Influenza (Flu) in Healthcare Settings
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Healthcare-Associated Influenza (Flu) Guidelines
Excerpted from: Guidelines for Preventing Healthcare Associated Pneumonia, 2003
Background
I. Epidemiology
Pneumonia in patients with influenza may be due to the influenza virus itself, a secondary bacterial infection, or a combination of both (894-896). Influenza-associated pneumonia (as well as other influenza complications) can occur in any person but are more common in the very young (<24 months of age) or old and in persons in any age group with immunosuppression or certain chronic medical conditions, such as severe underlying heart or lung disease (897-904).
In North America, influenza typically occurs annually in the winter from December through April; peak activity in a community usually lasts from 6 to 8 weeks (905;906). During influenza epidemics in the community, outbreaks in health-care institutions can occur and are often characterized by abrupt onset and rapid spread of the infection (907-911). Most reported institutional outbreaks of influenza have occurred in nursing homes (912-919); however, outbreaks also have been reported on pediatric and chronic care wards, HSCT units, and medical and neonatal ICUs (755;904;908;920).
Influenza is transmitted from person to person primarily via virus-laden large droplets that are generated when infected persons cough, sneeze, or talk; these large droplets can then be directly deposited onto the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near the droplet source. Transmission also may occur by direct (e.g., person-to-person) or indirect (person-fomite-person) contact. Influenza virus can survive for 24-48 hours on nonporous surfaces and 8-12 hours on porous surfaces such as paper or cloth and can be transmitted to persons’ hands from these surfaces (921). Airborne transmission by droplet nuclei has been suggested, albeit inconclusively, in some reports (922-924); however, this route is probably less important than person-to-person spread by either droplet or contact transmission (909).
The most important reservoirs of influenza virus are infected persons. Infected persons are most infectious during the first 3 days of illness; however, they can shed the virus beginning the day before and up to 7 or more days after onset of symptoms 765;925;926). Children and severely immunodeficient persons may shed virus for longer periods (927-930). In addition, asymptomatic persons who are infected with influenza virus can shed the virus and potentially be infectious (931).
II. Diagnosis
Clinically, influenza may be difficult to distinguish from febrile respiratory illnesses caused by other pathogens. During periods when influenza viruses are circulating in the community, clinical definitions that include fever and respiratory symptoms may have positive predictive values ranging from 30% to 81% (932;933). In addition, infants can manifest a sepsis-like syndrome and 40% of young children can have vomiting or diarrhea (925;934). Clinically defined influenza-like illness, however, can be useful for evaluating control measures during hospital or nursing-home outbreaks with laboratory-confirmed cases of influenza illness (935).
Influenza can be diagnosed by virus isolation from respiratory secretions or by serologic conversion; however, recently developed rapid diagnostic tests can allow faster diagnosis and earlier treatment of influenza illness and facilitate prompt initiation of antiviral prophylaxis as part of outbreak control (936-940). Because rapid tests are generally less sensitive than viral culture and because only viral culture can provide information on circulating influenza virus subtypes and strains (and allow antiviral-susceptibility testing when needed), a subset of patients with suspected influenza illness should be tested by viral culture also (936-939;941).
III.Surveillance
An active surveillance program for influenza-like illness can help health-care facilities identify facility-acquired cases of influenza early in their course and prevent influenza from spreading to other patients and health-care personnel (942). Before the influenza season, health-care personnel should be trained to recognize influenza illness and made aware of the available mechanisms for reporting patients with suspected influenza to those in charge of infection control. In addition, they should learn about the use of diagnostic tests for influenza as well as the use of droplet precautions (in addition to standard precautions) for patients with confirmed or suspected influenza. Infection control personnel should determine the facility-specific threshold levels of influenza or influenza-like illness at which laboratory diagnostic testing for influenza and outbreak control measures should be initiated. For example, an investigation that includes performance of diagnostic laboratory tests on patients and personnel who have influenza-like illness should be considered upon identification of a single case of facility-acquired laboratory-confirmed influenza or a cluster (e.g., >3 cases) of facility acquired influenza-like illness detected within a short period (e.g., 48-72 hours) on the same floor or unit. Laboratory testing for influenza in personnel or patients with influenza-like illness can allow prompt work exclusion of personnel infected with influenza and early initiation of appropriate patient isolation precautions. In LTCFs, an active surveillance for influenza as well as for pneumonia can help identify facility-acquired cases of influenza.
IV. Prevention and Control of Influenza
A. Vaccination of Patients and Health-Care Personnel
Vaccination of persons at high risk for complications of influenza and persons who can transmit influenza to high-risk persons, i.e., health-care personnel and high-risk patients’ household members, is the most effective measure for reducing the impact of influenza and should be done before the influenza season each year (941;943-946). Both an inactivated and a live attenuated influenza vaccine (LAIV) are now available. The inactivated vaccine is administered by the intramuscular route and is approved for use in persons aged 6 months and older; LAIV is administered via a nasal spray and is approved for use only in healthy persons aged 5-49 years (941). There are no data assessing the risk of transmission of virus from LAIV recipients to immunosuppressed contacts. In the absence of such data, use of the inactivated influenza vaccine is preferred for vaccinating household members, health-care personnel, and others who have close contact with immunosuppressed individuals because of the theoretical risk that a live attenuated vaccine virus could be transmitted to, and cause disease in, the immunosuppressed individual. Although the risk of transmission of the live attenuated vaccine virus is thought to be low, use of the inactivated vaccine is preferred for persons (e.g., health-care personnel) exposed to persons at increased risk of influenza-related complications (947).
When high vaccination rates are achieved in closed or semi-closed settings, the risk of outbreaks is reduced because of the induction of herd immunity (948;949). High-risk groups for whom annual vaccination is recommended include persons >65 years of age; residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions; adults and children who have chronic disorders of the pulmonary or cardiovascular diseases, including asthma; adults and children who have required medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by HIV infection); children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy and therefore might be at risk for Reye syndrome after influenza infection; and women who will be in the second or third trimester of pregnancy during the influenza season (941;951-954). Vaccination of all persons aged 50-64 years also is recommended because of the high prevalence of chronic medical conditions that increase the risk of severe influenza illness in this age group and because of the benefits that healthy persons 50- 64 years old obtain from vaccination, i.e., decrease in the risk of influenza and its potential sequelae such as work absenteesim, medical visits, and antibiotic use (941;944;955;956). Because children aged 6-23 months are at substantially increased risk for influenza-related hospitalization, influenza vaccination for all children in this age group is encouraged when feasible (941).
Health-care personnel have been implicated in the transmission of influenza to patients; annual vaccination of health-care personnel, as well as others in close contact with persons at high risk for influenza complications, is recommended (907;908;941;942;944;957). Vaccination of health-care personnel is associated with decreased mortality among nursing home residents (945;946) and reduced health-care personnel illness and absenteeism (944;958).
Influenza vaccine, however, has been underutilized in institutional settings, even after it became a covered benefit of Medicare Part B (959). In order to improve vaccination coverage rates among adults, in March 2000, the ACIP published recommendations for the use of SOP, under which nurses and pharmacists are authorized to administer vaccinations according to an institution or physician-approved protocol, without an examination of the patient by a physician (408). ACIP recommended the use of SOP in LTCFs, inpatient and outpatient facilities, managed-care organizations, assisted living facilities, correctional facilities, pharmacies, adult workplaces, and home health care agencies (408) after SOP programs were shown to be the most effective method of increasing adult vaccination rates (960). To further facilitate the implementation of the SOP to Medicare- and Medicaid-eligible patients, in October 2002, the US Department of Health and Human Services Centers for Medicare and Medicaid Services published an interim final rule that removes the physician-signature requirement for the administration of influenza and pneumococcal vaccines to Medicare and Medicaid patients in hospitals, long-term care facilities, and home health agencies in states where such is allowed (961).
While vaccination of high-risk patients and health-care personnel is the primary focus of efforts to prevent and control influenza in health-care settings, the use of antiviral agents can be an important adjunct (941). Four licensed agents are available in the United States: amantadine, oseltamivir, rimantadine, and zanamivir. Amantadine and rimantadine are chemically related drugs with activity against influenza type A, but not influenza type B (962-964). Amantadine was approved for influenza A (H2N2) prophylaxis in 1966 and approved for both treatment and prophylaxis in 1976. Rimantadine was approved for treatment and prophylaxis of influenza A in 1993 (941). Oseltamivir and zanamivir are neuraminidase inhibitors with activity against both influenza A and B viruses. Both drugs were approved in 1999 for the treatment of uncomplicated influenza infections, and oseltamivir was approved in 2000 for prophylaxis (941). Zanamivir is administered as an inhaled powder while the other three drugs are ingested. The four antiviral drugs differ in age-group indications, pharmacokinetics, side effects, and cost (941). Additional information about the drugs is available in their respective package inserts.
When administered for treatment within 2 days of illness onset, amantadine and rimantadine can reduce the duration of uncomplicated influenza A illness, and zanamivir and oseltamivir can reduce the duration of uncomplicated influenza A or B illness, by approximately 1 day (941;962;963;965-969). None of the four drugs has been demonstrated to be effective in preventing serious influenza-related complications (e.g., bacterial or viral pneumonia or exacerbations of chronic illness).
When administered for prophylaxis before exposure to influenza virus type A, both amantadine and rimantadine are approximately 70-90% effective in preventing illness (962;964;970). These drugs have been studied extensively as components of influenza-outbreak control programs in nursing homes (916;962;971-973).
Studies in community settings suggest that oseltamivir and zanamivir are approximately 82-84% effective in preventing febrile influenza illness, although only oseltamivir is currently approved by the FDA for use as prophylaxis (974-977). The experience with prophylactic use of these agents in institutional settings or among patients with chronic medical conditions is limited, however (915;977-979).
Anti-influenza virus agents can be used 1) as short-term prophylaxis for high-risk persons who receive their vaccination late in the season; 2) as prophylaxis for persons for whom vaccination is contraindicated; 3) as prophylaxis for immunocompromised persons who may not produce protective levels of antibody in response to vaccination; 4) as prophylaxis, either for the duration of influenza activity in the community or until immunity develops after vaccination, for unvaccinated health-care personnel who provide care to high-risk patients; and 5) when vaccine strains do not closely match the epidemic virus strain (941).
The decision about which antiviral agent to use as adjunct to vaccination
in the prevention and control of health-care-related influenza is based in
part on virologic and epidemiologic surveillance information from the health-care
setting and the community. An antiviral agent can limit the spread of influenza
in the health-care setting if the drug is administered to all or most patients
once influenza illnesses begin in the facility (916;977;980;981). Therefore,
if an influenza antiviral agent is to be given as prophylaxis to high-risk
persons and treatment for infected persons, it should be administered as
early in the outbreak as possible to reduce viral transmission
(916;941;980).
Side effects from influenza antiviral agents have been reported. Both amantadine and rimantadine are associated with central nervous system (CNS) side effects such as nervousness, insomnia, impaired concentration, mood changes, and light-headedness; however, amantadine is associated with a higher incidence of adverse CNS reactions (13% of healthy adults taking amantadine 200 mg/day) than is rimantadine (6% of healthy adults taking rimantadine 200 mg/day) (964;982). Gastrointestinal side effects occur in approximately 1%-3% of persons taking either drug (964). Serious side effects (e.g., marked behavioral changes, delirium, hallucinations, agitation, and seizures) have been observed mostly among persons with renal insufficiency, seizure disorders, or certain psychiatric disorders, and/or in association with high plasma concentrations (972;980). Dose reductions of both amantadine and rimantadine are recommended for certain patient groups, such as children <10 years of age, children weighing <40 kg, persons >65 years of age, and persons with renal insufficiency.
In clinical trials, oseltamivir use was associated with nausea and vomiting although few persons discontinued its use because of these symptoms (969;975). A reduction in the dose of oseltamivir is recommended for persons with renal insufficiency (941). Zanamivir was not associated with significantly different side effects compared to inhaled lactose placebo in clinical trials (966;968;974). However, respiratory-function deterioration has been reported in persons taking zanamivir, some of whom had underlying airway disease, e.g., asthma or chronic obstructive pulmonary disease. Because of this risk and the lack of demonstrable efficacy in persons with underlying lung disease, zanamivir is generally not recommended for persons with underlying lung disease (983).
Drug-resistant viruses can emerge in up to approximately one third of patients who are given either amantadine or rimantadine for treatment of influenza (963;984;985). Because of the potential risk of transmission of drug-resistant viruses, infected persons taking either amantadine or rimantadine should avoid contact as much as possible with others during treatment and for 2 days after discontinuing treatment (985-987). This is particularly important if the contacts involve uninfected high-risk persons (986;988).
Development of viral resistance to oseltamivir and zanamivir during their use for patient treatment has been identified but does not appear to be frequent (989-992). However, the experience with oseltamivir or zanamivir for use in influenza outbreak control and the number of tests conducted for viral resistance to either agent have been considerably less than with amantadine or rimantadine (941). In studies using oseltamivir, 1.3% of post-treatment viral isolates from patients >13 years of age and 8.6% from patients 1-12 years old had decreased susceptibility to oseltamivir (990). In clinical trials of zanamivir use, no isolates with reduced susceptibility have been reported and only one resistant isolate from an immune-compromised child on prolonged therapy has been reported, although only a small number of post-treatment isolates have been tested (983;992).
D. Isolation Precautions and Other Measures
Measures in addition to vaccination and chemoprophylaxis are recommended for control of influenza outbreaks in health-care facilities. During the patient’s infectious stage, droplet precautions (i.e., placing in private rooms, when possible, or cohorting patients who are potentially infectious with influenza or have influenza-like illness; masking by personnel upon entering the room or when performing an activity within 3 feet of a person with suspected or proven influenza; limiting to only essential purposes the movement or transport of a potentially infectious patient from his/her room; and, if patient movement or transport from the room is necessary, minimizing patient dispersal of droplets by making the patient wear a surgical mask, if possible) are recommended in addition to standard precautions for personnel (i.e., hand decontamination, gloving when handling the patient’s respiratory secretions, and gowning when soiling with the patient’s respiratory secretions is likely) (279). The added value of placing patients with influenza in rooms for airborne infection isolation (i.e., negative-pressure rooms) and using N95 respirators, or of using contact precautions, has not been assessed. In theory, however, contact precautions may be beneficial in infant cases because their secretions are difficult to contain. Other measures, although not well studied, may be considered, particularly during severe outbreaks: 1) curtailment or elimination of elective admissions, both medical and surgical; 2) restriction of cardiovascular and pulmonary surgery; 3) restriction of persons with acute respiratory illnesses from visiting patients; and 4) work restriction for health-care personnel with acute respiratory illness (911;993).
Updated information regarding prevention and control of influenza, including the use of influenza vaccine and antiviral medications, is published annually by the ACIP in the Morbidity and Mortality Weekly Report (941).
Recommendations
Prevention and Control of Heath-Care Associated Influenza
I. Staff Education
Provide health-care personnel continuing education or access to continuing
education about the epidemiology, modes of transmission, diagnosis, and means
of preventing the spread of influenza, in accordance with their level of
responsibility in preventing healthcare-associated influenza (1029;1044-1046).
CATEGORY II
II. Surveillance
A. Establish mechanisms by which facility personnel are promptly alerted
about increased influenza activity in the community.
CATEGORY II
B. Establish protocols for intensifying efforts to promptly diagnose cases of facility acquired influenza.
Determine the threshold incidence or prevalence of influenza or influenza-like
illness in the facility at which laboratory testing of patients with
influenza-like illness is to be undertaken and outbreak control measures
are to be initiated (942).
CATEGORY II
Arrange for laboratory tests to be available to clinicians for prompt diagnosis
of influenza, especially during November-April (936-939).
CATEGORY II
III. Modifying Host Risk For Infection
In acute-care settings (including acute-care hospitals, emergency rooms,
and walk-in clinics) or ongoing-care facilities (including physicians’ offices,
public health clinics, employee health clinics, hemodialysis centers, hospital
specialty-care clinics, outpatient rehabilitation programs, or mobile clinics),
offer vaccine to inpatients and outpatients at high risk for complications
from influenza beginning in September and throughout the influenza season
(410;941;1047;1048). Groups at high risk for influenza-related complications
include those aged >65 years; residents of nursing homes and other chronic-care
facilities that house persons of any age who have chronic medical conditions;
adults and children aged >6 months who have chronic disorders of the pulmonary
or cardiovascular system, including asthma; 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 immunosuppression (including immunosuppresssion
caused by medications or HIV); children and adolescents (aged 6 months-18
years) who are receiving long-term aspirin therapy; and women who will be
in the second or third trimester of pregnancy during the influenza season
(941;950-954;957). In addition, offer annual influenza vaccination to all
persons aged 50-64 years, close contacts of children aged <24 months,
and healthy children aged 6-23 months (941).
CATEGORY IA
In nursing homes and other long-term care facilities, establish an SOP for
timely administration of the inactivated influenza vaccine to high-risk persons
as identified in Section III-A-1 (408;409;941;1029).
CATEGORY IA
Obtain consent for influenza vaccination (if such is required by local or
state law) from every resident (or his/her guardian) at the time the resident
is admitted to the facility or anytime afterwards, before the next influenza
season (941;1029;1049).
CATEGORY IB
Routinely vaccinate all residents, except those with medical contraindication(s)
to receipt of influenza vaccine, (under an SOP or with the concurrence of
the residents’ respective attending physicians) at one time, annually,
before the influenza season. To residents who are admitted during the winter
months after completion of the facility’s vaccination program, offer
the vaccine at the time of their admission 941;957;1049;1050).
CATEGORY IA
In settings not included in sections III-A-1 and -2, where health care is
given (e.g., in homes visited by personnel from home health-care agencies),
vaccinate patients for whom vaccination is indicated, as listed in section
III-A-1, and refer patient’s household members and care givers for
vaccination, before the influenza season (941).
CATEGORY IA
Personnel Beginning in October each year, provide inactivated influenza
vaccine for all personnel including night and weekend staff (941;944-946;956;958).
Throughout the influenza season, continue to make the vaccine available to
newly hired personnel and to those who initially refuse vaccination. If vaccine
supply is limited, give highest priority to staff caring for patients at
greatest risk for severe complications from influenza infection, as listed
in section III-A-1 above (941).
CATEGORY IA
Educate health-care personnel regarding the benefits of vaccination and
the potential health consequences of influenza illness for themselves and
their patients (941).
CATEGORY IB
Take measures to provide all health-care personnel convenient access to
inactivated influenza vaccine at the work site, free of charge, as part of
employee health program (941).
CATEGORY IB
IV. Prevention of Person-To-Person Transmission
Place a patient who is diagnosed to have influenza in a private room or
in a room with other patients with confirmed influenza, unless there are
medical
contraindications to doing so (279).
CATEGORY IB
Place a patient suspected to have influenza in a private room and promptly
perform rapid diagnostic laboratory tests to facilitate early downgrading
of infection-control precautions to the minimum required for the patient’s
infection (279).
CATEGORY II
Wear a surgical mask upon entering the patient’s room or when working
within 3 feet of the patient (279).
CATEGORY IB
Limit the movement and transport of the patient from the room to those for
essential purposes only. If patient movement or transport is necessary, have
the patient wear a surgical mask, if possible, to minimize droplet dispersal
by the patient (279).
CATEGORY II
No recommendation can be made for wearing eye-protective device upon entering
the room of a patient with confirmed or suspected influenza or when working
within 3 feet of the patient.
UNRESOLVED ISSUE
No recommendation can be made for observance of contact precautions (in
addition to droplet precautions) for patients with confirmed or suspected
influenza (279;921).
UNRESOLVED ISSUE
Decontaminate hands before and after giving care to and/or touching a patient
or after touching a patient’s respiratory secretions, whether or not
gloves are worn: if hands are visibly dirty or contaminated with proteinaceous
material or are visibly soiled with blood or body fluids, wash them with
either a nonantimicrobial soap and water or an antimicrobial soap and water;
and if hands are not visibly soiled, use an alcohol-based hand rub for their
decontamination (278).
CATEGORY IA
Wear gloves if hand contact with patient’s respiratory secretions
is expected (279;921).
CATEGORY II
Wear a gown if soiling of clothes with patient’s respiratory secretions
is expected (279).
CATEGORY II
No recommendation can be made for maintaining negative air pressure in rooms
of patients in whom influenza is suspected or diagnosed, or in placing together
persons with influenza-like illness in a hospital area with an independent
air-supply and exhaust system (909;922;924).
UNRESOLVED ISSUE
In acute-care facilities, utilize the facility’s employee health service
or its equivalent to evaluate personnel with influenza-like illness and determine
whether they should be removed from duties that involve direct patient contact.
Use more stringent criteria for personnel who work in certain patient-care
areas (e.g., ICUs, nurseries, and organ-transplant [especially HSCT] units)
where patients who are most susceptible to influenza-related complications
are located (920;993;1051).
CATEGORY IB
V. Control Of Influenza Outbreaks
A. Determining the Outbreak Strain
Early in the outbreak, perform rapid influenza virus testing on nasopharyngeal
swab or nasal-wash specimens from patients with recent onset of symptoms
suggestive of influenza. In addition, obtain viral cultures from a subset
of patients to determine the infecting virus type and subtype (936-939).
CATEGORY IB
B. Vaccination of Patients and Personnel
Administer current inactivated influenza vaccine to unvaccinated patients
and healthcare personnel (941;945;946;957).
CATEGORY IA
C. Antiviral Agent Administration
When a facility outbreak of influenza is suspected or recognized: Administer
amantadine, rimantadine, or oseltamivir as prophylaxis to all patients without
influenza illness in the involved unit for whom the antiviral agent is not
contraindicated (regardless of whether they received influenza vaccinations
during the previous fall) for a minimum of 2 weeks or until approximately
1 week after the end of
the outbreak. Do not delay administration of the antiviral agent(s) for prophylaxis
unless the results of diagnostic tests to identify the infecting strain(s)
can be obtained within 12-24 hours after specimen collection (931;941;964;1050).
CATEGORY IA
Administer amantadine, rimantadine, oseltamivir, or zanamivir to patients
acutely ill with influenza, within 48 hours of illness onset. Choose the
agent appropriate for the type of influenza virus circulating in the community
(931;941;964;967;1050;1052).
CATEGORY IA
Offer antiviral agent(s) (amantadine, rimantadine, or oseltamivir) for prophylaxis
to unvaccinated personnel for whom the antiviral agent is not contraindicated
and who are in the involved unit or taking care of patients at high-risk
(931;941;964;975;1050).
CATEGORY IB
Consider prophylaxis for all healthcare personnel, regardless of their vaccination
status, if the outbreak is caused by a variant of influenza that is not well
matched by the vaccine (941).
CATEGORY IB
No recommendation can be made about the prophylactic administration of zanamivir
to patients or personnel (915;941;974;977).
UNRESOLVED ISSUE
Discontinue the administration of influenza antiviral agents to patients
or personnel if laboratory tests confirm or strongly suggest that influenza
is not the cause of the facility outbreak (962).
CATEGORY IA
If the cause of the outbreak is confirmed or believed to be influenza and
vaccine has been administered only recently to susceptible patients and personnel,
continue prophylaxis with an antiviral agent until 2 weeks after the vaccination
(941;1053).
CATEGORY IB
To reduce the potential for transmission of drug-resistant virus, do not
allow contact between persons at high risk for complications from influenza
and patients or personnel who are taking an antiviral agent for treatment
of confirmed or suspected influenza uring and for 2 days after the latter
discontinue treatment (963;984;985;987;988).
CATEGORY IB
D. Other Measures in Acute-Care Facilities:
When influenza outbreaks, especially those characterized by high attack rates and severe illness, occur in the community and/or facility:
Curtail or eliminate elective medical and surgical admissions (993).
CATEGORY II
Restrict cardiovascular and pulmonary surgery to emergency cases only (993).
CATEGORY II
Restrict persons with influenza or influenza-like illness from visiting
patients in the health-care facility (993).
CATEGORY II
Restrict personnel with influenza or influenza-like illness from patient
care (993).
CATEGORY IB
Content source:
Division of Healthcare Quality Promotion (DHQP)
National Center for Preparedness, Detection, and Control of Infectious Diseases
On this page
Background
Recommendations Prevention/Control of Health Care-Associated Influenza
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