| These guidelines are divided
into seven sections plus attachments:
Introduction
Section 1 discusses prevention of
influenza and pneumococcal disease
Section 2 provides definitions
and characteristics of respiratory illnesses
Section 3 addresses the use
of surveillance to detect cases
Section 4 outlines management
of single cases
Section 5 outlines the management
of respiratory illness outbreaks in LTCFs (includes a flow chart)
Section 6 covers specimen collection
including transport
Section 7
reviews data collection and the summary
Upper
and Lower Acute Respiratory Illnesses in LTCF ( PDF format, including
forms )
Introduction
These guidelines supersede Guidelines for Prevention and Control
of Upper and Lower Acute Respiratory Illnesses (including Influenza
and Pneumonia) in Long Term Care Facilities, 1997 and cover all
long term care facilities (LTCFs) within Maryland except those
designated as assisted living centers. These guidelines, however,
may be tailored for alternative settings such as assisted living
centers. At this time, the Maryland Department of Health and Mental
Hygiene does not recognize differences between acuity levels or
units within a LTCF.
Each year outbreaks of respiratory illness including pneumonia
occur in LTCFs such as nursing homes. Because of their underlying
health status, residents in LTCFs are at high risk for developing
serious complications or dying when they become ill. Historically,
specific emphasis has been placed on influenza. In the United
States, influenza is associated with an average of 20,000 deaths
yearly, and an even larger number of hospitalizations. Not only
are morbidity and mortality a problem, but because people are
in close proximity to one another, once the influenza virus is
introduced into the LTCF, it can spread rapidly. During some nursing
home outbreaks over half of the residents have been affected.
In addition to the burden of influenza, other respiratory viruses
that cause the “common cold” and bacterial pathogens
causing respiratory illness affect residents and staff of LTCFs
each year. Because infection with these agents can compromise
an already poor health status of the LTCF resident, control of
these agents in the LTCF is also critical.
In order to facilitate the investigation of respiratory disease
outbreaks and implementation of control measures, the following
guidelines have been established. These guidelines emphasize priorities
regarding prevention and control of influenza and pneumococcal
disease including pneumonia as follows:
-
to prevent pneumococcal disease through immunization
-
to prevent outbreaks through influenza immunization
and antiviral drug use
-
to detect the occurrence of an outbreak early
-
to stop transmission of the influenza virus
through control measures
-
to measure the level of morbidity and mortality
-
to identify the etiologic agent, e.g., the
strain of influenza virus responsible for the outbreak
Section 1. Prevention:
Two measures are available in the United States to minimize the
impact of influenza: vaccination and use of antiviral drugs. Annual
vaccination before the influenza season of high risk persons and
employees, volunteers, and family members in contact with those
at high risk is the most important way of reducing the impact of
influenza. Effective October 1, 2000, Maryland law mandates that
LTCFs vaccinate residents and employees with the influenza vaccine
each year. Those refusing the vaccine must sign a waiver declining
immunization. Two antiviral drugs, amantadine and rimantadine, are
effective only against influenza type A infections and are used
in both prevention and treatment. Oseltamivir and
zanamivir are new antiviral drugs approved in 1999 for treatment
only of both influenza type A and B. Additional
information can be found in the annually updated Centers for Disease
Control and Prevention (CDC), Morbidity and Mortality Weekly Report
(MMWR), Prevention and Control of Influenza. An example of the most
recent MMWR document is MMWR 2000; Vol. 49, No. RR03 (website:www.cdc.gov).
Pneumococcal Pneumonia:
Pneumococcal vaccine is available to prevent illness due to Streptococcus
pneumoniae. Pneumococcal pneumonia is a common complication of
influenza. Effective October 1, 2000, Maryland law requires LTCFs
to vaccinate residents with pneumococcal vaccine (unless previously
vaccinated) or to sign a waiver if refused. The Code of Maryland
Regulations (COMAR 10.06.01.12-1) also puts this responsibility
upon the physician in attendance for a resident of a LTCF. The
physician is responsible for educating the resident or their guardian
on the availability of pneumococcal vaccine and administering
the vaccine to individuals who have not already been immunized
with pneumococcal vaccine or referring the individual to a health
care provider who will administer the vaccine. Further information
regarding the vaccine can be found in the CDC MMWR Recommendations
of the Immunization Practices Advisory Committee, Prevention of
Pneumococcal Disease (most recent version: MMWR 1997; Vol. 46,
No. RR-8)(website :www.cdc.gov).
Included in these Guidelines is the Vaccine Administration and
Waiver Record form to assist with documentation of vaccines given
to LTCF residents and employees
Download Vaccine Administration Record in PDF format
Return to section index
Section 2. Case Definition, Clinical
Characteristics, and Outbreak Definitions
A. Case Definitions
A case of acute respiratory disease (ARD) is
defined as a person with mild to moderate symptoms of one or more
of the following: rhinitis, pharyngitis, laryngitis, bronchitis,
and cough. These symptoms are usually caused by a rhinovirus, of
which there are more than 100 recognized subtypes. The incubation
period is between 12 hours and 5 days but usually 2 days. Getting
freshly shed virus particles from one person onto the mucous membranes
of another is thought to be the most important mode of transmission.
Inhaling virus particles by the airborne route is another way to
spread rhinoviruses. The duration of illness is normally 2-7 days.
A case of acute febrile respiratory disease (AFRD) is defined
as a person with one or more respiratory symptoms (rhinitis, pharyngitis,
laryngitis, bronchitis, and cough) in the presence of a temperature
of 37.8°C (100°F) or greater orally or 38.3°C (101°F)
rectally. Acute febrile respiratory diseases are caused by numerous
agents including viruses and bacteria. The incubation period is
1 to 10 days. While influenza is primarily spread via airborne transmission,
the chief mode of transmission for non-influenza agents is contact
with infectious secretions either directly or indirectly through
contaminated hands or environmental surfaces (bed rails, telephones,
etc). A person infected with one of these agents can shed the agent
from a few days prior to symptom onset and throughout the course
of active disease.
A case of influenza or influenza-like illness (ILI) is defined
as a person with temperature of 37.8°C (100°F) or greater
orally or 38.3°C (101°F) rectally PLUS cough
during the influenza season (October 1 through May 31). A person
with laboratory confirmed influenza is also considered a case even
if the person does not have cough and fever. The incubation period
for influenza is short, usually 1 to 3 days. Communicability includes
the period immediately prior to clinical onset and throughout the
course of active disease.
A case of pneumonia is defined as a person with clinical
symptomatology PLUS a new X-ray finding of pneumonia
that is not felt to be aspiration pneumonia. For the purposes of
these Guidelines, specific emphasis is placed on Streptococcus pneumoniae
(the “pneumococcus”), respiratory viruses, Haemophilus
influenzae, aerobic gram-negative bacilli, and Staphylococcus aureus.
Pneumococcal pneumonia is characterized by fever, chills, cough,
and pleuritic pain. The case-fatality rate remains 20% to 40% among
patients with substantial underlying disease. The organism is spread
by droplet, direct, or indirect inoculation. Person-to-person transmission
of the organism is common, but illness among casual contacts and
attendants is uncommon. The incubation period may be as short as
1 to 3 days. Appropriate antibiotic therapy will render patients
noninfectious within 1 to 2 days.
B. Outbreak Definitions
An outbreak of acute febrile respiratory disease
(AFRD) or ILI is defined as three or more clinically defined
cases (see above) in a facility within a 7 day period; an outbreak
of influenza is one or more laboratory proven case of influenza.
Unless indicated by laboratory results, influenza and ILI apply
only between Oct 1 and May 31.
An outbreak of pneumonia is two or more cases of pneumonia
in a ward/unit within a 7 day period.
Return to section index
Section 3. Surveillance
Each LTCF should have their designated infection control practitioner
(ICP) routinely maintain records on the occurrence of fever and
illness in residents and employees. Employees should report respiratory
illness (as well as other acute illnesses such as diarrhea) to the
appropriate staff person at the LTCF throughout the year. The one-time
pneumococcal vaccination and yearly influenza vaccination status
of each current resident should also be recorded in the resident’s
chart and employee information should be recorded in the employee
record (see Vaccine Administration and Waiver Record form, page
12). In addition, ICPs may wish to maintain a separate log or database
documenting the vaccination status of each resident and employee.
These methods will enable rapid assessment of susceptible individuals
in the event of an outbreak.
Influenza and/or ILI should be suspected during the influenza season
from Oct 1 through May 31. When a person who meets the case definition
is identified, the case management procedures as described below
should be followed unless the fever is known to have another cause.
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Section 4. Single Case Management
A stepped-care approach has been developed for case and outbreak
management of respiratory illness in LTCFs. This section covers
single cases among LTCF residents and employees.
Acute Respiratory Disease
A. Residents
- Observe case for signs/symptoms that suggest need for physician
consult.
- Encourage the case to limit contact with other residents
and others, etc. (if possible) by limiting group activities
while ill, washing hands, and using tissues to cover mouth and
nose while coughing and sneezing.
B. Employees
- Exclude from direct patient care (if possible) and review
vigilance for hand washing and covering the mouth when coughing
or sneezing.
Acute Febrile Respiratory Illness, Influenza, or ILI
A. Residents
- Observe case for signs/symptoms that suggest a need for physician
consult.
- Restrict the case to his/her room (i.e., restrict the case
from participating in group activities) until the patient no
longer has active symptoms.
- Consider confirmation of the diagnosis with appropriate viral
throat culture and/or rapid antigen test or sputum Gram stain
and bacterial culture, or consultation with a physician.
- If between October 1 and May 31, suspect influenza
or ILI.
- Give antiviral treatment to the case regardless of vaccination
status within the first 48 hours of illness when a physician
has a high suspicion of an influenza type A diagnosis and when
the Maryland Department of Health and Mental Hygiene (DHMH)
has determined that influenza type A is in the community. This
information can be obtained by calling the local health department
or DHMH Epidemiology and Disease Control Program at 410-767-6700.
- Give influenza vaccine to any unvaccinated roommates of a
case and to other unvaccinated residents and staff during the
influenza season.
- Observe the roommates of a case and others in the facility
closely for similar signs and symptoms of influenza-like illness.
B. Employees
- When a case of acute febrile respiratory disease, influenza
or ILI is recognized in an employee, exclude from the facility
or from clinical duties until the employee is no longer symptomatic.
Pneumonia
A. Residents
- Recommend diagnostic testing to establish the diagnosis and
to determine the cause of pneumonia (e.g., chest X-ray, sputum
Gram stain and bacterial cultures, and/or bronchoscopy).
- Consult with a resident’s physician regarding appropriate
antibiotic treatment.
- Restrict case to his/her room until completion of first 48
hours of antibiotic therapy if treated with antibiotics.
- Report individual case of pneumonia caused by organisms that
are reportable in accordance with State regulations, e.g., Legionella
pneumophila, to your local health department.
- If the pneumonia is caused by Streptococcus pneumoniae, attempt
vaccination of residents who have previously waived pneumococcal
vaccination.
B. Employees
- Verify diagnosis of pneumonia by obtaining chest x-ray results.
- Exclude from the facility until completion of first 48 hours
of antibiotic therapy if given and until the employee is no
longer symptomatic.
Return to section index
Section 5. Outbreak Management
A. Reporting
Per the Code of Maryland Regulations 10.06.01, nursing homes
and other LTCFs should report outbreaks of diseases of public
health importance including outbreaks as defined in these guidelines.
Reporting should be made within 24 hours to a local health department.
Please contact your local health department for an emergency telephone
number where they can be reached during weekends and after work
hours in the event of an outbreak.
Note: Acute upper respiratory disease outbreaks
(i.e., colds) are not reportable to the local health department.
The LTCF may call the local health department if consultation
is needed.
B. Outbreak Control Measures
Acute Febrile Respiratory Disease, Influenza, or ILI
When an outbreak of acute febrile respiratory disease, influenza,
or ILI is recognized in a LTCF, the control measures for a single
case should be instituted immediately on each case.
In addition, the following control measures should be implemented
and maintained for the duration of the outbreak. All outbreak control
measures can be lifted when no new cases have occurred for three
consecutive days.
- Stop new admissions of residents after one case of lab proven
influenza or three or more cases of acute febrile respiratory
disease or influenza-like illness in a 7 day period; the Health
Officer may allow new admissions to an unaffected ward or unit
based on the progression of the outbreak.
- Allow readmissions to the facility, preferably to an unaffected
ward or unit.
- Institute visitor precautions (e.g., posting a sign to alert
visitors that an outbreak is occurring; encourage/advise visitors
to refrain from visiting if they have respiratory symptoms or
are at risk of illness). A ban on visitors is not necessary.
- Assign employees to care for the same group of patients during
a shift, to the extent possible.
During the influenza season (October 1 through May
31):
- Require influenza vaccine for unvaccinated residents and employees
or obtain a waiver.
- Consider antiviral prophylaxis (e.g., amantadine or rimantadine)
for ill and well residents (regardless of vaccination status)
and unvaccinated employees if influenza type A is present in the
community (as determined by positive lab findings or DHMH).
Pneumonia
- During pneumonia outbreaks, in addition to the recommendations
made for the management of a single case with pneumonia, follow
the recommendations listed above for acute febrile respiratory
disease, influenza, and ILI outbreaks.
- Follow the recommended diagnostic procedures for pneumonia
and AFRD in the following section.
- Consider using the attached questionnaires: Respiratory Illness
Employee Questionnaire and Respiratory Illness Resident Questionnaire.
- If legionellosis is diagnosed, contact your local health department
for further recommendations.
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Section 6. Specimen Collection
Influenza
If influenza is suspected based on clinical symptoms, laboratory
testing will confirm the diagnosis. A case of influenza can be laboratory
confirmed by three techniques. Most commonly, a viral throat culture
is used to detect influenza; however, influenza infection can be
confirmed using serology, as well as a rapid antigen detection method.
A. Viral Throat Culture
A throat culture should be collected on up to 10
to 12 cases within 72 hours of illness onset (a "viral throat
swab" kit should be used if submitting samples to the DHMH
Laboratory). The following steps should be followed closely when
preparing to submit viral throat swabs for laboratory culture:
Procedures for Collection and Transport of Viral Throat
Specimens
- Obtain viral throat swab kits from DHMH Laboratories Administration,
Specimen Mailing Assemblies (Outfit Room) at 410-767-6120 or your
local health department
- Complete the accompanying Virus Throat Swab form (DHMH-72) including
clinical diagnosis. Note "influenza" if influenza is
suspected as the clinical diagnosis.
- Open sterile cotton-tipped swabs. Hold two swabs together and
swab the posterior pharynx and tonsillar areas vigorously with
swabs.
- Immerse swab-tips in media and break off the top portion of
the wooden swab to allow the swabs to fit into the tube.
- Refrigerate specimen immediately after collection unless transporting
immediately. Alternatively, the specimen can be frozen at -70
degrees C; this requires a specialized freezer. Do not freeze
in a regular freezer (-15 degrees C).
- Refrigerated specimens should be transported on wet ice or cold
packs to DHMH Virology Laboratory, 201 W. Preston Street, Baltimore,
MD 21201. "Wet ice" is a mixture of ice with a small
amount of water; specimens should be placed into the water portion.
Specimens frozen at -70°C should be shipped on dry ice.
Failure to follow the above procedures will render the specimens
unsatisfactory and the DHMH laboratory will not process them.
B. Rapid Antigen Detection
Techniques have been developed to allow the rapid
detection of influenza type A antigen in as little as 15 minutes.
These techniques vary greatly and include several different detection
systems, such as the immunofluorescence assay (IFA) and the enzyme
immunoassay (EIA). In addition, these systems are available as commercially
sold kits. When compared to viral cultures (which are thought to
be the "gold standard” for influenza detection), these
rapid testing methods were able to detect from 87 to 99 percent
of all positive influenza cases.
As with many laboratory tests, there is always a potential for
a false-positive and false-negative result. However, use of rapid
detection methods in conjunction with a viral throat culture should
minimize false-positive results. In addition, use of both methods
allows a more efficient administration of antiviral medications
and infection control measures, while also permitting the identification
and typing of circulating strains of influenza virus.
Decision regarding the choice of rapid detection method should
be made in conjunction with the clinical laboratory used by the
LTCF. Cost, technical support, and resources available for testing
may all factor into the choice of rapid influenza detection methods.
DHMH will perform a rapid antigen detection test for influenza
A on any viral throat kit specimen submitted for influenza detection
between October 1 and April 30.
C. Serology
Serological specimens do not need to be routinely
collected. If serological specimens are recommended by DHMH then
two blood specimens (acute and convalescent) are needed to demonstrate
a significant rise in anti-influenza antibody titer. The first specimen
should be collected as early as possible after onset of illness,
and the second specimen three weeks later. In either instance, obtain
5-8 ml of blood in a RED TOP TUBE. Do not freeze whole blood since
this will result in complete hemolysis and renders the specimen
unsatisfactory for testing. Serum or clotted blood specimens may
be transported unrefrigerated to the laboratory.
AFRD or Pneumonia
For patients with acute febrile respiratory disease
(AFRD) or pneumonia during an outbreak of pneumonia, obtain diagnostic
testing. If the patient has been hospitalized, obtain information
on the diagnostic work-up and if not performed, recommend that it
be done as follows:
A. Chest x-ray on patients with
AFRD or suspected pneumonia; chest-x- ray results on patients with
“confirmed” pneumonia.
B. Sputum specimen (see NOTE)
for:
i. Bacterial culture-- include Mycoplasma and Streptococcus
pneumoniae among the organisms for which the laboratory tests.
ii. Gram stain
iii. Legionella culture—special media is
required to grow Legionella. Legionella can not be isolated from
routine bacterial culture. Consult with the laboratory where you
are submitting specimens for instructions.
NOTE: If expectorated sputum is
not obtainable, recommend that a sputum specimen be induced. If
the patient is intubated, obtain a trachial aspirate specimen;
if the patient undergoes bronchoscopy, obtain a bronchio-alveolar
lavage (BAL) specimen.
C. Viral throat culture:
Request that the laboratory culture for influenza,
parainfluenza, adenovirus, and RSV. Specimens should be refrigerated
and transported on wet ice within 72 hours of collection to DHMH.
The swabs must remain refrigerated or on wet ice at all times.
The swabs must not be frozen.
D. Paired serum specimens for viral
antibody titers--(red top tube)
i. An acute specimen should be collected as early
as possible after the onset of illness.
ii. A convalescent specimen should be collected
3 weeks later.
Ask the laboratory to hold the acute specimen until
the convalescent specimen is submitted. Consult EDCP for specific
tests to request.
E. Blood culture (prior to antimicrobial
treatment)--check with lab for collection tube
F. Urine for Legionella antigen--sterile
container, no preservative necessary
Please note: Specimens may be sent
to DHMH (except for blood cultures) or to a private laboratory.
Except for emergencies, the DHMH laboratory is not open Sunday for
receipt of specimens. Please plan accordingly. Specimens can be
sent to: DHMH Laboratories Administration, 201 West Preston Street,
Baltimore, MD 21201.
Return to section index
Section 7. Data Collection
and Summary
Pertinent information regarding each resident and employee case
should be entered into the LTCF Infection Control Professional’s
surveillance log and updated daily. Once an outbreak has been identified,
cases should be placed on a "line list" (see line listing
form for influenza,
page 13). The local health department at the conclusion of the outbreak
should fill out a summary sheet and a copy should be forwarded to
the Division of Outbreak Investigation (see outbreak summary form
for respiratory illness outbreaks, page 11). For each respiratory
illness outbreak, indicate the number of residents and employees
meeting case definitions for influenza, ILI, ARD, AFRD, and pneumonia.
Return to section index |
