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OUTBREAK MANAGEMENT Guidelines for Health Care Facilities Prepared by: Niagara Region Public Health Infectious Disease Program and Environmental Health Division “Dedicated to Achieving a Healthier Niagara” TABLE OF CONTENTS Contact Information ............................................................................................................ 2 Introduction ......................................................................................................................... 3 Upper Respiratory Outbreak 1.1 Education ................................................................................................................ 4 1.2 Policy Preparation ................................................................................................... 5 1.3 Surveillance – Line Listing Form ........................................................................... 6 (Sample) Completing An Outbreak Line List ................................................... 8 1.4 Outbreak Definition ................................................................................................ 9 (Sample) Outbreak Management Summary Checklist ................................... 10 1.5 Case Definition ..................................................................................................... 11 1.6 Specimen Collection – Nasopharyngeal Swabs .................................................... 12 1.7 Control Measures .................................................................................................. 15 Respiratory Outbreak Control Measures ........................................................ 19 1.9 Declaring Over ...................................................................................................... 20 1.10 Influenza Outbreaks .............................................................................................. 21 Recommended Policy Statement For Influenza Outbreak .............................. 23 Websites With Information About Influenza .................................................. 27 1.11 Respiratory Outbreak Associated Organisms: ...................................................... 26 A Reference Chart For Health Care Workers Enteric Outbreak 2.1 Surveillance – Line Listing Form ......................................................................... 28 2.2 Outbreak Definition .............................................................................................. 29 (Sample) Outbreak Management Summary Checklist ................................... 30 2.3 Case Definition ..................................................................................................... 31 2.4 Specimen Collection ............................................................................................. 32 Labelling An Enteric Outbreak Kit ................................................................. 33 2.5 Food Sampling Guidelines .................................................................................... 35 2.6 Control Measures .................................................................................................. 36 Enteric Outbreak Control Measures................................................................ 39 2.7 Declaring Over ...................................................................................................... 40 2.8 Enteric Outbreak Associated Organisms: ............................................................. 41 A Reference Chart For Health Care Workers APPENDIX Hand Hygiene Using Hand Rubs Hand Hygiene With Soap And Warm Water Putting On Personal Protective Equipment (PPE) Taking Off Personal Protective Equipment (PPE) What You Need To Know About Outbreaks Sample Transfer Letter Sample Letter To Physicians Niagara Region Public Health Outbreak Management 1 REVISED October 2012 CONTACT INFORMATION Niagara Region Public Health staff can assist you by telephone or by facility visit with information regarding management of an enteric or upper respiratory outbreak. If you suspect an outbreak in your facility, contact Niagara Region Public Health at 905688-8248 ext. 7330/7554, 24 hours a day. For after hours (Monday to Friday 4:30 pm – 8:30 am, Saturday, Sunday and holidays) follow the emergency instructions on the voice automated message and contact the dispatch phone number 905-984-3690. Environmental Health Division Infectious Disease Program Program Managers: Heather Hague Lois Lacroix x7329 x7553 Team Leaders: Sandra Jacobs Lorrie Ross x7333 x7391 Public Health Nurses: Yvonna Cahill x7435 Sandy Crayford x7474 Linda Green x7388 Megan Height x7387 Danya Huneault x7447 Martha Jespers x7557 Pamela Lof x7551 Cathy Martin x7326 Sandra Romagnoli x7346 Angela Roy x7551 Jennifer Sharron x7346 Linda Warkentin x7558 Dayna Young x7115 Health Promoter: Tracy Haley Program Manager: Dave Carey x7417 Public Health Inspectors: Sam DiMeo Melania Iancov Bruce Lance Rick Legge Sobaan Afzal Health Promoter: Rob Levay x7214 x7628 x7270 x7456 x7290 x7385 x7341 Niagara Region Public Health Outbreak Management 2 REVISED October 2012 INTRODUCTION The purpose of this guide is to facilitate the investigation of respiratory and enteric outbreaks in health care facilities. Effective management of outbreaks in health care facilities is challenging. Early recognition of outbreaks, rapid initiation of control measures and effective communication are critical for minimizing the extent of an outbreak. To ensure effective outbreak management, all information must be exchanged with designated contacts and must be documented carefully, particularly in the early stages of an investigation. The objectives of this guide are: To assist facilities prevent outbreaks of respiratory and enteric disease To assist facilities develop a surveillance system to monitor respiratory and enteric illness and identify early outbreaks To assist facilities collaborate with Public Health in investigating and managing outbreaks of respiratory and enteric infections including: Consulting promptly with Public Health when there is suspicion of an outbreak Activating an Outbreak Management Team (OMT) Ensuring that OMT members understand their roles and responsibilities Outlining outbreak control measures Ensuring collection of appropriate specimens in a timely manner to verify diagnosis Updating information regarding changes to recommendations or procedures as needed The following manual provides consensus opinion of several resources including: 1. National Advisory Committee on Immunization: http://www.phacaspc.gc.ca/naci-ccni/ 2. Public Health Laboratory, A Guide to the Control of Enteric Disease Outbreaks in Health Care Facilities, 1993 3. A Guide to the Control of Respiratory Disease Outbreaks in LTCF – Public Health Branch & Long Term Care Homes Branch, MOHLTC, 2004 http://www.health.gov.on.ca/english/providers/pub/pubhealth/ltc_respoutbreak/ltc _respoutbreak.pdf 4. Provincial Infectious Diseases Advisory Committee (PIDAC) Knowledge Products (best practice documents) http://www.oahpp.ca/resources/pidac-knowledge/index.html It is our intent to review these recommendations periodically as new knowledge becomes available, both in the literature and from our local experiences. Users of this manual are invited to communicate their views, experiences, problems and improvements so that these may be addressed in the future. Niagara Region Public Health Outbreak Management 3 REVISED October 2012 1.1 EDUCATION Ongoing education of staff, volunteers, residents and residents’ families about infection prevention and control, and outbreak management policies must be part of an effective Infection Control Program. Topics for consideration in education programs for all staff and residents are: Surveillance of Infections Hand Hygiene Routine Practices and Personal Protective Equipment (PPE); e.g. appropriate use of gloves, gowns, eye protection, and masks (N95/surgical) Specimen Collection (How to obtain a Nasopharyngeal Swab; How to Collect an Enteric Stool Specimen) Environmental Cleaning and Sanitation Respiratory/Enteric Outbreak Control Measures Influenza Immunization and Exclusion Policy During Confirmed Influenza Outbreaks Public Health Nurses from the Infectious Disease Program and Public Health Inspectors from the Environmental Health Division are available to assist your facility in providing education to staff, volunteers, residents and families. Niagara Region Public Health Outbreak Management 4 REVISED October 2012 1.2 POLICY PREPARATION Each facility must have a policy to address respiratory disease surveillance, prevention (including annual influenza immunization) and outbreak control. These policies must be based on current guidelines available from the Ministry of Health and Long-Term Care, the local public health unit, and PIDAC Best Practice Guidelines. Policies should address the following topics: Procedures for surveillance, early recognition for potential infectious conditions and management of an outbreak including the composition and mandate of the Outbreak Management Team (OMT) Process to rapidly access specimen kits, testing, and results of laboratory tests in the event of a suspect outbreak Ensuring that at least one nursing staff is available daily who is competent in the appropriate technique for the collection of nasopharyngeal specimens Exclusion policy for unimmunized staff members during an influenza outbreak Staffing contingency plan addressing varying levels of available staff due to failure to immunize, unwillingness or contraindication to antiviral agents or illness A policy on use of antiviral medications during confirmed influenza outbreaks. Oseltamivir (TAMIFLUTM) as first line of defense. Obtaining consent for prophylaxis with antivirals from residents or substitute decision-makers Obtaining pre-approved orders from physicians or a “medical directive” signed by the Medical Director for antiviral prophylaxis Establishing lines of communication between the facility, health unit, and laboratory Ongoing effective communication with residents, families of residents, staff, and media Annual review of policies related to outbreak prevention and control Niagara Region Public Health Outbreak Management 5 REVISED October 2012 1.3 SURVEILLANCE – LINE LISTING FORM See attached line listing forms, and sample on “Completing an Outbreak Line List”: LTCF – Respiratory/Enteric Acute Care – Respiratory/Enteric (Residents) Acute Care – Respiratory/Enteric (Staff) Surveillance is an essential component of an effective infection prevention and control program. Surveillance is the ongoing systematic collection, collation, analysis and interpretation of data; and the dissemination of information to those who need to know in order that action is taken. Surveillance establishes baseline information about the frequency and types of infections that exist in a health care facility. This information can be used to determine deviations from baseline. An important goal of surveillance is to ensure early identification of a potential outbreak or an outbreak in its early stages so that control measures can be instituted as soon as possible. A designated, trained Infection Control Professional should be responsible for surveillance and outbreak management activities. In their absence, a competent person must be designated to continue these functions, including on weekends and during holiday periods. Surveillance should be done for both resident and staff populations, however, it is recognized with current resources many LTCFs are unable to conduct active staff surveillance year round. In an effective Infection Control Program, staff surveillance is also recommended. Resident Surveillance Continuous facility-wide surveillance is useful to establish baseline levels of infection throughout the year. Potential outbreaks are recognized when infection rates increase above the baseline. It is important that LTCFs are also able to recognize outbreaks during off-hours (weekends, holidays). Targeted surveillance for respiratory symptoms should be enhanced during the influenza season (November to April) and when influenza activity has been reported in the local community. All staff providing direct care must be aware of the symptoms of respiratory illness, the criteria for a suspected outbreak and the procedures for reporting to the ICP. Facilities are required to have ongoing surveillance programs to determine the presence of infections. Key features of these programs shall include: A sufficiently sensitive surveillance program to identify sentinel events and trends Analysis of surveillance data by the ICP in order to trigger actions to reduce or eliminate transmission of infection Surveillance strategies that take community disease prevalence and the unique epidemiology of infection in long term care into account Niagara Region Public Health Outbreak Management 6 REVISED October 2012 Staff Surveillance The Ontario Hospital Associate states “HCWs have a responsibility to their residents and colleagues regarding not working when ill with symptoms that are likely attributable to an infectious disease. This includes staff with influenza-like illness, febrile respiratory illness, gastroenteritis and conjunctivitis. All employees should be educated on the importance of reporting illness (including colds, influenza, diarrhea or when the cause is unknown etc.). Staff should be reminded that staying home will reduce the spread of infection within the facility. All employees are responsible for promptly reporting any infections they have, or may have come into contact with to their supervisor. This step is very important in preventing the infection from spreading to residents. Methods of Surveillance Daily surveillance is the most effective way to detect respiratory infections. There are two methods to conduct daily surveillance: active and passive. i. Passive Surveillance Passive surveillance involves looking for infections while providing routine daily care or activities. Residents with respiratory and other symptoms should be noted on the daily surveillance form. This form should be easy to use and include patient identification and location, date of onset, a checklist of relevant signs and symptoms, including fever, diagnostic tests and results when available. The completed form should be forwarded to the ICP on a daily basis. Any suspected outbreak should be reported immediately to the ICP. It is important to maintain a high index of suspicion for respiratory infections, especially during flu season (November – April). ii. Active Surveillance Active surveillance involves seeking out residents with symptoms of an infection. Several strategies may be used including: Conduct Unit rounds; receive verbal report from Unit staff of clinical observations Chart review of medical and/or nursing progress notes which may note fevers Review Unit reports, and physician/staff communication books Review laboratory reports and pharmacy antibiotic utilization records All available sources of information within the facility may contribute to the surveillance activities. The method used by each facility should be practical in that setting. Analysis of data collected should be performed by the ICP or designate. Results of surveillance data should be reviewed on a regular basis to determine whether these meet the criteria for infection in each resident and if a suspected outbreak exists. Niagara Region Public Health Outbreak Management 7 REVISED October 2012 (SAMPLE) COMPLETING AN OUTBREAK LINE LIST It is important to complete facility name, outbreak number and date declared on each sheet submitted to ensure they are not mixed in with other outbreaks. Provided by Public Health Earliest date symptoms began Tick all that are appropriate and meet case definition Date of case’s last influenza and pneumococcal vaccination Number in sequence. Do not change without consulting Public Health nurse Indicate resident or staff Niagara Region Public Health Outbreak Management Include important additional information Date specimen collected 8 Lab will give results to Public Health Date symptoms ended REVISED October 2012 1.4 OUTBREAK DEFINITION An outbreak should be suspected anytime that illness exceeds the normal baseline distribution in a given area, at a given time. Reporting of respiratory infection outbreaks is legislatively required under the Health Protection & Promotion Act (HPPA) from the following institutions: nursing homes, homes for the aged, acute and chronic care hospitals operating under the Public Hospital Act. Although not required under the HPPA, reporting of respiratory infection outbreaks in retirement homes is strongly recommended. Suspect an outbreak whenever there are: Two or more cases of acute respiratory symptoms occurring within 48 hours, in one geographic area. Symptoms may include: - abnormal temperature - dry cough (new) - productive cough (new) - runny nose/sneezing - nasal congestion/stuffy nose - sore throat - hoarseness/difficulty swallowing - chills - myalgia - malaise - headache - decreased appetite Criteria for a potential influenza outbreak: o one laboratory confirmed case of influenza OR o two cases of influenza-like illness occurring with 48 hours in a geographic area (i.e., unit, floor) OR o more than one unit having a case of acute respiratory illness with 48 hours Note: The clinical presentation of influenza in an elderly, fully immunized population can differ from the usual clinical presentation of influenza. Because influenza in the elderly often causes tiredness (malaise), muscle aches (myalgia), loss of appetite, headache, and chills. In the elderly, fever could be absent or manifest as follows: abnormal temperature for the resident or a temperature <35.5 oC or >37.5oC. An outbreak can be declared at any time by the Medical Officer of Health, or their designate, or the ICP or designate for the LTCF. There should be a discussion between the Medical Officer of Health or designate and the facility regarding whether to declare a facility-wide outbreak or unit specific outbreak when the cases are on one unit and can be confined to that unit. See: Sample Outbreak Management Summary Checklist Niagara Region Public Health Outbreak Management 9 REVISED October 2012 (SAMPLE) OUTBREAK MANAGEMENT SUMMARY CHECKLIST CHECKLIST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Notify charge RN, Infection Control Practitioner or Director of Resident Care or Associate Director of Resident Care. For evenings and weekends, notify the manager on-call. Initiate a line listing of all symptomatic patients/residents/staff using the Public Health line list form. Notify Public Health, Infectious Disease Program 905-688-8248 ext. 7330 or after hours 905-984-3690. Have the following information available: Date of onset / Signs and symptoms Total # of patients/residents/staff on unit and/or facility Total # of patients/residents/staff ill at present Total # of patients/residents/staff immunized against influenza (for upper respiratory outbreaks only) Enteric/nasopharyngeal swab kits on hand (check expiry date) Have Outbreak Management Manual available for reference. Obtain an outbreak number. Establish outbreak case definition. Implement outbreak control measures. Refer to Outbreak Management Manual for specific respiratory or enteric outbreak control measures. Place outbreak signs in appropriate areas: □ Front entrance □ Stairwells/Elevators □ Outbreak unit Cohort and isolate symptomatic patients/residents and place proper signage on door of room. Cohort staff. Collect and refrigerate nasopharyngeal swab or enteric specimens as directed by Public Health. Contact Infectious Disease Program for pickup. Notify: □ Medical Advisor/MRP physician for facility □ Administrator □ Housekeeping □ Dietary □ Pharmacy □ O.T., P.T., Recreation Therapy, Volunteer Co-ordinators □ Pastoral Care Notify other units of outbreak and heighten surveillance ill patients/residents. Educate patients’/residents’ family members of limited visitation, adherence to outbreak control measures and appropriate use of PPE if needed. Fax the line listing daily to Public Health, Infectious Disease Program 905-682-6470. For confirmed Influenza Outbreaks refer to Influenza Outbreak Management Guidelines section of the Outbreak Management Manual. Niagara Region Public Health Outbreak Management 10 Nurse Initial REVISED October 2012 1.5 CASE DEFINITION Different respiratory viruses often cause similar acute respiratory symptoms. As a result, each respiratory outbreak requires its own case definition. The case definition should be developed for each individual outbreak based on its characteristics. The case definition should also be reviewed during the course of the outbreak, and modified if necessary, to ensure that the majority of cases are captured by the definition. A Case Definition Example: “Any resident or staff presenting with two or more of the following symptoms: fever, sore throat, cough and runny nose.” Niagara Region Public Health Outbreak Management 11 REVISED October 2012 1.6 SPECIMEN COLLECTION – NASOPHARYNGEAL SWABS Once the outbreak has been declared, your facility will be assigned an outbreak number that will be used to identify all lab specimens collected for testing. The outbreak number is: 2246 - 201X - three digit number (Health Unit - Year - Outbreak Number) Specimen collection is critical to determining the causative agent in each respiratory outbreak. Ensure that staff is familiar with the procedure for the collection of nasopharyngeal swabs. See “Nasopharyngeal Specimen Collection Technique” attached. Check with Public Health staff regarding available to assist with education of staff on this procedure (i.e., videos). Note: Consult with your Medical Director prior to collecting nasopharyngeal (NP) swabs. To identify the causative agent: 1) It is best to collect nasopharyngeal specimens as early as possible from the most acutely ill residents and staff, preferably within the first 48 hours of onset of symptoms. 2) If possible, 5 specimens only should be obtained initially. Further specimen collection will be determined based on results and progress of outbreak. 3) Staff obtaining specimens must ensure correct labeling of specimens to ensure testing by Public Health Lab. This includes the name of the case, date of birth, and the outbreak number on the nasopharyngeal specimen vial and requisition form. See: “How to Complete Public Health Lab Test Requisition Form” attached. 4) Nasopharyngeal specimens must be refrigerated after collection until pick up and transport to the lab to ensure optimal results. 5) Notify the Public Health Infectious Disease program that specimens are ready for pick-up. Note: once a causative organism is identified, no further collections of nasopharyngeal specimens are recommended. For further testing, consult with Public Health. Niagara Region Public Health Outbreak Management 12 REVISED October 2012 NASOPHARYNGEAL SPECIMEN COLLECTION Nasopharyngeal swab method for respiratory virus detection Anterior naris Mid-inferior portion of inferior turbinate Posterior pharynx Patient's head should be inclined from vertical to about 70% The laboratory needs high levels of organism to culture successfully for respiratory viruses such as RSV, influenza A & B virus or parainfluenza virus. A properly taken nasopharyngeal swab will yield high levels of organism. Ensure the following equipment is available: NP Swab kit from Public Health Gloves Mask Goggles 1. 2. 3. 4. 5. 6. Insert nasopharyngeal swab into one nostril. Press the swab tip on the mucosal surface of the mid-inferior turbinate. Briefly rotate the swab once it has been inserted. Leave swab in place for a few seconds to absorb material. Withdraw swab and insert into transport medium. Break swab shaft at scored line to fit in tube well below the cap, and replace cap to vial, closing tightly. 7. Refrigerate the specimen 8. Fill out Public Health Laboratory requisition form completing all sections: Health Card number Agency Name and outbreak number Tests requested: V23 (influenza A/B) Specimen type and site: Nasopharyngeal Swab Reason for test: to diagnose disease Clinical information: symptoms 9. Contact Public Health Infectious Disease Program at 905-688-3762 x7330 for pick up of nasopharyngeal specimens as soon as possible after collection - after hours please call dispatch 905-984-3690 N.B. Rule of thumb to determine when swab is placed properly: Insert swab to one half the distance from the tip of the nose to the tip of the earlobe. Niagara Region Public Health Outbreak Management 13 REVISED October 2012 HOW TO COMPLETE PUBLIC HEALTH LABORATORY TEST REQUISITION Resident Health Card Resident Gender Resident Date of Birth yy/mm/dd Resident FIRST NAME Resident LAST NAME Facility Name Address Phone Number Outbreak Number Provided by Niagara Region Public Health Enter Test Code V23 (Influenza A/B) Date Specimen Collected Onset Date Specimen Type Check appropriate box(s) Leave This Area Blank Niagara Region Public Health Outbreak Management 14 REVISED October 2012 1.7 CONTROL MEASURES Facilities that suspect they have an outbreak should implement initial outbreak control measures to prevent further spread of illness. Facilities should consider establishing an Outbreak Management Team and meet regularly including all representatives who have decision making authority in the facility. Members should include: Medical Advisor/Director Administrator Director of Nursing/Director of Resident Care Infection Control Officer/Infection Control Nurse Public Health Nurse/Public Health Inspector Housekeeping/Laundry Supervisor Food Services Supervisor Recreational Activities Supervisor Pharmacist The following control measures are recommendations from Public Health: 1. Isolation of Symptomatic Cases Restrict cases (ill residents) to their room until 5 days after the onset of acute illness or until symptoms have completely resolved (whichever is shorter). For some pathogens the periods of communicability may be longer than 5 days, but for practical reasons, this could be applied to outbreaks caused by respiratory viruses other than influenza. Implement droplet precautions (i.e., post signs) http://ricn.on.ca/photos/custom/CSICNfiles/Droplet%20STOP%20Sign_Front%20&%20Back.pdf Restriction of ill residents to their room is recommended as long as it does not cause the resident undue stress or agitation and can be done without applying restraints. 2. Cohorting Residents/Staff Cohorting is defined as the grouping together of individuals in a specific area to limit the contact between infected cases and non-infected cases, in order to decrease opportunities for transmission of infectious agents. If cases are confined to one unit, all residents from that unit should avoid contact with residents in the remainder of the facility. If possible, exposed staff should remain caring for symptomatic cases on a daily basis and avoid transferring to another unit/floor during the outbreak. During non-influenza outbreaks, discuss the possibility of one staff member looking after only ill residents and others looking after only well residents. Alternatively, discuss the possibility of keeping staff members working on only one unit if possible. Attempts should be made to minimize movement of staff, students, or volunteers between floors/wings especially if some units are unaffected. These measures should not be required during influenza outbreaks where all persons are immunized or on an appropriate antiviral drug. Niagara Region Public Health Outbreak Management 15 REVISED October 2012 Allied health professionals (e.g., respiratory therapists, physiotherapists, occupational therapists, speech therapists, recreational therapists) should be cohorted to the outbreak unit where possible, or provide care on non-outbreak units before entering the outbreak unit (preferably on a one-on-one basis) 3. Hand Hygiene Hand hygiene stations should be set up at designated areas in the facility (i.e., entrances, outside elevators, patient/resident care areas) Hand hygiene should be performed: o Before initial patient/resident or patient/resident environment contact o Before sterile procedures o After body fluid exposure risk o After patient/resident or patient/resident environment contact Alcohol based hand rubs (ABHR) are the first choice for hand hygiene in clinical situations when hands are not visibly soiled. Using ABHRs is more effective than washing hands (even with an antibacterial soap) when hands are not visibly soiled. When visible soil is present and running water is not immediately available, use moistened towellettes followed by ABHR. Residents, staff and volunteers should be instructed in proper hand hygiene to facilitate staff and visitor hand hygiene Refer to Appendix: “Hand Hygiene using Hand Rubs”. 4. Masking/Gowning/Gloving/Eye Protection is Recommended for Direct Patient Care of Ill Residents The use of surgical masks, gowns, and gloves is recommended for direct patient care of ill residents during an outbreak to prevent transmission of organisms. Staff wearing masks must remove their mask before caring for another resident, and when leaving the residents dedicated space/room. Visitors do not need to wear gloves or masks if they are visiting one resident only; however, if providing direct patient care to an ill resident they should be encouraged to wear gown, surgical mask and gloves. Eye protection/safety glasses, goggles and face shields should be worn when there is a potential for splattering or spraying of blood, body fluids, secretions/excretions, including cough producing aerosol generating procedures while providing direct resident care (i.e., collection of NP swab). Personal eyewear is not sufficient. Refer to Appendix: “Sequence for Donning and Removing Personal Protective Equipment.” 5. Enhanced Environmental Cleaning/Sanitizing Ensure cleaning and sanitizing of environmental surfaces frequently contaminated by residents/staff (i.e., hand rails, door knobs, bathroom units, furniture). Ensure a process for proper disposal of contaminated materials; double bagging of waste is not required. Cleaning and sanitizing methods should be reviewed by Public Health Inspector. Disposable dishes and cutlery are not required. Niagara Region Public Health Outbreak Management 16 REVISED October 2012 6. 7. 8. 9. Refer to: PIDAC Best Practices for Environmental Cleaning for Prevention and Control of Infections and Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices Exclusion of Symptomatic Staff from Work/Facility Staff who meet case definition are excluded from the facility for 5 days from onset of symptoms or until asymptomatic, whichever comes first; if the causative agent is known, other measures may apply. For a confirmed influenza outbreak, ill staff, students or volunteers taking antiviral medication for treatment (not prophylaxis) shall be excluded from work for 5 days from onset of symptoms or until symptoms have resolved, whichever is shorter. Limited Visiting Any symptomatic (potentially infectious) visitors should be excluded at anytime, especially during influenza season. Signs should be posted in the facility indicating that there is an outbreak and visitors should be warned that they may be at risk of acquiring infection within the facility. During an outbreak, visitors should visit only their own friend/relative, in their own room (not in a common area), and should wash their hands before and after the visit at hand hygiene stations in the facility. See Appendix: “What You Need to Know About Outbreaks”. Public Health does not recommend closing the facility to visitors/volunteers; only in the case of extremely virulent disease would the Medical Officer of Health order the facility to be closed to the public. Suspension of Social Activities As much as possible, all social activities should be restricted to each respective unit. The Outbreak Management Team must find a balance between restricting activities to control the spread of infection, and providing therapeutic opportunities from social activities. Visitation by outside groups (e.g., entertainers, meetings, community groups, etc.) is not recommended. Also, visitation of multiple residents is not recommended. Onsite adult and childcare programs may continue provided there is no interaction between residents and participants of the program. Restrict New Admissions, Re-Admissions and Transfers Restricting admissions unnecessarily will create a backlog in acute care or other community facilities; on the other hand, admitting persons who are susceptible into an outbreak situation poses a risk to their health. Residents can be transferred from the outbreak facility to a hospital with prior notification to Hospital Infection Control Officer or designate. Residents admitted from the outbreak facility to hospital with respiratory illness can be re-admitted to the LTCF at any time, provided that appropriate care/accommodation can be given. New admissions (from community), residents admitted to hospital prior to the outbreak, or admitted to hospital for reasons other than respiratory illness may be admitted/re-admitted to the LTCF if the following conditions are met: a) the resident or substitute decision-maker has been informed of the outbreak status and provided consent; Niagara Region Public Health Outbreak Management 17 REVISED October 2012 b) the resident’s physician has been informed of the outbreak status and provided consent (taking into consideration the severity of the particular outbreak relative to the resident’s condition) c) if the outbreak is due to influenza, the resident is protected from influenza by vaccination and an anti-viral drug Resident transfers from anywhere in the facility to another Long Term Care facility is not recommended during an outbreak. Possible exception of this recommendation should be discussed with the Medical Officer of Health on an individual basis. Note: A resident’s bed will be kept for up to 30 days while he/she receives treatment in an acute care facility, or 60 days for psychiatric leave. In the event that a resident’s hospital stay exceeds 30 days due to a closure of a long term care facility because of an outbreak, the Ministry of Health and Long-Term Care will extend the period for time the resident may remain away from the facility. 10. Advise Hospital Infection Control Staff of Outbreak Prior to Transferring a Resident Prior to transfer of residents to hospital, designated staff at the outbreak facility should contact the Infection Control Professional directly by phone to inform them that the resident is coming from an outbreak situation. Inform them of the outbreak, the pathogen if known, and if the resident is symptomatic or not. For influenza outbreaks only, complete outbreak notification form to provide required information and send with resident on transfer to hospital. See Appendix: Transfer Letter. 11. Working at Other Facilities During respiratory outbreaks, staff/volunteers should not work at any other facility. If asymptomatic staff choose to work at another facility, they must wait one incubation period (i.e., 72 hours) after working the last shift at the outbreak facility (if the causative organism is known, the waiting period may differ). Staff working at 2 facilities must inform the receiving DOC (Director of Care) or designate at the nonoutbreak facility. During an Influenza A or B outbreak, previously immunized staff (> 2 weeks prior to outbreak) have no restrictions on their ability to work at other facilities, provided the individual changes their uniform between facilities. However, unimmunized staff must wait one incubation period (72 hours) from the last day they worked at the outbreak facility prior to working in a non-outbreak facility, to ensure that they are not incubating influenza. Note: If influenza isolates that have been strain characterized indicate a different lineage than is contained in the influenza vaccine for the current season, recommendations for staff working at other facilities may vary from above. 12. Medical Appointments Non-urgent appointments made before the outbreak shall be rescheduled. Niagara Region Public Health Outbreak Management 18 REVISED October 2012 RESPIRATORY OUTBREAK CONTROL MEASURES The following control measures are in force until further notice: Isolation of symptomatic cases Cohorting residents/staff Hand Hygiene Masking, gowning, gloving and eye protection (when appropriate) is recommended for direct patient care of ill residents Enhance environmental cleaning and sanitizing Exclusion of symptomatic staff from work Limited visiting Suspension of social activities Restrict new admissions, re-admissions & transfers Advise Hospital Infection Control Staff of the outbreak prior to transferring a resident/patient Staff/volunteers should not work at another health care facility Niagara Region Public Health Outbreak Management 19 REVISED October 2012 1.9 DECLARING OVER The length of time from the onset of symptoms of the last case until the outbreak is declared over can vary and is dependent on whether the last case was a resident/patient or staff. Prior to declaring an outbreak over, the facility must not have experienced any new cases of infection (resident or staff) which meet the case definition for the period of time as defined by the Outbreak Management Team (OMT). As a general rule, respiratory outbreaks (e.g. Influenza) can be declared over if no new cases have occurred in 8 days from the onset of symptoms of the last resident/patient case. Note: For other respiratory organisms that may be isolated during the outbreak, discussion should be held with Public Health to determine when outbreak will be declared over. The rationale for this definition is, if the outbreak were continuing, given active surveillance, new cases would have been identified within 8 days since 8 days is the outer limit of the period of communicability of influenza (5 days) plus one incubation period (3 days). Note: if symptoms in the last resident/patient case resolve sooner than 5 days, or if the last case is a staff member who should stay at home during the period of communicability, the time until the outbreak is declared over can be shortened accordingly. Since large LTCFs tend to have some sporadic influenza or respiratory infection cases in non-outbreak situations, the OMT may need to attempt to differentiate between these sporadic cases and outbreak-associated cases in identifying the last outbreak related resident case. Niagara Region Public Health Outbreak Management 20 REVISED October 2012 1.10 INFLUENZA OUTBREAKS (i) PREVENTION – INFLUENZA IMMUNIZATION Vaccination is recognized as the cornerstone for preventing or attenuating influenza for those at high risk of serious illness or death from influenza infection and related complications. Health care workers and their employers have a duty to actively promote, implement and comply with influenza immunization recommendations in order to decrease the risk of infection and complications in the vulnerable populations for which they care. Educational efforts aimed at health care workers and the public should address common doubts about disease risk for health care workers, their families and patients, vaccine effectiveness and adverse reactions. The provision of influenza vaccination for health care workers who have direct patient contact is an essential component of the standard of care for the protection of their patients. Health care workers who have direct patient contact should consider it their responsibility to provide the highest standard of care, which includes annual influenza vaccination. In the absence of contraindications, refusal of health care workers who have direct patient contact to be immunized against influenza implies failure in their duty of care to patients (Source: CCDR http://www.phac-aspc.gc.ca/naci-ccni/ ). LTCFs should: □ Ensure that all staff are provided with information annually regarding the influenza vaccine and exclusion policy □ Promote and implement accessible influenza vaccination clinics □ Keep an updated record of all resident and staff influenza immunizations and update list throughout the influenza season. □ Report immunization status among residents, staff, and volunteers to the local medical officer of health by the outlined date provided by the MOHLTC. □ Advise outside agencies that provide staff to the LTCF of the facility’s immunization/exclusion policy □ Develop a staffing contingency plan based on immunization rates in their facility (ii) RECOMMENDED POLICY STATEMENT – Influenza Outbreaks In order to protect vulnerable patients during an outbreak, it is reasonable to exclude from direct patient contact those health care workers with confirmed or presumed influenza, and unvaccinated health care workers who are not receiving antiviral prophylaxis. Facilities should have an Exclusion Policy for use for staff and volunteers who choose not to be immunized and/or take antiviral drugs. Things to consider or include in the development of Exclusion policy: How and when the exclusion policy comes into effect Who falls under the definition of staff Niagara Region Public Health Outbreak Management 21 REVISED October 2012 Hierarchy of immunization status, and what to do at each step Consequences of failure to comply Managing shared staff working in a facility with a declared outbreak Length of exclusion time clearly defined when staff are on an antiviral drug How to verify staff are taking the antiviral How staff will be educated and update re: policy Obtaining antiviral prescription pre-season Define HR issues, e.g., time off designation, cost of anti-virals. See sample “Recommended Policy Statement for Influenza Outbreaks” attached. Residents Prior to, or upon admission, each resident should be assessed regarding vaccination and medical status. Based on this assessment, informed consent from the resident or substitute decision-maker should be obtained for influenza and pneumococcal vaccines, and antiviral drugs for influenza prophylaxis in the event of an outbreak. Immunity after influenza vaccination usually lasts less than 1 year. However, in the elderly, antibody levels may fall below protective levels in 4 to 6 months. To ensure that protection lasts throughout the influenza season, the recommended time for influenza immunization is from October to mid-November unless otherwise advised by your local public health unit. If the resident is admitted after the facility’s fall vaccination program and before the influenza season is over (usually late March), vaccination must be offered, unless the person has already received the current season’s influenza vaccine. If the influenza immunization status of a resident is not available or unknown, the resident should be considered unvaccinated, and vaccination should be given. The immunization record of the resident should be retained in a readily accessible part of their health record. Upon transfer, the resident’s recent immunization status should be shared with the receiving Health Care facility. Staff Annual immunization against influenza should be required for all persons carrying on activities in the LTCF unless medically contraindicated. Influenza immunization may be received at the annual influenza clinic or from any other private health care provider. All staff who receive the influenza vaccine from a source other than the LTCF must provide proof of influenza immunization. Only the following should be accepted as proof of influenza immunization: A personal immunization record documenting receipt of the current season’s influenza vaccine signed by a health care professional A signed physician’s note indicating immunization Documented immunization from another facility or institution If this documentation is not available, the LTCF should not consider the staff member immunized, and the employer must offer influenza immunization to the person. Niagara Region Public Health Outbreak Management 22 REVISED October 2012 RECOMMENDED POLICY STATEMENT FOR INFLUENZA OUTBREAKS Policy: (Name of facility) has an established protocol for staff during a confirmed influenza outbreak that complies with the recommendations of Niagara Region Public Health. Purpose: To ensure the residents and workers are protected from possible exposure to and transmission of influenza during an influenza outbreak. Positive Isolate of Influenza A and/or B Staff** immunized >2 weeks prior to outbreak Staff not immunized: options 1. Take antivirals AND receive flu vaccine and return to work; antiviral needs to be taken for 2 weeks minimum or until outbreak is declared over, whichever comes first May continue to work as long as not symptomatic with flu like symptoms (may also work between facilities) 2. Take flu vaccine only and return to work in 2 weeks or when outbreak Is declared over Notes: * if influenza isolates differ than what is contained in the influenza vaccine for the current season, recommendations for vaccinated staff may differ ** If unimmunized staff choose to work at another facility, they must wait one incubation period (i.e. 72 hours) after working the last shift at the outbreak facility *** Definition of staff: All persons who carry on activities in the long term care facility, including but not limited to employees, volunteers, students, attending physicians, and both health care and non-health care contract workers 3. If influenza vaccine is medically contraindicated or refused; take antivirals only and return to work. Antiviral must be taken for the duration of the outbreak. 4. Refuse options 1, 2 and 3 above: must remain off work until outbreak is declared over Although the Public Health Department would prefer to have facilities voluntarily respond to the above recommendations, here is legislative authority under Section 22 of the Health Protection and Promotion Act to exclude staff from work who wish not to comply with vaccination or antiviral agents. Niagara Region Public Health Outbreak Management 23 REVISED October 2012 (iii) INFLUENZA OUTBREAK MANAGEMENT When a positive isolate of Influenza A or B is received, an outbreak of influenza will be confirmed and the following recommendations will be reviewed with your facility by Public Health staff. To reduce the impact of influenza and ensure that residents and staff are protected from possible exposure to and transmission of influenza during an outbreak, the following actions are recommended (see Summary Table below): Antiviral Prophylaxis (Prevention) Antiviral medication for prevention (prophylaxis) shall be given to all residents, whether vaccinated or unvaccinated, and to all unvaccinated staff members. Currently recommended medications for prophylaxis are neuraminidase inhibitors –oseltamivir (Tamiflu TM) and zanamivir (RelenzaTM). Oseltamivir (Tamiflu TM) is the recommended drug of choice for both prophylaxis and treatment in influenza outbreaks. Consult with pharmacy for prophylactic dosage recommendations for residents (ideally, this is done pre-influenza season). NACI does not recommend amantadine for prophylaxis for this season. Prophylaxis should be given until the outbreak is declared over. Antiviral medication may be ordered for 14 days initially and repeated if the outbreak lasts longer than 14 days. Facilities may wish to consult with their pharmacy representatives. Prescriptions of neuraminidase inhibitors, as for all other medications for residents are the responsibility of the medical directors or attending physicians of the residents. For staff, prescriptions of neuraminidase inhibitors are the responsibility of staff member’s family physician. Offer Sample Letter to Physicians (see Appendix) for staff to take to their physician which reviews the recommendations. Antiviral Treatment For residents who have been ill for <48 hours, antiviral medication for treatment should be given. Consult with pharmacy regarding treatment dose recommendations for residents. Treatment decisions are the responsibility of the attending physicians. Oseltamivir (Tamiflu TM) is the recommended drug of choice for both prophylaxis and treatment in influenza outbreaks. Treatment must be started within 48 hours of onset of symptoms to be effective and may decrease the rate of complications. For residents who have been ill >48 hours, consult with Medical Advisor to determine if antivirals are appropriate. Staff Recommendations (refer to Sample “Recommended Policy Statement for Influenza Outbreaks”) Staff immunized with influenza vaccine at least 2 weeks prior to the outbreak may continue to work as long as they are not symptomatic with flu-like symptoms; immunized staff may also continue to work between facilities Unimmunized staff have 3 options: Niagara Region Public Health Outbreak Management 24 REVISED October 2012 1) Take antivirals AND receive flu vaccine and return to work; antiviral medications need to be taken for 2 weeks minimum or until outbreak is declared over, whichever comes first 2) Take flu vaccine only and return to work in 2 weeks or when outbreak is declared over 3) If influenza vaccine is medically contraindicated or refused, take antivirals only and return to work; antiviral medication must be taken for the duration of the outbreak If options 1, 2 and 3 are refused, then staff must remain off work until the outbreak is declared over. Note: If unimmunized asymptomatic staff chooses to work at another facility, they must wait one incubation period (72 hours) after working the last shift at the outbreak facility. Note: It is reasonable to allow staff to work with residents as soon as they start antiviral prophylaxis. Summary of Outbreak Recommendations: Antiviral Medication for Prevention and Treatment of Influenza A & B RESIDENTS Recommendation Lab confirmed case of Influenza A or B Antiviral treatment dose for 5days Symptomatic <48 hours, but not lab Antiviral treatment dose for 5 days, then confirmed switch to antiviral prophylaxis dose for the duration of the outbreak Symptomatic > 48 hours, but not lab Consult with Medical Advisor to determine confirmed if antivirals are appropriate Asymptomatic regardless of their Antiviral prophylaxis for the duration of vaccination status the outbreak Residents on antiviral prophylaxis who Switch to antiviral treatment dose for 5 become symptomatic days STAFF Recommendation Staff immunized > 2 weeks prior to the May continue to work if asymptomatic outbreak Unimmunized staff 1. Take antivirals AND receive flu vaccine and return to work; antivirals need to be taken for 2 weeks minimum or until the outbreak is declared over, whichever comes first. 2. Take flu vaccine only and return to work in 2 weeks, or when outbreak is declared over. 3. If flu vaccine is medically contraindicated or refused – take antivirals only and return to work. Antiviral must be taken for the duration of the outbreak. *Refuse options 1, 2 and 3 must remain off work until the outbreak is declared over Niagara Region Public Health Outbreak Management 25 REVISED October 2012 1.11 RESPIRATORY OUTBREAK ASSOCIATED ORGANISMS: A Reference Chart For Health Care Workers ORGANISM Influenza Type A or B SYMPTOMS Sudden onset of fever, chills, muscle aches, headache, runny nose, sore throat, dry cough Parainfluenza Type 1, 2, 3 and 4 cold: stuffy nose, cough 1 to 3 days PERIOD OF COMMUNICABILITY 24 hours before onset of symptoms and up to 3 to 5 days after onset of symptoms for adults, up to 7 days in young children **Not related to the virus which causes influenza Person-to-person by droplet and direct contact or exposure to contaminated environmental surfaces 2 to 8 days, average 4 to 6 days person-to-person by droplet and direct contact or exposure to contaminated environmental surfaces 2 to 6 days 3 to 8 days, but virus shedding may last longer in young infants and in immunosuppressed in whom it may continue for 3 to 4 weeks VACCINE Nasopharyngeal Swab (virus testing) Flu vaccine Protects against Influenza A or B Rapid Test (1 hr) Nasopharyngeal Swab (virus testing) Rapid Test (24 hours) Type 1: average 4 to 7 days after onset of symptoms Virus Culture (7 days) Nasopharyngeal Swab (virus testing) Type 3: average 8 to 9 days Rapid test (1 hour) Runny nose, sore throat, mild to moderate fever, pneumonia and/or bronchiolitis Fever, runny nose, sore throat DIAGNOSIS Virus Culture (7 days) Pneumonia and bronchiolitis can develop in the elderly Less common cause of outbreaks Adenovirus Person-to-person by droplets (coughing and sneezing) and direct contact with virus contaminated surfaces (doorknobs, etc.) INCUBATION (Note: elderly population may not always develop fever) Similar to a common Respiratory Syncytial Virus (RSV) MODE OF TRANSMISSION Recommended annually Vaccine available for high-risk infants/children No vaccine Virus culture (7 days) Person-to-person by droplet and direct contact of exposure to contaminated environmental surfaces 2 to 14days During the first few days of illness and shedding continues for longer periods, even months Nasopharyngeal Swab (virus testing) No vaccine Person-to-person by droplet and direct contact of exposure to contaminated environmental surfaces 12 hours to 5 days, usually 48 hours 24 hours before onset of symptoms and for 5 days after onset Nasopharyngeal Swab (virus testing) No vaccine Asymptomatic infections are common Most frequent cause of the common cold Rhinovirus Runny nose, sore throat, sneezing, watery eyes, fatigue, fever is uncommon Niagara Region Public Health Outbreak Management Virus Culture (7 days) 26 REVISED October 2012 WEBSITES WITH INFORMATION ABOUT INFLUENZA 1. www.health.gov.on.ca - Ministry of Health and Long Term Care Current health issues. Updated regularly. 2. http://www.oahpp.ca/resources/flubulletin.html The Ontario Influenza Bulletin – the most useful site for Ontario specific data on influenza. These are published weekly for the province and have region specific data for nursing home outbreaks, sentinel physician activity and laboratory testing. 3. http://www.phac-aspc.gc.ca/fluwatch/index-eng.php Public Health Agency of Canada web page on influenza surveillance. Updated every two weeks, with data on laboratory results for respiratory virus identification, and influenza activity across Canada 4. www.oma.org/ Up to date information on influenza 5. http://www.phac-aspc.gc.ca/naci-ccni/ Current Canada Communicable Disease Reports (CCDR) 6. http://www.sanofipasteur.ca Sanofi Pasteur web page for flu product monograph 7. http://www.gsk.ca GlaxoSmithKline web page for flu product monograph 8. http://www.novartis.ca Novartis web page for flu product monograph 9. http://www.niagararegion.ca/living/health_wellness/disease-prevent/flu-clinicschedule Niagara Region – Public Health web page Niagara Region Public Health Outbreak Management 27 REVISED October 2012 ENTERIC OUTBREAK 2.1 SURVEILLANCE – LINE LISTING FORM See attached line listing forms, and sample on “Completing an Outbreak Line List”: LTCF – Respiratory/Enteric Acute Care – Respiratory/Enteric (Residents) Acute Care – Respiratory/Enteric (Staff) A surveillance system for enteric illness is an essential component of an institutional infection control program and will provide the necessary information on baseline rates and early recognition of an outbreak. Designated staff should initiate a line listing with details that include onset date, unit/floor location and sign/symptoms. Plotting cases on the institution’s floor plan is a useful tool for determining if, how and to what extent the illness is spreading within the facility. Designated staff should continue to maintain and update the line listing on a daily basis. Staff should provide updates to Niagara Region Public Health, Infectious Disease Program on a daily basis by fax. Staff is often reluctant to provide details about personal illness. This information is often critical to effective outbreak management. Symptomatic staff are also good candidates for submitting laboratory samples. Niagara Region Public Health Outbreak Management 28 REVISED October 2012 2.2 OUTBREAK DEFINITION An outbreak should be suspected anytime that illness exceeds the normal baseline distribution in a given area, at a given time. Reporting of enteric outbreaks is legislatively required under the Health Protection & Promotion Act (HPPA) from the following institutions: nursing homes, homes for the aged, acute and chronic care hospitals operating under the Public Hospital Act. Although not required under the HPPA, reporting of enteric outbreaks in retirement homes is strongly recommended. Suspect an enteric outbreak whenever there are a greater than expected number of cases of enteric illness occur on a given unit or throughout the facility among patients, residents, and staff. The decision as to whether an outbreak has occurred depends on the population and the usual frequency of the illness in the particular population. It is necessary to have relevant data on the incidence of enteric infections in the facility compiled regularly through ongoing surveillance. Determining if an outbreak exists: Compare rate of illness with baseline Check for any other causes of illness (i.e. Laxative Use) If cases are above the expected number and an alternate cause cannot be determined, an outbreak exists. All enteric outbreaks in institutions are reportable regardless of whether they are caused by: A reportable agent (e.g., salmonella, E.coli) A non-reportable agent (e.g., Norovirus) An unknown cause Niagara Region Public Health Outbreak Management 29 REVISED October 2012 (SAMPLE) OUTBREAK MANAGEMENT SUMMARY CHECKLIST CHECKLIST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Notify charge RN, Infection Control Practitioner or Director of Resident Care or Associate Director of Resident Care. For evenings and weekends, notify the manager on-call. Initiate a line listing of all symptomatic patients/residents/staff using the Public Health line list form. Notify Public Health, Infectious Disease Program 905-688-8248 ext. 7330 or after hours 905-984-3690. Have the following information available: Date of onset / signs and symptoms Total # of patients/residents/staff in unit or facility Total # of patients/residents/staff ill at present Total # of patients/residents/staff immunized against influenza (for upper respiratory outbreaks only) Enteric/nasopharyngeal swab kits on hand (check expiry date) Have Outbreak Management Manual available for reference. Obtain an outbreak number. Establish outbreak case definition. Implement outbreak control measures. Refer to Outbreak Management Manual for specific respiratory or enteric outbreak control measures. Place outbreak signs in appropriate areas: □ Front entrance □ Stairwells / Elevators □ Outbreak unit Cohort and isolate symptomatic patients/residents and place proper signage on door of room. Cohort staff. Collect and refrigerate nasopharyngeal swab or enteric specimens as directed by Public Health. Contact Infectious Disease Program for pickup. Notify: □ Medical Advisor/MRP physician for facility □ Administrator □ Housekeeping □ Dietary □ Pharmacy □ O.T., P.T., Recreation Therapy, Volunteer Co-ordinators □ Pastoral Care Notify other units of outbreak and heighten surveillance of ill patients/residents. Educate patients’/residents’ family members of limited visitation, adherence to outbreak control measures and appropriate use of PPE if needed. Fax the line listing daily to Public Health, Infectious Disease Program 905-682-6470. Niagara Region Public Health Outbreak Management 30 Nurse Initial REVISED October 2012 2.3 CASE DEFINITION Case definitions are outbreak specific and must be developed at the onset of each outbreak. A case definition for the outbreak will be developed on the initial call to the Public Health. The definition will be a collaborative effort of the Public Health staff and the Infection Control Professional or designate of the facility based on clinical manifestations. Initially a case definition should be general to all persons who could potentially have an enteric infection. As the outbreak progresses, the case definition can be revised to become more specific. For example, at the onset of the outbreak investigation, the case definition may read: “A resident/patient or staff member shall be considered a case if he/she exhibits the following symptoms: 2 or more bouts of nausea, vomiting, and/or diarrhea within a 24 hour period”. To be defined as a case within a gastroenteritis outbreak, at least one of the following must be met: Two or more episodes of loose/watery bowel movements (conforms to the shape of the container) within a 24-hour period, or two or more episodes of vomiting within a 24-hour period. OR One episode of loose/watery bowel movements (conforms to the shape of the container) and one episode of vomiting within a 24-hour period OR Laboratory confirmation of a known gastrointestinal pathogen and at least one symptom compatible with gastrointestinal infection – nausea, vomiting, diarrhea, abdominal pain or tenderness. Note: Consult with your Medical Director prior to collecting any specimen. Niagara Region Public Health Outbreak Management 31 REVISED October 2012 2.4 SPECIMEN COLLECTION Enteric Outbreak Kit Instructions for the collection and transportation of enteric specimens (faeces) Obtain Supplies, Complete Requisitions; and Label all Specimen Vials 1) Check expiry date, do not use expired kits. 2) Remove the specimen collection vial(s) from the biohazard bag. 3) Complete an “Enteric Disease Investigation Multiple Specimen Submission Form”. Include the outbreak number which is assigned by Niagara Region Public Health Department (NRPH). 4) On the main kit label located on the biohazard bag, fill in the required information with a pen (see example on reverse). Peel this label off of the bag and place this label on the completed submission form in the following areas; a) In the column marked “label” on the “Enteric Disease Investigation Multiple Specimen Submission Form” 5) Record on each vial used Patient/Resident Name (First & Last) Date of Birth (DOB) Outbreak # assigned by NRPH 6) Peel off 1 of the 4 corresponding kit numbered stickers located on the biohazard bag. Place 1 sticker on each vial used. **Important: If the patient/resident name and kit number sticker are not on each of the vials, the specimen will not be tested. Collect Specimen Faeces that have been in contact with water in toilet are unacceptable. 7) Using the spoon from each vial, select different sites of the faeces specimen, preferably blood, mucus or pus, and transfer to the vials as follows: a) Virology/Toxin (White capped vial which is empty) Add faeces up to the line indicated. Replace and tighten cap. b) Bacteriology (Green capped vial with red-coloured transport medium) Add 2-3 spoonfuls, mix into the transport medium. Replace and tighten cap. c) Parasitology (Yellow capped vial with clear liquid preservative) Add faeces up to the line indicated. Mix well. Replace and tighten cap. Transportation 8) Place all vials in the biohazard bag. Place the completed requisition in the outside pocket. Do not place the requisition inside the biohazard bag containing the specimens. 9) Refrigerate specimens immediately. Do not freeze specimens. 10) Call the Infectious Disease Program as soon as possible to pick up specimens. **See next page for Labelling Example Niagara Region Public Health Outbreak Management 32 REVISED October 2012 Labelling an Enteric Outbreak Kit Enter date specimen collected Enter case name & date of birth (DOB) Enter onset date of case symptoms Enter health card number Outbreak # 2246-201X-XXX Place one sticker on each vial used Niagara Region Public Health Outbreak Management 33 REVISED October 2012 Outbreak Number Provided by Niagara Region Public Health 2246-year-3digit number Your Facility Name Address Telephone/ Fax Number For Lab Use Only Affix Completed Main Kit Label Here Niagara Region Public Health Outbreak Management 34 REVISED October 2012 2.5 FOOD SAMPLING GUIDELINES The purpose of these guidelines is to provide a standardized method of collecting samples of hazardous and high risk foods from meals in institutional kitchens as a precaution in the event of a food-borne disease outbreak. They also ensure that the laboratory would receive samples of adequate quality and quantity. HAZARDOUS FOOD Is defined as “any food that is capable of supporting the growth pathogenic organisms or the production of the toxins of such organisms”. Such foods typically include milk, milk products, eggs, meat, poultry, fish and shellfish. For example: Breakfast: Eggs; scrambled or that have had additional handling and processing. Lunch/Supper: All entrees, sandwich fillings, all sauces, soups gravies; anything containing mayonnaise, salad dressing, i.e., potato, macaroni salad. Any dessert product containing milk, cream, whip cream topping. Vegetables combined with creamed sauces. Samples of each potentially hazardous and high risk foods should be taken at every meal and retained by the institution for a period of not less than 5 days. Foods that are further processed should also be sampled (i.e., pureed roast beef). Samples may be kept in the refrigerator or freezer. SIZE OF SAMPLE Solid Food- Minimum 100 grams. Liquid Food-Minimum 100 mL. CONTAINER Must be sanitized food containers or self-closing plastic bags. LABELLING Contents (i.e. pureed roast beef) Date of meal (i.e. February 25, 1992) Time of meal (i.e. 5:00 p.m.) Niagara Region Public Health Outbreak Management 35 REVISED October 2012 2.6 INFECTION PREVENTION AND CONTROL MEASURES Facilities that suspect they have an outbreak should implement initial outbreak control measures to prevent further spread of illness. Facilities should consider establishing an Outbreak Management Team and meet regularly including all representatives who have decision making authority in the facility. Members should include: Medical Advisor/Director Administrator Director of Nursing/Director of Resident Care Infection Control Officer/Infection Control Nurse Public Health Nurse/Public Health Inspector Housekeeping/Laundry Supervisor Food Services Supervisor Recreational Activities Supervisor The following infection prevention and control measures are recommendations for management of enteric outbreaks from Public Health. NOTE: For confirmed CDI outbreaks, not all control measures as outlined below may apply. Consult with Public Health for specific recommendations for control of CDI outbreaks in health care facilities. 1. Isolation of Symptomatic Cases Cases should be isolated in their rooms for 48 hours from the cessation of symptoms as long as this does not cause them mental or physical harm Implement contact precautions (i.e., post signs) http://ricn.on.ca/photos/custom/CSICNfiles/Contact%20STOP%20Sign_Front%20&%20Back.pdf Optimally, room isolation should be used but if this is not feasible, ward/unit isolation could be applied No restriction is required for asymptomatic roommates of cases, however as much as possible, restrict all residents to their units 2. Cohorting Residents/Staff Cohorting is defined as the grouping together of individuals in a specific area to limit the contact between infected cases and non-infected cases, in order to decrease opportunities for transmission of infectious agents If possible, exposed staff should remain caring for symptomatic cases on a daily basis and avoid transferring to another unit/floor during the outbreak Strict cohort nursing is not always possible when many staff are ill Allied health professionals (e.g., respiratory therapists, physiotherapists, occupational therapists, speech therapists, recreational therapists) should be cohorted to the outbreak unit where possible, or provide care on non-outbreak units before entering the outbreak unit (preferably on a one-on-one basis) 3. Hand Hygiene To facilitate staff and visitor hand hygiene, hand hygiene stations should be set up at designated areas in the facility (i.e., entrances, outside elevators, patient/resident care areas) Hand hygiene should be performed: o Before initial patient/resident or patient/resident environment contact o Before sterile procedures o After body fluid exposure risk Niagara Region Public Health Outbreak Management 36 REVISED October 2012 4. 5. 6. 7. 8. o After patient/resident or patient/resident environment contact Alcohol based hand rubs (ABHR) are the first choice for hand hygiene in clinical situations when hands are not visibly soiled. Using ABHRs is more effective than washing hands (even with an antibacterial soap) when hands are not visibly soiled. When visible soil is present and running water is not immediately available, use moistened towellettes followed by ABHR. Residents, staff and volunteers should be instructed in proper hand hygiene to facilitate staff and visitor hand hygiene. Refer to Appendix: “Hand Hygiene using Hand Rubs” Gowning/Gloving if Contact with Contaminated Material is likely The use of gowns and gloves is recommended for direct patient care of ill residents during an outbreak to prevent transmission of organisms Visitors do not need to wear gloves or gowns if they are visiting one resident only; however, if providing direct resident care to an ill resident they should be encouraged to wear a gown and gloves and should be asked to wash their hands before and after the visit. Refer to Appendix “Sequence for Donning and Removing Personal Protective Equipment.” Enhanced Environmental Cleaning/Sanitizing Ensure cleaning and sanitizing of environmental surfaces frequently contaminated by residents/staff (i.e. hand rails, door knobs, bathroom units, furniture) Ensure a process for proper disposal of contaminated materials Cleansing and sanitizing methods should be reviewed by Public Health Inspector Disposable dishes and cutlery are not required Refer to: PIDAC Best Practices for Environmental Cleaning for Prevention and Control of Infections and Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices Exclusion of Symptomatic Staff from Work/Facility Staff who meet case definition are excluded from the facility until they have been 48 hours symptom free (i.e. food handlers, health care workers including volunteers and students) Limited Visiting Signs should be posted in the facility indicating that there is an outbreak and visitors should be warned that they may be at risk of acquiring infection within the facility During an outbreak, visitors should visit only their own friend/relative, in their own room (not in a common area), and should be encouraged to wash their hands before and after the visit at hand hygiene stations in the facility Public Health does not recommend closing the facility to visitors/volunteers. Only in the case of extremely virulent disease would the Medical Officer of Health order the facility to be closed to the public. See Appendix: What You Need to Know About Outbreaks. Suspension of Social Activities As much as possible, restrict activities to their respective units. The Outbreak Management Team must find a balance between restricting activities and to control the spread of infection and providing therapeutic opportunities from social activities. Niagara Region Public Health Outbreak Management 37 REVISED October 2012 Visitation by outside groups, e.g., entertainers, meetings, community groups, etc., is not recommended. Also, visitation of multiple residents is not recommended. Onsite adult and childcare programs may continue provided there is no interaction between residents and participants of the program. 9. Restrict New Admissions, Re-Admissions and Transfers Restricting admissions unnecessarily will create a backlog in acute care or other community facilities; on the other hand, admitting persons who are susceptible into an outbreak situation poses a risk to their health Residents can be transferred from the outbreak facility to a hospital with prior notification to Hospital Infection Control Officer or designate Residents admitted from the outbreak facility to hospital with enteric illness can be re-admitted to the LTCF at any time, provided that appropriate care can be given. New admissions (from community), residents admitted to hospital prior to the outbreak, or admitted to hospital for reasons other than enteric illness may be admitted/re-admitted to the LTCF if the following conditions are met: (a) the resident or substitute decision-maker has been informed of the outbreak status and provided consent; (b) the residents physician has been informed of the outbreak status and provided consent (taking into consideration the severity of the particular outbreak relative to the residents condition) Resident transfers from anywhere in the facility to another Long Term Care facility is not recommended during an outbreak. Possible exception of this recommendation should be discussed with the Medical Officer of Health on an individual basis. 10. Advise Hospital Infection Control Staff of Outbreak Prior to Transferring a Resident Prior to transfer of residents to hospital, designated staff at the outbreak facility should contact the Infection Control Professional directly by phone to inform them that the resident is coming from an outbreak situation Inform them of the outbreak, the pathogen if known, and if the resident is symptomatic or not 11. Working at Other Facilities During enteric outbreaks, staff/volunteers should not work at any other facility. If asymptomatic staff chooses to work at another facility, they must wait one incubation period (i.e. 48 hours) after working the last shift at the outbreak facility (if the causative organism is known, the waiting period may differ). Staff working at 2 facilities must inform the receiving DOC (Director of Care) or designate at the non-outbreak facility. 12. Medical Appointments Non-urgent appointments made before the outbreak shall be rescheduled. Niagara Region Public Health Outbreak Management 38 REVISED October 2012 ENTERIC OUTBREAK CONTROL MEASURES The following control measures are in force until further notice: Isolation of symptomatic cases Cohorting residents/staff Hand Hygiene Gowning/gloving if contact with contaminated material is likely Enhance environmental cleaning and sanitizing Exclusion of symptomatic staff from work Limited visiting Suspension of social activities Restrict new admissions, re-admissions & transfers Advise Hospital Infection Control Staff of the outbreak prior to transferring a resident/patient No food from outside sources Staff/volunteers should not work at another health care facility Niagara Region Public Health Outbreak Management 39 REVISED October 2012 2.7 DECLARING OVER The Medical Officer of Health or designate, in collaboration with the Outbreak Management Team determine when to declare an outbreak over, taking into consideration the enteric organism causing the outbreak. An outbreak of unknown etiology where the symptoms are consistent with a viral illness can be declared over 48 hours from the cessation of symptoms of the last resident case. Niagara Region Public Health Outbreak Management 40 REVISED October 2012 2.8 ENTERIC OUTBREAK ASSOCIATED ORGANISMS: A Reference Chart For Health Care Workers ORGANISM SYMPTOMS MODE OF TRANSMISSION INCUBATION Gastrointestinal (diarrhea) Fecal-oral route 3 to 10 days Diarrhea, abdominal cramps, fever may occur Fecal-oral route Unknown PERIOD OF COMMUNICABILITY DIAGNOSIS Most communicable during the Stool specimen first few days of an acute illness Adenovirus Contact with contaminated environmental surfaces Clostridium difficile Symptoms characteristically last 24 to 48 hours Probably by the fecal-oral route 24 to 72 hours During the acute stage of disease and up to 48 hours after Norwalk diarrhea stops Stool specimens 24 to 72 hours During the acute stage of disease, and later while virus shedding continues Stool specimens Contaminated food or water Exposure to contaminated surfaces and vomitus Vomiting, fever, and watery diarrhea (severe) Rotavirus Stool specimen from patient/resident with diarrhea *Rectal swabs are not accepted and will not be tested Diarrhea, nausea, vomiting, cramps, headache, fever, chills, malaise Norovirus/ Norwalk-like Virus Until formed stools Symptoms last for an average of 4 to 6 days Probably fecal-oral with possible contact or respiratory spread Virus is not usually detectable after the eighth day of infection **Most common in daycare outbreaks ____________________________________________________________41________________________________________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management APPENDIX _____________________________________42_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________43_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________44_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________45_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________46_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________47_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management _____________________________________48_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management SAMPLE TRANSFER LETTER Please be advised that _______________________________ is being transferred from a Name of Resident Facility where there is as suspected OR confirmed influenza outbreak. Please ensure that appropriate isolation precautions are taken upon receipt of this resident. At the time of transfer, this resident was confirmed OR suspected OR appears free of influenza. Resident is on antiviral medication ________________________ starting on ___________________. Dose of the medication ___________________ Resident’s vaccination status is: pneumococcal yes______ Influenza yes______ no ______ no ______ For further information, contact _______________________, Infection Control Name of Infection Control Practitioner Professional at __________________________________________ Name of Facility at ____ ____- ___________ Phone Number _____________________________________49_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management SAMPLE LETTER TO PHYSICIANS Dear Doctor ______________________ (staff member’s name) is an employee currently working in a Long Term Care Facility that has a confirmed Influenza A/B outbreak. It is recommended that the employee receive antiviral prophylaxis before returning to work. The recommended antiviral medications of choice for prophylaxis during influenza outbreaks is: Oseltamivir (Tamiflu™) 75mg. daily x 14 days or until outbreak is declared over OR Zanamivir (Relenza™) Two 5 mg inhalations (10 mg) once daily for a minimum of 2 weeks or until the outbreak is declared over If you have any questions, please contact Niagara Region Public Health, Infectious Disease Program at 905-688-8248 ext 7330. _____________________________________50_______________________________________________ Niagara Region Public Health REVISED October 2012 Outbreak Management