Guidelines for the Prevention and Control of Influenza Outbreaks in Residential Care Facilities for Public Health Units in Australia
4.6 Outbreak control measures
These measures should be discussed with the facility and, if necessary, a copy of this section can be provided. Note that these are recommendations only, and may need to be varied according to the circumstances within each facility. However, proposed changes should be discussed by the PHU and the facility representative.
4.6.1 Non-pharmacological control measures for residents
Restriction of cases to their roomsRestrict ill residents to their rooms until 5 days after the onset of acute illness or until symptoms have completely resolved (whichever is shorter).
Restriction of residents to their unitIf the outbreak is confined to one unit, all residents from that unit should avoid contact with residents in the other units of the facility.
Admissions and re-admissions
New AdmissionsAdmissions of new residents during the outbreak are generally not recommended.
Return of cases from hospitalThe return from hospital of residents who met the case definition is permitted provided appropriate care can be provided.
Return of non-cases from hospitalThe return of residents who are not known cases is generally not recommended during an outbreak, unless measures can be enforced to prevent transmission. Factors to be considered include:
Medical appointmentsConsider rescheduling of non-urgent medical appointments made before the outbreak.
Transfer to hospitalWhen a resident is transferred to a hospital from a facility experiencing an outbreak, the facility should advise the hospital infection control practitioner in advance and provide details of the outbreak. This will ensure respiratory outbreak control measures are in place when the resident arrives at the hospital. Before a resident is transferred out of the facility, the facility should complete an “Outbreak Transfer Notification Form” (Appendix 9) and this form should be sent with the resident’s file to the hospital.
Transfer to another long-term care facilityResident transfers (from anywhere in the facility) to another facility are not recommended during an outbreak.
Communal meetingsRestrict all residents to their units as much as possible. The facility OIMT representative and the PHU should discuss restriction of activities, revisiting the issue as the outbreak progresses.
4.6.2 Non-pharmacological control measures for staff and volunteers
Reporting of respiratory illnessStaff/volunteers should report any respiratory illness to the facility OIMT representative.
Exclusion of staff and volunteersAll staff or volunteers with respiratory symptoms (even if they are vaccinated or taking antiviral medication) should be excluded from work for 5 days from the onset of symptoms or until symptoms have resolved, whichever is shorter.
Working at other facilitiesStaff experiencing respiratory symptoms or fever should not work in any health care setting.
During an influenza outbreak
Cohort staffingAttempts should be made to minimise movement of staff between floors/wings of the facility, especially if some units are unaffected. Discuss the possibility of one staff member (or group of staff) looking after only ill residents and others looking after only well residents. These measures should not be required during influenza outbreaks where all staff have been vaccinated and the current vaccine covers the circulating strain, or when staff are taking appropriate antiviral drug therapy.
Exclusion of unimmunised staffDuring a confirmed influenza outbreak, it is recommended that only immunised staff should be working in the outbreak facility. Asymptomatic unimmunised staff can work at the affected facility if they are receiving appropriate antiviral prophylaxis, but all staff should be vaccinated unless there are contraindications.
Hand washingDirect contact with respiratory secretions is the main source of transmission of influenza virus, and the virus can also be transmitted by contact with contaminated fomites. Effective hand washing will interrupt transmission of the disease. Facility staff should employ good hand washing/hand disinfection before and after providing care to both ill and well residents (see section 2.2). Appropriate techniques and disinfectants can be recommended during site visit and infection control audit.
MasksMasks should be worn while providing care and removed and discarded before providing care to another resident and on exiting the room. Hands should be washed or disinfected immediately after removing the mask. P2 (N95) masks, properly tested and fitted, are preferable, but if not available surgical masks can be used.
4.6.3 Control measures for visitors
Notification of visitorsThe facility should post a “Visitor Restriction Sign” (Appendix 10) at all entrances to the facility, indicating there is an outbreak at the institution. Visitors should be advised of the potential risk of acquiring illness within the facility and of the visiting restrictions as indicated below. The next of kin / guardian of ill residents should be contacted and advised of the illness in their relative, and other frequent visitors could also be advised.
Total cessation of visitation is not usually justifiable. Visitation restrictions should be discussed by the OIMT.
Visitor restrictionsIll visitors should not be permitted into the facility. Visitors should be advised not to enter the facility if they do not wish to become exposed to the virus. Visitors who choose to visit during an outbreak should be advised to visit only the resident they have come to see.
Visitation by groups should not be permitted. Visits to multiple residents should be restricted. If a visitor develops a respiratory illness after visiting the facility, they should notify the facility and should not be permitted in the facility. The PHU should be notified of the illness if an influenza diagnosis is made so that it can be investigated as part of the outbreak.
Visiting ill residentsA “Visitor Restriction Sign” (Appendix 11) should be placed on the door of the rooms of ill residents or in other visible locations advising all visitors to check at the nursing station before entering the room. Visitors are to be advised of the following:
4.6.4 Environmental cleaningThorough and frequent cleaning of objects that are in high traffic areas should be reinforced during an outbreak. These objects include all washrooms, handrails, tables, doorknobs, lift buttons, etc. Ensure that the chemical concentration of disinfectants is appropriate and solutions made-up frequently (Appendix 1).
4.6.5 Influenza vaccinationDuring influenza outbreaks, influenza vaccine should be offered to all unvaccinated residents, staff members, and recommended for unvaccinated visitors and volunteers. It takes approximately two weeks for a protective immune response to develop.
Vaccination of staff, volunteers and visitors may occur at the facility, as long as there is a health professional present who is trained in immunisation and the activity complies with relevant state/territory legislation. Alternatively, staff, volunteers, and visitors may be directed to a local GP or their own GP for vaccination.
4.6.6 Antiviral medicationIn Australia, three antivirals are registered for use against influenza: amantadine, oseltamivir, and zanamavir (Appendix 12). All may be active against influenza A, but only oseltamivir and zanamivir are effective against influenza B. The decision to use antivirals for treatment is a matter for the patient’s doctor, who should consult an infectious diseases physician if necessary.
Antivirals have been recommended for use in the management of influenza outbreaks in residential care facilities.2, 5 Prophylactic use is recommended for all RCF residents who have not had laboratory confirmed influenza until the outbreak is declared over. Antivirals are also recommended for all unvaccinated staff, or for all staff (regardless of vaccination status) if the outbreak is caused by a strain of influenza virus that is not well-matched by the current vaccine, if this is known (except staff who have had laboratory confirmed influenza). The decision to use antivirals for prophylaxis will be guided by the PHU. Antivirals are currently not included in the Schedule of Pharmaceutical Benefits for the treatment or prophylaxis of influenza, but can be obtained on prescription from a community pharmacy or, in the event of local shortages, direct from the distributors.
To minimise the risk of antiviral resistance emerging during influenza outbreaks in RCFs, measures should be taken to minimize contact between persons taking antivirals for treatment and those taking antivirals for prophylaxis. Where contact is unavoidable (e.g., patient care by staff), infection control measures must be strictly enforced.
Comparison between the three currently licensed antivirals in Australia (Appendix 12) suggests that oseltamivir may be the most suitable drug for chemoprophylaxis of residents during RCF influenza outbreaks, although amantadine (only for influenza A outbreaks) and zanamivir may be considered for staff.
The conditions under which antivirals are most likely to be effective in the control of an influenza outbreak in a RCF are: