1. Influenza in Long-Term Care
Bill Cayley Jr MD MDiv
UW Health Augusta Family Medicine
Influenza in Long-Term Care
Bill Cayley Jr MD MDiv
UW Health Augusta Family Medicine

2. Acknowledgement
This presentation is an adaptation of material available to the public on the website of the Centers for Disease Control (

3. Learning Objectives Participants will be able to: Describe influenza
Describe the importance of influenza in long-term care
Describe how to reduce the risk of influenza in long-term care
Learning Objectives - After this presentation, participants will be able to:
Describe influenza
Describe the importance of influenza in long-term care
Describe how to reduce the risk of influenza in long-term care

4. Influenza Influenza is… Seriousness
Viral respiratory illness
Fever, muscle aches, headache, malaise, nonproductive cough, sore throat, and rhinitis
Seriousness
Usually resolves in 3-7 days
Severe illness in presence of chronic disease
Pulmonary or cardiac disease, diabetes
Risks
Serious illness or death in long-term care residents
Serious illness in long-term care personnel
Influenza is NOT: upset stomach, a bad cold
Influenza
Uncomplicated influenza illness is characterized by the abrupt onset of constitutional and respiratory signs and symptoms (e.g., fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis). Among children, otitis media, nausea, and vomiting also are commonly reported with influenza illness. Uncomplicated influenza illness typically resolves after 3--7 days for the majority of persons, although cough and malaise can persist for >2 weeks. However, among certain persons, influenza can exacerbate underlying medical conditions (e.g., pulmonary or cardiac disease), lead to secondary bacterial pneumonia or primary influenza viral pneumonia, or occur as part of a coinfection with other viral or bacterial pathogens. Young children with influenza virus infection can have initial symptoms mimicking bacterial sepsis with high fevers, and febrile seizures have been reported in up to 20% of children hospitalized with influenza virus infection. Influenza virus infection also has been uncommonly associated with encephalopathy, transverse myelitis, myositis, myocarditis, pericarditis, and Reye syndrome. Influenza can cause substantial illness and death among long-term care facility residents and illness among personnel in long-term care facilities.
Adapted from: (accessed 26 September 2006), (accessed 26 September 2006)

5. The Influenza Virus Two types of viruses Transmission:
Influenza A – subtypes by H & N antigens
Influenza B
Transmission:
Small droplets from cough or sneeze
Settle in airways of nearby persons
Direct or indirect contact w/ infected surfaces
“Incubation” period of 1-4 days
“Contagious”
Adults – from 1 day before to 5 days aftetr start of symptoms
Children – for 10 or more days
The Influenza Virus
Influenza A and B are the two types of influenza viruses that cause epidemic human disease. Influenza A viruses are further categorized into subtypes on the basis of two surface antigens: hemagglutinin and neuraminidase. Influenza B viruses are not categorized into subtypes. Since 1977, influenza A (H1N1) viruses, influenza A (H3N2) viruses, and influenza B viruses have been in global circulation. In 2001, influenza A (H1N2) viruses that probably emerged after genetic reassortment between human A (H3N2) and A (H1N1) viruses began circulating widely. Both influenza A and B viruses are further separated into groups on the basis of antigenic characteristics. New influenza virus variants result from frequent antigenic change (i.e., antigenic drift) resulting from point mutations that occur during viral replication. Influenza B viruses undergo antigenic drift less rapidly than influenza A viruses.
Influenza is primarily transmitted from person to person via large virus-laden droplets (particles >5 µm in diameter) that are generated when infected persons cough or sneeze; these large droplets can then settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near (e.g., within 3 feet) infected persons. Transmission may also occur through direct contact or indirect contact with respiratory secretions such as touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth. Adults can spread influenza to others from the day before getting symptoms to approximately 5 days after symptoms start. Children can spread influenza to others for 10 or more days.
Adapted from: (accessed 26 September 2006),

6. Impact of Influenza Hospitalization rates for children <5 years
500/100,000 children with high-risk medical conditions
100/100,000 children without high-risk medical conditions
From through
54,000 to 430,000 influenza hospitalizations per epidemic
226,000 influenza-related excess hospitalizations per year
63% of all hospitalizations were among persons >65 years
Influenza-related deaths
Pneumonia, exacerbations of cardiopulmonary other chronic diseases
Deaths of adults >65 years account for >90% of deaths from pneumonia and influenza
Impact of Influenza
Among children aged <5 years, hospitalization rates have ranged from approximately 500/100,000 children for those with high-risk medical conditions to 100/100,000 children for those without high-risk medical conditions. Hospitalization rates among children aged <24 months are comparable to rates reported among persons aged >65 years.
During seasonal influenza epidemics from through , the estimated overall number of influenza-associated hospitalizations in the United States ranged from approximately 54,000 to 430,000/epidemic. An average of approximately 226,000 influenza-related excess hospitalizations occurred per year, and 63% of all hospitalizations occurred among persons aged >65 years. Since the 1968 influenza A (H3N2) virus pandemic, the number of influenza-associated hospitalizations is generally greater during seasonal influenza epidemics caused by type A (H3N2) viruses than seasons in which other influenza virus types predominate.
Influenza-related deaths can result from pneumonia and from exacerbations of cardiopulmonary conditions and other chronic diseases. Deaths of adults aged >65 years account for >90% of deaths attributed to pneumonia and influenza. In one study, approximately 19,000 influenza-associated pulmonary and circulatory deaths per influenza season occurred during , compared with approximately 36,000 deaths during Estimated rates of influenza-associated pulmonary and circulatory deaths/100,000 persons were among persons aged years, 7.5 among persons aged years, and 98.3 among persons aged >65 years. In the United States, the number of influenza-associated deaths has increased in part because the number of older persons is increasing, particularly persons aged >85 years. In addition, influenza seasons in which influenza A (H3N2) viruses predominate are associated with higher mortality; influenza A (H3N2) viruses predominated in 90% of influenza seasons during , compared with 57% of influenza seasons during
Adapted from: (accessed 26 September 2006)

7. Increased Risk of Complications
Children 6-23 months
Children and adolescents (aged 6 months--18 years) on receiving long-term aspirin therapy
Women who will be pregnant during the influenza season
Adults and children with chronic pulmonary or cardiovascular disease
Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, etc.
Adults and children who have any condition that can compromise respiratory function or the handling of respiratory secretions
Residents of nursing homes and other chronic-care facilities
Persons aged >65 years.
Increased Risk of Influenza Complications
children aged months;
children and adolescents (aged 6 months--18 years) who are receiving 'long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza virus infection;
women who will be pregnant during the influenza season;
adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma (hypertension is not considered a high-risk condition);
adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunodeficiency (including immunodeficiency caused by medications or by human immunodeficiency virus [HIV]);
adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration;
residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions; and
persons aged >65 years.
Adapted from: (accessed 26 September 2006)

8. Long-term Care Environment
Susceptible patients
Mainly over 65
High-risk cardiac, pulmonary, and medical conditions
High risk of transmission
Close quarters
Airborne or contact transmission
Staff transmission to patients
Multiple factors increase the potential for clusters or outbreaks of influenza in long-term care facilities:
Susceptible patients (Population is predominantly over 65, high frequency of high-risk cardiac, pulmonary, and medical conditions)
High risk of transmission (Patients and staff are in close quarters, increased likelihood of airborne or contact transmission)
Health staff may become ill and transmit virus to more susceptible patients

9. Prevention Strategies
Surveillance
Education
Influenza Testing
Respiratory Hygiene
Standard Precautions
Droplet Precautions
Restrictions for Ill Visitors and Personnel
when widespread influenza activity is occurring in the surrounding community
Antiviral Chemoprophylaxis
1. Surveillance
Conduct surveillance for respiratory illness and use influenza testing to identify outbreaks early so that infection control measures can be promptly initiated to prevent the spread of influenza in the facility.
2. Education
Educate personnel about the signs and symptoms of influenza, control measures, and indications for obtaining influenza testing.
3. Influenza Testing
Develop a plan for collecting respiratory specimens and performing rapid influenza testing (e.g., rapid diagnostic test, immunofluorescence) and viral cultures for influenza (see Flu: Lab Diagnosis) when respiratory illness clusters occur or when influenza is otherwise suspected in a resident.
4. Respiratory Hygiene/Cough Etiquette Programs
Respiratory hygiene/cough etiquette should be implemented whenever residents or visitors have symptoms of respiratory infection to prevent the transmission of all respiratory tract infections in long-term care facilities. Respiratory hygiene/cough etiquette programs include the following:
Posting visual alerts instructing residents and persons who accompany them to inform health-care personnel if they have symptoms of respiratory infection and discouraging those who are ill from visiting the facility.
Providing tissues or masks to residents and visitors who are coughing or sneezing so that they can cover their mouth and nose.
Providing tissues and alcohol-based hand rubs in common areas and waiting rooms.
Ensuring that supplies for handwashing are available where sinks are located and providing dispensers of alcohol-based hand rubs in other locations.
Encouraging coughing persons to sit at least 3 feet away from others, if possible. Residents with symptoms of respiratory infection should be discouraged from using common areas where feasible.
5. Standard Precautions
During the care of any resident with symptoms of a respiratory infection, health-care personnel should adhere to Standard Precautions:
Wear gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
Wear a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
Change gloves and gowns after each resident encounter and perform hand hygiene as discussed below.
Decontaminate hands before and after touching the resident, after touching the resident’s environment, or after touching the resident’s respiratory secretions, whether or not gloves are worn.
When hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap (either plain or antimicrobial) and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Alternatively, wash hands with soap (either plain or antimicrobial) and water.
6. Droplet Precautions
In addition to Standard Precautions, health-care workers should adhere to Droplet Precautions during the care of a resident with suspected or confirmed influenza for 5 days after the onset of illness:
Place resident into a private room. If a private room is not available, place (cohort) suspected influenza residents with other residents suspected of having influenza; cohort confirmed influenza residents with other residents confirmed to have influenza.
Wear a surgical or procedure mask upon entering the resident’s room or when working within 3 feet of the resident. Remove the mask when leaving the resident’s room and dispose of the mask in a waste container.
If resident movement or transport is necessary, have the resident wear a surgical or procedure mask, if possible.
7. Restrictions for Ill Visitors and Health-care Personnel when widespread influenza activity is occurring in the surrounding community
Notify visitors (e.g., via posted notices) that adults with respiratory symptoms should not visit the facility for 5 days and children with symptoms for 10 days following the onset of illness.
Evaluate health-care personnel with influenza-like illness and perform rapid influenza tests (see Flu: Lab Diagnosis) to confirm the causative agent is influenza and exclude those with influenza-like symptoms from patent care for 5 days following onset of symptoms, when possible.
8. Antiviral Chemoprophylaxis
Antiviral chemoprophylaxis should be given to residents and offered to health-care personnel in accordance with current recommendations during influenza outbreaks. Antiviral chemoprophylaxis should continue for at least 2 weeks, and as long as 1 week after the last resident case occurred. Persons receiving antiviral chemoprophylaxis should be actively monitored for potential adverse effects, and for possible infection with influenza viruses that are resistant to antivirals.
Adapted from: (accessed 26 September 2006)

10. Respiratory Hygiene
Visual alerts instructing residents and persons who accompany them to inform health-care personnel if they have symptoms of respiratory infection
Discourage those who are ill from visiting the facility.
Tissues or masks for residents and visitors who are coughing
Tissues and alcohol-based hand rubs
Ensure that supplies for handwashing are available
Encourage coughing persons to sit 3 feet away from others
Residents with symptoms of respiratory infection should be discouraged from using common areas where feasible.
Respiratory Hygiene/Cough Etiquette Programs
Respiratory hygiene/cough etiquette should be implemented whenever residents or visitors have symptoms of respiratory infection to prevent the transmission of all respiratory tract infections in long-term care facilities. Respiratory hygiene/cough etiquette programs include the following:
Posting visual alerts instructing residents and persons who accompany them to inform health-care personnel if they have symptoms of respiratory infection and discouraging those who are ill from visiting the facility.
Providing tissues or masks to residents and visitors who are coughing or sneezing so that they can cover their mouth and nose.
Providing tissues and alcohol-based hand rubs in common areas and waiting rooms.
Ensuring that supplies for handwashing are available where sinks are located and providing dispensers of alcohol-based hand rubs in other locations.
Encouraging coughing persons to sit at least 3 feet away from others, if possible. Residents with symptoms of respiratory infection should be discouraged from using common areas where feasible.
Adapted from: (accessed 26 September 2006)

11. Standard Precautions
Wear gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
Wear a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
Change gloves and gowns after each resident encounter
Decontaminate hands before and after touching the resident
When hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands.
Standard Precautions
During the care of any resident with symptoms of a respiratory infection, health-care personnel should adhere to Standard Precautions:
Wear gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
Wear a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
Change gloves and gowns after each resident encounter and perform hand hygiene as discussed below.
Decontaminate hands before and after touching the resident, after touching the resident’s environment, or after touching the resident’s respiratory secretions, whether or not gloves are worn.
When hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap (either plain or antimicrobial) and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Alternatively, wash hands with soap (either plain or antimicrobial) and water.
Adapted from: (accessed 26 September 2006)

12. Droplet Precautions Place resident into a private room,
OR cohort suspected influenza residents with other residents suspected of having influenza; cohort confirmed influenza residents with other residents confirmed to have influenza.
Wear a surgical or procedure mask upon entering the resident’s room or when working within 3 feet of the resident. Remove the mask when leaving the resident’s room and dispose of the mask in a waste container.
If resident movement or transport is necessary, have the resident wear a surgical or procedure mask.
Droplet Precautions
In addition to Standard Precautions, health-care workers should adhere to Droplet Precautions during the care of a resident with suspected or confirmed influenza for 5 days after the onset of illness:
Place resident into a private room. If a private room is not available, place (cohort) suspected influenza residents with other residents suspected of having influenza; cohort confirmed influenza residents with other residents confirmed to have influenza.
Wear a surgical or procedure mask upon entering the resident’s room or when working within 3 feet of the resident. Remove the mask when leaving the resident’s room and dispose of the mask in a waste container.
If resident movement or transport is necessary, have the resident wear a surgical or procedure mask, if possible.
Adapted from: (accessed 26 September 2006)

13. Influenza Vaccine Two types of vaccines protect against influenza
“Flu shot" - killed virus injectable vaccine
Nasal-spray - weakened live viruses ( years)
Viruses
One A (H3N2) virus, one A (H1N1) virus, and one B virus
Both flu vaccines cause antibodies
Timing
Best to get vaccinated in October or November, influenza peaks between late December and early March
Immunity
Takes about two weeks after vaccination
Can I still get sick?
Vaccination may prevent disease or reduce severity
What kind of flu vaccines are there? There are two types of vaccines that protect against the flu. The "flu shot" is an inactivated vaccine (containing killed virus) that is given with a needle, usually in the arm. A different kind of vaccine, called the nasal-spray flu vaccine (sometimes referred to as LAIV for Live Attenuated Influenza Vaccine), was approved in The nasal-spray flu vaccine contains attenuated (weakened) live viruses, and is administered by nasal sprayer. It is approved for use only among healthy people between the ages of 5 and 49 years. The flu shot is approved for use among people over 6 months of age, including healthy people and those with chronic medical conditions. Each of the two vaccines contains three influenza viruses, representing one of the three groups of viruses circulating among people in a given year. Each of the three vaccine strains in both vaccines – one A (H3N2) virus, one A (H1N1) virus, and one B virus – are representative of the influenza vaccine strains recommended for that year. Viruses for both vaccines are grown in eggs.
How do flu vaccines work? Both flu vaccines (the flu shot and the nasal-spray flu vaccine (LAIV)) work in the same way; they cause antibodies to develop in the body, and these antibodies provide protection against influenza virus infection.
When should I get a flu vaccination? Beginning each September, the flu shot should be offered to people when they are seen by health-care providers for routine care or as a result of hospitalization. Try to get vaccinated in October or November because flu activity in the United States generally peaks between late December and early March. You can still benefit from getting vaccinated after November, even if flu is present in your community. Vaccine should continue to be offered to unvaccinated people throughout the flu season as long as vaccine is still available. Once you get vaccinated, your body makes protective antibodies in about two weeks.
Does flu vaccine work right away? No. It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against influenza virus infection. In the meantime, you are still at risk for getting the flu. That's why it's better to get vaccinated early in the fall, before the flu season really gets under way.
Can I get the flu even though I got a flu vaccine this year? Yes. The ability of flu vaccine to protect a person depends on two things: 1) the age and health status of the person getting the vaccine, and 2) the similarity or "match" between the virus strains in the vaccine and those in circulation.

14. Vaccination
Health-care personnel and all residents of long-term care facilities should be encouraged to receive annual influenza vaccination
The National Healthy People 2010 goal for annual influenza vaccination long-term care residents is 90%.
Vaccination is the primary measure to
Prevent influenza
Limit transmission
Prevent complications from influenza in long-term care facilities
Vaccination of elderly persons may not prevent infection, but can reduce serious complications from influenza
Vaccination
Health-care personnel (e.g., all paid and unpaid workers who have contact with residents and visitors, including volunteer workers) and persons at high risk for complications from influenza, including all residents of long-term care facilities, should be encouraged to receive annual influenza vaccination according to current national recommendations. The National Healthy People 2010 goal for annual influenza vaccination coverage of residents of all long-term care facilities is 90%.
Vaccination is the primary measure to prevent influenza, limit transmission, and prevent complications from influenza in long-term care facilities.
Vaccination of elderly persons may not prevent infection, but can reduce serious complications from influenza in this population.
Adapted from: (accessed 26 September 2006)

15. Summary Influenza is a serious viral illness
Long-term care residents are at high risk of death or illness
Long-term care staff are at risk for illness or transmission
Contact precautions and respiratory hygiene help reduce transmission
Vaccination is vital!

16. CDC Resources Questions & Answers: Flu Vaccine
Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities

17. THANKS!