Public Health Guidance for the Prevention and Management of Influenza-like Illness (ILI), Including the Pandemic (H1N1) 2009 Influenza Virus, Related to Communal Living Settings

Posted: 2009-11-19

Definition

A communal living setting is described as a setting where individuals who may or may not be related to each other share in common all or part of the living quarters. These types of settings could include homeless and other types of shelters, work camps, drop-in centres and hostels. 

The length of stay in a communal living setting may be short-term, such as in the case of a hostel or homeless shelter where accommodation may be provided for as short as one night, or longer term, as in the case of a hostel where individuals may stay for several weeks at a time. Communal living settings usually involve shared recreation, eating and washroom facilities. Sleeping quarters may be shared or separate. 

Because of the unique characteristics associated with remote and isolated communities, this guidance may need to be adapted to address work camps and other communal settings in these communities.

Background Information

The pandemic (H1N1) 2009 influenza virus has rapidly spread across the world. While influenza activity would normally be expected to wane almost entirely during the summer months, the pandemic (H1N1) 2009 influenza virus continued to circulate at low levels in Canada and a resurgence has been seen this fall.

To date, infection with the pandemic (H1N1) 2009 influenza virus has resulted in Influenza-Like- Illness (ILI) similar to seasonal influenza.

• The surveillance case definition for ILI in the general population is the acute onset of respiratory illness with fever and cough and with one or more of the following - sore throat, muscle aches, joint pain or weakness which could be due to influenza virus. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.

It has been observed with the pandemic (H1N1) 2009 influenza virus that gastrointestinal symptoms have been present in at least one third of the cases and a wider age range of individuals may not experience fever.

• The clinical case definition for ILI for treatment or isolation purposes in a given setting should be adapted to ensure appropriate sensitivity and specificity for this setting.

This pandemic (H1N1) 2009 influenza virus is thought to be spread from person to person in the same way as seasonal influenza where transmission occurs predominantly through droplets produced from coughing or sneezing. Indirect transmission also likely occurs through self-inoculation after contact with surfaces or objects contaminated with the virus from infected persons.

The incubation period for pandemic (H1N1) 2009 influenza virus is understood to be approximately four days with a range of one to seven days and the period of communicability seven days in uncomplicated cases. This may be longer in children (up to ten days) and other individuals in whom symptoms and virus shedding may persist (i.e. those who are immunocompromised or severely ill). Consistent with seasonal influenza, transmission of the pandemic (H1N1) 2009 influenza virus is most likely during the initial days of infection when the individual is symptomatic and has a high viral load.

Like seasonal influenza, the pandemic (H1N1) 2009 influenza infection in humans can vary in severity from mild to severe, with approximately two-thirds of hospitalized cases to date occurring in individuals with known risk factors for complications from influenza such as chronic illness, immunosuppression or pregnancy. This virus also appears to result in more severe disease in the 5-64 year old age group than does seasonal influenza; however, most individuals with pandemic (H1N1) 2009 influenza virus infection have not required hospitalization and have recovered in the community.

Introduction

This document provides guidance for local public health officials that may be used when providing guidance to operators of communal living facilities for the prevention and control of ILI in these settings. It is recommended that local public health officials take into account such factors as the local situation of pandemic (H1N1) 2009 influenza virus when providing guidance. 

In the case of homeless shelters, it is anticipated that the potential for a more severe illness from a pandemic (H1N1) 2009 influenza virus may be seen as the homeless may have compromised immune systems due to chronic and acute illness, may not seek medical attention until very sick, often live in crowded conditions and social distancing will be difficult to achieve. In these settings there is likely a high risk of transmission of influenza.¹

Recommendations

Immunization

Immunization is the best protection against influenza. It is recommended that public health officials and facility operators work together to ensure that the residents can receive the pandemic vaccine as soon as is reasonably possible.

Education Programs

It is recommended that operators of communal living facilities develop education programs for staff, volunteers and residents/service users on the signs and symptoms of ILI, the need to practice frequent hand cleaning using the correct technique and respiratory cough/sneeze etiquette practices. Education programs may include putting up posters and/or signage throughout facilities to encourage hand hygiene and respiratory etiquette as well as to discourage the sharing of dishes and utensils unless washed between uses. Educational materials should be designed to meet the needs of staff, residents and service users and thus literacy level and language requirements may need to be considered.

Information on signs and symptoms, hand hygiene and respiratory etiquette can be found at FightFlu.ca

Self Care

It is recommended that staff and volunteers be educated to stay at home if ill with symptoms of an ILI. Staff and volunteers who are ill with symptoms of an ILI should isolate themselves at home and not return to work until they are feeling well and able to return to their normal activities. Staff and volunteers who become ill while at work should isolate themselves in a room separate from others until they can leave the facility. It is recommended that staff and volunteers who become ill while at work not use mass transit to travel home whenever possible.    

Monitoring and Support for Residents/Service Users

It is recommended that operators of communal living facilities develop plans and procedures for the monitoring and support of residents/service users for signs and symptoms of ILI and for the isolation of sick persons once identified. Operators of communal living facilities should be advised to consult with local public health officials when they observe a higher number of cases of ILI than expected or when the illness appears to be more severe.

Residents/service users who are displaying the signs and symptoms of a possible ILI should be isolated in their sleeping quarters and encouraged to continue practising good respiratory etiquette and hand hygiene. If unable to practise respiratory etiquette and if available, a surgical mask could be worn to reduce the risk of spreading the virus within the setting.

In the case of shared sleeping quarters, it is recommended that ill residents/service users be cohorted (grouped together) as much as possible. Where possible, beds should be located at least 2 metres apart². A head-to-foot sleeping arrangement can help to provide distancing between individuals. Consideration may be given to the use of temporary barriers in large shared sleeping quarters to separate ill service users (e.g. curtains hung between beds) if a separate room is not available.

The number of staff caring for ill residents/service users should be limited where possible. It is recommended that facilities make arrangements to support residents/service users who are ill with supplies of fluids, food, tissues and waste receptacles. 

Stockpiling supplies in preparation for an outbreak of an ILI is recommended and stockpiles should include food, fluids, tissues, hand washing supplies, extra linens and cleaning supplies.   

More information on caring for persons who are ill with ILI can be found at How to look after someone at home with H1N1 Flu Virus.

Hand Hygiene and Respiratory Etiquette

Hand hygiene and covering coughs and sneezes are an important means of preventing the transmission of pandemic H1N1 influenza virus.

Respiratory etiquette involves coughing and sneezing into one's elbow or sleeve rather than one's bare hands if tissues are unavailable, or coughing/sneezing into a disposable tissue, discarding the tissue immediately and cleaning one's hands afterwards.

Hand washing facilities should be provided with a constant supply of clean water, hand soap and a single-use hand drying method (e.g., paper towels). Hand washing facilities may be supplemented with alcohol-based hand rubs with a concentration of at least 60% alcohol; however it should be noted that alcohol-based hand rubs are not an effective means of hand cleaning if hands are visibly soiled.

For safety reasons, in some communal living settings such as homeless shelters and drop-in centers, it may be advisable to have alcohol-based hand rubs dispensed by staff or from secure dispensers. Product specific Material Safety Data Sheets and the product labels provide additional information regarding placement, storage and warnings associated with alcohol-based hand rubs.

It is recommended that supplies of tissues and waste receptacles be provided throughout facilities. Waste receptacles should be emptied frequently into the regular trash disposal containers.

Environmental Cleaning

It is recommended that operators of communal living facilities conduct regular training with all staff and volunteers on correct cleaning procedures, cleaning product use and hand hygiene. In addition to routine cleaning and sanitation practices, it is recommended that there be an increase in the frequency of cleaning of common areas and high-touch surfaces such as doorknobs, hand rails and faucet taps. Typically, no special disinfectants or waste handling practices are required for influenza. Waste handling would be according to usual standards and many readily available household or commercial disinfectant cleaning products are effective against influenza viruses. More specific information can be found on the cleaning product label.

Linens such as bedding and towels can be laundered in the usual manner using routine laundry products and tumbled dry on a hot setting. Staff should be educated regarding the need to wash their hands after cleaning or handling soiled linens.

It is not recommended that residents/service users be responsible for the sanitation of the facility unless trained in the use of cleaning products and cleaning procedures and are supervised.

Other Recommendations

Because individual facilities may not be able to provide an increased level of service if required, it is recommended that service providers engage in community-based planning for outbreaks of ILI with other service providers and community organizations. Such planning could include:

• Developing contingency plans for staffing and business continuity such as combining resources with other shelters,
• Educating and training staff to recognize the signs and symptoms of a severe respiratory illness,
• Identifying appropriate medical treatment facilities in their neighbourhoods and,
• Developing plans for the safe transportation of severely ill individuals to a medical treatment facility.

Operators of homeless shelters should review policies around the length of stay for service users. Allowing service users to stay in one shelter for longer periods of time rather than moving to different shelters may assist in reducing the transmission of ILI.

It is recommended that operators of facilities that close during the day consider arrangements that would allow service users who are mildly ill with an ILI to stay during the day.

Good ventilation may help to reduce the risk of transmission of influenza. Consequently, ensuring to the extent possible that all rooms in communal living settings are kept well ventilated or, where a mechanical ventilation system is used, the system is maintained to provide at least the minimum number of air changes per hour as specified by local building codes, should be considered. This applies to all rooms used by staff, volunteers and residents/service users. 

Closure of Shelters

The Public Health Agency of Canada does not recommend general closures of facilities such as homeless shelters and drop-in centers due to the pandemic (H1N1) 2009 influenza as this would place an undue burden on the populations served by these services.

The decision to close facilities such as homeless shelters lies at the discretion of local authorities and service providers, taking into consideration the local situation and the capacity of facilities to continue to maintain service levels.

It is recommended that local public health officials work with service providers to establish processes to help prevent and control the spread of ILI in these settings.

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