Readiness Guideline for Epidemic Respiratory Infection in Long Term Care Facilities Rachel N. Plotinsky MD Epidemic Intelligence Service Officer, NH Centers for Disease Control and Prevention NH Department of Health and Human Services Division of Public Health Services

Epidemic Respiratory Illness (ERI) Planning

Background Modeled on hospital ERI plan, originally created by DHMC Readiness Committee, and being modified by other NH hospitals Outlines plan for responding to various levels of threat posed by ERI To serve as a guideline for LTCFs –Will be adapted to specific needs/abilities of each facility Still in draft form

ERI Plan Features Matrix based on transmission risk –Alert levels “Ready”, Green,Yellow,Orange, Red modeled on federal 5 Considerations at each level –Access control –Surveillance, screening and triage –Infection control precautions –Communication and education –Additional preparedness activities Emphasis on achieving goals of Ready

Alert Matrix Type of transmission?Where are cases?Are there cases at LTCF? Alert Level None or sporadicAnywhere in worldNoReady Person-to-personAnywhere outside US, bordering countries NoGreen Person-to-personIn the US, Canada or Mexico NoYellow Person-to-personAt facilityYes, nosocomial transmission, known sources Orange Person-to-personAt facilityYes, nosocomial transmission, unknown source Red

WHO PANDEMIC PHASES Interpandemic period Phase 1. Present in animals, low risk to humans Phase 2. Present in animals, higher risk of human disease Pandemic alert period Phase 3. Human infection present, but no or very limited human-to- human spread Phase 4. Evidence of increased human- to-human transmission, but still limited Phase 5. Evidence of significant human-to-human transmission (substantial pandemic risk). b Pandemic period Phase 6. Evidence of sustained transmission in general population. Postpandemic Period

Current State of Affairs: Global

5 Considerations: Level Ready Access control –Security, plan to control access, IDs Surveillance, screening and triage –Screening residents for new cough Infection control precautions –Use of droplet precautions for all residents with new cough Communication and education –Form Readiness Committee –Develop plan for communicating internally Additional preparedness activities –Influenza vaccination for residents, staff –“Ask for a mask,” cough etiquette signs for visitors, volunteers

Staff Illness and Protection Staff, volunteers with fever and cough should: –Alert ICP –Practice hand hygiene after touching face –Wear surgical mask or use tissue to cover nose and mouth –Stay out of work while ill Clinicians should: –Manage residents with cough using droplet precautions until cause of respiratory illness is determined Staff should be fit-tested for N-95 masks

Level Green Efficient human-to-human transmission of potentially ERI –None at LTCF –None in US or bordering countries

5 Considerations Level Green Access control –Required IDs Surveillance, screening and triage –“Ask for a Mask” campaign –Screen for new cough expanded by Relevant risk factors (e.g. travel) New admissions with suspect diagnosis of ERI Infection control precautions expand to airborne and contact for suspect ERI Communication and education Additional preparedness activities prn

Level Yellow Efficient human-to-human transmission of potentially ERI –None at LTCF –Confirmed in US or bordering countries

5 Considerations Level Yellow Access control: all wearing IDs Surveillance, screening and triage –Expanded Infection control precautions –No change Communication and education –No change Additional preparedness activities –Weekly meeting of Readiness Committee

Level Orange Recognized nosocomial transmission at LTCF OR Local human-to-human transmission

5 Considerations Level Orange (1) Access control –One entrance with security posted –Restrict volunteers, visitors –Most activities suspended Surveillance, screening and triage –Mandatory screening All entering facilities –Registration of exposed staff; daily screening –Isolation and quarantine?

5 Considerations Level Orange (2) Infection control precautions –N-95s Daily communication and education internally and with families of residents, as applicable Additional preparedness activities –Twice daily meetings of Readiness Committee –Redeployment of staff from other areas of LTCF

Level: Red Uncontrolled nosocomial transmission of ERI OR Widespread local human-to-human transmission

5 Considerations Level Red Access control –Only essential employees can enter Surveillance, screening and triage –Daily (no change) Infection control precautions –All staff surgical masks at least, hand hygiene Communication and education Additional preparedness activities

Appendix Criteria for hospital transfer –Only if clinically indicated Protective equipment Room setup Staffing –Dedicated staff to ERI patients Employee surveillance –Keep track of those interacting with ERI patients Cohorting residents, staff Review/acceptance sign off sheet

Questions? NH Department of Health and Human Services Division of Public Health Services