Influenza Outbreak Prevention and Control in Long-Term Care Facilities (LTCF)

Outbreak Prevention

The following activities may prevent or mitigate an outbreak in a LTCF:

Annual influenza vaccination of all residents
Vaccinating healthcare providers – this not only protects the healthcare provider from developing influenza but also protects the residents from contracting influenza from the healthcare provider.
Implementation of Standard and Droplet Precautions when a person is suspected or confirmed to have influenza
Active surveillance and influenza testing for new illness cases
Restriction of ill visitors and staff from entering the facility
Administration of influenza antiviral medications for prophylaxis and treatment when influenza is detected in the facility
Other prevention strategies, such as respiratory hygiene/cough etiquette and hand hygiene.

Outbreak Management

A cluster of influenza in a LTCF is defined as three or more cases of acute febrile respiratory illness (AFRI) occurring within 48 to 72 hours, in residents who are in close proximity to each other (e.g., in the same area of the facility).

An outbreak in a LTCF is defined as a sudden increase of AFRI cases over the normal background rate or when any resident tests positive for influenza. One case of confirmed influenza by any testing method in a long-term care facility resident is an outbreak.

Control Measures

1. Report all clusters and outbreaks to Public Health.
If an outbreak of influenza-like illness does occur, please contact your local or district health department or the Georgia Department of Public Health at 404-657-2588 for assistance in outbreak investigation and control.

2. Collect specimens
Collect respiratory specimens and perform rapid influenza testing and viral cultures for influenza when respiratory illness clusters occur or when influenza is otherwise suspected in a resident. Because rapid tests for influenza are only moderately sensitive, negative specimens should also be tested by viral culture and/or PCR. Contact the Georgia Department of Public Health Influenza Surveillance Coordinator or your local health department epidemiologist to facilitate specimen collection and shipping to the Georgia Public Health Laboratory. Virology and molecular laboratory submission forms should accompany the specimens.

3. Administer Antiviral Prophylaxis
Antiviral prophylaxis should be given to residents and offered to health care personnel in accordance with current CDC recommendations during influenza outbreaks. Antiviral chemoprophylaxis should continue for at least 2 weeks, and as long as 1 week after the last resident case occurred. Persons receiving antiviral chemoprophylaxis should be actively monitored for potential adverse effects, and for possible infection with influenza viruses that are resistant to antiviral medications. Two influenza antiviral drugs are recommended for use in the United States during the 2008-09 flu season: oseltamivir and zanamivir. Oseltamivir and zanamivir are effective against both influenza A and B viruses.

4. Reinforce Respiratory Hygiene/Cough Etiquette
Reinforce respiratory hygiene/cough etiquette whenever residents or visitors have symptoms of respiratory infection to prevent the transmission of all respiratory tract infections in long-term care facilities. Respiratory hygiene/cough etiquette includes:

Posting visual alerts instructing residents and persons who accompany them to inform health care personnel if they have symptoms of respiratory infection and discouraging those who are ill from visiting the facility.
Providing tissues or masks to residents and visitors who are coughing or sneezing so that they can cover their mouth and nose.
Providing tissues and alcohol-based hand rubs in common areas and waiting rooms.
Ensuring that supplies for handwashing are available where sinks are located and providing dispensers of alcohol-based hand rubs in other locations.
Encouraging persons who are coughing to sit at least 3 to about 6 feet from others. Residents with symptoms of respiratory infection should be discouraged from using common areas where feasible.

5. Adhere to Standard Precautions
During the care of any resident with symptoms of a respiratory infection, health care personnel should adhere to Standard Precautions:

Wear gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
Wear a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
Change gloves and gowns after each resident encounter and perform hand hygiene as discussed below.
Decontaminate hands before and after touching the resident, after touching the resident’s environment, or after touching the resident’s respiratory secretions, whether or not gloves are worn.
When hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Alternatively, wash hands with soap and water.

6. Implement Droplet Precautions
In addition to Standard Precautions, health-care providers should adhere to Droplet Precautions during the care of a resident with suspected or confirmed influenza for 5 days after the onset of symptoms.

Place resident in a private room. If a private room is not available, place (cohort) suspected influenza residents with other residents suspected of having influenza; cohort residents with confirmed influenza with other residents confirmed to have influenza
Wear a surgical or procedure mask upon entering the resident’s room. Remove the mask when leaving the resident’s room and dispose of the mask in a waste container
If resident movement or transport is necessary, have the resident wear a surgical or procedure mask, if possible

7. Restrict Activity for Ill Visitors and Ill Health care Personnel when Influenza is Detected in the Community

Notify visitors that adults with respiratory symptoms should not visit the facility for 5 days and children with symptoms for 10 days following the onset of illness
Evaluate health care personnel with influenza-like illness and perform rapid influenza tests to confirm the causative agent is influenza and exclude those with influenza-like symptoms from patient care for 5 days following onset of symptoms, when possible
Cancel common activities and serve all meals in patient rooms
Limit new admissions.

Resources for Influenza Prevention and Control in Long Term Care Facilities:

CDC’s Flu Gallery: This link is where you will find free, downloadable materials from CDC to promote influenza vaccination and other prevention measures.