cough/sneeze and a
  fever
• 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

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Summary

• 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

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Please, Lord, enough already!
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Acknowledgements

• 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