Preventing and Responding to Influenza in MN LTC … and Responding to Influenza in MN LTC...
52
Preventing and Responding to Influenza in MN LTC Facilities Karen Martin, MPH – Influenza Surveillance Mary Ellen Bennett, MPH, RN, CIC – Infection Control Jennifer Heath, DNP, MPH, RN – Vaccination 1
Transcript of Preventing and Responding to Influenza in MN LTC … and Responding to Influenza in MN LTC...
Preventing and Responding to Influenza in MN LTC Facilities
Karen Martin, MPH – Influenza SurveillanceMary Ellen Bennett, MPH, RN, CIC – Infection Control
Jennifer Heath, DNP, MPH, RN – Vaccination
1
•Activity Update
•Infection Control Measures
•Influenza Vaccination
•Antiviral Medications
2
Minnesota Department of Health Weekly Influenza & Respiratory Activity Report for week ending October 28, 2017 | WEEK 43 4
Weekly Influenza & Respiratory Illness Activity Report
A summary of influenza surveillance indicators prepared by the Division of Infectious Disease Epidemiology Prevention & Control
Week Ending January 6, 2018 | WEEK 1All data are preliminary and may change as more information is received
Minnesota Influenza Geographic Spread
No ActivityDuring the week ending January 6, 2018 (Week 1),
surveillance indicators showed widespread geographic spread of influenza.
Since the start of the influenza season, one pediatric influenza-related death
has been reported.
Sporadic
Local
Regional
Widespread
Based on CDC’s Activity Estimates Definitions: http://www.cdc.gov/flu/weekly/overview.htm
Minnesota Influenza Surveillance: http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/Weekly U.S. Influenza Surveillance Report: http://www.cdc.gov/flu/weekly/World Health Organization (WHO) Surveillance: http://www.who.int/influenza/surveillance_monitoring/updates/en/Neighboring states’ influenza information:
Iowa http://www.idph.state.ia.us/IdphArchive/Archive.aspx?channel=FluReportsWisconsin http://www.dhs.wisconsin.gov/communicable/influenza/surveillance.htmNorth Dakota http://www.ndflu.com/default.aspxSouth Dakota http://doh.sd.gov/diseases/infectious/flu/
Minnesota Department of Health Weekly Influenza & Respiratory Activity Report for week ending October 28, 2017 | WEEK 43 5
0
5
10
15
20
25
30
35
40
45
50
40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Num
ber o
f lab
-con
firm
ed o
utbr
eaks
MMWR Week
2013-14
2014-15
2015-16
2016-17
2017-18
Respiratory Disease Outbreak Surveillance (continued)
Long-Term Care (LTC) OutbreaksLTC facilities report to MDH when they suspect an outbreak of influenza in their facility. Laboratory-confirmed outbreaks are reported here.
New LTC outbreaks this week
New LTC outbreaks last week
Total this season (to date)
23 19 55
Confirmed Influenza Outbreaks in LTC by Season
Current week
Minnesota Department of Health Weekly Influenza & Respiratory Activity Report for week ending October 28, 2017 | WEEK 43 6
0
5
10
15
20
25
30
35
0
50
100
150
200
250
300
350
400
450
500
550
600
40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Percent of positive molecular tests
Num
ber o
f pos
itive
mol
ecul
ar te
sts
MMWR Week
B
A (not subtyped)
A H3
A (H1N1) pdm09
2014-15 % + by PCR
2015-16 % + by PCR
2016-17 % + by PCR
2017-18 % + by PCR
Laboratory Surveillance The MN Lab System (MLS) Laboratory Influenza Surveillance Program is made up of more than 310 clinic- and hospital-based laboratories, voluntarily submitting testing data weekly. These laboratories perform rapid testing for influenza and Respiratory Syncytial Virus (RSV). Significantly fewer labs perform PCR testing for influenza and three also perform PCR testing for other respiratory viruses. MDH-PHL provides further characterization of submitted influenza isolates to determine the hemagglutinin serotype to indicate vaccine coverage. Tracking the laboratory results assists healthcare providers with patient diagnosis of influenza-like illness and provides an indicator of the progression of the influenza season as well as prevalence of disease in the community.
% molecular tests positive this week
% molecular tests positive last week
23.7% 26.6%
Specimens Positive for Influenza by Molecular Testing*, by Week
* Beginning in 2016-17, laboratories report results for rapid molecular influenza tests in addition to RT-PCR results
Current week
Minnesota Department of Health Weekly Influenza & Respiratory Activity Report for week ending October 28, 2017 | WEEK 43 7
050
100150200250300350400450500550600650700750
40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20
Num
ber o
f Hos
pita
lizat
ions
MMWR Week
2012-13
2013-14
2014-15
2015-16
2016-17
2017-18
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20
Num
ber o
f Hos
pita
lizat
ions
MMWR Week
B (no genotype)
B (Yamagata)
B (Victoria)
A (not subtyped)
A H3
A H1 (unspecified)
A (H1N1)pdm09
A (H1N2v)
A (H3N2v)
A&B
Unknown
Hospitalized Influenza SurveillanceHospitalized influenza cases are based on disease reports of laboratory-positive influenza (via DFA, IFA, viral culture, EIA, rapid test, paired serological tests or RT-PCR) and specimens from hospitalized patients with acute respiratory illness submitted to MDH-PHL by hospitals and laboratories. Due to the need to confirm reports and reporting delays, consider current week data preliminary.
Hospitalized Influenza Cases by Type Minnesota (FluSurv-NET*)
Hospitalized Influenza Cases by Season, Minnesota (FluSurv-NET*)
*Influenza Surveillance Network
Season Total hospitalizations (historic)
2012-2013 3,0682013-2014 1,5402014-2015 4,1382015-2016 1,5412016-2017 3,7382017-2018 1,765 (to date)
Hospitalizations this week
Hospitalizations last week
Total hospitalizations(to date)
503 598 1,765
Current week Current week
Minnesota Department of Health Weekly Influenza & Respiratory Activity Report for week ending October 28, 2017 | WEEK 43 8
14.87.0 10.3
25.5
137.3
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
0
200
400
600
800
1000
1200
1400
0-4 5-24 25-49 50-64 65+
Hospitalizations per 100,000 Persons
Num
ber o
f Hos
pita
lizat
ions
Age Group (years)
# of hospitalizations
Incidence (cases) per100,000 Persons
26.4
39.8
11.723.3 25.8 24.6 18.8 18.3
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
0
200
400
600
800
1000
1200
1400N
umbe
r of H
ospi
taliz
atio
ns
Region
# of hospitalizations
Incidence (cases) per100,000 Persons
Number of Influenza Hospitalizations and Incidence by Region, Minnesota
October 1, 2017 – January 6, 2018
Number of Influenza Hospitalizations and Incidence by Age, Minnesota
October 1, 2017 – January 6, 2018
Median age (years) at time of admission
74.0
Region Hospitalizations this week
Total (to date)
Central 63 (13%) 198 (11%)Metro 336 (67%) 1,208 (68%)Northeast 5 (1%) 38 (2%)Northwest 13 (3%) 37 (2%)South Central 25 (5%) 75 (4%)Southeast 28 (6%) 124 (7%)Southwest 17 (3%) 41 (2%)West Central 16 (3%) 44 (3%)
Hospitalized Influenza Surveillance (continued)
Hospitalizations per 100,000 Persons
Identifying and Reporting Influenza Outbreaks
• Identifying an Outbreak
• Outbreak definition: at least two residents with onset of influenza-like illnesses within 72 hours of each other AND at least one resident has laboratory-confirmed influenza.
• Reporting an Outbreak to MDH
• Submit a Long-Term Care Facility Influenza and RSV Report Form, 2017–18 (www.health.state.mn.us/divs/idepc/diseases/flu/ltc/ltcreport.pdf) to MDH by email or fax when an influenza outbreak is identified in your LTC facility. Please call 651-201-5924 if you have questions regarding reporting or influenza outbreak control measures.
1/12/2018 9
Sign Up for Weekly Influenza Updates
• http://www.health.state.mn.us/divs/idepc/diseases/flu/stats/index.html
1/12/2018 10
Infection Prevention
• Influenza characteristics• Surveillance• Isolation • Prevention• Tools for management • References
12
Presenter
Presentation Notes
Influenza is a major infection prevention event in a Long Term Care facility. Today I will discuss characteristics of influenza, surveillance, and isolation. I will also give you some tools for prevention and management, along with some influenza references.
Influenza Characteristics
Presenter
Presentation Notes
First I will discuss Influenza Characteristics.
Influenza in Elderly Persons
14
Disease Presentation• Influenza-like illness (ILI) in elderly persons may be atypical• New onset of cough, sore throat, nasal congestion or rhinorrhea, or a
temperature 100° F or greater; however, fever may be absent• Atypical complaints: anorexia, mental status changes, and unexplained
fever may be the presenting symptoms
Disease Presentation in General Population• Fever or feeling feverish/chills, cough, sore throat, runny or stuffy
nose, muscle or body aches, headaches, fatigue (tiredness)
Presenter
Presentation Notes
Influenza-like illness presentation in elderly persons may be atypical. There may be a new onset of cough, sore throat, nasal congestion or rhinorrhea, or a temperature of 100° F or greater. Sometimes the fever may be absent. In the elderly, there may be atypical complaints such as anorexia, mental status changes, and unexplained fever. In the general population, the most common symptoms are fever (or feeling feverish with chills), cough, sore throat, runny or stuffy nose, muscle and body aches, headaches, and fatigue.
Influenza in Elderly Persons
15
Complications: • Worsening respiratory status: (residents with COPD or CHF) • Primary viral pneumonia and bacterial suprainfection (leading to
tracheobronchitis or pneumonia)
Transmission• Large respiratory droplets (particles >5 µ in diameter) expelled from
resp. tract• Close contact (< 3 feet) usually is required for transmission• Direct contact with respiratory droplets or secretions• Touching the nose or mouth
Presenter
Presentation Notes
Complications of influenza in the elderly can be: A worsening respiratory status especially in residents with COPD (chronic obstructive pulmonary disease) or congestive heart failure. A primary viral pneumonia and potentially a secondary bacterial pneumonia can occur. This can also lead to tracheobronchitis. Transmission of influenza is by Large respiratory droplets (particles >5 micron in diameter) being expelled from respiratory tract during coughing or sneezing. Close contact (< 3 feet), is usually required for transmission. There can also be transmission by direct contact with respiratory droplets or secretions, and then touching your nose or mouth.
Influenza in Elderly Persons
16
Incubation• 1 to 4 days, usually 2 days
Contagiousness (or Infectious Period)• 24 hours prior to onset of illness to at least 5 days after onset of
symptoms• Immunocompromised shed virus for 7 days or more after onset of
symptoms
Duration• 1-2 weeks with severe symptoms in the first few days
Presenter
Presentation Notes
Influenza Incubation period is 1 to 4 days and usually occurs at 2 days The Contagiousness (or Infectious Period) is 24 hours prior to onset of illness to at least 5 days after onset of symptoms; The Immunocompromised person may shed virus for 7 days or more after the onset of symptoms. Duration of Symptoms can be from 1-2 weeks with the most severe symptoms being in the first few days.
Surveillance
Presenter
Presentation Notes
Now I will discuss Surveillance.
Surveillance for Influenza & ILI in LTC Facilities
• Residents are monitored for illness on a routine basis • Clusters of illness or infection can be detected by this
type of monitoring • A log of illnesses and infection is kept by nursing staff• Influenza and influenza like illness can be kept on the
routine tracking forms or the facility can use a special influenza tracking form from MDH
18
Presenter
Presentation Notes
In long term care, residents are always monitored for illness. Clusters of illness or infection can be detected by staff knowing what to look for and reporting it promptly. A log of illnesses and infection is required to be kept by nursing staff in long term care. Influenza and influenza like illness can be kept on the routine tracking log the facility uses. If an outbreak occurs, the facility can continue to use their routine tracking log or they can use a special influenza tracking form that is provided by MDH.
Tracking Tool
Infection and Antibiotic Use Tracking tool (Appendix L)http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/asp/ltc/
19
Presenter
Presentation Notes
This is a snap shot of the log that MDH has on its antimicrobial stewardship web page to document illness and infection in the residents. Many MN facilities are using the MDH log for illness and treatment documentation. You may have your own version of a log. Although the MDH log was created for antimicrobial tracking, it can also be used to track illness due to influenza or ILI.
Line List
Influenza-like Illness (ILI) Line List: Do not submit to MDHhttp://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/index.html 20
Presenter
Presentation Notes
MDH also has this two-page form specifically for influenza that might be useful in an influenza outbreak situation to help you collect data on each resident with influenza like illness. This form does not need to be submitted to MDH if a facility has an outbreak. There are 2 pages to this form and the facility should use both pages to list information about residents who are ill with influenza like illness. This can help you track and trend illness around your facility.
Isolation for Influenza and Influenza Like Illness (ILI)
Presenter
Presentation Notes
Now I will discuss Isolation for influenza and influenza like illness.
CMS LTC Interpretive Guidance –Transmission Based Precautions
The diagnosis of many infections is based on clinical signs and symptoms, but often requires laboratory confirmation. However, since laboratory tests (especially those that depend on culture techniques) may require two or more days to complete, transmission-based precautions may need to be implemented …….. a resident with influenza and signs of infection should wear a facemask (e.g., surgical or procedure facemask) when leaving his/her room for medically-necessary care (i.e., droplet precautions for the duration of the illness). State Operations Manual, Appendix PP – Guidance to Surveyors 11-22-2017 see pages 673-714 for Infection Control https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
22
Presenter
Presentation Notes
CMS has a document that highlights the CMS Conditions of Participation, and lists the details that the surveyors will be enforcing. This document is called the State Operations Manual. The latest version of this document is from November 2017 and can be found at the link at the bottom of this slide. The point that is made in this excerpt from the State Operations Manual, is that a resident should be put into isolation presumptively when symptoms present because it may take a couple of days for test results to come back. This action will limit spread of the virus to others in the facility. This document also states that when a resident with influenza symptoms leaves his or her room for care, the resident should wear a face mask. This is in accordance with the recommendations from CDC for Droplet Precautions.
Standard and Droplet Precautions
23
• Standard precautions: use for all patients• Droplet precautions: use with standard precautions for residents with
known or suspected influenza or influenza-like illness• Precautions should be in place for the duration of the symptoms of illness
o Best to have a private room if available – can cohort ill persons o Signageo Procedure mask: correct don/doff procedureo Care of patient care equipment – clean all equipment going in and out
with a EPA registered disinfectanto Hand hygiene
https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
Presenter
Presentation Notes
Standard precautions are used for all residents of course. Droplet precautions should be used in addition, for any resident with suspected influenza or influenza-like illness. The Precautions are to remain in place for the duration of illness (usually at least 5-7 days post onset and maybe longer in the immunosuppressed and elderly). A single room is recommended. Cohorting with another an influenza resident is acceptable if necessary. Again, limit transport and movement of residents outside of the room to medically necessary purposes. If transport or movement is necessary, again, instruct resident to wear a mask; the person transporting the resident does not need to wear a mask. Droplet Isolation signage should be placed at the resident’s door. Personal Protective Equipment, (regular masks) should be available. Equipment going in and out of the resident’s room should be cleaned with an EPA registered disinfectant. The common pop up used in most facilities wipes are effective.
CMS LTC Interpretive Guidance –Transmission Based Precautions
• Clearly identify the type of precautions and the appropriate PPE to be used;
• Place signage in a conspicuous place outside the resident’s room such as the door or on the wall next to the doorway identifying the CDC category of transmission-based precautions (e.g. contact, droplet, or airborne), instructions for use of PPE, and/or instructions to see the nurse before entering. Ensure that signage also complies with residents’ rights to confidentiality and privacy;
• Make PPE readily available near the entrance to the resident’s room; • Don appropriate PPE upon entry into the environment (e.g., room or
cubicle) of resident on transmission-based precautions;
State Operations Manual, Appendix PP – Guidance to Surveyors 11-22-2017 see pages 673-714 for Infection Control https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
24
Presenter
Presentation Notes
To clarify signage and personal protective equipment placement, the CMS State Operations Manual states that: The facility should clearly identify the type of precautions being used, by posting a Droplet Precautions sign at the entrance to the resident’s room. They also say that personal protective equipment (masks in this case), should be readily available near the entrance to the resident’s room.
Enforce Correct Mask Use
25
• Hand hygiene before and after touching (masks are contaminated)
• Follow instructions for donning and removal by type of mask (i.e., ear loops, ties)
• Do not wear around the neck, on an ear, on top of the head, or re-use between residents
• Provide easy access to masks, alcohol hand sanitizer, and waste receptacles
http://www.apic.org/Resource_/TinyMceFileManager/consumers_professionals/APIC_DosDontsofMasks_hiq.pdf
Presenter
Presentation Notes
Enforcing the correct usage of masks is critical. APIC has developed a nice poster on this topic. The link to the poster can be found at the bottom of the slide. I have seen these posters displayed in a number of long term care facilities. The facility should Provide easy access to masks and waste receptacles It is helpful to have the alcohol hand sanitizer at the entrance to the residents room. The staff should perform hand hygiene before and after touching mask. Masks collect infectious droplets on the external side, but are also contaminated with a wearer’s respiratory droplets Use mask instructions for the type of mask used, be it ear loops or ties Do not wear a mask around the neck, on top of the head, or re-use between residents Remove the mask when no longer in the resident room.
How to put on a face mask1. Clean your hands with soap and water or hand sanitizer before touching the mask.2. Remove a mask from the box and make sure there are no obvious tears or holes in either side of the mask. 3. Determine which side of the mask is the top. The side of the mask that has a stiff bendable edge is the top and is meant
to mold to the shape of your nose.4. Determine which side of the mask is the front. The colored side of the mask is usually the front and should face away
from you, while the white side touches your face.5. Follow the instructions below for the type of mask you are using.
Face Mask with Ear loops: Hold the mask by the ear loops. Place a loop around each ear.Face Mask with Ties: Bring the mask to your nose level and place the ties over the crown of your head and secure with a bow.Face Mask with Bands: Hold the mask in your hand with the nosepiece or top of the mask at fingertips, allowing the headbands to hang freely below hands. Bring the mask to your nose level and pull the top strap over your head so that it rests over the crown of your head. Pull the bottom strap over your head so that it rests at the nape of your neck.
6. Mold or pinch the stiff edge to the shape of your nose. 7. If using a face mask with ties: Then take the bottom ties, one in each hand, and secure with a bow at the nape of your
neck.8. Pull the bottom of the mask over your mouth and chin. 26
Presenter
Presentation Notes
These are instructions on how to put on a mask. I will not read these but have included this information in the slides for you.
Prevention
Presenter
Presentation Notes
Prevention
Employee Illness
• Offer vaccination to all employees throughout the season • Vaccinate new employees who start during the season • Staff should know the symptoms of influenza so they can
recognize it in themselves and the residents• Enforce staff not working when they are sick• Staff should know that they can be infectious 1 day before
they exhibit classic symptoms of influenza• Encourage staff to notify managers if they do develop an
influenza like illness28
Presenter
Presentation Notes
Employees play a large role in the prevention of influenza in the facility. The facility should: offer vaccination to all employees throughout the season Vaccinate new employees who start during the season enforce staff not working when they are sick and Encourage staff to notify managers if they do develop an influenza like illness The Staff should know the symptoms of influenza so they can recognize it in themselves and the residents The Staff should also know that they can be infectious for 1 day before THEY exhibit classic symptoms of influenza
Visitors Entering the Facility• Post signs at entry to restrict ill
visitors• Publish visitor restriction notices to
the local community• Limit visitor movement in facility• Alcohol hand rubs at entry with
signage• Cover your cough signs• Encourage visitors to get a flu shot
29
Presenter
Presentation Notes
Some things that you should always have in place are: Posting signage at facility entry points restricting ill visitors. Posting notices in facility newsletters and other communications to the resident’s family AND reminding them that ill persons should not visit. Instructing visitors to limit their movement within the facility. Placing alcohol-based hand sanitizer at entry points to the facility with signage that instructs visitors to clean their hands upon entering the facility. Posting Cover your Cough signs throughout the facility Encouraging all visitors to receive seasonal influenza vaccine as soon as possible.
Visiting the Ill Resident
• Limit visiting to persons necessary for the resident’s well-being and care
• Hand hygiene before entering, after leaving the resident’s room
• Instruct visitors how to wear and dispose of PPE as per facility policy
• Instruct visitors to not visit other residents before removing PPE (if worn) and perform hand hygiene
30
Presenter
Presentation Notes
In addition, during an outbreak: Limit visitors for residents with influenza-like illness, to persons who are necessary for the patient's emotional well-being and care. Instruct visitors to clean their hands before entering and upon leaving the resident’s room. Instruct visitors to wear masks as indicated. Instruct visitors to remove masks and perform hand hygiene if they are going to visit other residents
Visiting Restrictions
• Stronger measures can be implemented at the digression of the facility during an influenza outbreak
• For instance• Alerting visitors about the outbreak• Restricting visiting for children• Screening all visitors for illness before
visiting
31
Presenter
Presentation Notes
In addition, stronger measures can be put in place by the facility if an outbreak occurs. The facility can alert visitors that there is an outbreak, children can be restricted from visiting, and a program can be put into place to screen all visitors for influenza like illness.
Tools
Presenter
Presentation Notes
Here are some tools that may help you during influenza season.
Tip Sheet
33
• Before an Outbreak Occurs• Identifying an Outbreak• Reporting an Outbreak to MDH• Testing• Monitor• Control• Additional Control Measures to Consider• Treatment• Chemoprophylaxis
www.cdc.gov/flu/pdf/professionals/interim-guidance-outbreak-management.pdf
Presenter
Presentation Notes
There is an MDH Tip Sheet that is adapted from CDC. It is available ……
Signs – Droplet Precautions
Washington State Isolation Signs – scroll down to SIGNS. Can download or purchase actual sign for $1.10http://www.wsha.org/quality-safety/projects/standardization/ 34
Example of a transmission based precaution isolation sign
Do not put resident’s name on the sign
Note: MDH does not endorse any particular sign
Presenter
Presentation Notes
This is a sample of a Droplet Precautions Sign. It is from Washington State and it is available for printing from their web site. It is also available for purchase at a nominal fee. MDH does not endorse any particular sign but this one is a good example.
References
• MDH www.mdhflu.com
• CDC www.cdc.gov/flu/
• Minnesota Immunization Information Connection (MIIC) http://www.health.state.mn.us/miic
35
Presenter
Presentation Notes
Here are some links to references. The MN Department of Health, the CDC, and the MN Department of Health MIIC website.
Intramuscular Route
• Nearly all flu vaccine formulations
• Exception is intradermal vaccine
• Needle length is important!
• 1” or 1 ½” for many, but not all, adults
• Isolate the muscle
• 90 degrees
Presenter
Presentation Notes
The intramuscular route is used for inactivated presentations that are not specified as intradermal, including IIV3, IIV4, cell-based IIV and the recombinant influenza vaccine. Unfortunately, I hear providers dismiss the importance of injection technique– but in fact, this is the most important factor in delivering the vaccine into the muscle where it will be most effective and cause the patient the least amount of discomfort. Use of longer needles has been associated with less redness or swelling than occurs with shorter needles because of injection into deeper muscle mass (92). Appropriate needle length depends on age and body mass. For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone (91,95--97). You need to be familiar with the anatomy of the area into which you injecting. Intramuscular injections are administered at a 90-degree angle to the skin, usually into the deltoid for adults and the anterolateral aspect of the thigh for children. A decision on needle size and site of injection must be made for each person on the basis of the size of the muscle and the thickness of adipose tissue around the muscle. For many, but not all adults a 1’’ or 1 ½” needle will be appropriate. For people weighing less than 130 pounds, a 5/8” needle is usually sufficient if the tissue is not bunched up. In the printed or PDF version of the Flu Guide, we have included several links to instructional videos for IM injections.
Storage and Handling of Flu Vaccine
• Maintenance of temperature is critical to the vaccine’s viability and effectiveness
• Loss of inventory, thousands of dollars even with a modest amount of vaccine
• Colder is not better• Especially vulnerable to freezing temperatures
• CDC’s guidance recently changed, ideal temperature is 40F or 4.4C
• Temperature monitoring • Several options for monitoring
• Temps recorded by a human twice per day
• Utilize MDH’s resources linked in the Fall Flu Guide.
Presenter
Presentation Notes
Proper storage and handling of influenza vaccine is critical to maintain it’s effectiveness. The parameters for storage of vaccines are very specific– don’t just assume that your refrigerator is doing the job. Influenza vaccines are especially sensitive to freezing temperatures, one reason why you need to be vigilant about storage and handling practices. It is also for this reason that it is not recommended to use a dorm style fridge– that is a fridge with the freezer compartment behind the same main door.
Storage and Handling of Flu Vaccine
• Appropriate storage units• CDC recommends “stand-alone” or pharmacy grade units
• Combination units are less capable of maintaining consistent temperatures in both compartments
• Temperature monitoring • Several options for monitoring: data logger, electronic temperature monitoring or
thermometer
• All systems should be calibrated with certificate
• Temps recorded by a human twice per day
• Utilize MDH’s resources linked in the Fall Flu Guide.
Presenter
Presentation Notes
Proper storage and handling of influenza vaccine is critical to its viability and effectiveness. Inactivated vaccines, like influenza are especially sensitive to freezing temperatures. Because the temperature is highly variable in dormitory-style refrigerators, they are not appropriate for vaccine storage at any time. You should have a written policy for vaccine storage and handling that includes an emergency plan for power failures– be sure to communicate the location of your plan to all staff. Flu vaccine is often transported on-site, which requires several considerations. MDH and CDC have several resources available for your use, For guidance, see the MDH fact sheet, Proper Storage, Handling, and Shipping of Influenza Vaccine at: www.health.state.mn.us/divs/idepc/diseases/flu/vaccine/sh/storage.html
Essential Resource
1/08/2018 40
Vaccination of Residents
• Continue to vaccinate• Vaccine protects against 3 or 4 strains
• Second doses not recommended
• Standard, high-dose, or adjuvanted– no preference
• Be mindful of proper administration techniques• Frail patients may require “bunching” or a shorter needle length for IM administration
• Obese patents may require a longer needle length
• Use the Minnesota Immunization Information Connection (MIIC)• http://www.health.state.mn.us/miic
01/08/2018 41
Vaccination of HCP
• Continue to vaccinate
• New employees, former decliners
• If you cannot provide vaccine refer employees to other sources: pharmacy, clinic, community vaccinator
• Un and underinsured adult vaccine program: http://www.health.state.mn.us/divs/idepc/immunize/adultvax/clinicsearch.html
• Consider your educational resources
• Tailor to a lay audience
• Seek out translations (or interpreters)– even if proficient in English
• Use the Minnesota Immunization Information Connection (MIIC)
• http://www.health.state.mn.us/miic
01/08/2018 42
Finding the Flu and Vaccine Materials
www.mdhflu.com
Presenter
Presentation Notes
Because you may have received a link to this webinar via email, I’m going to show you where to find the flu materials on our website. When you type in www.mdhflu.com, you will be taken to this page. Look at the “for health professionals” section. You will find information on testing, rapid testing, vaccine, antivirals, infection control, and reporting on this page. To find the flu guide, we’re going to click on “vaccine”
Influenza For Health Professionals
Presenter
Presentation Notes
This is our influenza vaccine page where you will find a link to this webinar and the fall flu guide right at the top. I recommend you print this and keep it handy throughout the vaccination season. Occasionally, we have needed to update this piece mid-season and if we do, we send out a notification via the gov delivery list for health professionals.
Antiviral Medications for the 2017-2018 Season
• Antiviral medications reduce illness and severe outcomes of influenza based on evidence from randomized controlled trials, meta-analyses of randomized controlled trials, and observational studies. https://www.cdc.gov/flu/professionals/antivirals/index.htm
• Three FDA-approved influenza antiviral drugs recommended by CDC this season to treat influenza:
• oseltamivir (available as a generic version or under the trade name Tamiflu®),
• zanamivir (trade name Relenza®), and
• peramivir (trade name Rapivab®).
• Oseltamivir (Tamiflu®) is the most common antiviral used in LTC facilities.
• Circulating strains are sensitive to oseltamivir at this time.1/12/2018 46
Antiviral Shortage?
• Manufacturers report being able to meet expected demand of season
• No supply shortage, but temporary spot shortages have been reported in parts of the country
• CDC recommends
• Call pharmacy in advance
• Call multiple pharmacies if needed
• Remember to ask for generic and brand-name oseltamivir
1/12/2018 47
CDC Antiviral Recommendations for LTC and Assisted Living
• Can be difficult logistically and financially
• Antiviral recommendations for LTC and assisted living are consistent with previous years
• Severe season underscores need for treatment/prophylaxis
• Priority groups specified if unable to implement for entire facility immediately
1/12/2018 48
Treatment with Antiviral Medications
• Treat residents with confirmed or suspected influenza with antivirals immediately.
• Treatment should not wait for laboratory confirmation of flu.
• Antiviral treatment works best when started within the first 2 days of symptoms, but can be beneficial after that period.
• Dosing: oseltamivir (Tamiflu®) antiviral treatment is typically 75 mg twice daily for 5 days.
• Longer treatment courses for patients who remain severely ill after 5 days of treatment can be considered.
• Always consult the resident’s physician for dosing guidance.
• Patients with renal impairment may require lower doses.
01/08/2018 49
Chemoprophylaxis with Antiviral Medications
• All eligible well residents in the entire LTC facility (not just currently affected wards) should promptly receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined.
• Priority should be given to residents living in the same unit or floor as an ill resident. However, all non-ill residents are recommended to receive antiviral chemoprophylaxis to control influenza outbreaks.
• Dosing: In the LTC facility setting, oseltamivir (Tamiflu®) antiviral chemoprophylaxis is typically 75 mg once daily for a minimum of 2 weeks, continuing for 7 days after the last known case was identified.
• Always consult the resident’s physician for dosing guidance.
• Patients with renal impairment may require lower doses.
• Consider offering prophylaxis to staff in the facility. Alternatively, have staff contact their primary care provider to discuss prophylaxis.
1/12/2018 50
Resources
• CDC
• https://www.cdc.gov/flu/professionals/antivirals/index.htm
• MDH
• http://www.health.state.mn.us/divs/idepc/diseases/flu/ltc/index.html
1/12/2018 51
Questions?
1/12/2018 52
