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Influenza and the Nursing Home Population
Julie L. Freshwater, PhD MPHInfluenza Surveillance Coordinator
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Objectives
•Present provisional data from the 2010-2011 influenza season in the nursing home population
•Understand the term outbreak in the nursing home setting
•Understand the importance of laboratory testing in this population
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Testing for Influenza*• Rapid tests
▫Sensitivities are approximately 50-70%▫Specificities are approximately 90-95%
• Serology▫2 weeks or more
• DFA/IFA▫2 – 4 hours
• Viral Culture▫3 – 10 days
• PCR▫2 – 4 hours*CDC Influenza Diagnostic Table
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OLS Testing for Influenza
•PCR for:▫Influenza
AH3 AH1N1 (SO) B
•When negative for influenza:▫Culture for:
Parainfluenza Adenovirus RSV
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Definition of Influenza-like Illness
Temperature ≥ 100◦ F
AND
Cough and/or
Sore throat
In absence of any other known cause
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LTCF Outbreak Definition
•One (1) positive laboratory test for influenza
in conjunction with other similar illnesses on
the unit indicates an outbreak is occurring
OR
•Three cases of influenza-like illness within
72 hours
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Importance of Laboratory Testing
•Starting or stopping antiviral treatments
•Chemoprophylaxis for residents and staff
•Mitigating morbidity and mortality
•Reducing costs
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If positive for influenza
•Begin prophylaxis on ALL residents • Treatment should continue for 14 days
or for 7 days after onset of symptoms of last person infected
•Unvaccinated staff should receive antiviral treatment
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Importance of positive lab
•Place ill residents in private rooms or cohort with other ill residents
• Ill staff should stay off work until 24 hours without fever
•Keep staff from floating between floors/units
• Implement control measures
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LTCF Outbreak Control Measures•Use standard and droplet precautions
•Attention to hand hygiene
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Additional control measures
•Consider
▫Limiting new admissions
▫Limiting or stopping visitation to the facility
until no new cases for 48 hours
▫Stopping or limiting group activities
▫Serve meals in residents’ rooms
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Specimens for Influenza Testing •Nasopharyngeal swabs
•Obtain 8-10 from recently ill
•Ship to OLS for sub-typing
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Respiratory Outbreaks January-September 2011•51 respiratory outbreaks or clusters•30 in long term care facilities•Clinical Syndrome/Diagnosis:
▫Influenza▫Influenza/Pneumonia ▫Upper or Lower Respiratory Tract Infection▫Pneumonia
•14 counties
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LTCF Influenza Outbreaks January – September 2011 (Provisional Data)
•19 of 30 (63%) respiratory outbreaks were attributed to influenza▫15 of 19 (79% ) lab confirmed ▫4 of 19 (21% ) were rapid test positive with
no confirmatory testing•Only influenza AH3 , no AH1N1 in
residents
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Nursing Home Case #1•Started January 31, 2011 with one rapid
test (+)
•Two more residents on February 12
•Vaccination status of 44 of 73 (60%) staff members unknown
•2 staff members tested positive for influenza, specifics were not available
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Nursing Home #1 Final Count
•5 out 6 specimens sent to OLS for testing were positive for AH3
•14 of 55 (25%) residents met the case definition of ILI
•25 of 73 (34%) staff met case definition
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Nursing Home #2• Illness started February 28, 2011
•19 residents with ILI, 1 rapid test (+)
•8 staff with ILI, 2 rapid test (+)
•46 of 71 (65%) staff members immunized against influenza
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Nursing Home Case #2 Final Count•16/125 residents met case definition
Instead of 19 originally on line list
•14/171 staff met case definition Additional 6 staff members ill from original 8
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Nursing Home #3
• Illness started March 30, 2011
▫10 of 56 residents
▫0 of 35 staff members
•5 were rapid test (+)
•Doctor wanted to just provide anti-virals
for those that were ill
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Nursing Home #3•April 4, 2011
▫26 of 56 (46%) residents were ill 5 residents were sent to the hospital
▫13 of 35 (37%) staff reported illness
•6 specimens were sent to OLS in saline
•Antivirals administered to everyone at this time
•Last onset April 10, 2011
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Nursing Home #3 Final Count
•3 specimens sent to OLS were AH3 (+)
•Five residents hospitalized, two residents
died
•15 of 56 (27%) residents met case
definition
•14 of 35 (40%) staff met case definition
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Conclusion • Influenza symptoms are very similar to
other respiratory diseases•Laboratory testing is essential in
determining etiologic agent▫Results can guide treatment
Antivirals? Antibiotics?
▫Results can guide control measures Respiratory and cough etiquette Restriction of activities enforced or lifted
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