Guidance for the Preparedness and Management of Influenza-Like Illness (ILI), Including Pandemic (H1N1) 2009, in Residential Facilities in Remote and Isolated Communities

Posted 2009-11-04

Table of Contents

• Introduction

• PREPAREDNESS and PREVENTION

  • Planning Considerations
  • Education Programs
  • Hand Hygiene and Respiratory Etiquette
  • Environmental Cleaning
  • Vaccines

• MANAGEMENT

  • Outbreak Control
  • Screening
  • Assessment and Treatment
  • Self-Isolation of Ill Individuals
  • Closure of residential facilities
• References

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Introduction

This guidance document has been prepared to provide guidance to facility managers and planners on preparing for and  managing outbreaks of influenza-like illness (ILI) ⁱ, including pandemic (H1N1) 2009 in residential facilities (e.g. personal care homes, group homes, women’s shelters, homeless shelters, correctional institutions, and addictions facilities) in remote and isolated communities.

Residential facilities in remote and isolated communities may not fit the standard description of a closed facilityⁱⁱ in an urban centre.  For guidance on managing an outbreak in a closed facility, which should be used in collaboration with provincial/territorial plans/authorities, refer to Guidance for the Management of Pandemic (H1N1) 2009 Outbreaks in closed facilities ¹.  Residential facilities in remote and isolated communities may be more similar to home environments and therefore require guidance specific to their situation. Some of the challenges these facilities face include a lack of surge capacity, limitations of space and access to resources, and long distance to larger centers where health care and other services might be provided.

These guidelines are based on the management of seasonal influenza outbreaks, and our evolving understanding of the behaviour of pandemic (H1N1) 2009 influenza virus. The guidelines provide recommendations for planning considerations, and outbreak management of ILI in residential settings.  They do not supersede clinical and public health judgment or provide guidance on the management of individual patient care.  Facility managers and planners are encouraged to work with their regional health authority in planning and responding to an ILI outbreak.

PREPAREDNESS and PREVENTION

Planning Considerations

The following factors should be considered in planning for influenza outbreaks in residential facilities:

• Business continuity or ability to maintain essential services during an outbreak, including availability of volunteers.  There may be difficulty maintaining operations given small numbers of staff in facilities in remote and isolated communities. Strategies to deal with this may need to be developed in collaboration with public health/health care providers.  Guidance can be found in the Guidelines for Health Services Planning in Remote and Isolated Communities².
• Harmonization of the facility plan with the community’s pandemic/emergency plan.
• Health status of residents.
• Access to health care, primary and urgent.
• Access to pharmaceuticals and basic necessities.
• Access to medical advice 24 hours a day.
• Availability of timely information regarding pandemic (H1N1) 2009.
• Movement of people in and out of the facility (i.e., public and residents).

Some general planning activities are listed in Annex A: Planning Checklist of the Canadian Pandemic Influenza Plan for the Health Sector (CPIP)³, and may be applicable to residential facilities in remote and isolated communities.

Education Programs

It is recommended that education programs for staff, volunteers and residents/service users be developed on the following:

• Early identification and isolation of ill persons exhibiting ILI symptoms;
• Be aware of signs and symptoms of ILI;
• When ill, stay away from others as much as possible to help prevent infecting others;
• Careful and frequent hand hygiene and respiratory etiquette;
• Avoiding touching one’s eyes, nose and mouth;
• Do not share drinks, eating utensils, cigarettes;
• Avoiding contact with people who are sick with ILI and, if unable to do so, maintaining a 2-metre separation from others as much as possible;
• When the vaccine is available, get immunized.

Hand Hygiene and Respiratory Etiquette

Proper hand hygiene and respiratory etiquette (covering coughs and sneezes) are important means of preventing the transmission of the pandemic (H1N1) 2009 influenza virus.

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

Hand washing with plain soap and water is a very effective method of hand hygiene in the community, as the mechanical action is effective at removing visible soil as well as microbes.  Where hand washing is not possible, use of alcohol-based hand rubs (with 60-90% alcohol) is recommended; however, alcohol-based hand rubs alone may not be effective if hands are visibly soiled. In settings such as homeless shelters and drop-in centers, alcohol-based hand rubs should be dispensed by staff or from dispensers secured to the wall.

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

Environmental Cleaning

Cleaning of high-touch objects and surfaces (e.g. doorknobs, faucet handles, work surfaces, computer keyboards, telephones, hand rails, etc.) will help to prevent the transmission of the influenza virus from objects-to-person and person-to-person through contaminated hands.

To help mitigate the risk of individuals becoming infected through self-inoculation after touching contaminated surfaces, it is recommended that residential facilities frequently (at least twice daily) clean high-touch surfaces and ensure that adequate hand hygiene supplies are available at all times.  Facilities in remote and isolated communities should give consideration to stockpiling an adequate amount of household cleaners.

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. Dishes, clothing, and sheets used by an individual with ILI can be washed using ordinary detergent and water.

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.

Vaccines

Vaccination is the primary prevention strategy for influenza.  Current recommendations on seasonal flu vaccination, when available, can be found on the National Advisory Committee on Immunization website at www.naci.gc.ca.  

Pandemic (H1N1) 2009 vaccine became available in October 2009. The sequencing strategy for pandemic vaccine identifies groups and individuals that will benefit most from immunization, and those who care for them⁴.  These include:

• people with chronic medical conditions under the age of 65;
• pregnant women;
• children six months to under five years of age;
• people living in remote and isolated settings or communities;
• health care workers involved in pandemic response or who deliver essential health services;
• household contacts and caregivers of individuals who are at high risk, and who cannot be immunized (such as infants under six months of age or people with weakened immune systems); and
• populations otherwise identified as high risk.

MANAGEMENT

Outbreak Control

Facilities should notify their health care provider or regional health authority, as per usual practice, whenever the number of cases of ILI is higher than expected or there is severe illness. Unless protocols are in place that note otherwise, the Medical Officer of Health will determine the extent of outbreak control measures and the need for restrictions on admissions and transfers from the facility.  Facilities are encouraged to work with their regional health authority for information and to assist in the response.

Screening

Residents, employees and visitors should self-screen for signs of ILI. Signage describing the signs/symptoms of ILI is generally posted at the entrance of a facility instructing those with these symptoms to not enter the premises. Staff, volunteers or visitors who have been ill with ILI should remain at home until they are feeling well and able to fully participate in all normal day-to-day activities.

Assessment and Treatment

Usual practices for accessing medical services and medications should be followed. For health services during an emergency, it is best to be plan ahead with regular healthcare providers and regional health authorities. Facility managers and planners are encouraged to work with their regional health authority in responding to an ILI outbreak. To date, infection with the pandemic influenza (H1N1) 2009 virus has resulted in symptoms similar to seasonal influenza.

If health care is provided in your facility, guidance can be found in the following documents:

• Interim Guidance for Ambulatory Care of Influenza-Like Illness in the context of H1N1 influenza virus, found at:

http://www.phac-aspc.gc.ca/alert-alerte/h1n1/guidance-orientation-amb-07-16-eng.php.

• Guidance for the Clinical Management of Patients with Influenza-Like Illness in the context of pandemic (H1N1) 2009 in Remote and Isolated Communities, found at: link to be added when posted.
• Annex G of CPIP, Health Services: Clinical Care Guidelines and Tools, found at: http://www.phac-aspc.gc.ca/cpip-pclcpi/ann-g-eng.php.

Antiviral prescription and overseeing their use should occur according to regular facility practices. Treatment for influenza with antiviral medication is the same for residents of these facilities as it is for the general public.

Reports of adverse reactions to antiviral medications are an important source of information that will help guide their safest and most effective use. Consult a healthcare provider if an adverse reaction is suspected.

Self-Isolation of Ill Individuals

As noted above, to help reduce transmission between ill persons and those who are healthy, prompt recognition of symptoms and early self-isolation of individuals with symptoms is key. Individuals with ILI should self-isolate until they are feeling well and able to fully participate in all normal day–to-day activities.

 

Where possible, beds should be located at least 2 meters apart. 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.  Staying connected with others is important during a pandemic, especially for individuals who are isolated for the purpose of infection control.  Where possible, ensure that appropriate methods of contacting family and friends are made available to isolated residents (e.g. phone, e-mail, texting)

Staff movement between floors, in multi-level facilities, may be restricted. It is anticipated that, during a pandemic outbreak, affected residents in facilities with special requirements will, in most cases, be treated and recover within those facilities.  Medical attention should be sought for residents who become severely ill.  

In the event of a more widespread or severe outbreak, facilities may restrict the admission of all non-essential staff, visitors and the public for the duration of that episode, for the protection of residents, staff, friends and relatives of residents.  Similarly, affected residents may be isolated within facilities until the risk of transmission has passed.This may not be feasible in circumstances where there are overcrowding or transient (temporary) populations.

Although there is only limited evidence to support the use of masks in households as a means to reduce influenza transmission within the household, there may be some benefit in having the ill individual wear a mask when in a room with well individuals in an effort to help reduce the risk of spreading the virus to others.

There is currently insufficient evidence to suggest that the wearing of masks by asymptomatic individuals (e.g. caregivers) will help to reduce the transmission of influenza in the household setting. While asymptomatic caregivers may choose to use a facial or surgical mask when caring for someone with ILI who is not wearing a face mask, this may not provide any benefit unless strict adherence to proper mask use and good personal hygiene practices are followed, including regular hand hygiene. 

Closure of residential facilities

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. The Public Health Agency of Canada does not recommend general closures of facilities such as homeless shelters and drop-in centers due to pandemic H1N1 (2009) influenza as this would place an undue burden on the populations served by these services. It is recommended that local public health officials work with service providers to establish programs to help prevent and control the spread of ILI in these settings. 

References

Footnotes