I 6A4E RI Outbreak Guidelines March17

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Respiratory Infection Outbreak Guidelines for
Healthcare Facilities
Reference Document for use by Health Care Organizations
for Internal Policy/Protocol Development
February 2011
Revised from Provincial Infection Control Network
Reference for Respiratory Outbreak Prevention and Control Guidelines
February 2007
British Columbia Provincial Infection Control Network
Revision Working Group
Joanne Archer, RN, BTech, MA Terry Dickson, RN
Educator/Consultant Infection Control Practitioner
Provincial Infection Control Network Fraser Health
Dr. Larry Gustafson, MD, MHSc Dr. Martin Petric, PhD, FCCM
Medical Health Officer Clinical Virologist
Fraser Health BC Center for Disease Control
Monica Sephton, RN, BSN Dr. Danuta Skowronski, MD, MHSc, FRCP
Infection Control Practitioner Physician Epidemiologist
Northern Health BC Center for Disease Control
Joanne Tench, RN
Infection Control Practitioner
Interior Health
Acronyms
ABHR Alcohol based hand rub
AGMP Aerosol generating medical procedure
BAL Broncho-alveolar Lavage
BCWCH British Columbia Women’s and Children’s Hospital
BCCDC British Columbia Centre for Disease Control
DFA Direct Fluorescent Antibody Assay
ET Endotracheal
GRG Guidelines review group
HCP Health Care provider
HMPV Human Metapneumo virus
HPIV Human Parainfluenza Virus
ICP Infection Control Practitioner/Professional
IFA Indirect Fluorescent Antibody Assay
ILI Influenza-like Illness
ICO Infection Control Officer
MHO Medical Health Officer
NP Nasopharyngeal
OHN Occupational Health Nurse
OPMT Outbreak Prevention and Management Team
PHAC Public Health Agency of Canada
PHN Public Health Nurse
PICNet Provincial Infection Control Network of British Columbia
POC Point of care
PPE Personal Protective Equipment
RI Respiratory Infection
RSV Respiratory Syncytial Virus
RT-PCR Reverse Transcription Polymerase Chain Reaction
SARS Severe Acute Respiratory Syndrome
TB Tuberculosis
VIRAP Viral Rapid Testing
WH&S Workplace Health and Safety
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
Table of Contents
1. Introduction .............................................................................................................................................................. 5
2. Purpose..................................................................................................................................................................... 5
3. Scope ........................................................................................................................................................................ 5
4. Literature Search Strategy ............................................................................................................................................ 6
5. Methods .................................................................................................................................................................... 6
6. Outbreak Prevention and Management Team................................................................................................................. 6
6.1 Roles and Responsibilities During a Respiratory Infection Outbreak ............................................................................ 7
6.2 Outbreak Prevention and Management Team Meetings.............................................................................................. 8
6.2.1 Responsibilities of the OPMT in the Non-Outbreak Period ............................................................................ 8
7. Identifying an Outbreak............................................................................................................................................. 10
7.1 Case Definition for Respiratory Infection ............................................................................................................... 10
7.2 Suspected and Declared outbreaks......................................................................................................................... 10
7.3 Identifying the Source.......................................................................................................................................... 11
8. Collection of specimens............................................................................................................................................. 11
8.1 Selecting the Appropriate Diagnostic Testing Methodology ...................................................................................... 11
8.2 General Recommendations for Specimen Collection and Transport........................................................................... 12
9. Reporting and Notification ........................................................................................................................................ 13
10. General Principles of Control ................................................................................................................................... 13
10.1 Immunizations .................................................................................................................................................. 13
10.1.1 Influenza vaccine................................................................................................................................... 13
10.1.2 Pneumococcal polysaccharide vaccine ...................................................................................................... 13
10.1.3 Immunization of Visitors........................................................................................................................ 14
10.2 Routine Practices............................................................................................................................................... 14
10.2.1 Hand Hygiene ....................................................................................................................................... 14
10.2.2 Respiratory Hygiene...............................................................................................................................14
10.2.3 Point of Care Risk Assessment (22).......................................................................................................... 15
10.2.4 Patient/Resident Placement .................................................................................................................... 16
10.2.5 Risk Reduction Strategies (22) ................................................................................................................. 16
10.2.6 Education of Healthcare Providers, Clients and Families/Visitors/Volunteers (22) ........................................ 16
10.3 Additional Precautions (22)................................................................................................................................. 16
10.3.1 Isolation/Spatial/Barrier Separation......................................................................................................... 17
11. Personal Protective Equipment for Contact/Droplet Precautions ................................................................................. 18
11.1 Facial Protection (22) ........................................................................................................................................ 18
11.2 Gloves ............................................................................................................................................................. 19
11.3 Gowns ............................................................................................................................................................. 19
12. Aerosol Generating Medical Procedures (30, 31, 35, 48-51) .......................................................................................... 19
12.1 Patients Requiring Mechanical Ventilation (49): ..................................................................................................... 20
13. Transfers to Other Facility/Department .................................................................................................................... 20
14. Cohorting of Patients/Residents ............................................................................................................................... 20
15. Activity Restrictions ................................................................................................................................................ 21
15.1 Group Activity Restrictions................................................................................................................................. 21
15.2 Visitor Restriction.............................................................................................................................................. 21
16. Admissions and Transfers ........................................................................................................................................ 22
17. Healthcare Provider Exposure and Illness .................................................................................................................. 23
18. Ongoing Surveillance of Patients/Residents and Staff.................................................................................................. 23
19. Housekeeping......................................................................................................................................................... 23
19.1 Cleaning Processes............................................................................................................................................. 23
19.2 Disinfectants..................................................................................................................................................... 24
20. Problem Solving When Control Measures Appear to be Failing .................................................................................... 24
21. Declaring the Outbreak Over ................................................................................................................................... 25
22. Debrief of Lessons Learned ..................................................................................................................................... 25
23. Influenza Specific Information and Interventions........................................................................................................ 25
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
23.1 Epidemiology.................................................................................................................................................... 25
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
23.2 Types of Influenza Viruses (56) .......................................................................................................................... 26
23.3 Potential Complications of Influenza A and B Infections (57)................................................................................. 26
24. Healthcare Provider Yearly Immunization Clinics ....................................................................................................... 26
25. Immunization for Residential Care Residents.............................................................................................................. 27
26. Immunization for Acute Care Patients....................................................................................................................... 27
27. Antivirals ............................................................................................................................................................... 28
27.1 Planning for Antiviral Use................................................................................................................................... 28
Glossary...................................................................................................................................................................... 29
Appendix 1: Public Health Agency of Canada, Rating Scale for Strength and Quality of Evidence .......................................... 32
Appendix 2: Checklist of Yearly Preparation for RI Outbreaks........................................................................................... 33
Appendix 3: Quick Reference Checklist .......................................................................................................................... 34
Appendix 4: Common Viral and Bacterial Pathogens That Cause RI Outbreaks ................................................................... 36
Appendix 5: Laboratory Services for Viral testing of Respiratory Specimens ........................................................................ 39
Appendix 6: Procedures for Respiratory Specimen Collection ............................................................................................ 41
Appendix 7: Laboratory Requisition Samples................................................................................................................... 44
Appendix 8: Initial Outbreak Report Form..................................................................................................................... 46
Appendix 9: 2010-2011 British Columbia Centre for Disease Control Staff Influenza Immunization and Exclusion Policy ....... 47
Appendix 10: Outbreak Surveillance Form - Patients/Residents/Clients ............................................................................. 53
Appendix 11: RI Outbreak Surveillance Form – HCPs...................................................................................................... 54
Appendix 12: Daily Update Outbreak Report for OPMT .................................................................................................. 55
Appendix 13: Outbreak Summary Report for OPMT........................................................................................................ 56
References .................................................................................................................................................................. 57
1. Introduction
Respiratory infections (RI) are often spread when droplets, generated from coughing and sneezing by
infected people, come into contact with the mucous membranes of the eyes, mouth, nose, or airway of a
another person. Because microorganisms in droplets can often survive on surfaces, infections can also be
spread indirectly when people touch contaminated hands, surfaces and objects and inoculate themselves by
touching their mucous membranes.
Outbreaks of respiratory infection in BC predominantly occur between October and March each year.
Influenza is a major cause of respiratory outbreaks, but outbreaks can also be caused by other viruses such
as parainfluenza virus, respiratory syncytial virus (RSV), coronavirus, rhinovirus, human metapneumovirus
and adenovirus, and less commonly by bacterial pathogens such as Mycoplasma pneumoniae, Legionella sp.,
Chlamydia pneumoniae, and Streptococcus pneumoniae (1). The dominant causal organisms are highly variable from
season to season and across geographic areas or specific locales or settings. For example, in a Canadian study
by Loeb et al. (2000) the most common organism identified was parainfluenza virus, followed by Influenza
A, although in just over 1/3 of the outbreaks studied multiple causal organisms were identified(2). Another
study by Falsey et al. (2008) found the most common organism involved in RI outbreaks in Boston
residential care facilities to be human metapneumovirus followed by coronavirus 228E (3).
Of the etiologic agents, influenza A and B viruses are of greatest concern because of their epidemic seasonal
behaviour and their relatively high levels of morbidity and mortality, especially amongst the population at the
extremes of life (4). For both Influenza A and B there are effective interventions that can prevent infections
and mitigate outbreaks such that early identification of their possible contribution to respiratory illness is
important.
2. Purpose
These guidelines describe the infection prevention and control practices for respiratory infections that are
primarily droplet spread. Implementing these guidelines will enable the healthcare system to detect and
contain clusters and outbreaks of common respiratory infections and assist in the detection of novel
pathogens.
3. Scope
These guidelines are not intended to replace local or regional processes, but rather to serve as a reference for
all healthcare settings when developing or updating their own policies. The recommendations described in
this document exemplify best practices in the prevention and control of seasonal droplet-spread respiratory
outbreaks.
These guidelines are designed to address seasonal respiratory infections (RI) that are primarily spread by
large droplets. Although the basic control measures described in these guidelines are to be used for
outbreak prevention and control of all respiratory infections, specific respiratory infections such as SARS,
tuberculosis or an emerging pathogen with unknown characteristics require special consideration and
additional control measures.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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While evidence has shown that some seasonal respiratory infections have a component of aerosol spread the
burden of transmission by the airborne route remains controversial(5). For known airborne spread
infections (e.g. measles, TB), specific guidelines should be followed as laid out by your regional health
authority, the BC Center for Disease Control (6), and the Public Health Agency of Canada (7). These
illnesses are beyond the scope of this document. Pandemic Influenza events also fall beyond the scope of
this document.
4. Literature Search Strategy
Electronic searches of Medline, Science Direct, PubMed, Google Scholar and Cinahl (2006 -November
2010) were carried out to identify new findings to update this document. References cited in eligible papers,
that were considered to be relevant were also obtained. Of those titles identified approximately.300 abstracts
were reviewed and approximately 100 full articles were read.
5. Methods
The recommendations made within this guideline are graded based on the level of supporting evidence
available, using the Public Health Agency of Canada rating scale for strength and quality of evidence
(Appendix 1). The grading level assigned does not relate to the importance of the recommendation, but to
the strength of the supporting evidence. Evidence tables were created by the writer where strong evidence to
support the recommendations was available. These tables were reviewed by the PICNet Guideline Review
Group (GRG). For recommendations based on the expert opinion of the GRG members, any differences in
opinion were resolved through discussion and consensus. This process was reviewed and approved by the
PICNet Guidelines Steering Committee.
6. Outbreak Prevention and Management Team
Organizational leadership is critical in all healthcare settings to ensure effective outbreak prevention and
control. Ideally, all facilities should have a designated Outbreak Prevention and Management Team (OPMT).
This group is responsible for ensuring that measures for preventing outbreaks are in place and for directing
and overseeing the management of all aspects of any outbreak. OPMT members should have decision
making authority for their discipline within the facility or unit. A lead person from this group should be
appointed to coordinate the meeting(s) during an outbreak. The membership of an OPMT will depend upon
the facility’s location, size and contractual status.
Membership may include:
A medical advisor (if available)
Infection control physician (if available)
Medical Health Officer (MHO) or delegate
An administrator or Director of Care
An Infection Control Professional (ICP) or person responsible for infection prevention and control
(IPAC) at that site
An Occupational Health Nurse or person responsible for Workplace Health and Safety (WH&S)
A Public Health Communicable Disease representative or Public Health Nurse (PHN)
A laboratory manager or representative
A person responsible for support services such as housekeeping and laundry
A foods services supervisor
Communications coordinator
Front line healthcare providers (HCP) representative (e.g. charge nurse)
A written process for RI Outbreak Management which includes current membership of the OPMT with
contact information should be available to all HCPs. This should be reviewed yearly and updates made.
See Appendix 2 for a quick check list to prepare for RI outbreaks. Category BIII
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6.1 Roles and Responsibilities During a Respiratory Infection Outbreak
The BC Public Health Act and Community Care and Assisted Living Act define the roles and
responsibilities of the MHO and Public Health in outbreak control. The remaining roles and responsibilities
have been recommended by consensus of the RI Outbreak Management Guidelines Working Group with
the understanding that in some Health Authorities or facilities responsibilities may be delegated or shared
differently depending upon the type of care provided, resources or physical setting. There is therefore some
overlap in the description of roles.
British Columbia Centre for Disease Control (BCCDC) Public Health Microbiology & Reference
Laboratory
Provides advice on sample collection and testing and undertakes timely processing of samples and reporting
back of results to a designated contact person.
Facility Administrator/Manager or Director of Care
Ensures that patients/residents/clients receive care in a safe environment by working collaboratively with
ICP/PHN/MHO to ensure that HCPs are familiar with outbreak prevention and control processes and
ensures timely implementation of control strategies which may include providing additional resources.
Works collaboratively with WH&S to monitor and report HCPs illness.
Healthcare Provider (HCP: includes all disciplines who provide services to or around patients)
Work collaboratively with MHO/PHN/ICP, Facility Managers to ensure best practices are used for the
prevention and control of RI Outbreaks. This includes early recognition of clusters of RI infections, diligent
use and promotion of hand hygiene, early recognition of possible outbreaks and timely implementation of
control strategies.
Infection Control Officer (ICO)
Usually a physician but may be a senior ICP that is responsible for leading the IPAC program in a facility.
Provides primary direction in outbreak pre-planning and control.
Infection Control Professional (ICP)
Works with the MHO and/or PHN and in conjunction with the facility manager and HCPs to ensure that
appropriate outbreak mitigation measures are in place in preparation for an outbreak occurrence. Acts as a
consultant and provides support/resources prior to and during an outbreak to ensure control strategies are
initiated promptly; communicates/liaises promptly with Public Health and/or the MHO when outbreaks are
suspected and/or have been declared.
Local Laboratory/ Medical Microbiologist
Provides advice on appropriate laboratory specimens to facilitate diagnostics (in conjunction with BCCDC)
and assists in timely transportation of specimens to BCCDC where appropriate. In some cases may perform
initial specimen testing.
Media/Public Relations
With guidance from the MHO and Outbreak Prevention and Management Team develops appropriate
public announcements.
Medical Director or Facility Individual Physicians
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February 2011
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Works collaboratively with the Facility Manager and PHN/ICP/MHO to ensure that
patients/residents/clients receive appropriate care in a safe environment.
Medical Health Officer (MHO)
Consults with IPAC, Public Health Nurse, Occupational Health, Medical Director, Administrators and
Nursing HCPs, concerning outbreak declaration, control measures and declaration of end of outbreak. The
Medical Health Officer has legislative authority and responsibility, according to the Public Health Act, to
control the outbreak. The MHO may delegate this responsibility. In many situations, jointly developed
protocols are in place to guide outbreak detection and management and the Medical Health Officer may not
be directly involved with each outbreak. Even if such protocols are in place, the authority of the Medical
Health Officer to direct the local response remains in place.
Public Health Nurse (PHN)
Consults with IPAC, MHO, Occupational Health, Medical Director, Administrators and Nursing HCPs,
concerning outbreak declaration, control measures and declaration of end of outbreak.
Support Services
Assists in outbreak management by ensuring additional resources such as personnel, supplies, enhanced
cleaning etc. are available.
Occupational Health/Workplace Health and Safety (WH&S)
In collaboration with IPAC or the Facility Manager, monitors and tracks HCPs illness; provides support and
education related to sick time and compensation of healthcare providers.
6.2 Outbreak Prevention and Management Team Meetings
Depending on their location, ownership or contractual status, each healthcare facility may have a very
different RI Outbreak Management Team. The team may include a hospital-based Infection Control
Practitioner, an Occupational Health Nurse, a Public Health Nurse, an Environmental Health Officer, a
Medical Microbiologist, or a Medical Health Officer. It is very important for each facility to determine who
will serve as resources in case of an outbreak, and to maintain a current list of contact names and numbers.
Current contact names and numbers are needed for the following services:
The outbreak management resource person for your facility
The facility Infection Control Practitioner (if applicable)
The facility Medical Microbiologist (if applicable)
The Medical Health Officer on-call or the Medical Microbiologist on-call
The laboratory where the facility will be sending specimens for testing and where testing materials
can be obtained.
6.2.1 Responsibilities of the OPMT in the Non-Outbreak Period
Plan implementation of control measures:
Ensure that posters, educational material and control measures are in place and available and
discussed with staff.
Discuss the use of additional control measures, such as antiviral prophylaxis, and plan for their
implementation.
Assure appropriate and sufficient quantities of personal protective equipment (PPE) and supplies are
accessible (i.e. alcohol hand sanitizer, cleaner/disinfectants, masks, gowns etc).
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Discuss the implementation of the staff exclusion policy for a confirmed influenza outbreak, and
review the staffing contingency plan. If staff exclusions critically compromise staffing levels, delegate
an OPMT member to contact the Medical Health Officer to discuss options.
Determine if additional influenza immunizations are required for non-immunized staff members or
patients/residents, and if so, plan how they will be implemented.
Confirm the plan for the collection and submission of specimens for laboratory testing.
Plan communication strategy:
Identify any additional persons/institutions that require notification of the outbreak, and person
responsible for doing so. This may include the Director of Care, any OPMT members not present at
the meeting, the Licensing Program (for settings licensed under the Community Care and Assisted
Living Act), facility laboratory services, BC Ambulance, Handidart, Medigas, etc.
Identify facilities or institutions that have admitted a resident/patient from the facility up to two days
before symptoms started in the first case of the outbreak.
Determine if additional communication or education is required for residents/patients, family and
staff groups.
Identify the individual who will be responsible for the ongoing monitoring of the outbreak in both
residents and staff members, and the most efficient and effective method for doing this.
Identify the individual who will be receiving the laboratory results and how this information will be
communicated within the facility.
Identify the individual who will be communicating with the Public Health on a daily basis, and to
ensure that contact numbers are readily available.
Identify who will be the media spokesperson (this may be a designated person from the Health
Authority
Decide how frequently the OPMT will meet, and to set the next meeting date and time.
The Outbreak Prevention and Management Team members for the facility and the Public Health
representative should meet as soon as possible after an outbreak is suspected or confirmed to take the
following actions:
Review the line listing information to ensure that all members of the team have a common
understanding of the situation
Develop a working case definition for this particular outbreak. The signs and symptoms noted in a
particular outbreak may be somewhat different from the generic case definition for RI. Furthermore,
the case definition for residents/patients may be different from that developed for staff members.
Residents or patients who meet the working case definition will be considered ‘cases’ regardless of
the results of laboratory testing unless another diagnosis is confirmed.
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February 2011
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7. Identifying an Outbreak
7.1 Case Definition for Respiratory Infection
Prior to laboratory confirmation of infection by a particular organism, the following case definition should
be used to identify possible cases of respiratory infection (RI):
New or worsening cough and
Fever >38ºC, or a temperature that is abnormal for that individual
Additional symptoms including myalgia/arthralgia, prostration, nasal discharge, sore throat,
headache
Note: There may be groups within the population that would not meet this definition, yet are
infected with an organism that can cause respiratory outbreaks. For example, young children, the
elderly, the immuno-compromised, or those taking medications such as steroids, NSAIDS, or
ASA, may not develop a fever or may have a lowered temperature as a result of the infection.
A temperature<35.6ºC or > 37.4ºC in the elderly may be an indication of infection
7.2 Suspected and Declared outbreaks
Early detection of respiratory outbreaks and implementation of control measures will reduce the impact on
the health of both staff members and residents/patients. Use a definition for a ‘suspected outbreak’ to
investigate cases for the presence of a causative RI organism and to facilitate the efficient implementation of
control measures should this be considered likely.
The local Medical Health Officer or delegate determines whether illness in a healthcare setting constitutes an
outbreak of RI and assists with recommendations to contain and minimize the health consequences. At the
discretion of the local Medical Health Officer and/or delegates, some control measures may be implemented
at the “suspected outbreak” stage while other more invasive measures await confirmation.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
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Definition of a ‘suspected RI outbreak’
One laboratory confirmed case of an RI-causing organism and no other cases of RI.
or
Two cases of RI occurring within 7 days in a geographic area (i.e. unit or floor). One of
the two cases may be in a staff member epidemiologically linked to the
resident/patient/client.
or
More than one unit having a case of RI within 7 days.
When these occur in an acute care facility, staff should be on the alert for more cases and be
ready to implement full unit wide control measures (contact/droplet precautions).
Definition of a ‘declared RI outbreak’
When there are additional cases identified beyond those recognized within the “suspect
outbreak” definition.
7.3 Identifying the Source
A variety of respiratory pathogens are capable of causing outbreaks in healthcare facilities. Very specific
control measures are applied when an outbreak is caused by Influenza A or B, but facilities may be unclear
about control measures needed to control outbreaks that are known or suspected to be due to other
pathogens. For instance, there may be a laboratory diagnosis of other viral pathogens (e.g. RSV,
parainfluenza), or when a laboratory is unable to identify an organism, there may be a general consensus that
the outbreak is likely caused by undefined organisms capable of causing 'common cold-like' illness.
Respiratory viral infections are transmitted among the general population either as sporadic episodes or as
institutional and community outbreaks. Since many respiratory virus infections present with relatively
common symptoms, a definitive laboratory diagnosis is important for the appropriate management of the
patients, implementation of IPAC measures and in the case of influenza, the therapeutic and prophylactic
use of antiviral drugs for both the patients and staff (4). In general, influenza infections are known to spread
rapidly through institutions and in older adults are associated with more complications than other respiratory
viruses (8). Accordingly, in institutional outbreaks, it is particularly desirable to rule in or rule out influenza
when testing for the etiological agent of the respiratory infection.
Appendix 3 provides a table of the common viral and bacterial pathogens that cause RI outbreaks.
8. Collection of specimens
8.1 Selecting the Appropriate Diagnostic Testing Methodology
Laboratory testing for respiratory viruses is performed using a number of different technologies. These
range from isolation of the virus in cell culture to immuno-specific detection of the virus by
immunofluorescence microscopy or enzyme immunoassays (point-of-care tests) to nucleic acid based tests
such as reverse transcriptase-polymer chain reaction (RT-PCR). In addition, influenza infections in
particular can be diagnosed retrospectively by serological tests such as the hemagglutination-inhibition assay.
Each approach has its advantages and disadvantages for both sporadic and epidemic virus testing.
Turn-around-time is an important issue for specific testing approaches. Laboratories recognize that this
should be kept to a minimum since test results obtained after several days are of limited value for the
management of these infections (9). Immuno-specific and nucleic-acid based tests now allow laboratories to
make a diagnosis within a matter of hours of the specimen being received. However, the overall time for
obtaining a laboratory diagnosis by the physician also includes specimen collection, transport to the
laboratory, and communication of the findings to the submitting physician in addition to the laboratory
testing itself, which includes the pre-analytical documentation. Depending on the access to the laboratory,
the overall turn-around time may be prolonged; hence the healthcare provider should be aware of the
particulars of each available testing methodology, the appropriateness of its use in a specific clinical context
and the expected time that is likely to be required to obtain a laboratory diagnosis. Please see Appendix 4
for a table showing the facilities that provide viral testing for respiratory specimens.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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In general, point-of-care tests (POC), which have been developed for the diagnosis of influenza, are
appropriate for use in institutional outbreak investigations. They can readily be performed on site or at a
nearby laboratory thereby minimizing transportation times. These tests can readily be performed by
appropriately trained laboratory personnel or nursing staff. However, it is recommended that local testing
centers perform routine quality control on their tests in conjunction with an established virology laboratory
(10). Point-of-care tests are generally limited for the diagnosis of influenza A and B viruses and respiratory
syncytial virus (RSV). While they are relatively insensitive for establishing a diagnosis on a single patient,
they are nevertheless acceptable if specimens from several patients are tested. These results are useful in
establishing the presence of an outbreak if the tests from several patients are positive.
8.2 General Recommendations for Specimen Collection and Transport
When an institutional outbreak of a respiratory infection is suspected, specimens are collected for virus
testing. The type of respiratory specimen collected and the method will depend on the patient/resident’s
condition and the resources available. Examples of specimens include: nasopharyngeal washings (using
suction or with a syringe), nasopharyngeal swabs, nasal swabs and Baylor nasal washes. For institutional
outbreaks, specimens from up to 6 symptomatic individuals should be initially submitted. If no etiological
agent can be identified, further specimens may be sent.
Throat swabs are usually contraindicated for respiratory virus diagnosis. They are generally
unacceptable for direct fluorescent antibody (DFA) and may have limited acceptance for RT-PCR
tests.
Respiratory specimens should be collected as per the instructions of the laboratory processing the
specimen or as outlined below. Detailed procedures for specimen collection are provided in
Appendix 5
Specimens should be collected only from symptomatic individuals within 48 to 72 hours of onset of
symptoms, including HCP if available. From acutely ill patients, specimens collected after 72 hours
may be acceptable for testing by RT-PCR and virus isolation in cell culture.
Always label the specimen with the patient/resident’s full name, date of birth and Provincial Health
Number. Complete the laboratory specific requisition form for each specimen. These must be sent
with the specimens to the laboratory.
Wear PPE when collecting the specimens as required (i.e. gloves, mask, eye protection and gowns).
This is to protect from a splash or a spray with a body fluid, substance, excretion or secretion (i.e. if
the patient/resident coughs or sneezes during the procedure).
Keep specimens at refrigerator temperature (2°C to 8°C) as much as possible after collection and
during transport to the laboratory; this may be achieved by using an ice pack. Do not freeze the
specimens.
Complete the laboratory specific respiratory outbreak lab form and fax to the lab as instructed on
the form. See Appendix 6 for the BCCDC Respiratory Illness Outbreak Laboratory Form (check
BCCDC website for most up to date version: www.phsa.ca/labforms) and the VIRAP Influenza-like
Illness Specimen Contact Sheet for BC Women’s and Children’s Hospital (BCWCH); other forms
can be obtained from your selected laboratory. Please ensure that you provide the name and
telephone number to which test results are to be communicated.
Transport to the laboratory according to established processes.
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February 2011
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9. Reporting and Notification
According to the British Columbia Public Health Act all RI outbreaks in healthcare facilities must be
reported to the MHO and/or designated Public Health contact (i.e. PHN, Communicable Disease team).
The facility Manager/Director of Care or Infection Control Professional should also notify the Infection
Control Officer and mobilize the Outbreak Prevention and Management Team. An example of an initial
Outbreak Report Form is found in Appendix 7
Ancillary services used by the facility also should be alerted in the event of an outbreak. These may include:
HandiDart
Lab service provider
Medigas
BC Ambulance Service
Cleaning service provider
Other service providers: physiotherapy, podiatry, hairdressing, music therapist, etc.
Category BIII
10. General Principles of Control
10.1 Immunizations
10.1.1 Influenza vaccine (11)
Influenza is a respiratory infection that causes substantial illness and death in BC health settings as well as
illness among healthcare providers every year. Influenza immunization of health-care personnel and long-
term care facility residents can help prevent outbreaks (12). Influenza outbreaks may still occur with sub-
optimal immunization coverage among healthcare personnel or in the event of substantial virus drift away
from the selected vaccine components. Although influenza immunization may not always prevent infection,
it can prevent serious complications (13). Even with some drift of the circulating virus away from the
vaccine component, cross-protection against the drift variant can be provided by vaccination.
Influenza immunization of people capable of transmitting influenza to patients or residents is considered a
part of the duty of care for patients/residents/clients. This includes all persons carrying on activities within
the facility, i.e., employees, students, attending physicians, and both healthcare and non-healthcare contract
workers and volunteers (12, 14-19). Category AI
The National Advisory Committee on Immunization (NACI) publishes an Advisory Statement on Influenza
vaccine each June.(11) It can be viewed using the following link:
http://www.phac-aspc.gc.ca/im/index-eng.php
10.1.2 Pneumococcal polysaccharide vaccine
(20)
Streptococcus pneumoniae is a bacterium and an important contributor to deaths associated with influenza every
winter. A vaccine against S. pneumoniae exists and, unlike influenza vaccine, does not have to be repeated
every year. Therefore, ensuring that eligible high-risk people receive their free pneumococcal vaccine will
protect them each winter.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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The pneumococcal polysaccharide vaccine is recommended for and provided free to people who are at high
risk of getting serious infections including elderly or immunocompromised patients or residential care
residents. Healthcare settings are encouraged to develop processes for obtaining pre-printed orders for
pneumococcal immunization for residents on admission to complex care settings.
Assessment of eligibility for pneumococcal immunization should be part of yearly immunization clinics for
all healthcare settings. Certain individuals with specific health concerns will be eligible for a booster of
pneumococcal vaccine five years after the initial dosing. For a complete listing of eligibility criteria please see
Section 7 of Chapter II of BCCDC Communicable Disease Manual: BC Immunization Program (21).
10.1.3 Immunization of Visitors
Visitors should be provided with information regarding the need for influenza and pneumococcal
immunization and locations where they can receive immunization. Category BIII
10.2 Routine Practices (22)
Routine Practices is the term used by the Public Health Agency of Canada to describe the system of
infection prevention and control practices used to prevent the transmission of infections in all healthcare
settings. Routine Practices should be used with all patients/residents/clients at all times. A full description of
these may be obtained from: http://www.phac-aspc.gc.ca/dpg-eng.php
Close attention to Routine Practices is fundamental to preventing transmission of microorganisms among
patients/residents/clients and HCP in all healthcare settings. The basic elements of Routine Practice that are
especially important for control of respiratory infections are:
10.2.1 Hand Hygiene
Hand hygiene is everybody’s responsibility: HCPs, clients, visitors and volunteers. Hand hygiene is an
effective way to prevent the transmission of microorganisms. Compliance with hand hygiene
recommendations requires continuous reinforcement.
Either alcohol based hand rub (ABHR) or soap and warm water are accepted methods of hand
hygiene.
o soap and water is required if hands are visibly soiled
o ABHR is recommended at “point of care” places in patient care areas
Patients/residents/clients who are able to participate in self-care should be taught, encouraged and
reminded of the importance of hand hygiene before eating or preparing food, after using the toilet or
other personal hygiene activities, before leaving their homes for common/public areas and when
returning home from public places.
Ensure that hand hygiene facilities are available to patients/residents/clients prior to meals etc.
Patients/residents/clients who are unable to participate in hand hygiene due to physical or mental
impairments should be assisted with hand hygiene prior to meals etc.
10.2.2 Respiratory Hygiene
All patients/residents/clients and visitors should be encouraged to practice good respiratory hygiene. This
includes (22):
1. Performing hand hygiene after coughing, sneezing or using tissues
2. Using disposable, single use tissues for wiping noses
3. Covering the nose and mouth when sneezing and coughing (even when this is due to allergies or
chronic illness).
4. Keeping hands away from the mucous membranes of the eyes and nose
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10.2.3 Point of Care Risk Assessment (22)
A Point of Care Risk Assessment is the evaluation of the interaction between the Healthcare Provider
(HCP), the patient/resident/client and the environment to determine the potential for exposure to
pathogens. Prior to any patient/resident/client interaction all HCP have a responsibility to always assess the
infectious risk posed to themselves and to others (e.g. other patients/residents/clients, visitors, other HCP).
Risk Assessments for any interaction includes:
The patient/resident’s/client/s symptoms and whether they may be consistent with an infectious
process (cough, fever, nausea/vomiting)
The type of interaction that will occur (e.g. direct care vs. bringing something into the room for
them vs. performing an aerosol generating medical procedure)
The potential for contamination of themselves or any equipment used
Identification of barriers (e.g. PPE) required to prevent transmission (e.g. gloves, mask)
Whether all secretion/excretions are contained (e.g.compliance with respiratory hygiene, wounds
well covered)
Whether the person is able to follow instructions (e.g. cognitive abilities, mental health condition)
The setting in which the interaction will take place (e.g. single room vs. multi-bed room, vs.
outpatient or common area)
In reality, HCP do Risk Assessments many times a day for their safety and the safety of others in the
healthcare environment. During a RI outbreak HCPs should be especially vigilant in identifying risk of
exposure to RI pathogens, especially when assisting those who are acutely ill (e.g. fever, cough).
Category BIII
Risk stratification table for RI
Risk
level
Organism-
related risk
Infectious person-
related risk
Procedure-related
risk
Host-related risk
Higher Unknown
organism in
person with
possible high
risk contacts
(i.e. recent
travel and
contact with
poultry)
Acute illness (i.e.
fever with frequent
productive coughing)
Use of aerosol
generating medical
procedures (AGMP)
Caregiver is immune-
compromised (e.g.
transplant recipient) or
Roommate is immune-
compromised (e.g.
transplant recipient) or
No vaccine or antiviral
prophylaxis taken
Lower Unknown
organism in
person with
known history
of no high risk
contacts (e.g.
resident of
long-term care
facility with no
current
outbreak)
Low severity illness
(i.e. infrequent non-
productive coughing,
mild symptoms)
No use of AGMP Caregiver and room-
mate not immune
compromised
or
Vaccine and/or
prophylaxis taken
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10.2.4 Patient/Resident Placement
In acute care facilities, a single room with a toilet and hand hygiene facilities is preferable.
If large numbers of patients/residents/clients require Contact and Droplet Precautions simultaneously,
single room accommodation may not be possible. In this case, it is advisable to cohort patients/residents
with similar symptoms. When single rooms are scarce and/or cohorting is not feasible:
Avoid placing a patient/resident with RI symptoms in the same room as a patient who is at high risk
for complications (e.g. immunocompromised, recent surgery etc.).
In a shared room, patient/resident’s beds should be 2 meters apart with a curtain drawn between
them.
In shared rooms, roommates and all visitors must be aware of the precautions to follow. Select
roommates who are able to comply with precautions Category BIII
10.2.5 Risk Reduction Strategies (22)
Risk reduction strategies include: engineering measures (e.g. negative pressure rooms) client screening, use of
personal protective equipment (PPE), environmental cleaning, proper disinfection and sterilization of
reusable equipment or use of “single use” only equipment, appropriate waste management and safe sharps
handling, appropriate client placement and using preventative workplace practices such as HCPs
immunization policies.
10.2.6 Education of Healthcare Providers, Clients and Families/Visitors/Volunteers (22)
All healthcare providers should receive general education on agency policies, which includes information
regarding the principles of infection prevention and control. Review of hand hygiene; Routine Practices and
Additional Precautions; and chain of infection should be included and refreshed periodically. Specific
information should be emphasized, as it relates to the work environment.
Education for patients/residents should include information about hand and respiratory hygiene. If the
patient/resident has an infection, this information should include practices necessary to reduce the risk of
spread.
Families/Visitors/Volunteers should be educated on respiratory and hand hygiene and any other situation
appropriate practices.
10.3 Additional Precautions (22)
Additional Precautions are used in addition to Routine Practices when an infection with a specific mode of
transmission is suspected or confirmed. These are required when Routine Practices are not sufficient to
prevent transmission. Many respiratory infections require Contact and Droplet Precautions.
Patients/residents/clients should be assisted to understand the nature of their infection and the precautions
being used, as well as the prevention of transmission of disease to others during their stay in the facility and
upon their return to the community. Category BII
Healthcare settings should ensure that staff members have quick and easy access to the PPE and cleaning
products required when providing care. Category BIII
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In outbreak situations, Additional Practices may differ for different organisms and illness severity, and they
may need to be modified in consultation with the MHO or delegate on an ongoing basis as the outbreak
progresses.
10.3.1 Isolation/Spatial/Barrier Separation
Residents or patients who meet the case definition for a respiratory infection should be encouraged to
remain in their room until they are no longer symptomatic or in the case of an outbreak, the date determined
by the Medical Health Officer or their delegate.
It should be noted that confinement of residents and patients, even for a few days, could have adverse
effects on the individual’s emotional well-being, especially those with mental illness or dementia (23-25).
Staff members need to make efforts not to socially isolate these individuals. Implement strategies designed
to diminish the negative impact and protect the patient/residents such as:
one to one supervision of meals for those who have difficulty swallowing
monitoring of patients/residents to ensure adequate nutritional and fluid intake
increasing frequency of rounds to provide oral fluids for patients/residents
planned one to one (or room to room) interactions with priority given to those who have cognitive
issues
physiotherapy or other rehabilitative therapy should continue if the individual is well enough
Category AII
Ideally, healthcare settings should accommodate all patients in single rooms to provide privacy for patient
and family; this would also facilitate IPAC activities. In reality, the number of single rooms in existing heath
care settings is limited, and most patient rooms and bathrooms must be shared. Critical care areas are
frequently large open units or are divided into cubicles without doors, and waiting areas may force ill people
to be in close proximity for long periods of time.
A patient, resident or client who meets the definition for a respiratory infection and needs to remain in a
common area, should be asked to don a surgical mask to reduce the likelihood of transmission of the
infection to others (26). If unable to tolerate a mask (i.e. children, people who have difficulties breathing
under the mask even with the administration of oxygen, people with dementia or other mental health
conditions), the person should be asked to remain in a separate area or at least two meters away from others
(26). Category BII
When a patient, resident or client with a respiratory infection must remain in a common area or must share a
room with others, the room-mate(s) and all visitors should be made aware of precautions to follow.
Category BIII
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In acute care facilities, consideration could be given to ensuring that room-mate(s) are not at high risk of
serious disease if transmission occurs, and are able to comply with precautions. This is not generally possible
in residential care facilities where residents’ rooms are their homes. Category BIII
11. Personal Protective Equipment for Contact/Droplet Precautions
While conducting personal risk assessments staff members should assess their likelihood of being exposed to
any body fluids by direct or indirect contact, by splashes, or by fine mist sprays. They should then choose
and don the appropriate personal protective equipment (i.e. gloves, surgical mask, eye protection) prior to
entering the space (within 2 meters) where the exposure may occur (22). Category BII
11.1 Facial Protection (22)
According to Routine Practices, facial protection (mask and face shield, or mask and other eye protection
such as goggles) should be worn by healthcare workers to protect the mucous membranes of the eyes, nose
and mouth during procedures and patient care activities likely to generate splashes or sprays of blood, body
fluids, secretions or excretions (22). Personal prescription eyeglasses are not effective PPE.
In addition to activities identified under Routine Practices, masks with eye protection should be worn when
within two meters of a coughing patient to help prevent acquisition of respiratory infections transmitted
primarily by large droplets. For the purpose of this document the term mask refers to fluid resistant surgical
masks, not to special masks or respirators (27-35). Category AII
Surgical masks are effective against large droplets, but have a broad variability of effectiveness against small
airborne particles. In Canada, there are no standardized requirements for surgical masks.(36, 37). While
masks are highly effective in containing respiratory viruses when properly worn by patients/residents, it is
advisable and prudent for HCPs to also wear a mask when within two meters of the patient/resident with RI
regardless of whether they are also wearing a mask (35). Category BII
Key recommendations for the use of surgical masks:
Should be used only once and changed if wet ( mask efficiency decreases when wet)
Should cover both the nose and the mouth
Should not be allowed to dangle around the neck
Avoid touching while being worn
Touch only the ties or elastics when removing and discard in an appropriate receptacle
Perform hand hygiene before and after removing the mask
Key recommendations for the use of eye protection:
Should cover the eyes well enough so that droplets are prevented from entering the eyes from any
direction (prescription eyeglasses are not suitable)
Note that the outside of the eye protection is contaminated after use
To remove, don clean gloves, handle by head band on ear pieces, decontaminate with disinfectant,
remove gloves, and perform hand hygiene
Reusable eye protection (e.g. goggles) may be labeled with the healthcare worker's name,
decontaminated, and re-used by the same person unless damaged
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Healthcare providers should also avoid touching their eyes or nose with their hands to prevent self-
inoculation with pathogens. Facial protection may be a helpful barrier in minimizing this mode of
transmission. Whenever possible, healthcare providers should use examination procedures that minimize
exposure to droplets (e.g. sitting next to rather than in front of a coughing patient when providing care, or
performing auscultations from behind)(38-40) . Category BII
11.2 Gloves
Use clean, non-sterile gloves for contact with blood, body fluids, secretions and excretions, mucous
membranes, draining wounds or non-intact skin (open skin lesions or exudative rash), for handling items
visibly soiled with blood, body fluids, secretions or excretions and when the healthcare provider has open
skin lesions on the hands (41-43). Category BII
The use of gloves does not preclude the need for hand hygiene. In view of the difficulties in compliance
with hand hygiene, healthcare providers may see the use of gloves as an alternative method of preventing
hand contamination. Unfortunately, hands can become contaminated through glove holes, tears or defects
or during glove removal, therefore it is recommended that hand hygiene be performed after removal of
gloves (44). Contamination of HCP hands despite glove use has been demonstrated after experimental
inoculation of gloved hands (45) and 13% of the time after contact with patients’ mucous membranes (46).
Key recommendations for the use of gloves:
Should be used as a supplement and not as a substitute for hand hygiene
Should not be reused or washed
Should be changed between care activities and procedures with the same patient after contact with
materials that may contain high concentrations of microorganisms
Should be removed immediately after completion of care or a specific task, at point of use and hand
hygiene performed before touching a clean environmental surface, or surfaces/equipment associated
with a different patient.
11.3 Gowns
Long sleeved gowns that cover the wrists should be used to protect uncovered skin and prevent soiling of
clothing during procedures and patient care activities likely to generate splashes or sprays of blood, body
fluids, secretions or excretions(22). Category BII
Healthcare providers should ensure any open skin areas and lesions on forearms or exposed skin is covered
with an occlusive dressing at all times. Intact skin that has been contaminated with blood, body fluids,
secretions or excretions should be thoroughly washed, as soon as possible, with soap and warm running
water for at least 15 seconds (47).
When Contact Precautions have been initiated, a gown should be worn if clothing or forearms will have
direct contact with the patient/resident, or environmental surfaces or objects associated with that
patient/resident. Gloves should be applied in such a way as to cover the cuffs of the gown sleeves.
Remove gloves and gown and perform hand hygiene before leaving the patients/residents room.
12. Aerosol Generating Medical Procedures (30, 31, 35, 48-51)
An aerosol generating medical procedure (AGMP) is a medical or surgical procedure that involves
manipulation of a patient’s airway in a manner that may stimulate coughing and/or promote the generation
of aerosols.
Some examples include:
Elective intubation and extubation
Bronchoscopy
Sputum Induction
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Autopsies
Some procedures that occur in unplanned, emergent settings and can be life-saving such as
cardiopulmonary resuscitation, emergent intubation and open suctioning of airways
It is prudent to avoid performing aerosol generating procedures on a patient with known or suspected
respiratory infection unless medically necessary. Until the infectious disease is resolved, either delay the
procedure (if clinically appropriate) or make procedural changes to the care performed to reduce the risk
(e.g. choose to use an aero chamber instead of a compressor to deliver aerosolized medications).
When performing or assisting with a planned or urgent AGMP on a patient with known or suspected RI,
only those healthcare workers essential to performing the procedure should be in the room. All HCPs
should wear a surgical mask and facial protection. If SARS, TB or an emerging pathogen is suspected
then an N95 respirator should be worn while performing an AGMP until the mode of transmission
and pathogenecity has been defined. Category BII
12.1 Patients Requiring Mechanical Ventilation (49):
Personnel caring for patients with RI on mechanical ventilators operating in a closed system may use
Routine Precautions alone unless there is a concern that the care provided may cause a breach in the circuit.
If the integrity of the system is breached (e.g., open suctioning, filter changes), staff members in the room
should use droplet/contact precautions. Ventilators with built in hydrophobic submicron filters in the
expiratory circuit should be used. If this is not possible, a disposable filter should be placed in the expiratory
circuit of the ventilator. Disposable filters and ventilator circuits should be bagged and sealed for disposal.
Category BIII
13. Transfers to Other Facility/Department
If a need for Additional Precautions has been established, any receiving unit, diagnostic service, or transport
personnel should be informed so they are aware of the precautions to follow.
The ill person should be out of their room for essential purposes only. Precautions should be maintained
during transport to minimize risk of transmission to others and contamination of environmental surfaces or
objects. Those responsible for transporting the patient should apply Additional Precautions as required.
Category BIII
14. Cohorting of Patients/Residents
“Cohorting” refers to the grouping together of individuals suspected or confirmed to have an infection with
the same pathogen within a specific area to limit the direct or indirect contact between infected individuals
and non-infected individuals, in order to decrease opportunities for transmission of infectious agents.
If possible, staff members should be assigned to work in either affected or unaffected areas of a facility but
not both, or either with ill or with well patients but not both. If this is not possible, staff members should
begin working in unaffected areas or with well patients first, with strict hand hygiene between. Attempts
should be made to minimize movement of staff members, students, or volunteers between floors, especially
if some areas are unaffected. Category BIII
Patients/residents known to be infected with the same organism (identified by diagnostic testing) may be
grouped together if possible. Category BIII
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15. Activity Restrictions
15.1 Group Activity Restrictions
In addition to restricting ill patients/residents to their room, if cases are confined to one unit, all residents or
patients from that unit should avoid contact with those from the remainder of the facility. Previously
scheduled events, (i.e. holiday events) may need to be rescheduled. The OPMT should discuss restriction of
activities with the Medical Health Officer or delegate, and this issue should be reexamined as the outbreak
progresses. Category BIII
Social activities may require restriction within each respective unit. The OPMT should find a balance
between restricting activities to control the spread of infection, and providing therapeutic opportunities for
social activities. Hand hygiene should be performed by all residents/patients before and after any social
activity and respiratory etiquette should be reinforced. Category BIII
15.2 Visitor Restriction
The institution should post outbreak notification signs at all entrances indicating that the facility is currently
managing an outbreak of respiratory infection. Visitors should be advised of the potential risk of acquiring
infections within the facility, of re-introducing infections into the facility, and of visitor restrictions currently
in effect. All visitors, family members, community and professional groups who carry on activities within the
healthcare setting should self-screen based on the signage posted and postpone or reschedule visits if
symptomatic.
If possible, it is recommended that family members of ill residents or patients be contacted and notified of
the infection of their relative. It may be helpful in some settings (e.g. residential care) to keep a telephone list
of frequent visitors, who may be contacted and advised of an outbreak. Category BIII
Ill visitors should not be permitted to enter a facility that is managing an outbreak. In addition, visitors who
have not been immunized against influenza should be encouraged to postpone visits. Visitors who choose
to visit during an outbreak should be required to:
Carry out hand hygiene on arrival and immediately prior to leaving the patient/resident room
Visit only one resident or patient and exit the facility immediately after the visit
Follow IPAC measures as directed by staff
Follow respiratory etiquette
Hand-washing facilities and/or hand hygiene products should be made available throughout the healthcare
setting for use by all persons entering and exiting. Category BIII
In general, a complete closure of the facility to all visitors/volunteers is not recommended and should only
be done in consultation with the MHO and with careful consideration of the risks/benefits to all
patients/residents. Category BIII
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16. Admissions and Transfers
All healthcare settings should ensure they have the ability to identify cases of RI, and to detect clusters or
outbreaks of RI. Individuals presenting for care in a healthcare setting who meet the case definition for RI
(i.e. fever and new or worsening cough) should be asked to perform hand hygiene and wear a surgical mask.
They should also be asked to either wait in a separate area or keep two meters away from other
patients/residents who are not wearing facial protection. Category BIII
Restricting admissions to a facility experiencing an outbreak unnecessarily has the potential of creating a
backlog in acute care, emergency departments or other community settings; on the other hand, admitting
persons who are susceptible into an outbreak situation poses a risk to their health and has the potential to
prolong the outbreak. Depending upon the infecting organism, the severity of illness, the extent of the
outbreak and the physical layout of the building, the admission restriction might not be applied or may be
applied to one floor, one wing or the entire facility. This decision needs to be made by the OPMT in
consultation with the Medical Health Officer or delegate.
Factors to consider include:
whether the outbreak is under control
whether the patient/resident’s attending physician is aware of the outbreak and has agreed to the
admission based on a review of the patient’s/resident’s current health status
whether adequate staff are available in the facility as not only may staff also become ill but outbreaks
often require an increase of human resources
whether the outbreak is due to influenza, and if so, whether the person has been immunized or is on
antiviral prophylaxis
whether the patient/resident or their substitute decision-maker has given informed consent for the
admission.
Admissions of new residents to the affected unit during the outbreak are generally not advisable.
The re-admission of residents/patients who met the case definition prior to discharge/transfer is
reasonable provided appropriate accommodations and care can be provided (i.e. it is assumed that the
person is now immune to the organism causing the outbreak). Category BIII
The re-admission of residents/patients who did not meet the case definition for RI prior to
discharge/transfer is generally not advisable during an outbreak (i.e. it is assumed that the person may not be
immune to the organism causing the outbreak). Category BIII
Transfers for non-urgent medical appointments made before the outbreak should be rescheduled.
Category BIII
When transfers to acute care are necessary during an outbreak, the sending facility should provide the
transferring agency (BC Ambulance Service), the hospital Infection Control Practitioner and admitting unit
or ward with the details of the outbreak to ensure control measures are in place when the resident arrives.
Category BIII
Transfers to residential care from acute care units dealing with outbreaks are not recommended.
Category BIII
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17. Healthcare Provider Exposure and Illness
Healthcare providers have a responsibility to their patients and colleagues to refrain from working when ill
with symptoms that are likely attributable to a communicable disease. For Registered nurses, this is
enshrined in the College of Registered Nurses of BC Standards of Practice (52). In the case of a respiratory
outbreak caused by influenza Please see the BCCDC Staff Influenza Immunization and Exclusion Policy in
Appendix 8
All healthcare settings should establish a clear expectation that staff members do not come into work when
ill with RI, and support this expectation with appropriate attendance management policies. Attendance
management policies should reinforce, rather than act as a disincentive to, staff fulfilling this responsibility
(49). Category BIII
Ensure that all staff have sound knowledge of precautions and PPE required, and how to put on and take
off PPE correctly to avoid exposure.
18. Ongoing Surveillance of Patients/Residents and Staff
An updated report with new cases of both patient/resident/clients and HCPs should be created by the
facility/unit manager or ICP and sent to the OPMT on a regular basis. Category BIII
Appendix 9: provides an example form for patient/resident/client surveillance.
Appendix 10: provides an example form for HCP surveillance.
Appendix 11: provides an example of a Daily Update Outbreak Report for OPMT
19. Housekeeping
19.1 Cleaning Processes
Dirt, organic material and debris acts to shield/protect microbes from contact with disinfectants. Thorough
cleaning removes this protection and facilitates effective disinfection. Consistent, regular cleaning assists in
reducing the potential for environmental transmission of microorganisms and processes should be in place
to ensure regular effective cleaning (53-55). Cleaning methods which use firm contact and friction reduces
the numbers of microorganisms. Use separate cloths for cleaning and for disinfection. Cleaning cloths
should be changed frequently to prevent spreading microorganisms from surface to surface. Soiled/used
cloths should not be re-dipped into disinfectant solution.
Increased frequency of cleaning high touch surfaces is an important contribution to the control of spread of
microorganisms during an RI outbreak. Surfaces that are considered to be “high touch” include:
Bed rails
Call bell cords
Institutional telephones
Bathroom surfaces (taps, toilet handle)
Door knobs, light switches
Hand rails in rooms and hallways
Elevator buttons
Tables, counter tops
Nourishment areas (fridges, ice machines, cupboard handles)
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Nurse’s station
Equipment that is shared between patients/residents/clients should be thoroughly cleaned and disinfected
between each use. Category BII
Special handling of linen, food trays, or other waste contaminated with secretions from patients suspected or
confirmed to have a communicable RI is not required. Category BIII
19.2 Disinfectants
Any disinfectant used in a healthcare setting is required to have a Drug Information Number (DIN) assigned
by Health Canada. The manufacturer should be able to provide evaluations that demonstrate the product’s
effectiveness against common bacterial and viral agents (preferably from a third party). Follow the
manufacturer’s instructions regarding dilution and contact time required to be effective. When organic
matter is present (e.g. blood, sputum, vomitus) many disinfectants require the surfaces be cleaned with a
detergent prior to disinfection. If in doubt about a cleaning product please contact the Public Health
representative/ICP in your area.
20. Problem Solving When Control Measures Appear to be Failing
The incubation period for respiratory viral illness varies, for example the incubation period for influenza is
one to four days. Therefore, in an influenza outbreak, it is expected that after a few days of outbreak control
measures, the number of new cases should diminish. If new cases continue to appear four to five days after
outbreak control measures were implemented the following factors should be explored and reviewed with
the MHO and Outbreak Management Team:
Has anyone with a cough been moving around the facility without a mask, and/or without
performing appropriate hand hygiene?
Is any equipment being used for sick and well patients/residents without being cleaned and
disinfected between uses?
Is personal protective equipment being changed between providing care to sick residents/patients
and those that are well?
Are there any lapses in hand-washing/hand sanitizing?
Are all hand hygiene stations well stocked with soap or alcohol-based hand sanitizer, and are new
refills of products easily to locate by all staff, volunteers and visitors?
Is the appropriate personal protective equipment available and being appropriately worn by staff
members
If influenza is involved in the outbreak and the above do not explain ongoing illness:
o are all residents immunized against influenza and taking antiviral medication, if appropriate?
o are all staff members, including physicians and volunteers, either immunized against
influenza or have they taken an antiviral medication?
o have residents/staff taking antiviral medication been appropriately screened for symptoms to
ensure the proper treatment versus prophylactic dose of antiviral is being used; under-dosing
may lead to the emergence of antiviral resistant strains?
o have more recent outbreak specimens been screened for the possible emergence of antiviral
resistance mutations in the virus?
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21. Declaring the Outbreak Over
The Medical Health Officer (MHO) or designate is responsible for declaring an outbreak of respiratory
infection within a healthcare facility and determining the duration of outbreak control measures.
The length of time from the onset of symptoms of the last case until outbreak control measures can be lifted
may vary and is dependent on a number of factors, including whether the last case was a patient or staff, the
adequacy of ongoing surveillance for new cases at the outbreak facility, and the epidemic curve of the
outbreak. Prior to lifting outbreak control measures, the facility should not have experienced any new cases
of infection (patients or staff) that meet the case definition for the period of time as defined by the MHO.
Usually, the MHO will suspend influenza outbreak control measures if no new cases have occurred within
eight days from the onset of symptoms in the last patient/resident case or four days after the last staff case.
The lifting of outbreak control measures sooner (or later) than eight days is at the discretion of the MHO or
designate.
It is important that vigilant observation for new cases continues even after the outbreak is declared over,
especially when the causative agent has not yet been identified. Category BIII
Once the outbreak has been declared over by the Medical Health Officer (MHO), all individuals notified of
the outbreak at the beginning of the investigation are to be notified that the outbreak is over. A summary of
the outbreak should be compiled and sent to the OPMT. An example of an Outbreak Summary Form is
provided in Appendix 12 Category BIII
22. Debrief of Lessons Learned
It is strongly recommended that the OPMT schedule a debriefing session as soon as feasible following the
conclusion of an outbreak. Category BIII
The purpose of the debriefing session is to evaluate how the outbreak management process unfolded and
identify interventions that worked well and opportunities for improvement. Examples of opportunities for
improvement are:
Communication within OPMT and to media
Timeliness in recognizing and reporting outbreak
Timeliness in implementing control measures
Effectiveness of control measures in limiting the outbreak.
23. Influenza Specific Information and Interventions
23.1 Epidemiology
In Canada, the period of peak winter influenza activity may vary from one year to the next but usually occurs
between November and April, with approximately 75% of all cases having an onset between late December
and early March (56). Seasonal influenza can cause severe infection and death in any age group but most
people fully recover with 90% of deaths due to seasonal influenza occurring among the elderly. The highest
attack rates occur in children, the highest death rates occur in people over the age of 65 years and those with
chronic cardiac, pulmonary, renal or metabolic disease, anemia or immuno-suppression. Current and specific
BC surveillance data on influenza is available using the following web link:
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http://www.bccdc.ca/dis-cond/DiseaseStatsReports/influSurveillanceReports.htm
23.2 Types of Influenza Viruses
(56)
The family Orthomyxoviridae has three genera, namely influenza A, B and C.
Influenza Type A causes mild to severe infections in all age groups. It includes numerous subtypes
characterized by different combinations of surface antigens called hemagglutinin (H) and
neuraminidase (N). Influenza A is capable of infecting both animals and humans, and it has been the
main causative agent in influenza outbreaks and past pandemics. Two influenza A subtypes currently
circulate in humans: influenza A/H1N1 and A/H3N2. Of these two subtypes, influenza A/H3N2
tends to cause the most severe outbreaks.
Influenza Type B usually causes a moderate infection and with complications primarily among
children. This influenza strain can only infect humans and causes outbreaks in the community.
Influenza Type C is rarely diagnosed in humans and is not known to be associated with outbreaks.
23.3 Potential Complications of Influenza A and B Infections
(57)
Pulmonary: sinusitis, otitis, laryngitis, croup, laryngeal obstruction and pneumonia which can be
fatal. Pneumonia typically results from secondary bacterial infection; primary viral pneumonia due to
influenza is rare except in association with pandemics or novel strains (such as avian influenza
infections in humans). If primary viral pneumonia is identified in otherwise healthy
individuals (particularly returning travelers) or as a cluster in a discrete geographic area then
clinicians should be aware of the possibility of a novel virus and should consult with their
local health authority to ensure proper management and submission of specimens to
BCCDC.
Cardiovascular: myocarditis occurring either early or late in the disease process which can be fatal;
pericarditis
Neurologic: encephalitis; aseptic meningitis; Guillain-Barre syndrome; severe myalgia; Reyes
syndrome.
Hematologic: rare cases of viremia occurring during incubation or the first 48 hours of illness;
disseminated intravascular coagulation (DIC).
Renal: renal failure associated with rhabdomyolysis or DIC
24. Healthcare Provider Yearly Immunization Clinics
All healthcare providers should receive an annual influenza vaccination to protect themselves, their families
and their patients/residents from influenza (12, 14-19, 58). Category AI
Self isolation is important when individuals have symptoms however the absence of symptoms does not
indicate that an individual could not carry and shed the influenza virus. HCPs should not rely on self
isolating as an option to immunization for protecting their families and patients/residents as this has been
found to be unreliable(19, 58). Category BII
Influenza immunization of HCP can begin as soon as vaccine becomes available each fall. Health
Authorities and facilities can obtain vaccine through BCCDC. Processes for ordering of influenza vaccine
will vary with each facility and should be initiated each year. Vaccine should be offered to HCP at a variety
of locations and at a variety of times throughout the influenza season, but HCP also have the option of
being immunized through Public Health clinics or by their family physician. Category BIII
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
26
There is an important link between an institutional culture of safety and the receptiveness of HCPs to
adopting safe workplace practices such as yearly influenza immunization. Yassi et. al. (2010) suggest that
using a strategy for staff immunization as a tool that protects HCPs well being rather than identifying them
as vectors of disease transmission may induce better compliance (59). This strategy is further supported by
another recent study by Kaboli et al. (2010) (60). Multiple strategies should be used to increase staff
influenza immunization, including the use of promotional and educational materials, mobile immunization
carts, competitions, incentives, or by senior staff modeling acceptance of immunization. Category BII
HCP who decline influenza immunization due to medical contraindications should be asked to provide
physician documentation of a valid medical contraindication. This documentation should be maintained by
the facility for reference in future years. Category BIII
HCP should be made aware of the consequences of choosing not to be immunized. In the event of an
outbreak, this includes exclusion from work and/or the requirement that they take an appropriate anti-viral
medication (neuraminidase inhibitor or amantidine). Anti-viral medication is not provided free to staff by the
Ministry of Health Services.
Appendix 8 provides the British Columbia Centre for Disease Control (BCCDC) Policy for Healthcare
Provider Immunization and Exclusion during an Influenza Outbreak.
25. Immunization for Residential Care Residents
Settings are encouraged to have consent/pre-printed orders for the administration of influenza vaccine for
all residents on admission and on an annual basis. Also encouraged is consent/pre-printed order for
pneumococcal vaccine on admission and an annual review process to determine requirement for a booster
dose. All persons should be screened for contraindications to the vaccine prior to receiving it (11).
Unless they have a valid medical contraindication, residents of residential care settings should receive the
influenza vaccine on or around November 1st of each year (this may be changed according to the Medical
Health Officer). Any new admissions during the influenza season (timing may vary and will be determined
by the local MHO) should also have their immunization status assessed for influenza and pneumococcal
polysaccharide vaccine, and immunization should be provided as required. A record of immunization status
should be maintained so that it is readily available in the event of a respiratory outbreak. Category BIII
Settings should consult with local Public Health offices to determine the need to maintain a supply of
pneumococcal and influenza vaccine on hand for new admissions. Issues such as cold chain and expiry of
vaccine should be addressed.
26. Immunization for Acute Care Patients
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
27
Between November and the end of March of each year, patients in acute care should be assessed for their
risk of influenza-related complications, and offered influenza and/or pneumococcal polysaccharide
immunization if they are not up to date with their immunization. It may be useful to include this as a regular
component of the admission assessment or discharge plan. Category BIII
27. Antivirals
Immunization of high-risk patients and health-care personnel is the primary measure to prevent and control
influenza in health-care settings. Antiviral agents can be an important adjunct in helping to quickly control
outbreaks of influenza.
When administered for treatment within two days of illness onset, antivirals can reduce the duration of
uncomplicated influenza illness and decrease the spread of the influenza virus (61, 62). The administration of
antiviral agents to all or most patients, as early as possible when respiratory infection is identified in a facility
can limit the spread of influenza in the health-care setting.
Three licensed agents are available in Canada: 1) Amantadine, Oseltamivir (Tamiflu) and Zanamivir
(Relenza). All require medical prescription. Antivirals used for treatment of influenza are most effective
when started within the first two days of illness. To guard against the emergence of resistant strains,
antivirals should be used selectively and prudently for appropriate clinical indications, most notably for
individuals with severe illness and those most likely to develop complications or die as a result of influenza
infection (63).
For more information, an updated influenza antiviral guidance document entitled "The Use of Antiviral
Drugs for Influenza: Guidance for Practitioners, 2010-11" has been posted on the Association of Medical
Microbiology and Infectious Disease, Canada (AMMI Canada) website available at the following link:
http://www.ammi.ca/index.php.
27.1 Planning for Antiviral Use
Residential Care facilities should pre-plan for antiviral medication dosage for prophylaxis and treatment of
residents during an outbreak. They should be prepared to give any of the antiviral agents depending upon
the strain of influenza involved. The sooner antivirals are given, the more effective they can be in controlling
the outbreak. Category BIII
Items to consider:
Prior to the influenza season, each facility should establish with its medical director the protocol for
administering antiviral medication in a timely manner during an outbreak. Patients/residents should
have contraindications and precautions to antiviral prophylaxis and therapy reviewed. A record of
antiviral orders should be maintained so that this information is readily available in the event of a
respiratory outbreak.
If Amantadine is to be used then creatinine clearance testing should be undertaken within twelve
months of antiviral use (11).
Availability of a recent result of a serum creatinine or creatinine clearance based on a 24-hour urine
collection is not required before starting Oseltamivir prophylaxis, unless there is reason to suspect
significant renal impairment (11).
Pre-printed antiviral orders for both prophylaxis and treatment should be approved by a physician
and available on each patient/resident chart at least one month prior to the start of the influenza
season.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
28
The facility should be ready to give antiviral medication on a few hours notice to all residents to
control an outbreak. In order to do that, each facility should establish a plan of action with the
pharmacy that provides services for them, so that antivirals are obtained in a timely fashion.
Category BIII
Glossary
Acute Care Facility: A hospital where lengths of stay average < 30 days, and where a variety of services are
provided, including surgery and intensive care.
Additional Precautions: Interventions implemented for certain pathogens or clinical presentations in
addition to routine infection control practices, to reduce the risk of transmission of microorganisms from
patient to patient, patient to HCP, and HCP to patient
Case: In epidemiology, a person in the population or study group identified as having the particular disease,
health disorder or condition under investigation. A variety of criteria may be used to identify cases: e.g.
diagnosis, registries and notifications, abstracts of clinical records, reporting of defects such as a dental
record. The epidemiologic definition of a case is not necessarily the same as the ordinary clinical definition.
Case Definition: A set of criteria that must be fulfilled in order to identify a person as a case of a particular
disease. Case definition can be based on demographic, clinical, laboratory or combined criteria or a scoring
system with points for each criterion that matches the features of the disease. If the diagnosis is based on a
scoring system e.g. Multiple Sclerosis, it is important to abide by the system for surveillance purposes and
when deciding whether to include or exclude cases in an epidemiologic study.
Cleaning: The physical removal of foreign material e.g. dusts, soil, organic material such as blood,
secretions, excretions and microorganisms using mechanical and/or chemical means. Cleaning physically
removes rather than kills microorganisms.
Cohort: Two or more patients/residents/clients colonized or infected with the same organism that are
separated physically, in a separate room or ward, from other patients who are not colonized or infected with
that organism
Cohort HCPs: The practice of assigning specified personnel to care only for patients/residents known to
be colonized or infected with the same organism. Such personnel would not participate in the care of
patients/residents/clients who are not colonized or infected with that organism
Contact Precautions: Interventions to reduce the risk of transmission of microorganisms through direct or
indirect contact. Contact Precautions include the use of gloves and gowns when giving direct care to
patients/residents/clients or when in contact with their environment.
Diarrhea: Stool that is of the consistency that it takes the shape of the container it is placed into.
Drug Identification number (DIN): In Canada, disinfectants are regulated under the Food and Drugs Act
and Regulations. Disinfectants must have a drug identification number (DIN) from Health Canada prior to
marketing. This ensures that labeling and supportive data have been provided and that it has been
established by the Therapeutic Products Directorate (TPD) that the product is effective and safe for its
intended use.
Disinfection: The inactivation of disease-producing microorganisms. Disinfection does not destroy
bacterial spores. Disinfection usually involves chemicals, heat or ultraviolet light.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
29
Droplet precautions: Interventions to reduce the risk of transmission of microorganisms via respiratory
droplets. Droplet precautions include the use of a surgical mask and eye/face protection whenever one is
within 2 meters of the patient/resident.
Environmental Health Officer (EHO) (Public Health Inspectors): Enforces the BC Public Health
legislation in regard to disease control and protection of the public. Works with the MHO in conjunction
with the facility ICP management and HCP to ensure that appropriate outbreak mitigation measures will be
put into place in the event of an outbreak. Acts as a consultant and provides support/resources prior to and
during an outbreak; communicates/liaises promptly with Infection Control and/or the MHO when
outbreaks are suspected and/or have been declared. Provides expertise in determining the source and means
of spread of the agent, especially where food or waterborne spread may be involved.
Hand Hygiene: A process for the removal of soil and transient microorganisms from the hands. Hand
hygiene may be accomplished using soap and running water or by the use of alcohol-based hand rubs.
Optimal strength of alcohol-based hand rubs should be 60% to 90% alcohol. Hand washing is required
whenever hands are visibly soiled. Alcohol based hand rubs have limited effect on non-enveloped viruses
(depending upon concentration) and spore forming bacteria (e.g. C. difficile).
Health Care Provider: Individual providing or supporting health care services that will bring them into
contact with patients/clients/ residents. This includes, but is not limited to: emergency service providers,
physicians, dentists, chiropractors, nurses, podiatrists, respiratory therapists and other allied health
professionals, students, support services (e.g. housekeeping, dietary, maintenance, hairdressers), and
volunteers.
Hospital-grade Disinfectant: A disinfectant that has a drug identification number (DIN) from Health
Canada indicating its approval for use in Canadian hospitals
Infection Prevention and Control Professional (ICP): Trained individual responsible for a health care
setting’s infection prevention and control activities.
Isolation: The physical separation of infected individuals from those uninfected for the period of
communicability of a particular disease
Medical Health Officer (MHO): a medical practitioner with training, knowledge, skills and experience in
community medicine who is designated to this position, for a geographical area, by the Lieutenant Governor
of BC under the Public Health Act. The MHO provides advice and direction on public health issues
including health promotion and health protection and their related practices, bylaws and policies. The MHO
reports to the public those matters which are deemed to be in the public interest.
Occupational Health: the specialized practice of medicine, public health and ancillary health professions in
an occupational setting. Its aims are to promote health as well as to prevent occupationally related diseases
and injuries and the impairments arising there from, and when work related illness or injury occurs to treat
these conditions.
Personal Protective Equipment (PPE): Clothing or equipment worn by individuals for protection against
hazards such as blood, body fluids, and infectious secretions.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Public Health Nurse: Public Health nurses care for the physical and mental health needs of the
community as a whole. They may work with families in the home, with community groups, in schools, in
government agencies and at workplaces.
Residential Care Facility: Residential care facilities provide 24-hour professional nursing care and
supervision in a protective, supportive environment for people who have complex care needs and can no
longer be cared for in their own homes
Routine Practices: Routine practices is the term used by Health Canada/Public Health Agency of Canada
to describe the system of infection prevention and control practices recommended in Canada to be used
with all clients/patients/residents during all care to prevent and control transmission of microorganisms in
health care settings.
Surveillance: Systematic, ongoing collection, collation, analysis, interpretation and communication of
health-related information that is disseminated in a timely manner to all who need to know and for which
action may be required. Surveillance is a central feature of epidemiological practice, where it is used to
prevent and control disease. Information that is used for surveillance comes from many sources, including
reported cases of communicable diseases, hospital admissions, laboratory reports, cancer registries,
population surveys, reports of absence from school or work, and reported causes of death. Surveillance
approaches may include passive reporting, enhanced reporting and active case identification and follow-up.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Appendix 1: Public Health Agency of Canada, Rating Scale for Strength
and Quality of Evidence
(1)
Categories for strength of each recommendation
CATEGORY DEFINITION
A Good evidence to support a recommendation for or against use
B Moderate evidence to support a recommendation for or against use
C Insufficient evidence to support a recommendation for or against use
(2)
Categories for quality of evidence
GRADE 1 DEFINITION
I Evidence from at least one properly randomized controlled trial
II Evidence from at least one well-designed clinical trial without
randomization; from cohort or case-controlled analytic studies,
preferably from more than one centre; from multiple time series; or from
dramatic results in uncontrolled experiments
III Evidence from opinions of respected authorities on the basis of clinical
experience, descriptive studies, or reports of expert committees.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Appendix 2: Checklist of Yearly Preparation for RI Outbreaks
Below is a checklist of strategies recommended for the prevention of respiratory outbreaks in healthcare
facilities. Not all strategies are applicable to all types of facilities.
□ Establish Outbreak Prevention and Management Team
□ Develop policies/procedures on Outbreak Prevention and Control
□ Develop policy on exclusion of non-immunized staff during an outbreak
□ Acquisition or development of educational material for staff/volunteers
□ Acquisition or development of educational material for patients, residents, families
□ Develop documentation system for recording influenza immunization status on patients, residents
□ Develop documentation system for recording influenza immunization status on staff
□ Develop report format to report “Readiness Status to Local Public Health Unit”
□ Develop Contact Name list for use during a Respiratory Outbreak
□ Develop and maintain an equipment inventory for use during an influenza outbreak
□ Develop pre-printed procedure for annual influenza immunization of residents
□ Develop pre-printed procedure for pneumococcal immunization of residents
□ Develop pre-printed procedure for use of antiviral medication on residents
□ Develop process for ordering of annual influenza vaccine
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Appendix 3: Quick Reference Checklist
This list is an example and meant to be modified and/or re-organized to meet individual facility needs.
Definition of a “suspected RI outbreak”
One laboratory confirmed case of a respiratory illness causing organism and no other cases of RI
or
Two cases of RI occurring within 7 days in a geographic area (i.e. unit or floor). One of the two
cases may be in a staff member epidemiologically linked to the patient/ resident.
or
More than one unit having a case of RI within 7 days.
Definition of a Respiratory Illness Outbreak
When there are additional cases identified beyond those recognized within the “suspect outbreak”
definition
Report
Report outbreak to the MHO or public health delegate
Notify appropriate Managers and Patient Care Leaders
Outbreak Prevention and Management Team should meet as soon as possible.
Notify service providers such as HandyDART, oxygen services, laboratory services, BC Ambulance,
etc. of outbreak and control measures required
Notify any facility that admitted a patient/resident/client from the outbreak area within the past 48
hours
Complete line listing of ill patients/residents/clients (see page 53 )
Complete line listing of ill HCPs (discuss with person responsible for occupational health) , where
this information is available (see page 54 )
Discuss with MHO or delegate the need to:
Postpone transfers to other units or facilities, admissions or re-admissions unless medically
warranted. Depending upon the physical layout of the building and the extent of the outbreak,
restrictions may apply to one wing or one unit, one floor or the entire facility.
Decrease or discontinue group activities and outings until the outbreak is resolved
Restrictions on visitors
Collect
Collect and send specimens as outlined on page 12
Establish Outbreak Control Measures
Review spread of common viral illnesses and disease prevention recommendations with staff and
volunteers.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
34
o Reinforce need for diligent hand hygiene and respiratory hygiene practices and use of
personal protective equipment (gloves, mask with eye protection, gowns in some cases) when
providing care or within 2 meters of a patient/resident/client with respiratory illness.
Educate and reinforce the use of diligent hand hygiene and respiratory hygiene to
patient/residents/clients and visitors
Wherever possible, confine ill residents to rooms until the acute symptoms have resolved
As much as possible, assign the same HCPs to take care of ill clients over the duration of the
outbreak.
Post outbreak signage and ABHR at each entrance to unit/facility
Ensure everyone has easy access to hand hygiene stations (e.g. soap and water, ABHR)
HCPs to use contact precautions when caring for ill individuals.
Advise all visitors of outbreak, emphasize hand hygiene upon entering and exiting site
Remind visitors not to enter the facility if they are ill (e.g. fever, cough, nausea, vomiting)
Ensure all visitors wear personal protective equipment as recommended by the HCPs. Non-
immunized visitors, including family, should be advised to consider if visits are necessary since they
can spread the disease before they realize they are infectious.
Visitors should only visit one patient/resident/client and not travel from room to room during visit
Increase cleaning and disinfection procedures for common areas and all frequently touched surfaces.
Whenever possible dedicate equipment to be used only on that patient/resident/client. In the event
that equipment must be shared it requires thorough cleaning and disinfection in between
patients/residents/clients.
If it is confirmed that Influenza is the causative organism by the laboratory.
o Exclude (or reassign) health care workers not protected by vaccination unless taking antiviral
prophylaxis. Those who need prophylaxis can obtain a prescription from the physician.
o Start antiviral prophylaxis administration to residents as advised by the Medical Health
Officer and in consultation with your Medical Director, if applicable.
o Exclude ill health care providers from the workplace until at least five days from onset of
symptoms or until acute symptoms have resolved, whichever is longer.
Ongoing surveillance
Management and HCPs should maintain a watch for RI symptoms in patients/residents/clients and
report any new onset to patient/resident/client care leaders
HCPs should self monitor for RI symptoms and report illness to supervisor. HCPs who are ill must
remain away from work until acute symptoms have resolved
Communicate status of outbreak daily to Outbreak Prevention and Management Team please see
page 55
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
35
Appendix 4: Common Viral and Bacterial Pathogens That Cause RI
Outbreaks
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
36
Viral
Organism
Epidemiology Incubation
period
Symptoms
and symptom
duration
Period of
communicability
Prophylaxis and
treatment
Influenza A -Typically spans
November to
April
-Causes mild to
severe
symptoms
-Causes
infection in all
age groups with
highest
incidence in
children; highest
mortality in
elderly and those
with
comorbidity
-Can infect
animals and
humans
-Causes most
outbreaks
-Probably 3-5 days
from clinical onset
in adults; up to 7
days in young
children
-Asymptomatic
people may be
infectious
Influenza B -November-
April
-Causes milder
infection
-Mostly affects
children
-Can cause
outbreaks
1-4 days -Fever*, cough
(often severe
and may last
longer than
other
symptoms),
headache,
muscle/joint
pain, sore throat,
prostration and
exhaustion.
-Gastro-
intestinal
symptoms may
occur in children
-2-7 days
-Probably 3-5 days
from clinical onset
in adults; up to 7
days in young
children
-Asymptomatic
people may be
infectious
-Yearly vaccine
(for A&B)
-Antivirals for
prophylaxis and
treatment:
Neuraminidase
inhibitors are
prefered (for
A&B): i.e.
Oseltamivir
Amantadine
(for seasonal
H1N1 only)
NOTE:
amantadine is
ineffective
against the
2009
pandemic
H1N1 virus
and seasonal
H1N1 has
mostly
disappeared –
therefore
amantadine
should now
only be rarely
considered)
Parainfluenza
virus
-Entire year
(little seasonal
pattern)
-Predominantly
causes infection
& outbreaks in
young children
and the elderly
2-6 days -Fever, cough,
wheezing
-Croup
-From shortly
prior to clinical
onset and for
duration of active
disease
Symptomatic
treatment only
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Respiratory
Syncytial
virus (RSV)
-Usually late
winter and early
spring
- Predominantly
causes infection
& outbreaks in
young children
and the elderly
Usually 4-6
days, range
2-8 days
-Fever, cough,
wheezing
-Bronchiolitis in
children
-Pneumonia in
adults
-From a day or so
before clinical
onset and usually
for 3-8 days.
However, viral
shedding may
persist for several
weeks or longer
after symptoms
have subsided,
especially in
children
Symptomatic
treatment only.
For severe
pediatric cases
consult a
Pediatrician or an
Infectious Disease
physician
Adenovirus -Usually fall and
winter
-Causes
infection in all
ages
Usually 4-5
days, range
2-14 days for
respiratory
disease
-Conjunctivitis,
sore throat,
fever, and other
respiratory
symptoms
-From up to a
week prior to
clinical onset and
for duration of
active disease
-Viral shedding
may persist for a
long period of
time
Symptomatic
treatment only
Common
respiratory
viruses such
as:
-Rhinovirus
-Coronavirus
Metapneumo-
virus
-Echovirus
-Coxsackie-
virus
-other entero-
viruses.
(Currently
included in
multiplex panels)
Throughout the
year with peaks
in the spring and
fall
Usually 2-3
days, but
may be
longer
‘Common cold’
type illness:
Sneezing, runny
nose, cough,
sore throat,
sinus congestion
malaise,
headache,
myalgia and/or
low grade fever
-Viral shedding
usually most
abundant during
the first 2-3 days
of clinical illness.
Shedding usually
ceases by 7-10
days, but may
continue for up to
3 weeks in young
children
Symptomatic
treatment only
Bacterial
Organism
Epidemiology Incubation
period
Symptoms
and symptom
duration
Period of
communicability
Prophylaxis and
treatment
Chlamydia
pneumoniae
Throughout
year, no
seasonality
21 days Fever, sore
throat,
prolonged
cough,
headache,
malaise
Not defined Antibiotics based
on clinical picture
Bordetella
pertussis
Neither
infection nor
immunization
provides lifelong
immunity
7-10 days
(range 5-21
days)
Mild URI with
minimal of no
fever, progresses
to cough and
then paroxysms
of cough with
inspiratory
whoop and
commonly
followed by
vomiting.
Duration 6-10
weeks
From onset of
early mild
symptoms and
first 2 weeks of
cough
Immunization,
chemoprophylaxis
for all household
and close contacts
regardless of age
and immunization
status. Antibiotic
therapy for
treatment
Legionella sp. Acquired
through
inhalation of
aerosolized
contaminated
water NOT
from person to
person
2-10 days Fever, cough,
progressive
respiratory
distress. Occurs
most commonly
in those who are
elderly,
immunocompro
mized or have
other underlying
lung disease.
Person to person
transmission not
documented
Antibiotic therapy
for treatment
Mycoplasma
pneumoniae
World wide non
seasonal more
common in
school age and
young adults
2-3-weeks
(range 1-4
weeks)
Fever, acute
bronchial cough
non-productive
initially
Duration of
symptoms
Mild illness may
resolve on own,
inherently resistant
to beta-lactam
agents.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
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Appendix 5: Laboratory Services for Viral testing of Respiratory
Specimens
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
39
Laboratory Tests offered Specimens
accepted
Area served Projected turn-around
time
BCCDC Public Health
Microbiology & Reference
Lab
Hours:
M-F: 8:30 to 20:00
S: 8:30-18:00
S-H: when required
Transport specimens to:
Virology Laboratory
BC Centre for Disease Control
655 W. 12th Avenue
Vancouver, BC, V5Z 4R4
Tel: 604.707.2623
-Multiplex RT-
PCR (Luminex)
-RT-PCR
(Influenza A/B,
and subtyping)
-Virus isolation
-POC for
Influenza
-All respiratory
specimens
-NP swab or
wash preferred
-Throat swabs
sub-optimal
All of BC.
Reference
Laboratory
M-F: Specimens
received by 14:30 - Same
day for all viruses.
Specimens received after
14:30-, same day POC
result for Influenza, next
day for other viruses
S-S-H: Specimens
received by 12:00- Same
day or next day for all
viruses
STAT requests with
Microbiologist consult: 4
hrs
BC Children’s Hospital
Virology Lab
Hours:
M-F: 8:00 to 23:00.
S-S-H: 8:00 to 20:00 (16:00 in
summer)
Transport specimens to:
Virology Lab, Children’s and
Women’s Health Centre of BC,
Virology Lab.
4500 Oak Street
Room 2G28
Vancouver, BC, V6H 3N1
Tel: 604.875.2345x7463
VIRAP
-DFA: Influenza
A/B, RSV,
Adenovirus,
Parainfluenza-1,
2 & 3., HMPV.
PCR or Resplex
on special
request
-NP wash
- ET aspirate
-BAL
BCCH,
BCWH, all of
BC
(pediatric/
maternal)
M-F: Specimens
received by 21:30 –
within 4 hrs for all
viruses
S-S-H: Specimens
received by 18:30 –
within hours for all
viruses
STAT requests with
microbiologist consult: 4
hours
SPH Virology and Reference
Laboratory
Hours:
M-F: 8:00 to 17:00
Transport Specimens to:
SPH Virology and Ref. Lab
Rm. 625 Burrard Bldg.
1081 Burrard St.
Vancouver, BC, V6Z 1Y6
Tel: 604.806.8420
DFA:Influenza,
RSV,
Adenovirus,
Parainfluenza-1,
2 & 3.
-Isolation in cell
culture
-PCR for
Influenza A and
B note: samples
for Flu PCR
must be
approved by the
Medical
Microbiologist)
-NP wash
(preferred
specimen)
-NP swab
-Baylor wash,
-BAL
Vancouver
General
Hospital and
all Providence
Health
Authority
hospitals
M-F: 8:00 to 17:00 –
within 24 hours of
receipt of specimen for
DFA and Flu PCR
results.
University Hospital of
Northern BC (UHNBC)
Hours:
M-F: 8:00-13:00
-DFA: Influenza,
RSV,
Adenovirus,
Parainfluenza-1,
-NP wash
- Other
respiratory
specimens are
-Patients
hospitalized
in Prince
George.
M-F: Specimens
received by 13:00 -
within 4 hrs for all
viruses
Transport specimens to:
UHNBC
1475 Edmonton St.
Prince George, BC
V2M 1F2
Tel: 250.565.2420
2 & 3.
-POC for RSV
on weekends
referred out
-All pediatric
specimens.
-Testing of
regional
specimens
will depend
on volume
and staff.
-May extend hours
January to March
(M-F only)
Vancouver Island Health
Authority (VIHA)
Testing Locations:
Royal Jubilee Hospital (RJH):
Mon-Fri.: 7:00 to 24:00.
Sat., Sun., stat holidays:0700-
2300
Nanaimo Regional General
Hospital (NRGH):
M-F: 8:00 to 21:00
S-S-H: 8:00 to 19:00
Victoria General Hospital
(VGH) Microbiology:
M-F: 8:00 to 16:00
Victoria General Hospital
(VGH) Molecular
M-F: 7:00 to 16:00
Sun: 7:00 to 14:42
All other VIHA locations transport
to VIHA hub testing location.
Transport specimens to:
Royal Jubilee Hospital (RJH):
1952 Bay St.
Victoria, BC. V8R 1J8
Tel: 250.370.8720
Nanaimo Regional General
Hospital (NRGH):
1200 Dufferin Crescent
Nanaimo, BC. V9S 2B7
Tel: 250.755.7691 x52202
Victoria General Hospital
(VGH) Microbiology:
1 Hospital Way
Victoria, BC. V8Z 6R5
Tel: 250.727.4489
Victoria General Hospital
(VGH) Molecular
1 Hospital Way
Victoria, BC. V8Z 6R5
Tel: 250.370.8111 x15332
RSV:
Performed at
RJH, NRGH, &
VGH by
Immuno-
chromato-
graphic test
Influenza A &
B:
Performed at
VGH Molecular
by NAT
-NP swab
preferred; will
test any
respiratory
specimens if
received.
RSV:
From all
VIHA
hospitals:
Inpatient
Pediatric
(0-2 yrs) or
Peds ICU or
STAT request
on Pediatric
patient
Influenza A
& B:
Inpatient
Pediatric
(2-16 yrs)
from all
VIHA
hospitals;
Outpatient
Pediatrics (0-
2 yrs); Adults
and
Outbreaks.
RSV: Same day testing
if sample received within
1-2 hours of lab closure.
If sample received at
VGH after routine
hours, sample is sent to
RJH for testing.
Influenza A & B:
Specimens received by
12:00-same day testing.
If received after 12:00,
testing performed on
next day during regular
VGH Molecular hours.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
40
Appendix 6: Procedures for Respiratory Specimen Collection
Nasal swab and nasopharyngeal swab
a) Assemble supplies:
I. Sterile swab with transport media
II. Personal protection equipment (i.e.., mask, gloves, eye protection, gowns)
III. Requisition and label, biohazard bag
b) Explain procedure to resident/patient.
c) Wash hands. Put on personal protection equipment to protect yourself if the patient/resident coughs
or sneezes while you are collecting the specimen.
d) If the patient/resident has a lot of mucous in his/her nose, this can interfere with the collection of
cells, ask the patient/resident to use a tissue to gently clean out visible nasal mucous before a swab is
taken. Influenza viruses are located in cells that line the surface of the nasal cavity and are shed into
respiratory secretions.
e) Seat resident/patient in a comfortable bed. It is best if the patient is placed in a high-fowler’s
position in bed with the back of the head supported. It may be necessary to have a second person
available to assist with collection.
f) Swab Collection (use one of the following two methods):
Method 1: Nasopharyngeal Swab – preferred method
Enter a flexible flocked swab several centimeters with a slow, steady motion along the floor of
the nose (straight back, not up the nose) until the posterior nasopharynx has been reached
(distance from nostrils to external opening of ear). If nasal mucosa is swollen, rotating the swab
during insertion may facilitate entry.
Place finger on the tip of the patient/resident’s nose and depress slightly
Once resistance is met (the swab should pass into the pharynx relatively easily), rotate the swab
several times and withdraw the swab
Method 2: Nasal Swab
With one hand behind the patient/resident’s head to steady him/her, incline the head as
appropriate and insert a cotton swab, from a regular Virus isolation tube, into the nostril
approximately 2 cm along the nasal septum (the centre of the nose), rub the swab vigorously but
gently along the lining of the septum several times to obtain cells. Vigorous swabbing is
necessary to get cells onto the swab especially for testing by immunofluorescence microscopy. .
g) Break off top of swab (it will snap off)
h) Place in transport medium.
i) Remove gloves, wash hands.
j) Ensure the specimen is labeled and transport to the laboratory with completed requisition.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
41
Nasopharyngeal washing –syringe drawback method
1. Assemble supplies:
5cc sterile syringe,
Sterile plastic suction catheter with standard tip
#8- Child or Adult
#10-Adult
Sterile saline 10 cc
Sterile specimen container with no preservative
Personal protection equipment (i.e., mask, gloves, eye protection, gowns as required)
Requisition, label, biohazard bag
2. Explain procedure to resident/patient/client or parent.
3. Wash hands. Put on personal protection equipment to protect yourself if the patient/resident coughs
or sneezes while you are collecting the specimen.
4. Position patient/resident supine with head supported by a pillow, folded blanket or slightly elevated
depending on comfort.
5. Obtain assistance from another staff member(s) as required. It may be necessary to “bundle” or
restrain a child to perform this test.
6. Draw 4cc of saline into syringe.
7. Attach catheter to syringe.
8. Measure distance on catheter from person’s nose to earlobe while maintaining catheter sterility.
9. Prime catheter with saline.
10. Gently insert catheter into nasal cavity until the nasopharynx is reached (see diagram below)
11. Expel the total amount of saline (the wash) with some force against the nasopharyngeal wall and
immediately draw the wash back into the syringe via the catheter. In most cases, the fluid will be
cloudy with some mucus present.
12. It may be necessary to repeat procedure using other nostril, i.e. insufficient sample obtained, sample
is not cloudy, does not appear to contain any cells, mucus, etc.,
13. Transfer the aspirate to a sterile container without transport medium. Use further sterile saline to
flush any remaining wash out of the catheter into the container (maximum 2 cc). Label specimen,
secure cap and place in transport bag.
14. Wash hands.
15. Ensure the specimen is labeled and transport to the laboratory with completed requisition.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
42
Nasopharyngeal washing – suction method
1. Assemble supplies:
3cc sterile syringe,
Plastic suction catheter with vacutip
#8- Child or Adult
#10-Adult
Sterile normal saline -10 cc
Sterile specimen trap (mucus trap)
Suction tubing and apparatus
Personal protection equipment (i.e. mask, gloves, eye protection, gowns as required)
Requisition, label, biohazard bag
2. Explain procedure to patient/resident.
3. Wash hands. Put on personal protection equipment to protect yourself if the person coughs or
sneezes while you are collecting the specimen
4. Position patient/resident/client supine with head supported by a pillow, folded blanket or slightly
elevated depending on comfort.
5. Obtain assistance from another staff member(s) as necessary. It may be necessary to “bundle” or
restrain if performing test on a child.
6. Draw up 3cc of saline into syringe.
7. Peel open package and remove specimen trap ensuring trap lid is secure.
8. Attach suction tubing to plastic connector. Turn suction regulator to low setting (<80mm/lg). Check
that suction is working.
9. Apply gloves, and remove suction catheter from package, maintaining sterility. Attach catheter to
tubing on trap.
10. Measure distance on catheter from nose to earlobe maintaining catheter sterility.
11. Instill saline into one nostril. Gently insert catheter into nasal cavity until the nasopharynx is reached
(see diagram below). Start suctioning, while gently rotating and withdrawing the catheter. (In most
cases, the fluid will be cloudy with some mucus present).
12. It may be necessary to repeat procedure using other nostril, i.e.., insufficient sample obtained, sample
is not cloudy, does not appear to contain any cells, mucus, etc.
13. Rinse catheter with small amount of remaining saline until specimen is rinsed through catheter into
specimen trap. Ensure trap remains upright to prevent aspiration of contents into main suction
container. Undo specimen container from suction equipment and attach sterile lid. Ensure lid is on
securely. Label specimen and place in transport bag.
14. Dispose of waste. Ensure suction equipment is cleaned and disinfected for next use.
15. Wash hands.
16. Ensure the specimen is labeled and transport to the laboratory with completed requisition.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
43
Appendix 7: Laboratory Requisition Samples
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
44
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
45
Appendix 8: Initial Outbreak Report Form for OPMT (example)
Brief Description of Outbreak Date: _________________
Location: _____________________________ Date of index case: _______________________
Predominant symptoms: __________________________________________________________
Progression to others: ____________________________________________________________
Number of immunized patients/residents: ___________ of total number: ______
Number of immunized HCPs: _____________ of total number: ________
Actions Taken
Date and time reported to MHO: _________________________
Activation of Outbreak Management Team: ___________________________
Notification of external service providers (e.g. BC Ambulance, Medigas):
______________________________________________________________________________
“Just in time” in-services to HCPs:___________________________________________________
______________________________________________________________________________
Cohorting of patients/residents and/or HCPs__________________________________________
Enhanced cleaning: _____________________________
Restriction (visitors, HCP, unit closure):_______________________________________________
Extra hand hygiene stations/signage: ________________________________________________
Specimens sent: ________________________________________________________________
Current Status:
Number of symptomatic patients/residents: ________ Number of symptomatic HCP: ______
Name of Reporting Person: _________________________________________
Adapted from forms submitted by Northern Health and Vancouver Coastal Health
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
46
Appendix 9: 2010-2011 British Columbia Centre for Disease Control Staff
Influenza Immunization and Exclusion Policy
Taken directly from the British Columbia Center for Disease Control
BC FACILITY INFLUENZA IMMUNIZATION POLICY October 18, 2010
I. PURPOSE:
To help ensure that those at greatest risk of complications and death from influenza are optimally protected
through the appropriate use of influenza vaccine, health care facilities must develop policies for annual
influenza vaccination of residents and staff, as well as policies for identifying, preventing and controlling
influenza outbreaks.
Immunization policies for residents should include annual immunization in the fall as well as immunization
any time during the influenza season (typically November to April) for any patient newly admitted or
transferred to a health care facility who was not immunized during the season or whose immunization status
is unknown. As a critical component of patient care, all facilities are required to adopt a written policy
advocating staff influenza immunization. Staff who choose not to be immunized must be made aware that
they can be excluded from work in the event of an influenza outbreak within their facility.
The National Advisory Committee on Immunization underscores that refusal of health care workers to be
immunized implies failure in their duty of care to their patients. Non-immunized staff assist in the spread of
influenza and pose an unacceptable risk to patients and co-workers during outbreaks. Their exclusion under
the authority of the local Medical Health Officer is a legitimate way to protect patients and is supported by
the BC Communicable Disease Policy Committee, the Health Act (Communicable Disease Regulations, Part
2; Sanitary Regulations Section 6 (e)) and Adult Care Regulations.
II. RATIONALE:
Influenza is a significant cause of death in Canada, especially amongst the elderly and frail. Many of the
deaths due to influenza can be prevented through immunization. Influenza immunization is safe and
effective and is the single most important way to prevent influenza-related complications and deaths.
Studies show that up to 25% of non-immunized health care workers are infected with influenza during the
winter months. Persons with influenza are infectious even before they become sick. In one study, 59% of
health care workers with documented influenza could not recall influenza symptoms and did not know they
had been infected. Persons with mild or unrecognized influenza illness still shed virus and can spread it to
others. Most health care workers continue to work even when they develop symptoms. In this way, staff
may introduce influenza into facilities and spread it amongst patients and co-workers. When outbreaks occur
in confined settings such as long term care (LTC) facilities, they spread very quickly and as many as 50% of
residents can be affected. These residents are at highest risk of developing serious and sometimes fatal
complications related to influenza.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
47
Recent meta-analysis found vaccine protection against laboratory-confirmed influenza in young adults of
80% (95%CI 56-91%) when measured during certain seasons of match and 50% (95%CI 27-65%) during
certain seasons of mismatch. The vaccine is also effective in reducing absenteeism and febrile respiratory
illness among health care workers and other working adults. Influenza immunization reduces not only the
duration and severity of illness, but also the amount of viral shedding. Influenza vaccine is less effective in
protecting older frail adults from infection. For this reason, influenza immunization of health care workers is
important to protect these vulnerable persons from influenza and its complications, including death. Three
cluster-randomised controlled trials and two cohort studies have now shown that immunizing health care
workers protects patients from the serious outcomes of influenza. Immunizing both care providers and
residents of care facilities reduces the risk of outbreaks and the disruption, illness and death these outbreaks
cause.
III. DEFINITIONS:
Incubation Period:
The time interval between initial contact with an infectious agent and the first appearance of symptoms
associated with the infection.
Influenza:
Influenza is a viral infection of the respiratory system. Symptoms of influenza include fever, cough, sore
throat, muscle ache, extreme fatigue and headache. Unlike the common cold and most other respiratory
viruses commonly called “the flu”, influenza virus infection can result in severe illness, pneumonia and even
death. The incubation period of influenza is 1-4 days; duration of virus shedding is usually not more than 5
days after onset of symptoms in adults.
Influenza-Like Illness (ILI):
Symptoms and signs consistent with influenza in the absence of laboratory confirmation. This is defined as:
onset of respiratory illness with cough and fever/chills and one or more of sore throat, sore joints, sore
muscles or prostration (generally feeling unwell and having to lie down). In the elderly or the very young,
fever and/or chills may not be present.
Transmission of Influenza:
Influenza is spread from person to person by inhalation of tiny droplets produced when a person infected
with influenza coughs, sneezes, laughs or even talks. It can also be spread by contact with infected
respiratory secretions through articles such as bedrails, facial tissue or utensils.
Influenza Outbreak:
An influenza outbreak is a cluster of cases occurring within a short period of time in a defined area or group
of people. An influenza outbreak in a facility is suspected when there are two or more cases of influenza-like
illness (ILI) in a defined area (i.e. unit or floor or ward) in a seven-day period. A suspect outbreak of ILI
should be reported to the Medical Health Officer or designate as soon as it is identified (within 24 hours or
sooner). The Medical Health Officer (in consultation with the physician/nurse responsible for managing
infection control will determine whether illness within a facility constitutes an outbreak of influenza and
what control measures should be implemented.
Influenza Vaccine:
Influenza vaccine is prepared from killed influenza virus. It stimulates the formation of immunity
(antibodies) against three strains of influenza virus likely to be circulating that season.
Anti-viral Medication:
Medication (drugs) capable of preventing or treating viral infection. Two classes of drugs are licensed in
Canada for the prevention and/or treatment of influenza: amantadine and the neuraminidase inhibitors
(zanamivir and oseltamivir) For both, treatment should be started within 48 hours of onset of symptoms to
be most effective. Amantadine is only effective against influenza A. The neuraminidase inhibitors are
effective against both influenza A and B. Oseltamivir is taken orally; zanamivir is inhaled. Oseltamivir has
been licensed in Canada for the post-exposure prevention of influenza A and B since December 2003. It is
not licensed for seasonal (pre-exposure) prophylaxis, although it has been used off-label (outside the licensed
indications) for this purpose. Zanamivir was also recently approved for use for both seasonal (up to 28 day)
and post-exposure prophylaxis against influenza A and B.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
48
During the 2005-2006 influenza season in Canada, more than 90% of all influenza A/H3N2 isolates were
resistant to amantadine. During the 2006-07 season, 25-30% of A/H3N2 isolates were also resistant to
amantadine. During the 2007-08 season, 99.5% of A/H3N2 isolates were amantadine-resistant. During the
2009-10 season, 100% of both A/H3N2 and pandemic A/H1N1 (pH1N1) isolates were amantadine-
resistant. Although seasonal A/H1N1 viruses retained sensitivity to amantadine when they were last
circulating, the pH1N1 virus has replaced seasonal A/H1N1 strains since it emerged in April 2009. As such,
the detection of influenza A is currently unlikely to be seasonal A/H1N1. Until this profile changes and
health authorities are officially notified, amantadine is no longer recommended for the treatment or
prophylaxis of influenza.
During the 2007-08 and 2008-09 season, oseltamivir resistance was identified among circulating seasonal
A/H1N1 viruses worldwide including Canada. pH1N1 after its emergence in April 2009 has replaced
seasonal A/H1N1. Testing of influenza isolates in Canada has indicated that most of the pH1N1 (99%) and
all A/H3N2 and influenza B isolates were sensitive to oseltamivir among those tested September 1, 2009
through May 6, 2010. Antiviral resistance testing at the WHO Collaborating Center for Surveillance,
Epidemiology and Control of Influenza at CDC on isolates collected during the period 13 Jun to 25 Sep
2010 showed that all pH1N1, A/H3N2 and influenza B isolates were sensitive to oseltamivir.
Recommendations described in this 2010-11 BC Facility Influenza Immunization Policy (dated October 18,
2010) will be updated based on evolving surveillance information during the season as appropriate. Health
care providers using oseltamivir are advised to consult surveillance updates through public health and stay
informed about influenza activity and resistance patterns during the 2010-2011 season. If oseltamivir
resistance is detected or suspected in a facility outbreak setting (for example, if an outbreak is not controlled
despite adequate antiviral prophylaxis), or if resistance is reported to be widespread in the community, up-to-
date advice of local and provincial health authorities should be followed regarding antiviral use.
Health Care Facility:
Facilities providing ongoing residential care to groups of individuals, especially the frail or elderly. This
includes acute care, long term care, intermediate care and extended care facilities and all other facilities that
provide ongoing residential care to groups of individuals, especially the frail or elderly.
Health Care Staff:
Persons carrying out paid or unpaid work in a health care facility. The policy applies to all staff members
who work, volunteer or train in the health care facility during the typical influenza season (November –
April, inclusive), regardless of whether they have direct or indirect contact with patients or residents.
Valid Medical Contraindication to Influenza Immunization:
Influenza vaccine should not be given to persons who had an anaphylactic or shock-like reaction to a
previous dose of influenza vaccine or with known anaphylactic or shock-like reaction to eggs or any other
component of the vaccine. Anaphylactic reaction consists of rapid onset of hives, swelling of the mouth and
throat, difficulty breathing and shock. It is rare following influenza immunization.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
49
IV. STAFF INFLUENZA IMMUNIZATION AND EXCLUSION POLICY:
1. Health care facilities in BC are committed to protecting patients and staff from the potentially
debilitating and sometimes fatal complications of influenza.
All health care facilities (acute, long term, intermediate and extended care facilities) are required to
have a written staff influenza immunization policy in place, in addition to a policy for annual
immunization of residents during the fall.
Policy for residents should include annual influenza immunization in the fall as well as provision for
immunizing newly admitted or transferred patients who are not immunized or whose immunization
status is unknown, any time during the influenza season (typically November to April).
Policy for staff should include annual influenza immunization in the fall as well as provision for
immunizing any new staff that start work during the influenza season (typically November to April).
The policy must include notice that non-immunized staff can be excluded from work in the event of
an influenza outbreak in the facility. At the time of hiring or placement, information about the
requirement for annual influenza vaccination must be provided to all persons carrying out activities
in the facility. Additionally, if the time of hiring or placement occurs during the influenza season, the
person responsible for the infection control program in the facility must ask any new employee for
documentation of immunization with the current year’s influenza vaccine. Persons who are not
newly placed or appointed to the facility should be informed about the requirement for annual
immunization against influenza.
2. All health care facilities, using their own occupational health resources, must offer influenza
vaccination to their staff each year.
Influenza immunization of staff can begin as soon as vaccine becomes locally available each fall.
Vaccine should be offered to staff at a variety of sites and at a variety of times throughout the
influenza season. Multiple strategies should be used to increase staff influenza vaccination, including
educational opportunities, promotional materials, mobile vaccination carts, competitions, incentives,
or by senior staff modeling receipt of immunization.
3. Staff members who decline influenza immunization due to medical contraindications should
provide physician documentation as valid medical contraindication.
This documentation should be maintained by the facility for reference in future years. Those who do
not provide this documentation shall not be considered to have valid medical contraindication for
the purposes of enforcing this exclusion policy. Persons who decline influenza vaccination but have
no medical contraindications should be offered vaccine in subsequent years.
4. Staff must be made aware of the consequences of choosing not to be immunized.
In the event of an outbreak, this includes exclusion from work and/or the requirement that they take
an anti-viral medication (neuraminidase inhibitor). Anti-viral medication is not provided free to staff
by the Ministry of Health Services. In advance of the influenza season, health care facilities should
prepare a list of staff who may be excluded from work in the event of an influenza outbreak.
Additionally, these persons should be assessed for eligibility for neuraminidase inhibitors prior to the
influenza season and this information should be kept on hand at the facility for timely
implementation of an anti-viral medication program when an outbreak occurs.
5. All health care facilities must maintain annual records of staff influenza vaccination status.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
50
This includes name, date of birth, position (job), where in the facility they work and date of influenza
vaccination. Staff immunized at an off-site clinic or by their family physician must provide written
documentation, including the date influenza vaccine was received. Staff who report a medical
contraindication to influenza vaccination should provide medical documentation. With appropriate
documentation, “Contraindication” should be indicated for that staff member on the facility staff
immunization record.
6. All health care facilities must remind persons carrying on activities in the facility that if they
experience symptoms of influenza-like illness, they must not work and must self-report this
as soon as possible to the person responsible for occupational health or infection control in
the facility.
7. All facilities must maintain watch for influenza-like illness and notify the Medical Health Officer
or designate immediately in the event of a suspected influenza outbreak (two or more cases
of ILI among staff and/or residents in a defined area within a one week period).
This is especially important during the typical influenza season from November to April. As
influenza has been identified in North America during the summer months, facilities should remain
alert for the possibility of influenza outbreaks year-round. As soon as an outbreak of influenza is
suspected during the influenza season, non-immunized residents and persons carrying on activities in
the facility who do not have contraindications to vaccination should be offered the vaccine.
8. The local Medical Health Officer or his/her designate will determine whether illness in a facility
constitutes an outbreak of influenza and will assist with recommendations to contain and
minimize the health consequences.
9. All facilities must provide their local health unit with influenza vaccination coverage data for
residents and staff.
Only summary data is required, not individual records.
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
51
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
52
V. EXCLUSION PROCEDURES:
In the event of an influenza outbreak:
 Discuss prevention and control measures, including the exclusion of staff, with the local Medical
Health Officer or his/her designate.
 Any staff with influenza-like illness (ILI) will be excluded for at least five days after the onset of
symptoms OR until acute symptoms completely resolve whichever is longer.
 Health care staff who have been vaccinated more than 14 days prior to the onset of the outbreak and
who do not have ILI can work in any facility without restriction.
 Non-immunized staff are subject to exclusion from work until the outbreak is declared over by the
local Medical Health Officer. Anti-viral medication should be recommend• An exception to
exclusion of non-immunized staff may be made if the non-immunized staff member takes anti-viral
medication as prescribed and the anti-viral medication is continued until the outbreak is officially
declared over and as instructed by the local Medical Health Officer (up to eight weeks). These
workers must be alert to the symptoms and signs of influenza, particularly within the first 48 hours
after starting antiviral prophylaxis and should be excluded from the patient care environment if these
develop. Careful assessment for ILI symptoms is also important in case the antiviral schedule for
treatment rather than prophylaxis of influenza infection is warranted and in order to reduce the
likelihood of resistance emerging due to suboptimal dosing in persons already infected.
 Staff who were not immunized prior to an outbreak of influenza, but who are immunized during the
outbreak, may return to work in the outbreak setting after 14 days have elapsed since vaccination or
when the outbreak is declared over by the local Medical Health Officer. Staff can return to work if
anti-viral medication is taken for 14 days after the date of their influenza immunization or until the
outbreak has been officially declared over, whichever is sooner. These workers must be alert to the
symptoms and signs of influenza, particularly within the first 48 hours after starting antiviral
prophylaxis and should be excluded from the patient care environment if these develop. Careful
assessment for symptoms of influenza-like illness is also important in case the antiviral schedule for
treatment rather than prophylaxis of influenza infection is warranted and in order to reduce the
likelihood of resistance emerging due to suboptimal dosing in persons already infected.
 Non-immunized, excluded staff must not have developed ILI symptoms and must wait one
incubation period (up to 4 days) from the last day they worked at the outbreak facility prior to
working in a non-outbreak facility. This is because they may be incubating influenza. If ILI
symptoms develop in that period, staff must be excluded for at least 5 days after ILI onset OR until
acute symptoms completely resolve whichever is longer.
 Exclusion of non-immunized staff should be considered as a control measure to prevent transmission
of influenza in the facility, and as an adjunct to other outbreak control measures. Where staff
exclusions would compromise staffing levels severely and place residents at risk, the local Medical
Health Officer may issue alternate recommendations.
Appendix 10: Outbreak Surveillance Form - Patients/Residents/Clients (example)
SYMPTOMS: C=cough F=Fever H=Headache ST=sore throat M=Myalgia N=Nausea V=Vomiting D=Diarrhea
ROOM TYPE: P=Private S=Semi-private M=Multi-bed
Adapted from forms submitted by Northern Health and Vancouver Island Health Authority
Respiratory Infection Outbreak Guidelines for Healthcare Facilities 53
February 2011
Patient Demographics Clinical Presentation Specimen(s) sent
Name Date
of
birth
y/m/d
Unit Room
#
Room
type
Date of
last
vaccine
Name and
date of
prophylaxis
Date of
onset of
symptoms
Symptoms Date
symptoms
resolved
Collection
Date/ Date
Submitted
Result
Appendix 11: RI Outbreak Surveillance Form – HCPs (example)
HCPs Information Clinical Presentation Specimen
Name DOB
y/m/d
Occupation Unit(s)
worked
Date of last
vaccine
Date of
symptom
onset
Symptoms (see
below)
Date of
symptom
resolution
Collection
Date/date
submitted
Result
SYMPTOMS: C=cough F=Fever H=Headache ST=sore throat M=Myalgia N=Nausea V=Vomiting D=Diarrhea
Respiratory Infection Outbreak Guidelines for Healthcare Facilities 54
February 2011
Adapted from forms submitted by Northern Health and Vancouver Island Health
Appendix 12: Daily Update Outbreak Report for OPMT (example)
Location: ______________________________________
Date: _______________________ Day _____ of Outbreak
Number of new cases today - Patients/Residents/Clients: _______________
Number of new cases today – HCPs: ___________
Date of symptom onset of last case: ____________
Number of patients/residents currently symptomatic: _______________
(include new cases)
Number of patients/residents recovered: ________________
New developments/concerns:
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Further actions required:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
Adapted from forms submitted by Northern Health, Fraser Health and Vancouver Coastal Health
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
55
Appendix 13: Outbreak Summary Report for OPMT (example)
Date of onset of outbreak: ___________ Date outbreak declared over:_______________
Microorganism identified: ________________________Laboratory Confirmed? Yes___ No___
Number of specimens identified in: __________ Suspected source: _______________________
Number of patients/residents exposed: _____ Total number of cases (patients/residents): ______
Attach rate for patients/residents (# of exposed divided by # of cases, multiply by 100):________
Number of HCPs exposed: _______ Total number of cases (HCPs): ______
Attach rate for HCPs (# of exposed divided by # of cases, multiply by 100): ________
Number of cases requiring higher level of care: ________
(e.g. transfer to hospital, transfer to ICU)
Number of deaths: _______
Unusual situations: _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Adapted from forms submitted by Northern Health and Vancouver Coastal Health
Respiratory Infection Outbreak Guidelines for Healthcare Facilities
February 2011
56
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