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Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes.

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Presentation on theme: "Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes."— Presentation transcript:

1 Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes

2 2 Presenter Catherine Edl, RN, BScN – Infection Prevention and Control Team – York Region Community and Health Services – 905-895-4511 ext. 4555 –

3 3 Webinar Instructions Please mute your phone – use *6 or mute button Questions: – If you have questions during the presentation, please use the chat box you see on your screen – Questions will also be taken the end of the presentation

4 4 Presentation Outline We will review: Organism transmission Common outbreak pathogens Outbreak identification, notification and first steps Outbreak control measures Importance of outbreak policies and procedures

5 Organism Transmission Back to Basics

6 6 Infectious Agent Source Portal of Exit Means of Transmission Susceptible Host Portal of Entry Chain of Transmission Organisms Where organisms live How organisms leave the host How organisms travel to new host How organisms enter a new host Factors that make a host more vulnerable to getting sick

7 Breaking the Chain Identify/manage the agent Reduce the reservoir Identify mode of transmission and prevent spread Reduce host susceptibility

8 8 How Are Organisms Spread? contact droplet droplet/contact airborne

9 9 Contact Transmission The spread of an infectious agent through touching The most common route Direct: hand to hand Indirect: touching a contaminated object

10 10 Droplet Transmission coughs or sneezes generate large respiratory droplets Infected droplets enter the eyes, nose or mouth of another person and can cause infection in the receiving host Droplets can land on surfaces contaminating them

11 11 Airborne Transmission Very tiny droplets exit the respiratory tract of an infected person when they cough or sneeze and remain suspended in the air and travel on air currents These tiny droplets need to be inhaled to cause infection Examples of germs spread via this route: – Tuberculosis, chickenpox

12 Outbreak Pathogens Respiratory & Enteric

13 13 Summary of Reported Respiratory Outbreaks in York Region (2012-2013) # of Outbreaks Causative AgentSetting Type Respiratory48 Undetermined (38%) Influenza (25%) Rhinovirus (13%) Coronavirus (8%) Parainfluenza (6%) RSV (6%) Entero/Rhinovirus (2%) Metapneumovirus (2%) Long term care home (98%) Retirement home (2%)

14 Respiratory Outbreak Causative Agents 2012-2013

15 Respiratory Outbreak Setting Types 2012-2013

16 16 Incubation period – 1-3 days Period of communicability – 24 hrs prior to symptom onset to 7 days Common symptoms – runny nose, fever (3-4 days), sore throat, coughing, extreme fatigue Treatment- antivirals should be started within 48 hrs of symptom onset Annual flu vaccine Influenza – A Common Causative Agent in Respiratory Outbreaks

17 Rates of Influenza Immunization Coverage for 2012-13 among Staff in York Region LTCHs YR Average 64% Data Source: The Seasonal Influenza Immunization rates at LTCHs reporting forms from 2009/10 to 2012/13.

18 18 Droplet and Contact Droplet – through the air by droplets excreted when infected individuals cough or sneeze – 2 metre rule Contact (direct and indirect) – touching people/objects – Viruses can survive on surfaces for long periods of time 2 metres How are Respiratory viruses spread?

19 19 Summary of Reported Enteric Outbreaks in York Region (2012-2013) # of Outbreaks Causative AgentSetting Type Enteric59 Undetermined (78%) Norovirus (13%) Rotavirus (3%) C.diff (2%) Girardia (2%) Campylobacter (2%) Child care (44%) Long term care home (27%) Other (17%) Retirement home (12%)

20 Enteric Outbreak Setting Type 2012-2013

21 Enteric Outbreak Causative Agents 2012-2013

22 22 Norovirus – A Common Causative Organism in Enteric Outbreaks Spread through stool and vomit – Droplet/contact precautions needed Noroviruses can survive on practically any surface including door handles, sinks, railings and carpet for long periods of time Highly infective virus! – only 10 virus particles are needed to cause illness

23 23 Contact (direct and indirect) – touching people/objects – viruses can survive on surfaces for long periods of time Droplet (if vomiting) – through the air by droplets excreted when infected individuals vomit – 2 metre rule How are Enteric viruses spread?

24 24 Virus TypeSpringSummerFallWinter Influenza √√√ RSV √√√ Para- influenza √√ Rhinovirus √√√ Enterovirus √√ Norovirus √√ What ‘season’ are we in?

25 25 Pocket Guide Book

26 Outbreak Identification, Notification & First Steps

27 27 Outbreak Identification Early detection of an outbreak is key Need to recognize when illness rates exceed your facility’s baseline Consult with Public Health when your facility has minimum two cases presenting with similar symptoms in a similar location within a specified timeframe Implementing outbreak control measures early is vital in controlling an outbreak Results in a shorter number of days in outbreak

28 28 If you suspect that you may have an outbreak, Call Public Health 905-830-4444, ext. 3588 during business hours 905-953-6478 after business hours

29 29 Public Health’s Role: Review line list and determine if in outbreak/surveillance Create case definition Provide investigation/outbreak number Review facility details: Determine which units are affected Number of residents on the unit and whole facility Number of staff on the unit and whole facility Facility lay-out Facilitate and coordinate specimen collection and testing by PHO lab Send outbreak notification to external stakeholders For respiratory outbreaks review rates of flu vaccination for staff and residents

30 30 Facility’s First Steps Once Outbreak Confirmed 1.Assemble the outbreak management team and set meeting 2.Notify stakeholder groups of outbreak 3.Collect clinical specimens (in consult with PH) and submit to Public Health Lab 4.Expect outbreak inspection from PHI 5.Further implementation of control measures

31 31 Outbreak Management Team (OMT) Meeting The OMT directs and oversees all aspects of an outbreak Plan your meeting as soon as possible - meet on day 1 or 2 of the outbreak Include representatives who have the authority to make decisions within your facility: Infection Control Designate DOC, Administrator, Medical Advisor Nursing Representative from each floor/unit where outbreak is occurring Pharmacist Public Health Nurse/Inspector (2) Environmental & Dietary Services Activity Coordinators Maintenance Representatives Other external service providers

32 32 Public Health Representation at the OMT Two members of the health unit will attend the OMT: Infectious Diseases Control Division (IDCD) representative Public Health Lead Outbreak Investigator (PHI or PHN) Case management Health Protection (HP) Division representative Public Health Inspector (PHI) Infection Prevention and Control Measures

33 33 OMT Meeting Discussion Review line list(s) and confirm case definition Confirm collection and submission of lab specimens Review the control measures necessary to prevent an OB from spreading further Identify additional people who need to be notified of the OB Prepare a communication plan, only if necessary Prepare internal communication for residents, staff and family

34 34 Essential Communication for the Facility During an Outbreak Notify courier services for swab/stool pick-ups Notify residents and family members Notify staff and volunteers Manage any media concerns Post signage: Outbreak signage needs to be posted at entrances to the facility and the affected unit(s) Contact/Droplet/Airborne signage should be posted outside the ill residents room as appropriate

35 35

36 36 Essential Communication with PH Throughout the Outbreak Daily line list faxed to public health at 905-898-5213 Line list is a system to track residents/staff symptoms that meet case definition Immediate notification to public health if there are hospitalizations or deaths within the institution

37 37 Enteric and Respiratory Outbreak Management Poster

38 38 Specimen Collection Kits Obtained from Public Health Respiratory Outbreaks NP Kit Enteric Outbreaks Stool Kit

39 39 Specimen Collection for Respiratory Pathogens Nasopharyngeal (NP) swabs Swab should be inserted one-half it’s length

40 40 NP Swab Collection Technique Wear appropriate PPE Tilt the patient’s head back Remove any excess mucous using the larger cotton tipped swab Gently bend the wire swab while in the sterile package, to give it a slight arc Insert the flexible NP swab into one nostril Rub the swab back and forth several times, and leave the swab in place a few seconds to absorb the material Withdraw the swab and insert into transport medium Refrigerate and transport to the lab as soon as possible Ensure that the outbreak # and two identifiers are on the requisition and the NP swab

41 41 Specimen Collection for Enteric Pathogens Stool Kits Bacterial, parasitic, and viral agents may produce gastroenteritis therefore the ‘Stool Kit’ has 3 vials - each with a colour-coded cap: Green - Bacterial examination Yellow - Parasitology examination White - Viral and toxin examination Ensure that the outbreak # and two identifiers are on the requisition and the specimen bottles Each kit includes complete instructions on specimen collection, storage, and transportation; if these instructions are not followed the sample may not be tested

42 42 Sending Specimens to Public Health Ontario Laboratory Confirm with Public Health investigator the contact information for courier services When specimens are ready for pick-up, call the courier. Inform the courier that the specimens will be going to the Public Health Ontario Laboratory (PHO Lab) If asked please quote the account # provided by Public Health All samples sent to the PHO Lab must be properly labelled and accompanied with the ‘General Test Requisition’ form supplied with the kits

43 43 Public Health Inspection Once an outbreak is declared, a PHI will visit your facility – Conduct an outbreak inspection Respiratory – inspect affected unit(s) Enteric – inspect affected unit(s) and kitchen Other areas will be inspected as needed – Common areas – Facility entrances – Collect samples if needed

44 44 Food Safety for Enteric Outbreaks Policies should be available on general safe food handling practices Outbreak Specifics Food retention policy needs to be in place Once an outbreak is declared, food samples should not be discarded Keep food samples (200 grams) of ready-to-eat potential hazardous food items, frozen (at or below -18°C) for 10 days Ensure symptomatic food handlers are identified, excluded and notify Public Health Discard all ready-to-eat foods prepared by staff that become ill with enteric symptoms while on shift

45 Preventing Further Spread Most often at the beginning of an outbreak the organism will be unknown…

46 46 Outbreak Control Measures Routine Practices – Hand hygiene and PPE Cleaning and disinfection Accommodations Visitor Restrictions Workload management Admissions/transfer considerations Outbreak policies Staff/volunteer education & health considerations It is really important that staff are educated on these control measures at the beginning of each outbreak and as needed. Environmental Controls Administrative Controls

47 47 Routine Practices Risk Assessment Hand Hygiene PPE

48 48 Risk Assessment To be performed prior to each resident interaction Consider the following: Risk of exposure to blood or bodily fluids The procedure and the skill level of the HCW performing the procedure Resident’s level of cooperation and cognitive awareness Using infection prevention strategies during every resident/HCW interaction

49 49 Hand Hygiene Key Points Supplies should be easily accessible, stocked and not expired Should be performed timely and properly by staff, visitors, volunteers, and residents Signage posted at hand sanitizer stations and hand wash sinks Hand sanitizer should be 70-90% alcohol based Use liquid soap

50 50 Hand Hygiene Resources Just Clean Your Hands Resources – Staff and Resident Areas 4 Moments for Hand Hygiene How to hand wash - 11 steps How to hand rub - 8 steps York Region Resources – Visitor Areas Correct hand washing procedures - 6 steps hand sanitizer poster - 3 steps

51 51 JCYH – 4 Moments

52 52 JCYH – How to Hand Wash (11 steps)

53 53 JCYH – How to Hand Rub (8 steps)

54 54 York Region – Hand Washing (6 steps)

55 55 York Region – Hand Sanitizer (3 steps)

56 56 PPE Key Points Risk Assessment prior to donning Proper use is key for protecting staff, visitors and residents Ensure additional precaution signs are posted Ensure PPE supplies are available Ensure appropriate use of PPE (type and sequence for removal) Ensure appropriate disposal of used PPE

57 57 PPE for Routine Practices Gloves – Use when touching any bodily fluids, mucus membranes and when you have non- intact skin Gowns – Use when contact of clothing/ exposed skin with bodily fluids is anticipated Mask and goggles – Use when anticipating splashes or sprays of bodily fluids

58 58 PPE & Additional Precautions PPE used in addition to Routine Practices: Contact Precautions Droplet Precautions Airborne Precautions Additional Precautions need to be established and discontinued promptly!

59 59 Additional Precautions - Contact Control Measures: PPE Gown and gloves for contact with client (direct) or environment of care (indirect) Environmental Controls Dedicate or disinfect shared equipment after each use Infectious agent/symptoms that require contact precautions are: Diarrhea or C. difficile Norovirus Influenza

60 60 Additional Precautions - Droplet Control Measures: PPE Surgical masks and eye protection within 2 metres of resident Environmental Controls Dedicate or disinfect shared equipment after each use Infectious agents/symptoms that require droplet precautions are: RSV Norovirus (if vomiting) Cough or shortness of breath and fever

61 61 Additional Precautions – Droplet/Contact Control Measures: PPE Surgical masks and eye protection within 2 metres of resident and gloves and gown if contact with resident or their environment anticipated Environmental Controls Dedicate or disinfect shared equipment after each use Infectious agents/symptoms that require droplet/contact precautions are: Influenza Norovirus (if vomiting) Cough or shortness of breath and fever

62 62 Additional Precautions - Airborne Control Measures: PPE Particulate respirator (N95 mask) Environmental Controls Single room, door closed Negative pressure room Infectious agents that require airborne precautions are: Tuberculosis Measles Chickenpox

63 63 Additional Precautions Signs

64 64 Donning and Doffing PPE Remember the sequence and importance of hand hygiene Wear the right PPE for the interaction anticipated so you reduce the risk of exposure Carefully remove PPE to reduce the risk of contaminating skin or clothing

65 65

66 66 PPE Cart Principles Also called ‘Isolation Station’ When does this cart need to be set up? – First symptom of resident Where should it be located? – Outside room, easily accessible, ‘clean area’ Covered or uncovered? – Covered is best Where to place in a dementia unit? – Communicate location by posting sign Placement of garbage? – Should be inside the room, PPE poster above

67 PPE Cart Set Up 67 1.Hand Sanitizer 2.Gloves 3.Gowns 4.Masks 5.Goggles 6.Wipes 7.Garbage 8.Signs In ill resident’s room, away from clean supplies

68 Environmental Controls

69 69 Key Points for Outbreak Cleaning and Disinfection (C&D) Follow the correct process: clean first, then disinfect Use a higher level of disinfection Increase the frequency of C&D in outbreak areas C&D of resident equipment is essential Ensure proper handling of laundry and waste

70 70 Cleaning Principles Cleaning is the physical removal of dirt and debris using soap, water and mechanical action (friction) Must always be the first step in order to maximize effectiveness of the disinfectant Clean spills/splashes/leaks promptly Clean from least contaminated to most contaminated (top to bottom)

71 71 Disinfection Principles Disinfectants kill germs Type of disinfectant used depends on the surface or item being disinfected Different levels: Higher and Lower Registered disinfectants have a drug identification number (DIN) Follow manufacturers’ instructions for dilution and contact time During an outbreak higher level disinfection must be used

72 72 Low Level or Hospital Grade Disinfectants Every Day Use Kill vegetative bacteria and enveloped viruses: – Staphylococcus aureus (includes MRSA) – Salmonella – HIV, Hepatitis B and C – RSV and Influenza Examples: – 500ppm-1,000ppm sodium hypochlorite (bleach) – 3% hydrogen peroxide – accelerated hydrogen peroxide – 70-95% alcohol – QUATs (Lysol, Everyday Disinfectant - ED)

73 73 Higher Level Disinfectants Outbreak Situations Kill mycobacteria, non-enveloped viruses and fungi: – Mycobacteria tuberculosis – Norovirus and Hepatitis A – Candida Examples: – 5,000ppm sodium hypochlorite (bleach) – 6% hydrogen peroxide – accelerated hydrogen peroxide

74 Bleach Solutions Low Level - every day (non-outbreak) High Level - outbreak

75 75 Outbreak Cleaning and Disinfection – Frequently Touched Surfaces Assume all frequently touched surfaces are contaminated Increase cleaning and disinfection frequencies of: – Common areas: Hallways, door knobs, light switches, dining areas, activity rooms, elevator buttons – Ill Resident rooms (at least daily): Bed rails, overbed table, washroom areas (faucets, sinks, toilets, counter tops)

76 76 Outbreak Cleaning and Disinfection - Resident Equipment Dedicate wherever possible or use disposable product if feasible If shared, clean and disinfect between residents Choose a cleaning and disinfecting method that is compatible with the equipment Examples of resident equipment: – BP cuff – Stethoscope – Thermometer – Wheelchairs/walkers – Lifts

77 77 Disinfectant Wipes Follow manufacturer’s recommendations Wipes are not recommended as a routine cleaning/disinfectant tool They should be used for items that cannot be soaked and for small items that must be disinfected between uses Ensure the surface or item remains wet for the required contact time (additional wipes may be needed) Wipes must be kept wet and discarded if they become dry

78 78 Toileting Equipment in Enteric Outbreaks Toilets/commodes should be dedicated for ill residents If toileting facilities cannot be dedicated, they should be cleaned after each use by the symptomatic resident If commodes/bedpans are used, same principles apply – Where are the contents being dumped? Visitor toilets should be separate from resident toilets Do not use disinfectant wipes to clean toilets or commodes

79 79 Do your environmental cleaning staff use a cleaning checklist for ill resident’s rooms?

80 80 Environmental Cleaning Best Practices Educational Toolkit For more information:

81 81 Resident Accommodations Ill residents should remain in their room: Private room preferred If in a multi-bed room, draw curtain around ill resident Keep 2 metres from other residents Meals should be eaten in their room If a resident has to leave their room: For respiratory symptoms, resident should wear a mask For enteric symptoms, the resident should be limited to using their own washroom

82 82 Length of Isolation Residents with enteric symptoms should be isolated in their rooms until 48 hours after their symptoms have resolved Residents with respiratory symptoms should be isolated in their rooms until 5 days after symptoms onset or until symptoms have completely resolved (minimum 48 hrs or whichever is shorter) Isolation should only be done as long as it does not cause the resident undue stress and can be done without using restraints

83 Administrative Controls

84 84 Workload Management Institute staff cohorting Outbreak plans need to address varying levels of available staff to ensure continued provision of care and full implementation of infection control measures

85 85 New resident admissions should not occur Re-admission of cases from a hospital is permitted with appropriate accommodation and care Re-admission of non-cases from a hospital is generally not permitted Resident appointments if non-urgent need to be rescheduled Admissions/Transfers

86 86 Staff and Volunteer Health Ill staff and volunteers to be excluded until no longer infectious For enteric outbreaks, exclude staff until they are 48 hours symptom-free For respiratory outbreaks, exclude staff for 5 days after symptom onset or until symptoms have completely resolved (minimum 48 hours or whichever is shorter) Staff that become ill at work should report to IC/OH

87 Visitor Restrictions Large group activities should be cancelled on the affected unit or facility depending on situation Visitors advised not to visit when ill Discourage children under the age of 12 from visiting

88 88 Visitors to LTCH Pamphlet Contains the following information: Hand hygiene Respiratory etiquette Planning a visit to a LTCH Food safety Online at

89 89 Education Resident and Visitor education to include: Proper hand hygiene methods and when to perform hand hygiene Routine practices and, in specific instances, proper use of PPE Transmission and prevention of disease including the requirement not to visit the LTCH when they are ill Outbreak management –what to expect (such as visitor restrictions)

90 90 Education Staff and Volunteer education to include: Transmission and prevention of infections Routine Practices (including hand hygiene) and Additional Precautions Cleaning and disinfecting of shared equipment and environmental surfaces Food safety Occupational Health policies Routine daily surveillance for signs of infection Roles and responsibilities of staff, administration, the ICP, and Public Health Specimen collection methods Outbreak management and control

91 Outbreak P&Ps All outbreak P&Ps should be updated annually or as needed in consultation with Public Health

92 92 Outbreak P&Ps should cover these topics as discussed today: Outbreak management team composition Communication during an outbreak Specimen collection Food Safety for Enteric Outbreaks Education of staff, volunteers and visitors Influenza outbreaks Control Measures

93 93 Influenza Outbreaks Policies should address the following: Annual influenza vaccination for residents and staff Exclusion for non-immunized staff during an influenza outbreak Antiviral use Collection of nasopharyngeal swabs Obtaining consent for prophylaxis with antivirals Obtaining pre-approved orders from physicians for antiviral prophylaxis

94 94 QUESTIONS? Un-mute your phone (*6) and ask questions over the phone line or through the chat box. After today, if you have any IPAC related questions, please call your Public Health Liaison at 1-877-464-9675 or 905-895-4511 or visit our website at

95 95 References PIDAC Best Practice Documents: – Current PIDAC documents can be downloaded from the following website: Control of Gastroenteritis Outbreaks in Long-Term Care Homes, MOHLTC, 2011 A Guide to the Control of Respiratory Infection Outbreaks in Long- term Care Homes, MOHLTC, 2004 Laboratory Guide for Gastroenteritis Outbreaks available at: guide/gastro_full_20080301.pdf guide/gastro_full_20080301.pdf

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