1. Influenza and the Nursing Home Population Julie L. Freshwater, PhD MPH Influenza Surveillance Coordinator 1

2. Objectives Present provisional data from the 2010-2011 influenza season in the nursing home population Understand the term outbreak in the nursing home setting Understand the importance of laboratory testing in this population 2

3. Testing for Influenza* Rapid tests ▫ Sensitivities are approximately 50-70% ▫ Specificities are approximately 90-95% Serology ▫ 2 weeks or more DFA/IFA ▫ 2 – 4 hours Viral Culture ▫ 3 – 10 days PCR ▫ 2 – 4 hours * CDC Influenza Diagnostic Table 3

4. OLS Testing for Influenza PCR for: ▫ Influenza  AH3  AH1N1 (SO)  B When negative for influenza: ▫ Culture for:  Parainfluenza  Adenovirus  RSV 4

5. Definition of Influenza-like Illness Temperature ≥ 100 ◦ F AND Cough and/or Sore throat In absence of any other known cause 5

6. LTCF Outbreak Definition One (1) positive laboratory test for influenza in conjunction with other similar illnesses on the unit indicates an outbreak is occurring OR Three cases of influenza-like illness within 72 hours 6

7. Importance of Laboratory Testing Starting or stopping antiviral treatments Chemoprophylaxis for residents and staff Mitigating morbidity and mortality Reducing costs 7

8. If positive for influenza Begin prophylaxis on ALL residents Treatment should continue for 14 days or for 7 days after onset of symptoms of last person infected Unvaccinated staff should receive antiviral treatment 8

9. Importance of positive lab Place ill residents in private rooms or cohort with other ill residents Ill staff should stay off work until 24 hours without fever Keep staff from floating between floors/units Implement control measures 9

10. LTCF Outbreak Control Measures Use standard and droplet precautions Attention to hand hygiene 10

11. Additional control measures Consider ▫ Limiting new admissions ▫ Limiting or stopping visitation to the facility until no new cases for 48 hours ▫ Stopping or limiting group activities ▫ Serve meals in residents’ rooms 11

12. Specimens for Influenza Testing Nasopharyngeal swabs Obtain 8-10 from recently ill Ship to OLS for sub-typing 12

13. Respiratory Outbreaks January-September 2011 51 respiratory outbreaks or clusters 30 in long term care facilities Clinical Syndrome/Diagnosis: ▫ Influenza ▫ Influenza/Pneumonia ▫ Upper or Lower Respiratory Tract Infection ▫ Pneumonia 14 counties 13

14. LTCF Influenza Outbreaks January – September 2011 (Provisional Data ) 19 of 30 (63%) respiratory outbreaks were attributed to influenza ▫ 15 of 19 (79% ) lab confirmed ▫ 4 of 19 (21% ) were rapid test positive with no confirmatory testing Only influenza AH3, no AH1N1 in residents 14

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16. Nursing Home Case #1 Started January 31, 2011 with one rapid test (+) Two more residents on February 12 Vaccination status of 44 of 73 (60%) staff members unknown 2 staff members tested positive for influenza, specifics were not available 16

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18. Nursing Home #1 Final Count 5 out 6 specimens sent to OLS for testing were positive for AH3 14 of 55 (25%) residents met the case definition of ILI 25 of 73 (34%) staff met case definition 18

19. Nursing Home #2 Illness started February 28, 2011 19 residents with ILI, 1 rapid test (+) 8 staff with ILI, 2 rapid test (+) 46 of 71 (65%) staff members immunized against influenza 19

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22. Nursing Home Case #2 Final Count 16/125 residents met case definition  Instead of 19 originally on line list 14/171 staff met case definition  Additional 6 staff members ill from original 8 22

23. Nursing Home #3 Illness started March 30, 2011 ▫ 10 of 56 residents ▫ 0 of 35 staff members 5 were rapid test (+) Doctor wanted to just provide anti-virals for those that were ill 23

24. Nursing Home #3 April 4, 2011 ▫ 26 of 56 (46%) residents were ill  5 residents were sent to the hospital ▫ 13 of 35 (37%) staff reported illness 6 specimens were sent to OLS in saline Antivirals administered to everyone at this time Last onset April 10, 2011 24

25. Nursing Home #3 Final Count 3 specimens sent to OLS were AH3 (+) Five residents hospitalized, two residents died 15 of 56 (27%) residents met case definition 14 of 35 (40%) staff met case definition 25

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27. Conclusion Influenza symptoms are very similar to other respiratory diseases Laboratory testing is essential in determining etiologic agent ▫ Results can guide treatment  Antivirals?  Antibiotics? ▫ Results can guide control measures  Respiratory and cough etiquette  Restriction of activities enforced or lifted 27