UPDATE ON CURRENT INFECTION CONTROL PRACTICES FOR LTCF

1. UPDATE ON CURRENT INFECTION CONTROL PRACTICES FOR LTCF Karen Hoffmann, RN, MS, CIC Associate Director Statewide Program for Infection Control and Epidemiology (SPICE) UNC School of Medicine - Chapel Hill www.unc.edu/depts/spice/

2. Topics • H1N1 Influenza Outbreak • Best Practices – Glucometers • Isolation Precaution Guidelines • Questions and Answers (Regulatory Focus Bulletin)

3. Objectives for lecture • Describe and compare Novel H1N1 and Seasonal flu epidemiology • List current prevention strategies for Pandemic Flu Control in LTCFs www.unc.edu/depts/spice/

4. Novel H1N1 Influenza 2009 • Influenza • upper respiratory tract infection • Winter-time human illness • Fever, myalgias, respiratory symptoms • incubation: 1 to 7 days • Transmitted by large droplet or direct contact • Infectious 1 day before first signs or symptoms appear

5. More about Influenza • Seasonal Influenza • 25-70% attack rate in LTCFs • 10% case fatality rate in LTCFs • Approximately 36,000 die annually • H1N1 strain circulating now • April 21, 2009: CDC announced isolation of new Influenza strain • Virulence comparable to seasonal flu • Swine origin – new strain to humans (bird, pig, man)

6. Structure and Nomenclature of the Influenza Virus Hemagglutinin (HA) Neuraminidase (NA) M2 Nucleoprotein (NP) M1 Polymerase (P) Proteins A/human/H1N1/Sydney A/human/H3N2/California B/human/Victoria Adapted from: Hayden FG et al. Clin Virol. 1997:911-42.

7. Yearly Flu Mortality“U-shape”

8. Pandemic Flu Mortality“W-shape”

9. H1N1 Flu Outbreak 2009 National Case Update from CDC • 3352 confirmed cases of Novel H1N1 in US • 45 states reporting cases • 2 confirmed deaths in Texas, 1 in Washington state (as of May 13, 2009, http://www.cdc.gov)

10. Interim Guidance on Prevention of Novel H1N1 Influenza Virus Infections in Long-Term Care Facilities

12. Review facility pandemic influenza plan and implement a syndromic surveillance plan • Screen all people arriving at the facility for illness • Do not admit a new resident to the LTCF if there is a history of febrile respiratory illness (fever greater than 100.4°F or 37.8° C plus one or more of the following: rhinorrhea or nasal congestion; sore throat; cough) until 7 days after the onset of their illness or 24 hours after their acute symptoms have resolved, whichever is longer. • Review residents’ immunization status for seasonal influenza and pneumococcal vaccines. Review employee seasonal influenza immunization status

13. Review facility pandemic influenza plan and implement a syndromic surveillance plan (cont’d) • Clinicians should maintain a high index of suspicion for influenza. If suspected, a nasopharyngeal swab should be obtained for influenza testing before initiating antiviral or antimicrobial treatment. Elderly may not always have fever but may have other symptoms including severe debilitating fatigue, aches and pains, headache, and chest discomfort. Treatment should not be deferred while awaiting laboratory results.

14. Isolation Precautions • Immediately place residents who develop febrile respiratory on contact isolation precautions with eye protection • the room door should remain closed except for access • residents should be discouraged from participating in group activities • roommate should be considered “exposed” and not moved

15. Isolation Precautions (cont’d) • Residents with known or suspected influenza should be managed in place with healthcare workers (HCWs) using the most protective available personal protective equipment. If N95 respirators are not available, use a tight fitting surgical mask while proceeding to acquire N95 respirators.

16. Isolation Precautions (cont’d) • Transfer of residents with known or suspected influenza to other facilities should be based on their clinical condition, not on their need for isolation alone. If transfer is required, notify the receiving facility and personnel involved with transport in advance so appropriate precautions can be taken.

17. Communication Plan • Maintain close communication between long-term care facilities, acute-care facilities, and local emergency medical services to ensure that transfers are not admitted with unrecognized febrile respiratory illness. • Determine that key points of contact outside the facility have been identified (e.g., local public health department).

18. Occupational Health • Consider implementing daily self-screening of personnel for symptoms of febrile respiratory illness (fever >100.4°F or 37.8°C plus one or more symptoms of flu • Instruct those who develop fever not to report to work, or if at work, to cease patient care activities and immediately notify their supervisors and infection control personnel • If sent home, they should not report to work at a second job.

19. Control of Outbreaks • In the event of an outbreak of acute febrile respiratory illness notify your local health department and follow the recommendations at this website: • www.cdc.gov/h1n1flu/guidelines_infection control.htm • recommended that ill patients be treated with oseltamivir or zanamivir • chemoprophylaxis with either oseltamivir or zanamivir be started as early as possible • chemoprophylaxis should be administered to all non-ill residents and should continue for a minimum of 2 weeks

20. Control of Outbreaks (cont’d) In addition to antiviral medications, other outbreak-control measures include: • appropriate infection control • establishing cohorts of patients with confirmed or suspected influenza • restricting staff movement between wards or buildings • restricting contact between ill staff or visitors and patients • active surveillance for new cases.

21. Control of Outbreaks (cont’d) • Medical directors of long-term care facilities should review their plans for outbreak control of influenza. Additional guidance for infection control measures in long-term care facilities can be found at: • www.cdc.gov/flu/professionals/infectioncontrol/institutions.htm

22. Respiratory Hygiene/Cough Etiquette Post visual alerts at the entrance to facilities instructing visitors and staff to practice respiratory hygiene and cough etiquette (sign is downloadable at: www.unc.edu/depts/spice/flu.html)

23. Hand hygiene with soap and water OR ABHR is essential to prevent spread of influenza

24. Respiratory Protection: Masks or N95 Respirators? • Seasonal Flu – CDC recommends surgical masks • Pandemic flu – WHO recommends • Surgical masks for routine care • N95 for aerosol generating procedures (fit-testing required by OSHA) • Pandemic flu – CDC/HHS recommends • N95 for close contact (< 6 feet), aerosol generating procedures or entering room of suspected or known in-patient

25. Respirators vs. Surgical Masks • Alternative to N95 respirator • Reusable PAPR (NOISH certified) • Can be used without fit-testing • OSHA requires respirator protection program for N95 • Medical evaluation, fit-testing and training • Facilities may make N95 respirators available on voluntary basis, only requirement is to provide copy of OSHA’s Appendix D, 1910.134

26. Summary of Effective Ways to Prevent Influenza in LTC facilities • Staff do not come to work while they are ill • Staff and LTC residents are vaccinated against seasonal influenza • Visitors do not enter the facility while they are ill • All staff, visitors and residents practice good hand hygiene and respiratory etiquette

27. WHAT NOT TO DO!

28. Best PracticesGlucometers Presentation by Karen K. Hoffmann Statewide Program for Infection Control and Epidemiology (SPICE) UNC School of Medicine

36. Recommended practices for preventing patient-to-patient transmission of hepatitis viruses from diabetes care procedures in long-term-care settings From the CDC, MMWR Weekly March 11, 2005 • Prepare medications such as insulin in a centralized medication area; multidose insulin vials should be assigned to individual patients and labeled appropriately.

37. CDC Recommended Practices (cont) • Wear gloves during fingerstick blood glucose monitoring, administration of insulin. • Change gloves between patient contacts and after every procedure that involves potential exposure to blood or body fluids, including fingerstick blood sampling.

38. CDC Recommended Practices (cont) • Store individual patient supplies and equipment, such as fingerstick devices and glucometers, within patient rooms when possible. • Keep trays or carts used to deliver medications or supplies to individual patients outside patient rooms. Do not carry supplies and medications in pockets.

39. CDC Recommended Practices (cont) • Consider using single-use lancets that permanently retract upon puncture. • Assign separate glucometers to individual patients. If a glucometer used for one patient must be reused for another patient, the device must be cleaned and disinfected.

40. Recommendations for Cleaning and Disinfection of Glucometers(SPICE) • Clean glucometer surface when visible blood or bloody fluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material.

41. Recommendations for Cleaning and Disinfection of Glucometers(SPICE) cont. • If no visible organic material is present, disinfect after each use the exterior surfaces following the manufacturer’s directions using a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal or HBV/HIV label claim, or a dilute bleach solution of 1:10 (one part bleach to 9 parts water) to 1:100 concentration.

42. Recommendations for Cleaning and Disinfection of Glucometers(SPICE) cont. • There is at least one manufacturer (Alcavis) that makes a both a 1:50 and a 1:100 concentration of bleach-only disinfecting wipe for environmental surface disinfection.

43. Recommendations for Cleaning and Disinfection of Glucometers (SPICE) - Additional Information • Directions for glucometer disinfection vary between manufacturers and models within brands. Alcohol should never be used because it can damage the light emitting diodes (LED) readout, causing “fogging” of the plastic screens. Alcohol is also not an EPA-registered detergent/disinfectant.

44. Recommendations for Cleaning and Disinfection of Glucometers(SPICE) - Additional Information • Many manufacturers do not recommend the use of quaternary ammonium compounds because of the corroding effects on metal parts. This includes products that combine bleach with detergents or disinfectants.

45. Recommendations for Cleaning and Disinfection of Glucometers(SPICE) - Additional Information • All manufacturers caution that having the cloth too saturated could allow liquid to get inside the glucometer and cause damage. Screens and ports currently are not sealed on these devices. Therefore, using a bleach-only disinfecting wipe is less likely to cause damage.

46. CDC 2007 HICPAC Isolation Guideline:Revision Karen K. Hoffmann, RN, MS, CICAssociate DirectorStatewide Program for Infection Control and Epidemiology (SPICE)919-966-3242

47. History of Infection Control Precautions in the United States 1970 • CDC “Isolation Techniques for use in Hospitals”, 1st Edition • Six Categories of Isolation

48. History of Infection ControlPrecautions in the United States • 1975 CDC “Isolation Techniques for Use in Hospitals”, 2ND Edition, color- coded sample category door signs • 1983 CDC Guideline for Isolation Precautions in Hospitals (Disease-specific and category-based precautions including blood and body-fluids) • 1985 Universal Precautions • 1987 Body Substance Isolation (Mostly focused on worker protection)

49. CDC 1975

50. History of Infection ControlPrecautions in the United States • 1996 Publication of CDC/HICPAC revised guidelines - Introduced Standard Precautions and kept 3 categories of transmission based precautions • 2007 Revision CDC HICPAC Guideline for Isolation Precaution - Broaden to include all healthcare settings