Guidance: Infection Prevention and Control Measures for Health Care Workers in Long-term Care Facilities

Human Cases of Pandemic (H1N1) 2009 Flu Virus

This fact sheet has been developed to provide guidance for health care workers (HCWs) in long-term care (LTC) facilities for the infection prevention and control management of residents with Influenza-like Illness (ILI) suspected or confirmed to be due to Pandemic (H1N1) 2009 (H1N1 2009).

The goal of H1N1 2009 Infection Prevention and Control Measures in Long-term Care is to keep the facility (or major areas of the facility) completely free of the influenza virus in the first place.

This Guidance is designed to help slow (mitigate) the transmission of this virus; it is expected that the infection prevention and control recommendations (particularly recommendations related to respiratory protection) may change as further information about the epidemiology (e.g., mode of transmission) and clinical course (e.g., mild or severe disease) of this virus is available and the outbreak evolves. In this document, a point of care risk assessment approach is used to help guide decisions regarding the type of droplet precautions/respiratory protection to apply (Appendix A).

This guidance document is being provided by the Public Health Agency of Canada in response to the Pandemic (H1N1) 2009 Flu Virus outbreak.  This guidance is based on current, available scientific evidence about this emerging disease, and is subject to review and change as new information becomes available.  The following guidance should be read in conjunction with relevant provincial and territorial guidance documents.  The Public Health Agency of Canada will be posting regular updates and related documents at www.phac-aspc.gc.ca.  The content of this document has been informed by discussion with and technical advice provided by the Infection Control Expert Advisory Group to PHAC.

At this time the evidence suggests that the incubation period for H1N1 2009 is up to 7 days and individuals may remain infectious for up to 7 days. These timelines are similar to prior experience with human swine influenza viruses. Spread of H1N1 2009 has been almost exclusively in the community setting to this point, and this is where most exposures for the general public and health care workers alike will occur. The clinical picture to date of human illness from H1N1 2009 is one of mild disease, however some will experience severe disease. H1N1 2009 is susceptible to the antiviral agents, oseltamivir and zanamivir, which represent therapeutic options for individuals in whom treatment is indicated. This information on morbidity and mortality and treatment options has been taken into account when updating this guidance. As noted above, as this virus spreads throughout the world, the clinical and epidemiological picture may change, requiring further modifications to this guidance. One goal of this revised guidance is, using a risk assessment approach, to support use of personal protective equipment most appropriate to the risk associated with the care to be provided, thereby protecting limited resources for those situations where protection is most needed.

The following criteria for influenza-like illness (ILI) can be used to determine the need for applying the infection prevention and control measures found in this guidance:

• Acute onset of respiratory illness with cough, with or without fever (in children under 5 years of age and adults 65 years of age and older fever may not be present with infection; additionally, fever has not been a consistent symptom with H1N1 2009; in children under 5 years of age GI symptoms may also be present)
• And one or more of: sore throat, arthralgia, myalgia, or prostration that could be due to influenza

It should be noted that the ILI screening criteria will also capture individuals who meet the criteria for severe respiratory illness (SRI). Individuals with SRI have chest radiograph findings of pulmonary infiltrates in addition to the screening criteria noted below. It should also be noted that these screening criteria will be updated as the epidemiological situation evolves.

Along with Routine Practices and Droplet/Contact Precautions required for care of residents with seasonal influenza, infection prevention and control measures in long-term care facilities to prevent H1N1 2009 from entering the facility, and control its transmission within the facility should include:

1. Source Control
2. Screening
3. Hand Hygiene
4. Respiratory Hygiene (also known as Respiratory Cough Etiquette)
5. Accommodation
6. Contact Precautions
7. Droplet Precautions/ Respiratory Protection (Mask1/N95 respirator; and eye/ face protection)
8. Resident Transfer
9. Cleaning and Disinfection of Equipment
10. Visitors
11. Social Activities and Outside Appointments
12. Treatment and Prophylaxis
13. Reporting

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Source control, achieved through administrative and engineering measures, is the most effective way to prevent the transmission of infectious agents, including H1N1 2009, in the long term care setting.

The infection prevention and control measures outlined below are to be practiced with symptom(s) onset and until symptom(s) have resolved.

1. Source Control:
   

   Source Controls (engineering [e.g. use of partitions to establish 2 metre distance between residents with ILI and others] and administrative [e.g. limiting access for visitors with symptoms of ILI]).
   The importance of applying administrative and engineering controls as the first strategy in protecting residents and HCW from exposure to infectious agents in the LTC facility cannot be overemphasized.  LTC organizations should complete assessments of each area of all of their LTC facilities including the physical plant (e.g. availability of single rooms, use of partitions, ability to establish 2 metre distance between residents with ILI and others) and the types of resident care activities undertaken in residential areas. Based on these assessments, organizations needs to determine what administrative and engineering controls are needed. This is especially important for residential care areas/settings where residents are returning from visits/appointments in the community where H1N1 2009 is circulating.

2. Screening:
   

   2.1 Families/ Visitors  - A key goal is to prevent introduction of H1N1 2009 into the facility; signage (in multiple languages, as appropriate) should be posted at all entrances to the LTC facility reminding persons entering the facility NOT to enter if they are having symptoms of ILI such as fever, cough, sore throat, arthralgia, or myalgia. Posted signage should provide clear instructions on how to perform respiratory hygiene and hand hygiene. At a minimum, passive screening² of families and visitors for respiratory symptoms should be performed. Active screening³ measures should be considered in anticipation of their being initiated if influenza is actively spreading in the community or during a community influenza outbreak.

   2.2 Staff - Staff should perform self-assessment for symptoms of ILI and should not work if they are experiencing an ILI.  Staff should be reminded of the importance of reporting their illness to those responsible for Occupational Health if they develop symptoms of ILI while on duty, and should be reminded to go home if they develop symptoms of ILI.

   2.3 Residents - Enhanced screening of residents for symptoms of ILI should be conducted; all residents should be monitored at least once per day.  Residents should be monitored for signs and symptoms of complications related to influenza and should be transfered to acute care as required (see Resident Transfer, #8 below).  In the event of a local community outbreak of H1N1 2009, monitoring should be increased to twice daily.

3. Hand Hygiene:
   

   All persons entering the facility should practice good hand hygiene.
   Signage with clear instructions for residents, HCWs, other staff, visitors, contractors, etc. to perform hand hygiene should be posted. 
   Alcohol-based hand rub should be available at the entrances to and exits from the facility, residential units, and at point-of-care in the resident’s room.
   HCWs should perform hand hygiene frequently using either alcohol based hand rubs (60-90%) or soap and water.

4. Respiratory Hygiene (Respiratory Cough Etiquette):
   

   All residents should be taught to perform hand hygiene, if physically/ cognitively feasible (See Hand Hygiene, #3 above); if residents are unable to perform hand hygiene, they should be assisted with hand hygiene.

   Residents should also be taught how to perform respiratory hygiene practices (coughing into sleeve, using tissues, wearing a mask1), if physically/ cognitively feasible.
   Residents suspected of having ILI should wear a mask (if tolerated) when HCWs, or other staff or visitors are present.

5. Accommodation:
   

   5.1 In the Absence of an Influenza Outbreak in the LTC Facility - Any resident who is identified with symptoms of ILI should be placed on additional (Droplet/Contact) precautions without delay and should be placed in a single room, if possible.  If it is not possible to place a resident with symptoms of ILI in a single room, a separation of two metres should be maintained between the bed space of the ill resident and all roommates, and privacy curtains should be drawn. Appropriate signage should be posted on the symptomatic resident’s room door indicating the precautions required. The resident with ILI should be restricted to his/ her room (bed space), including during meals and any other clinical or social activity. Contact tracing should be initiated and all resident(s) who share (d) a room with the ill resident should be considered as exposed to influenza and should be monitored for symptoms of ILI at least twice per day for seven days. Exposed roommates should not be transferred to any other room for seven days after the last exposure.

   5.2 During an Influenza Outbreak in the LTC Facility –If the LTC facility has an Influenza Isolation Area (IIA) consider opening the IIA to accommodate residents (depending on their care needs) with symptoms of ILI. Any resident (i.e. new admissions, residents returning from the community, residents acquiring influenza while in the LTC facility) who is identified with symptoms of ILI should be immediately transferred to the IIA. Additional precautions should be implemented without delay. Appropriate spatial separation should occur and privacy curtains should be drawn between all residents. Appropriate signage should be posted on the room door indicating the precautions required. Where possible, HCWs and other staff should be identified to work exclusively in the IIA. Residents admitted to the IIA should be expected to remain for a minimum of seven days (i.e. one period of communicability) (and symptoms are resolving before returning to their regular room).

   Recommendations in 5.1 for accommodation should be followed if an IIA is not opened.

6. Contact Precautions:

   Should wear gloves when entering the room of a resident suspected to have ILI.
   Should remove gloves just before leaving the room and dispose of them in an appropriate receptacle.
   Gowns should be required as per Routine Practices. When worn, gowns should be removed just before leaving the room and disposed of in a hands-free receptacle.
   Should use alcohol based hand rubs or soap and water after removing gown and gloves, and after leaving the resident’s room.

7. Droplet Precautions/Respiratory Protection
   

   Should wear a mask1 (droplet precautions) or N95 respirator (respiratory protection) when within 2 metres of a resident with ILI. The choice between a mask1 and N95 respirator should be based on the following:

   A mask1 should be worn:

   • If  within 2 metres of a resident with ILI

   An N95 respirator should be worn:

   • If conducting an aerosol-generating medical procedure, such as tracheal or oral suctioning (see AGMP2 below for detailed list of AGMP examples) on a resident with ILI, personnel in the room should be
   • limited to only those necessary. It is preferred that AGMP⁴ be done in single patient rooms. All individuals in the room should wear an N95 respirator.

   Whenever a mask1 or N95 respirator is required, the HCW should also wear eye or face protection (i.e. goggles, safety glasses or face shield). Eye or face protection should be removed after leaving the resident’s room and disposed of in either a hands-free waste receptacle (if disposable) or in a separate receptacle to go for reprocessing (if reusable).

   The mask1 or N95 respirator should be removed by the straps, being careful not to touch the mask1 or respirator itself, after leaving the resident’s room and disposed of in a hands-free waste receptacle.

   HCWs should perform hand hygiene before and after removing the mask1/respirator and eye/face protection and after leaving the resident’s room.
8. Resident Transfer:

   Residents with ILI who require urgent medical attention and transfer to an acute care facility should wear a mask1, if tolerated. 
   In addition to Routine Practices, HCWs involved in transporting the resident should wear mask1/respirator, eye or facial protection, and gloves as per above recommendations.
   Notify the EMS and receiving hospital of the need for Additional Precautions due to the resident’s illness.

9. Cleaning and Disinfection of Equipment:

   Equipment and environmental surfaces should be cleaned and disinfected daily.

   Any equipment that is shared between residents should be cleaned and disinfected before moving from one resident to another.
10. Visitors:

    10.1 In the Absence of an Influenza Outbreak - Passive screening measures (as in Screening, #2 above) should be practiced, reminding persons NOT to enter if they are having symptoms of ILI such as fever, cough, sore throat, arthralgia, or myalgia. Families and visitors should be asked to stay away until 24 hours after symptoms resolve or 7 days after the onset of their illness, whichever is longer. If an ill visitor is allowed to visit for compassionate reasons, the visitor should be asked to wear a mask at all times when in the facility and SHOULD NOT participate in activities in the long-term care setting while ill.

    10.2 During Active Influenza or an Influenza Outbreak in the Community – Consideration should be given to restricting visitor entrances to the LTC facility to a single door. Active screening of all family and visitors for symptoms of ILI should be initiated. Any family or visitor with symptoms of ILI should be restricted from entering (except for visitation of terminally ill residents). If an ill visitor is allowed to visit for compassionate reasons, the visitor should be asked to wear a mask at all times when in the facility and SHOULD NOT participate in activities in the long term care setting while ill.

    10.3 All visitors to a resident with ILI should be offered the same Droplet/Contact protection (i.e., personal protective equipment) as that worn by HCWs.

11. Social Activities and Outside Appointments:

    11.1 In the Absence of an Influenza Outbreak in the LTC Facility and Community – For the resident with ILI, all social activities and outside appointments for that resident should be postponed unless medically necessary (See Resident Transfer, #8). No restrictions for residents without symptoms are suggested.

    11.2 During an Influenza Outbreak in the LTC Facility –Organized social activities should be cancelled.

    11.3 During an Influenza Outbreak or Active Influenza in the Community - Organized community social activities should be cancelled. All family home visits, especially to homes where a family member has symptoms compatible with ILI should be discouraged. All outside appointments should be postponed unless medically necessary (See Resident Transfer, #8).

12. Treatment and Prophylaxis:

    The use of antiviral drugs to control outbreaks of influenza in closed facilities such as long-term care is to include treatment for residents with influenza and to provide prophylaxis to contacts (residents and staff).  During an influenza outbreak, antiviral prophylaxis may involve the whole facility, or an individual unit if the outbreak is restricted to that unit, and there is very little mixing of staff or residents between units. Further information can be found in Guidance for the Management of Pandemic H1N1 2009 outbreaks in closed facilities^1.

    Please refer to Annex E, Section 5.3.4, and ‘Canadian Pandemic Influenza Plan for the Health Sector. The Use of Antiviral Drugs during a Pandemic’, version May 12, 2009, Section 5.4, available at: http://www.phac-aspc.gc.ca/cpip-pclcpi/pdf-e/annex_e0513-eng.pdf and ‘Use of antivirals to treat H1N1 flu virus (Human Swine Flu)’ available at http://www.phac-aspc.gc.ca/alert-alerte/h1n1/antiviral-antiviraux05-01-eng.php.

13. Reporting:
    

    Notify the person responsible for infection prevention and control at the LTC facility of residents with symptoms of ILI.  The person responsible for infection prevention and control at your facility will notify Public Health of suspected or confirmed cases of H1N1 2009.

• ILI protocols and case-investigation form available at the following websites:
  http://www.phac-aspc.gc.ca/eri-ire/pdf/02-ILI-Surveillance-Protocol_e.pdf
  http://www.phac-aspc.gc.ca/eri-ire/pdf/03-ILI-Report-Form_e.pdf

• Nosocomial and Occupational Infections Section, Centre for Communicable Diseases and Infection Control, PHAC http://www.phac-aspc.gc.ca/nois-sinp/index-eng.php

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