Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homesand Retirement Homes

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Presenter• Catherine Edl, RN, BScN– Infection Prevention and Control Team– York Region Community and Health Services– 905-895-4511 ext. 4555– catherine.edl@york.ca

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Webinar Instructions• Please mute your phone – use *6 or mute button

• Questions:– If you have questions during the presentation,

please use the chat box you see on your screen– Questions will also be taken the end of the

presentation

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Presentation OutlineWe will review:• Organism transmission• Common outbreak pathogens • Outbreak identification, notification and first

steps• Outbreak control measures• Importance of outbreak policies and

procedures

Organism Transmission

Back to Basics

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Infectious Agent

Source

Portal ofExit

Means of Transmission

SusceptibleHost

Portal ofEntry

Chainof

Transmission

Organisms

Where organisms live

How organisms leave the host

How organisms travel to new host

How organisms enter a new host

Factors that make a host more vulnerable to getting sick

Breaking the Chain

• Identify/manage the agent

•Reduce the reservoir

• Identify mode of transmission and prevent spread

•Reduce host susceptibility

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How Are Organisms Spread?

• contact• droplet• droplet/contact• airborne

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Contact Transmission• The spread of an infectious agent through

touching• The most common route• Direct: hand to hand• Indirect: touching a contaminated object

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Droplet Transmission

• coughs or sneezes generate large respiratory droplets

• Infected droplets enter the eyes, nose or mouth of another person and can cause infection in the receiving host

• Droplets can land on surfaces contaminating them

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Airborne Transmission• Very tiny droplets exit the respiratory tract of

an infected person when they cough or sneeze and remain suspended in the air and travel on air currents

• These tiny droplets need to be inhaled to cause infection

• Examples of germs spread via this route:– Tuberculosis, chickenpox

Outbreak Pathogens

Respiratory & Enteric

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Summary of Reported Respiratory Outbreaks in York Region (2012-2013)

# of Outbreaks

Causative Agent Setting Type

Respiratory 48 Undetermined (38%)Influenza (25%)

Rhinovirus (13%) Coronavirus (8%)

Parainfluenza (6%)RSV (6%)

Entero/Rhinovirus (2%)Metapneumovirus (2%)

Long term care home (98%)Retirement home (2%)

Respiratory OutbreakCausative Agents 2012-2013

Rhinovirus13%

Metapneumovirus2%

Influenza25%

RSV6%Coronavirus

8%Parainfluenza6%

Entero/Rhinovirus2%

Undetermined38%

Respiratory Outbreak Setting Types 2012-2013

1 20

5

10

15

20

25

30

35

40

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Retirement HomeLTCH

Total # of OBs # of Influ OBs

# of

OBs

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• Incubation period – 1-3 days• Period of communicability – 24 hrs prior to

symptom onset to 7 days• Common symptoms – runny nose, fever (3-4

days), sore throat, coughing, extreme fatigue• Treatment- antivirals should be started within

48 hrs of symptom onset• Annual flu vaccine

Influenza – A Common Causative Agent in Respiratory Outbreaks

Rates of Influenza Immunization Coverage for 2012-13 among Staff in York Region LTCHs

YR Average

64%

Data Source: The Seasonal Influenza Immunization rates at LTCHs reporting forms from 2009/10 to 2012/13.

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Droplet and Contact• Droplet– through the air by droplets excreted when

infected individuals cough or sneeze– 2 metre rule

• Contact (direct and indirect)– touching people/objects– Viruses can survive on surfaces for long periods of time

2 metres

How are Respiratory viruses spread?

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Summary of Reported Enteric Outbreaks in York Region (2012-2013)

# of Outbreaks Causative Agent Setting Type

Enteric 59 Undetermined (78%)Norovirus (13%)Rotavirus (3%)

C.diff (2%)Girardia (2%)

Campylobacter (2%)

Child care (44%)Long term care home (27%)

Other (17%)Retirement home (12%)

Enteric Outbreak Setting Type 2012-2013

LTCH27%

Retirement Home12%

Child Care44%

Other17%

Enteric OutbreakCausative Agents 2012-2013

14%

78%

3%

2%2% 2%

Norovirus

Undetermined

Rotavirus

C.diff

Campylobacter

Girardia

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Norovirus – A Common Causative Organism in Enteric Outbreaks

• Spread through stool and vomit – Droplet/contact precautions needed

• Noroviruses can survive on practically any surface including door handles, sinks, railings and carpet for long periods of time

• Highly infective virus!– only 10 virus particles are needed

to cause illness

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• Contact (direct and indirect)

– touching people/objects– viruses can survive on surfaces for long periods of time

• Droplet (if vomiting)

– through the air by droplets excreted when infected individuals vomit

– 2 metre rule

How are Enteric viruses spread?

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Virus Type Spring Summer Fall Winter

Influenza √ √ √

RSV √ √ √

Para-influenza

√ √

Rhinovirus √ √ √

Enterovirus √ √

Norovirus √ √

What ‘season’ are we in?

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Pocket Guide Book

Mabel.Lim@oahpp.ca

Outbreak Identification, Notification & First Steps

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Outbreak Identification• Early detection of an outbreak is key• Need to recognize when illness rates exceed your facility’s

baseline• Consult with Public Health when your facility has minimum

two cases presenting with similar symptoms in a similar location within a specified timeframe

• Implementing outbreak control measures early is vital in controlling an outbreak• Results in a shorter number of days in outbreak

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If you suspect that you may have an outbreak,

Call Public Health• 905-830-4444, ext. 3588 during business

hours• 905-953-6478 after business hours

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Public Health’s Role:• Review line list and determine if in outbreak/surveillance• Create case definition • Provide investigation/outbreak number• Review facility details:

• Determine which units are affected • Number of residents on the unit and whole facility• Number of staff on the unit and whole facility• Facility lay-out

• Facilitate and coordinate specimen collection and testing by PHO lab

• Send outbreak notification to external stakeholders• For respiratory outbreaks review rates of flu vaccination for staff

and residents

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Facility’s First Steps Once Outbreak Confirmed

1. Assemble the outbreak management team and set meeting

2. Notify stakeholder groups of outbreak3. Collect clinical specimens (in consult with PH)

and submit to Public Health Lab4. Expect outbreak inspection from PHI5. Further implementation of control measures

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Outbreak Management Team (OMT) Meeting• The OMT directs and oversees all aspects of an outbreak• Plan your meeting as soon as possible - meet on day 1 or 2 of

the outbreak• Include representatives who have the authority to make

decisions within your facility:• Infection Control Designate• DOC, Administrator, Medical Advisor• Nursing Representative from each floor/unit where outbreak is

occurring• Pharmacist• Public Health Nurse/Inspector (2)• Environmental & Dietary Services• Activity Coordinators• Maintenance Representatives• Other external service providers

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Public Health Representation at the OMT• Two members of the health unit will attend

the OMT:• Infectious Diseases Control Division (IDCD)

representative • Public Health Lead • Outbreak Investigator (PHI or PHN)• Case management

• Health Protection (HP) Division representative• Public Health Inspector (PHI)• Infection Prevention and Control Measures

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OMT Meeting Discussion• Review line list(s) and confirm case definition• Confirm collection and submission of lab specimens • Review the control measures necessary to prevent an OB

from spreading further• Identify additional people who need to be notified of the OB• Prepare a communication plan, only if necessary• Prepare internal communication for residents, staff and family

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Essential Communication for the Facility During an Outbreak

• Notify courier services for swab/stool pick-ups• Notify residents and family members• Notify staff and volunteers• Manage any media concerns• Post signage: • Outbreak signage needs to be posted at entrances to the

facility and the affected unit(s)• Contact/Droplet/Airborne signage should be posted

outside the ill residents room as appropriate

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Essential Communication with PH Throughout the Outbreak

• Daily line list faxed to public health at 905-898-5213 • Line list is a system to track residents/staff symptoms

that meet case definition• Immediate notification to public health if there are

hospitalizations or deaths within the institution

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Enteric and Respiratory Outbreak Management Poster

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Specimen Collection KitsObtained from Public Health

Respiratory Outbreaks

NP Kit

Enteric Outbreaks

Stool Kit

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Specimen Collection for Respiratory Pathogens

Nasopharyngeal (NP) swabs• Swab should be inserted one-half it’s length

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NP Swab Collection Technique• Wear appropriate PPE • Tilt the patient’s head back• Remove any excess mucous using the larger cotton tipped swab• Gently bend the wire swab while in the sterile package, to give it a

slight arc• Insert the flexible NP swab into one nostril• Rub the swab back and forth several times, and leave the swab in

place a few seconds to absorb the material• Withdraw the swab and insert into transport medium• Refrigerate and transport to the lab as soon as possible• Ensure that the outbreak # and two identifiers are on the

requisition and the NP swab

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Specimen Collection for Enteric Pathogens

Stool Kits• Bacterial, parasitic, and viral agents may produce gastroenteritis therefore

the ‘Stool Kit’ has 3 vials - each with a colour-coded cap: • Green - Bacterial examination • Yellow - Parasitology examination • White - Viral and toxin examination

• Ensure that the outbreak # and two identifiers are on the requisition and the specimen bottles

• Each kit includes complete instructions on specimen collection, storage, and transportation; if these instructions are not followed the sample may not be tested

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Sending Specimens to Public Health Ontario Laboratory

• Confirm with Public Health investigator the contact information for courier services

• When specimens are ready for pick-up, call the courier. • Inform the courier that the specimens will be going to the

Public Health Ontario Laboratory (PHO Lab)• If asked please quote the account # provided by Public Health • All samples sent to the PHO Lab must be properly labelled

and accompanied with the ‘General Test Requisition’ form supplied with the kits

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Public Health Inspection• Once an outbreak is declared, a PHI will visit

your facility– Conduct an outbreak inspection • Respiratory – inspect affected unit(s)• Enteric – inspect affected unit(s) and kitchen• Other areas will be inspected as needed

– Common areas– Facility entrances

– Collect samples if needed

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Food Safety for Enteric Outbreaks• Policies should be available on general safe food handling

practicesOutbreak Specifics• Food retention policy needs to be in place• Once an outbreak is declared, food samples should not be

discarded• Keep food samples (200 grams) of ready-to-eat potential

hazardous food items, frozen (at or below -18°C) for 10 days• Ensure symptomatic food handlers are identified, excluded

and notify Public Health• Discard all ready-to-eat foods prepared by staff that become

ill with enteric symptoms while on shift

Preventing Further Spread

Most often at the beginning of an outbreak the organism will be

unknown…

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Outbreak Control Measures• Routine Practices

– Hand hygiene and PPE

• Cleaning and disinfection• Accommodations • Visitor Restrictions• Workload management• Admissions/transfer considerations• Outbreak policies• Staff/volunteer education & health considerations

It is really important that staff are educated on these control measures at the beginning of each outbreak and as needed.

Environmental Controls

Administrative Controls

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Routine Practices

• Risk Assessment• Hand Hygiene• PPE

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Risk AssessmentTo be performed prior to each resident interaction

Consider the following:• Risk of exposure to blood or bodily fluids• The procedure and the skill level of the HCW

performing the procedure• Resident’s level of cooperation and cognitive

awareness• Using infection prevention strategies during every

resident/HCW interaction

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Hand Hygiene Key Points• Supplies should be easily accessible, stocked and

not expired• Should be performed timely and properly by staff,

visitors, volunteers, and residents• Signage posted at hand sanitizer stations and

hand wash sinks • Hand sanitizer should be 70-90% alcohol based• Use liquid soap

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Hand Hygiene Resources

• Just Clean Your Hands Resources– Staff and Resident Areas

• 4 Moments for Hand Hygiene• How to hand wash - 11 steps • How to hand rub - 8 steps

• York Region Resources– Visitor Areas

• Correct hand washing procedures - 6 steps• hand sanitizer poster - 3 steps

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JCYH – 4 Moments

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JCYH – How to Hand Wash (11 steps)

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JCYH – How to Hand Rub (8 steps)

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York Region – Hand Washing (6 steps)

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York Region – Hand Sanitizer (3 steps)

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PPE Key Points• Risk Assessment prior to donning• Proper use is key for protecting staff,

visitors and residents• Ensure additional precaution signs are

posted• Ensure PPE supplies are available• Ensure appropriate use of PPE (type

and sequence for removal)• Ensure appropriate disposal of used

PPE

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PPE for Routine Practices Gloves – Use when touching any bodily fluids,

mucus membranes and when you have non-intact skin

Gowns – Use when contact of clothing/ exposed skin with bodily fluids is anticipated

Mask and goggles – Use when anticipating splashes or sprays of bodily fluids

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PPE & Additional Precautions PPE used in addition to Routine Practices:• Contact Precautions• Droplet Precautions• Airborne Precautions

Additional Precautions need to be established and discontinued promptly!

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Additional Precautions - ContactControl Measures:PPE Gown and gloves for contact with client (direct) or environment of care

(indirect)

Environmental Controls Dedicate or disinfect shared equipment after each use

Infectious agent/symptoms that require contact precautions are:Diarrhea or C. difficile

NorovirusInfluenza

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Additional Precautions - DropletControl Measures:PPE• Surgical masks and eye protection within 2 metres of

residentEnvironmental Controls• Dedicate or disinfect shared equipment after each use

Infectious agents/symptoms that require droplet precautions are:RSV

Norovirus (if vomiting) Cough or shortness of breath and fever

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Additional Precautions – Droplet/ContactControl Measures:PPE• Surgical masks and eye protection within 2 metres of resident

and gloves and gown if contact with resident or their environment anticipated

Environmental Controls• Dedicate or disinfect shared equipment after each use

Infectious agents/symptoms that require droplet/contact precautions are:Influenza

Norovirus (if vomiting) Cough or shortness of breath and fever

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Additional Precautions - Airborne

Control Measures:

PPE• Particulate respirator (N95 mask)

Environmental Controls• Single room, door closed• Negative pressure room

Infectious agents that require airborne precautions are:Tuberculosis

MeaslesChickenpox

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Additional Precautions Signs

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Donning and Doffing PPE

• Remember the sequence and importance of hand hygiene

• Wear the right PPE for the interaction anticipated so you reduce the risk of exposure

• Carefully remove PPE to reduce the risk of contaminating skin or clothing

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PPE Cart Principles• Also called ‘Isolation Station’• When does this cart need to be set up?

– First symptom of resident

• Where should it be located?– Outside room, easily accessible, ‘clean area’

• Covered or uncovered?– Covered is best

• Where to place in a dementia unit?– Communicate location by posting sign

• Placement of garbage?– Should be inside the room, PPE poster above

PPE Cart Set Up

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1. Hand Sanitizer2. Gloves3. Gowns4. Masks5. Goggles6. Wipes7. Garbage8. Signs

In ill resident’s room, away from clean supplies

Environmental Controls

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Key Points for Outbreak Cleaning and Disinfection (C&D)

• Follow the correct process: clean first, then disinfect

• Use a higher level of disinfection• Increase the frequency of C&D in outbreak

areas• C&D of resident equipment is essential• Ensure proper handling of laundry and waste

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Cleaning Principles

• Cleaning is the physical removal of dirt and debris using soap, water and mechanical action (friction)

• Must always be the first step in order to maximize effectiveness of the disinfectant

• Clean spills/splashes/leaks promptly• Clean from least contaminated to most

contaminated (top to bottom)

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Disinfection Principles• Disinfectants kill germs• Type of disinfectant used depends on the surface or

item being disinfected• Different levels: Higher and Lower

• Registered disinfectants have a drug identification number (DIN)

• Follow manufacturers’ instructions for dilution and contact time

• During an outbreak higher level disinfection must be used

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Low Level or Hospital Grade DisinfectantsEvery Day Use

• Kill vegetative bacteria and enveloped viruses:– Staphylococcus aureus (includes MRSA)– Salmonella – HIV, Hepatitis B and C– RSV and Influenza

• Examples:– 500ppm-1,000ppm sodium hypochlorite (bleach)– 3% hydrogen peroxide– accelerated hydrogen peroxide– 70-95% alcohol– QUATs (Lysol, Everyday Disinfectant - ED)

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Higher Level DisinfectantsOutbreak Situations

• Kill mycobacteria, non-enveloped viruses and fungi:– Mycobacteria tuberculosis – Norovirus and Hepatitis A – Candida

• Examples: – 5,000ppm sodium hypochlorite (bleach)– 6% hydrogen peroxide– accelerated hydrogen peroxide

Bleach Solutions• Low Level - every day (non-outbreak)

• High Level - outbreak

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Outbreak Cleaning and Disinfection – Frequently Touched Surfaces

• Assume all frequently touched surfaces are contaminated

• Increase cleaning and disinfection frequencies of:– Common areas:

• Hallways, door knobs, light switches, dining areas, activity rooms, elevator buttons

– Ill Resident rooms (at least daily):• Bed rails, overbed table, washroom areas (faucets, sinks, toilets,

counter tops)

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Outbreak Cleaning and Disinfection - Resident Equipment

• Dedicate wherever possible or use disposable product if feasible

• If shared, clean and disinfect between residents • Choose a cleaning and disinfecting method that is compatible

with the equipment• Examples of resident equipment:– BP cuff– Stethoscope– Thermometer– Wheelchairs/walkers– Lifts

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Disinfectant Wipes• Follow manufacturer’s recommendations • Wipes are not recommended as a routine

cleaning/disinfectant tool• They should be used for items that cannot be soaked and

for small items that must be disinfected between uses • Ensure the surface or item remains wet for the required

contact time (additional wipes may be needed)• Wipes must be kept wet and discarded if they become

dry

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Toileting Equipment in Enteric Outbreaks

• Toilets/commodes should be dedicated for ill residents• If toileting facilities cannot be dedicated, they should be

cleaned after each use by the symptomatic resident• If commodes/bedpans are used, same principles apply– Where are the contents being dumped?

• Visitor toilets should be separate from resident toilets• Do not use disinfectant wipes to clean toilets or

commodes

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Do your environmental cleaning staff use a cleaning checklist for ill

resident’s rooms?

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Environmental Cleaning Best

Practices Educational

ToolkitFor more information:

ricn@oahpp.ca

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Resident Accommodations• Ill residents should remain in their room:• Private room preferred • If in a multi-bed room, draw curtain around ill resident• Keep 2 metres from other residents• Meals should be eaten in their room

• If a resident has to leave their room:• For respiratory symptoms, resident should wear a mask• For enteric symptoms, the resident should be limited to

using their own washroom

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Length of Isolation• Residents with enteric symptoms should be isolated

in their rooms until 48 hours after their symptoms have resolved

• Residents with respiratory symptoms should be isolated in their rooms until 5 days after symptoms onset or until symptoms have completely resolved (minimum 48 hrs or whichever is shorter)

• Isolation should only be done as long as it does not cause the resident undue stress and can be done without using restraints

Administrative Controls

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Workload Management

• Institute staff cohorting• Outbreak plans need to address varying levels

of available staff to ensure continued provision of care and full implementation of infection control measures

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• New resident admissions should not occur• Re-admission of cases from a hospital is permitted

with appropriate accommodation and care• Re-admission of non-cases from a hospital is generally

not permitted• Resident appointments if non-urgent need to be

rescheduled

Admissions/Transfers

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Staff and Volunteer Health • Ill staff and volunteers to be excluded until no longer

infectious• For enteric outbreaks, exclude staff until they are

48 hours symptom-free• For respiratory outbreaks, exclude staff for 5 days

after symptom onset or until symptoms have completely resolved (minimum 48 hours or whichever is shorter)

• Staff that become ill at work should report to IC/OH

Visitor Restrictions

• Large group activities should be cancelled on the affected unit or facility depending on situation

• Visitors advised not to visit when ill• Discourage children under the age of 12 from

visiting

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Visitors to LTCH Pamphlet

Contains the following information: Hand hygiene Respiratory etiquette Planning a visit to a LTCH Food safety Online at www.york.ca

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Education Resident and Visitor education to include:

• Proper hand hygiene methods and when to perform hand hygiene

• Routine practices and, in specific instances, proper use of PPE

• Transmission and prevention of disease including the requirement not to visit the LTCH when they are ill

• Outbreak management –what to expect (such as visitor restrictions)

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Education Staff and Volunteer education to include:

• Transmission and prevention of infections • Routine Practices (including hand hygiene) and Additional

Precautions • Cleaning and disinfecting of shared equipment and environmental

surfaces • Food safety• Occupational Health policies • Routine daily surveillance for signs of infection • Roles and responsibilities of staff, administration, the ICP, and Public

Health • Specimen collection methods • Outbreak management and control

Outbreak P&Ps

All outbreak P&Ps should be updated annually or as needed in consultation

with Public Health

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Outbreak P&Ps should cover these topics as discussed today:

• Outbreak management team composition• Communication during an outbreak• Specimen collection• Food Safety for Enteric Outbreaks• Education of staff, volunteers and visitors• Influenza outbreaks • Control Measures

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Influenza OutbreaksPolicies should address the following:• Annual influenza vaccination for residents and staff• Exclusion for non-immunized staff during an

influenza outbreak• Antiviral use• Collection of nasopharyngeal swabs • Obtaining consent for prophylaxis with antivirals• Obtaining pre-approved orders from physicians for

antiviral prophylaxis

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QUESTIONS?Un-mute your phone (*6) and ask questions over the phone line or through the chat box.

After today, if you have any IPAC related questions, please call your Public Health

Liaison at 1-877-464-9675 or 905-895-4511 or visit our website at

www.york.ca/infectionprevention

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References• PIDAC Best Practice Documents:

– Current PIDAC documents can be downloaded from the following website: http://www.oahpp.ca/resources/pidac-knowledge/

• Control of Gastroenteritis Outbreaks in Long-Term Care Homes, MOHLTC, 2011

• A Guide to the Control of Respiratory Infection Outbreaks in Long-term Care Homes, MOHLTC, 2004

• Laboratory Guide for Gastroenteritis Outbreaks available at: http://www.oahpp.ca/services/documents/specimen-collection-guide/gastro_full_20080301.pdf