Influenza Outbreak

Reporting, Response, and

CDPH Guidelines

Long Term Care Facility

Influenza Symposium

November 6, 2018

LEARNING OBJECTIVES

❑ Explain when and why an influenza outbreak at a long-

term care facility (LTCF) is reportable to Public Health

❑ List at least five immediate control measures that should

be implemented when an influenza outbreak is detected

at an LTCF

❑ Explain the importance of antiviral treatment of the ill

and antiviral prophylaxis of the well when an influenza

outbreak is detected at an LTCF

OLDER ADULTS AT RISK

OLDER ADULTS AT RISK

WHY ARE FLU OUTBREAKS IN LTCFSREPORTABLE TO PUBLIC HEALTH?

▪ Outbreaks in long term care facilities have the

potential to affect a large number of residents

▪ Residents of long term care facilities are

vulnerable to severe influenza outcomes,

including hospitalization and death

▪ Appropriate and timely control measures can

mitigate the impact of influenza in these facilities

WHY ARE FLU OUTBREAKS IN LTCFSREPORTABLE TO PUBLIC HEALTH?

▪ Some facilities may not be aware of CDC and

CDPH influenza outbreak control

recommendations and/or may need assistance

▪ Reporting suspect and confirmed influenza

outbreaks in LTCFs enable public health

officials to monitor, prepare for, and better

respond to influenza outbreaks in these high

risk settings

INFLUENZA OUTBREAKS IN SAN DIEGO COUNTY, 2017-2018

OUTBREAKS 2012-2017

0

10

20

30

40

50

60

July August September October November December January February March April May June

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Ou

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Confirmed Influenza Outbreaks by Month of Report,County of San Diego, Fiscal Years 2012-2017

FY12-13 FY13-14 FY14-15 FY15-16 FY16-17 FY17-18

OUTBREAKS 2012-2017

39

17

79

15

34

117

0

20

40

60

80

100

120

FY12-13 FY13-14 FY14-15 FY15-16 FY16-17 FY17-18

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Confirmed Influenza OutbreaksCounty of San Diego, Fiscal Years 2012-2017

OUTBREAKS 2012-2017

554

362

1101

134

774

1660

0

200

400

600

800

1000

1200

1400

1600

1800

FY12-13 FY13-14 FY14-15 FY15-16 FY16-17 FY17-18

Tota

l Cas

es

Outbreak-Associated Influenza Cases,County of San Diego, Fiscal Years 2012-2017

OUTBREAKS 2012-2017

109

47

204

23

119

406

9 523

518

43

0

50

100

150

200

250

300

350

400

450

FY12-13 FY13-14 FY14-15 FY15-16 FY16-17 FY17-18

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Outbreak-Associated Hospitalizations and Deaths,

County of San Diego, Fiscal Years 2012-2017

Hospitalizations Deaths

OUTBREAK-ASSOCIATED DEATHSFY 2017-2018

Number of Deaths

Number of Outbreaks

Percentage of Outbreaks

0 78 66.7%

1 36 30.8%

2 2 1.7%

3 1 0.9%

TOTAL 117

▪ Influenza outbreaks in institutions/congregate living settings

reportable to public health if there is:

• At least one case of laboratory-confirmed influenza

in the setting of a cluster (>=2 cases) of influenza-

like illness (ILI) within a 72-hour period.

▪ Institutions/congregate living settings include long-term

health care settings (licensed by CDPH L&C), assisted and

independent living facilities, drug/alcohol rehab centers,

prisons/jails, overnight camps, university dormitories, etc.

INFLUENZA OUTBREAK REPORTING 2017-2018

• ILI is defined as fever (≥100°F or 37.8°C) plus

cough and/or sore throat, in the absence of a

known cause other than influenza.

• Symptoms may also include chills, headache,

myalgia, or runny nose

• Atypical presentation (e.g., lack of fever) may

occur with the elderly, as well as children with

neuromuscular disorders, and young infants

INFLUENZA-LIKE ILLNESS (ILI)

How should LTCFs report flu outbreaks?

Phone (Mon-Fri 8-5): 619-692-8499

After hours/holidays/weekends: 858-565-5255

Epidemiology ProgramEpidemiology and Immunization Services Branch (EISB)

County of San Diego Health and Human Services Agency

INFLUENZA OUTBREAK REPORTING

What information should a facility be

prepared to provide?

❑ Residents and staff with ILI

❑ Confirmed cases

❑ Hospitalizations

❑ Deaths

❑ Onset dates for first ill resident and first ill staff

❑ Any geographic clustering observed in facility

❑ CA Licensing & Certification notified

INFLUENZA OUTBREAK REPORTING

OUTBREAK INTAKE AND ASSESSMENT

OUTBREAK MANAGEMENT

LTCF staff manages the outbreak

Public health staff provides assistance including:

▪ Laboratory testing at SDC PHL as needed

▪Follow-up e-mail with reminders, links, tools,

other resources

▪Answer questions (have access to local, CDPH,

and CDC subject matter experts)

▪Report outbreak to CDPH as required

OUTBREAK MANAGEMENT

• Positive lab reports for confirmed cases will be requested (public health staff can assist by requesting results from diagnostic laboratories)

• Public health will request diagnostic laboratories forward positive outbreak-associated specimens to SDC PHL for further testing

• A case log should be used (template provided) to track cases; copy will be requested at end of outbreak

• Notification will be requested if:

• Outbreak-associated death• Sudden increase in cases or hospitalizations

OUTBREAK CASE LOG

SUMMARY OF CONTROL

MEASURES

CDPH Guidelines

ALL FACILITIES LETTER (AFL)

RETURNING RESIDENTS WITH FLU

▪ Ensure that new or returning residents with acute

respiratory illness be medically evaluated before

admission or transfer to determine appropriate placement.

▪ A returning resident who was hospitalized with influenza

and is clinically appropriate for discharge from the acute

care facility is past the acute phase of illness although

may still need to be on droplet precautions.

▪ Hospitalized patients with influenza should be

discharged when clinically appropriate, not based on the

period of potential virus shedding or recommended

duration of droplet precautions.

POSTPONING NEW ADMISSIONS

▪ The duration of limitations on admissions should be

determined on a case by-case basis in consultation with

the LHD.

▪ Considerations may include appropriate implementation

of control measures including chemoprophylaxis of non-

ill residents, and the identification of no additional cases

during active surveillance.

▪ Prolonged closures to all admissions might not be

necessary if transmission appears to be controlled and

there are unaffected units available where new

admissions could be placed.

CDPH GUIDANCE

▪ Reformatted into tables that can be used as stand-alone

documents and checklists to improve user friendliness

▪ Specific guidance for having an influenza prevention plan

prior to the flu season (Oct 1-Mar 31), and evaluation of the

plan post-season

▪ CDPH now recommends a 6-foot distance between

patients with influenza in multi-bed rooms (vs. 3-foot

distance recommended by CDPH in January 2018)

▪ Health care personnel should wear a facemask when

within 6 feet of a patient with suspected or confirmed flu

CDPH GUIDANCE - OCTOBER 2018

CDPH GUIDANCE - OCTOBER 2018

https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/LTCF_PreventingHAI.aspx

CDPH GUIDANCE - OCTOBER 2018

CDPH GUIDANCE - OCTOBER 2018

CDPH GUIDANCE - OCTOBER 2018

ACTION RECOMMENDATIONS

1. Perform active surveillance for

respiratory illness in residents and HCP

During flu season (Oct 1- Mar 31);

conduct daily active surveillance for acute

upper respiratory illness and pneumonia

among residents and HCP; use case log

2. Use diagnostic testing for influenza Test residents with suspected flu to

confirm diagnosis

3. Establish presence of an outbreak At least 2 residents with onset of ILI within

72 hours of each other AND at least 1

resident has lab-confirmed flu; RIDT

results should be confirmed by PCR

4. Communicate HCP, local health department (us!),

CDPH L&C, residents, family, visitors

5. Implement appropriate transmission-

based precautions and other infection

control measures

Single-bed room for cases; otherwise

cohort ill w/spatial separation of at least 6

feet w/privacy curtain; enhanced standard

and droplet precautions for 7 days after

onset or 24 hours after fever/respiratory

symptoms resolve, whichever is longer

CDPH GUIDANCE - OCTOBER 2018

ACTION RECOMMENDATIONS

6 . Treat with antiviral agents as

recommended

Treat all confirmed or suspected cases with

currently recommended antiviral medication

as soon as possible and ideally within 48

hours of onset; do NOT wait for confirmatory

test results

7. Administer antiviral

chemoprophylaxis as recommended

Administer to all non-ill residents, regardless

of vaccination status; priority to roommates

and residents on same floor or unit as other

recent cases

8. Define process for accepting and

transferring residents

Medically evaluate new or returning

residents with ARI to determine room

placement and infection control precautions;

develop plan to implement droplet

precautions for returning hospitalized

residents with influenza

9. Manage visitors Screen for/exclude visitors with acute

respiratory illness; encourage visitor

vaccination and respiratory

hygiene/etiquette; facemasks when visiting

residents on droplet precautions

CDPH GUIDANCE - OCTOBER 2018

ACTION RECOMMENDATIONS

10. Review vaccine records

▪ Influenza vaccine (residents, HCP)

▪ Pneumococcal vaccine (residents)

Encourage vaccination among residents

and HCP who declined previously

11. Determine end of outbreak Outbreak can be considered over when 1

week has passed with no new onsets of

ILI (CDPH says after last confirmed case

of influenza)

12. Perform assessment of outbreak

control measures

▪ Successful strategies

▪ Barriers

▪ Lessons learned

▪ Needs for the following season

Evaluate outbreak control processes and

experiences; obtain feedback from HCP,

residents, families/visitors

▪ Influenza antiviral prescription drugs can be used to treat influenza

or to prevent influenza.

▪ Clinical trials and observational data show that early antiviral

treatment can shorten the duration of fever and illness symptoms,

and may reduce the risk of complications from influenza.

▪ Early treatment of hospitalized adult influenza patients has

been reported to reduce death.

▪ Clinical benefit is greatest when antiviral treatment is

administered early, especially within 48 hours of influenza

illness onset.

▪ For institutional outbreak management, antiviral chemoprophylaxis

should be administered for a minimum of two weeks, and continue

for at least seven days after the last known case was identified.

ANTIVIRAL TREATMENT AND CHEMOPROPHYLAXIS

ADDITIONAL RESOURCES

Centers for Disease Control and Prevention (CDC) Guidance

http://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-

guidance.htm

California Department of Public Health (CDPH) Guidance

https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/LTCF_Preventing

HAI.aspx

County of San Diego, Epidemiology Program

http://sdepi.org

CONCLUSIONS

▪ Appropriate and timely control measures can

mitigate the potentially severe impact of

influenza on residents in long-term care facilities

▪ Outbreak reporting to public health helps ensure

facilities have the support needed to respond

while providing important flu surveillance data

▪ Updated CDPH guidance is now available as

stand-alone documents and checklists; these

tools should be used in preparation for and

response to influenza outbreaks in LTCFs

CONTACT INFORMATION

Epidemiology ProgramEpidemiology and Immunization Services Branch (EISB)

County of San Diego, Health and Human Services Agency

Phone: 619-692-8499

After Hours: 858-565-5255Secure Fax: 858-715-6458

Website: sdepi.org

Questions?