Respiratory & Enteric Outbreak Preparedness in Long-Term Care Homes and Retirement Homes Hello and welcome to our webinar

Presenter Catherine Edl, RN, BScN Infection Prevention and Control Team York Region Community and Health Services 905-895-4511 ext. 4555 catherine.edl@york.ca For those of you who don’t know me, my name is Catherine Edl and I am a Public Health Nurse with York Region Community and Health Services and I will be your presenter today. I’d like to extend a special thank-you to Mabel Lim, Infection Control Consultant of the CRICN and Kathy Torkos, Network Assistant also of the CRICN for hosting this webinar. These presentation slides and notes will be available on our website shortly after the webinar at www.york.ca/infectionprevention Also, so that we can keep improving, you will be sent an evaluation via email following the webinar – please take the time to complete it so that we can make improvements for next year.

Webinar Instructions Please mute your phone Questions: 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 Best to ask IT related questions through the chat box during the presentation if needed. Otherwise, please save questions to the end and we will open the phone line up and answer questions verbally or through the chat box.

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 We are coming up to respiratory outbreak season so we figured this would be a good time of year to review control measures as well as outbreak identification and managing an outbreak. The principles and practices contained in this presentation can be applied in both LTCHs and Retirement Homes. Note that the principles and practices contained in this presentation remain consistent for both settings, however, they may be implemented differently due to the setting type.

Organism Transmission Back to Basics It’s best to start with a brief review of the Basics – we’ll start with Organism Transmission

How organisms travel to new host Infectious Agent Source Portal of Exit Means of Transmission Susceptible Host Entry Chain of Transmission Organisms Factors that make a host more vulnerable to getting sick Where organisms live Exposure to an infectious organism is not always followed by disease. The spread of infection requires all 6 elements of the Chain of Transmission to be satisfied. How organisms enter a new host How organisms leave the host How organisms travel to new host

Breaking the Chain Identify/manage the agent Reduce the reservoir Identify mode of transmission and prevent spread Reduce host susceptibility Successfully preventing infection is all about reducing the chance of infection. So how can we reduce the chance of infection? We can: Identify/manage the agent: through regular, active surveillance; early identification; timely reporting of suspected outbreak and any changes in resident status; ill staff policies; visitor restrictions; etc. Reduce the reservoir: early identification and management of ill residents; vaccination; food safety; cleaning and disinfection; etc. Identify mode of transmission and prevent spread: regular use of routine practices (hand hygiene, risk assessment, use of PPE); timely implementation of additional precautions and other outbreak control measures; etc. Reduce host susceptibility: resident, volunteer and staff immunization; promotion of a healthy lifestyle; etc. Let’s now review how organisms are transmitted…

How Are Organisms Spread? contact droplet droplet/contact airborne There are 4 main ways an organism can be transmitted

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

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 Most common type of diseases associated with droplet transmission are respiratory in nature. The only exception is norovirus which is also spread through droplets when vomiting occurs. Droplets can be propelled up to 2 metres!! Droplets can land on surfaces contaminating them, thus making them a potential source of contamination for anyone that comes into contact with it – this is a good example of droplet/contact transmission.

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 Not usually seen in LTCHs or Retirement Homes

Outbreak Pathogens Respiratory & Enteric What pathogens are causing the outbreaks we experience here in York Region?

Summary of Reported Respiratory Outbreaks in York Region (2012-2013) # of Outbreaks Causative Agent Setting Type Respiratory 48 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%) This is data from Sept. 2012 – Aug. 2013 - Causative agent: Of the 48 respiratory outbreaks in York Region, there were various causative agents Setting type: Of the 48 respiratory outbreaks, 98% of the outbreaks had occurred in LTCHs and 2% in Retirement Homes Very rarely are respiratory outbreaks declared in day nursery settings or other community settings

Respiratory Outbreak Causative Agents 2012-2013 Graphic representation of causative agent data Data from Sept 2012 – August 2013 Reasons for such a large percentage of “undetermined” causative agents include: an organism that isn’t tested for, bad sample was taken, sample taken from wrong resident (one who is not ill), no samples were taken as OB was reported too late (call Public Health within 48 hrs of onset)

Respiratory Outbreak Setting Types 2012-2013 This bar graph represents outbreak data in terms of setting type. Of the 48 respiratory outbreaks, 41 were in LTCH and 7 were in Retirement Homes. Of the 41 outbreaks in LTCHs, 9 were confirmed influenza. Of the 7 outbreaks in Retirement Homes, 3 were confirmed influenza. Most of the influenza outbreaks occurred in December 2012 and January 2013.

Influenza – A Common Causative Agent in Respiratory Outbreaks 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 Period of Communicability -24 hrs prior to onset to 7 days but may be longer in immuno-compromised individuals Transmission through: indirect contact –touching surfaces that have been infected and then putting their hands near their mouth ,nose and eyes direct contact- person to person through coughing and sneezing Most common symptoms – runny nose, fever that usually lasts 3-4 days (although fever may be absent in the elderly), sore throat, coughing, extreme fatigue Treatment- antivirals should be given within 48 hrs after onset. Prophylaxis should be given to those who are not ill and should be started immediately Annual Flu vaccine should be encouraged for all staff and residents - to protect themselves and others, it reduces severe complications and time off work Vaccines allocated to York Region for the 2013-14 Season are: Agriflu (pre-filled syringe of 0.5mL) Vaxigrip (5mL multi-dose vial) Fluviral (multi-dose vial) Fluad (pre-filled syringe of 0.5mL, contains adjuvant) Used primarily for residents of LTCHs aged 65yrs or older Communication from our vaccine team to LTCHs/Retirement homes will likely be in early October

Rates of Influenza Immunization Coverage for 2012-13 among Staff in York Region LTCHs YR Average 64% Each bar represents the Staff immunization rate in a LTCH in York Region. 27 LTCHs are represented here; only 1 LTCH did not report their rate. The York Region average of 64% is not bad, however, there is always room for improvement especially when we see that most influenza outbreaks are in December and January and the vaccine is typically available in October for staff and residents. Influenza immunization is highly encouraged for you, as role models, and your staff. Data Source: The Seasonal Influenza Immunization rates at LTCHs reporting forms from 2009/10 to 2012/13.

How are Respiratory viruses spread? 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 If these droplets enter the mucous membranes (eyes, nose, mouth) of another person… The virus could incubate and cause symptoms in the new host… And so on, and so on… Viruses typically live on surfaces for hours (2-48 non-porous items, less for porous items). If you touch a contaminated object, then rub your eyes, transmission is possible.

Summary of Reported Enteric Outbreaks in York Region (2012-2013) # of Outbreaks Causative Agent Setting Type Enteric 59 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%) This is data from Sept. 2012 – Aug. 2013 - Causative agent: Of the 59 enteric outbreaks in York Region, 13% of the outbreaks were associated with Norovirus while 78% were unknown. Setting type: Of the 59 enteric outbreaks, 44% of the outbreaks occurred in child care settings followed by LTCHs, “Other” and Retirement Homes. “Other” setting type includes: school, food premise/restaurant, hospital It is very difficult to get stool samples from children in day nursery settings which leads to the high number of unknown causes for enteric outbreaks

Enteric Outbreak Setting Type 2012-2013 This is a graphic representation of what setting type had enteric outbreaks. We see most are in the Child Care setting at 44%, followed by LTCHs at 27% and Retirement homes at 12%. The ‘Other’ category at 17% includes settings such as schools, food premise/restaurants and hospitals.

Enteric Outbreak Causative Agents 2012-2013 Here is a graphic representation of the enteric outbreak causative agents. Norovirus is the second largest causative agent for enteric outbreaks at 13%.

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 Droplets may be generated with vomiting or aerosolized when cleaning up vomit. Immunity is not necessarily obtained with infection, one may be re-infected with same or different strain in the same season.

How are Enteric viruses spread? 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 If these droplets enter the mucous membranes (eyes, nose, mouth) of another person… The virus could incubate and cause symptoms in the new host… And so on, and so on… Viruses typically live on surfaces for hours (2-48 non-porous items, less for porous items). If you touch a contaminated object, then rub your eyes, transmission is possible.

What ‘season’ are we in? Virus Type Spring Summer Fall Winter Influenza √ RSV Para-influenza Rhinovirus Enterovirus Norovirus These viruses all have typical times of the year when they are most active.

Pocket Guide Book Mabel.Lim@oahpp.ca This resource is available from the Central Region Infection Control Network. You can contact Mabel Lim for copies. Mabel.Lim@oahpp.ca

Outbreak Identification, Notification & First Steps

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 Recognizing when illness rates exceed baseline can be a challenge in large, multi-floor facilities. It is important to consider how you collect surveillance data so you are aware when illness rates exceed baseline. The earlier you implement control measures, the better chance you have at minimizing the spread. Don’t wait to have an outbreak confirmed before implementing control measures!

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 It is ultimately the responsibility of the facility to manage the outbreak, but public health is here to assist you.

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 Line list is to be faxed to the health unit as soon as possible and then daily by noon. Line lists look at the following: What are the symptoms? (determine definition)   Unit or facility? We ask whether they are able to completely isolate the unit from the rest of the facility (residents not going to other parts of facility, dedicated staff to the affected unit, residents from the affected unit stay within unit all the time, even for meals)  What the facility looks like (how many floors, units eating/dining areas etc.)   Additional information about flu vaccinations rates will be required for respiratory outbreaks Public health will notify CCAC, EMS, fire, all LTCHs and hospitals in YR

Facility’s First Steps Once Outbreak Confirmed Assemble the outbreak management team and set meeting Notify stakeholder groups of outbreak Collect clinical specimens (in consult with PH) and submit to Public Health Lab Expect outbreak inspection from PHI Further implementation of control measures Public health’s inspection will focus on control measures such as PPE carts, donning and doffing PPE, cleaning and disinfection practices, hand hygiene and signage. For an enteric outbreak, public health will also inspect the kitchen with possible food samples taken.

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 OMT will meet at the beginning of the outbreak and may schedule additional meetings if necessary The OMT should include these members but is not limited to them – it is essential that everyone is on the same page when trying to manage an outbreak 31

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 For questions pertaining to the outbreak, call the IDCD investigator 32

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

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

This sign is available from your PHI or on our website

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 Line lists look at: demographics, symptoms, specimen collection, hospitalizations, deaths, resolved, relapse Line lists need to be faxed on a daily basis by noon Communication with the staff (DOC/ADOC/nursing staff ) by phone or email if issues arise that cannot be captured on the line list or there is a significant change in illness The weekday investigator should be notified of any hospitalizations/deaths within the institution asap and if on weekends the on-call staff should be notified.

Enteric and Respiratory Outbreak Management Poster This resource is available on our website

Specimen Collection Kits Obtained from Public Health Enteric Outbreaks Stool Kit Respiratory Outbreaks NP Kit You should have these on hand at all times in the event of an outbreak. Check expiry dates and consult with public health if new kits are needed. Return expired kits to public health for recycling.

Specimen Collection for Respiratory Pathogens Nasopharyngeal (NP) swabs Swab should be inserted one-half it’s length The laboratory needs high levels of organism for respiratory viruses such as RSV, influenza virus A & B or parainfluenza virus. All NP swabs should be kept in the fridge until it is picked up by the courier so that the organism is not compromised. Ensure that the swab is labelled well with two identifiers such as DOB and name - without two identifiers the lab will refuse to test.

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 As per PHL instructions. Keep NP swab in the fridge until picked up

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 Tests for viral/bacterial and parasites Needs to be kept in the fridge so the sample is not compromised Results usually within 3-4 days Two resident identifiers needed on the container

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 Refrigerate samples until picked up.

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 Samples may be taken of food, water or environmental is suspected to be a potential cause of outbreak

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 Policies should be available on the following: Food-service-worker hygiene (hand washing, confine hair, clean clothes and illness reporting); Kitchen sanitation (cross-contamination prevention, cleaning and sanitizing, dishwashing and general maintenance of kitchen); Safe food preparation and temperature control practices, including food-safety education; Record keeping for: temperature logs for refrigeration units and mechanical dishwashers; final cooking temperatures of food; and menu choices; catered and external/supplier information that provide food for residents. Records should be kept for no less than three (3) months; Routine retention of food samples – 200 grams of ready-to-eat potentially hazardous food items, from each meal, for a minimum of 5 days. Samples should be frozen or stored below -18°C; and Discard all ready-to-eat foods (i.e. food not to be cooked) prepared by dietary staff that become ill with enteric symptoms while on shift.

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

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 Environmental Controls Administrative Controls These are what Public Health is assessing when we conduct the outbreak audit. Environmental Controls include: cleaning and disinfection and resident accommodations Administrative Controls include: visitor restrictions, workload management, admissions/transfer considerations, workplace policies, staff/volunteer education & health considerations (immunizations) It is really important that staff are educated on these control measures at the beginning of each outbreak and as needed.

Routine Practices Risk Assessment Hand Hygiene PPE RP = Assumes blood and body fluid of ANY client could be infectious Risk assessment is the most important step and is often not done correctly. Think before you act!

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 Risk of exposure to body fluids or blood during the procedure - thorough hand hygiene is sufficient for minimal risk procedures, whereas higher risk procedures require both thorough hand hygiene and use of additional infection control practices The procedure and the skill level of the health-care worker performing the procedure need to be considered. Usually, the better trained a health-care worker is, the less likely they will be exposed to body fluids or blood The resident's level of cooperation and cognitive awareness need to be considered; for example, the more cooperative/cognitively aware, the lower the risk of transmission Use infection prevention strategies during every resident and health-care-provider interaction

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 One of the key elements of Routine Practices is hand hygiene Hand hygiene facilities should be at facility and room entrances, washrooms, point of care Alcohol has broad spectrum efficacy and is recommended for health care use Auditing has been shown to improve compliance during an outbreak

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 If you observe that the wrong signs are posted, direct them to the JCYH website

JCYH – 4 Moments Homes are not required to post these signs, but they may be posted in common areas.

JCYH – How to Hand Wash (11 steps) These should be posted in areas where HCW would perform hand washing

JCYH – How to Hand Rub (8 steps) These should be posted in areas where HCW would perform hand sanitizer

York Region – Hand Washing (6 steps) This can be posted in visitor areas

York Region – Hand Sanitizer (3 steps) This can be posted in visitor areas

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 The other key element of Routine Practices is PPE Ensure staff perform a risk assessment before interacting with a resident Ensure staff and visitors don and doff PPE properly The sequence for doffing (removal) is very important Ensure PPE supplies are available PPE carts should be set-up outside resident rooms Staff should know where PPE supplies are kept and have access to supply at all times Ensure the appropriate PPE is being worn at the appropriate time and not in common areas Ensure appropriate disposal of used PPE should be discarded immediately after use and inside the ill resident’s room if possible – this may be a challenge for Retirement Homes

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 Based on the above, the HCW is expected to do a risk assessment to determine what they should don to protect themselves.

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! In some instances, healthcare personnel are required to wear PPE in addition to that recommended for Routine Practices. The three Additional Precaution categories where this applies are Contact and Droplet Precautions and Airborne Infection Isolation. Educate client and family visitors about diseases transmission, hand hygiene & PPE use.

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 Contact Precautions requires gloves and gown for contact with the patient and/or the environment of care; in some instances, use of this PPE is recommended for even entering the patient’s environment.

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 Droplet Precautions requires the use of a surgical mask and eye protection within 2 metres of the ill resident

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

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 Very rare in LTCH and Retirement Homes Staff must be properly mask fit-tested for N95 mask use – see Ministry of Labour for guidelines

Additional Precautions Signs These signs are available to you for print from our website and should be posted on the door of a symptomatic resident with an infectious disease or suspected infectious disease.

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 Sequence of removal is very important – remove based on most contaminated items to least contaminated items. Treat all used PPE as contaminated.

These posters have been provided to all LTCHs and are also available on our website should any Retirement Homes like a copy

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 One of the top findings on the IC outbreak inspection conducted by our inspectors is the carts are not set up or they have inadequate supplies. Needs to be set up at the first symptom. Don’t wait for an outbreak to be declared. Should be located outside of the room of a symptomatic resident. Covered is best or kept in a clean area that is accessible to staff. For dementia units, placing a PPE cart outside the room may not be practical. Determine a location that is suitable (e.g., nursing station) and post a sign on the resident’s door communicating that PPE is to be worn and where it is located

In ill resident’s room, away from clean supplies PPE Cart Set Up Hand Sanitizer Gloves Gowns Masks Goggles Wipes Garbage Signs In ill resident’s room, away from clean supplies Ensure staff are dedicated to re-stocking the PPE carts.

Environmental Controls

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 Another top finding on the IC outbreak inspection – cleaning and disinfection issues: not following the correct process, not using the right level of disinfection and not cleaning frequently enough (surfaces and medical equipment)

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) The cleaning process removes microorganisms primarily by mechanical action but does not destroy those remaining on the object. Removes 99 to 99.9% of micro-organisms and foreign particulates on a surface allowing for maximum efficacy of the disinfectant. 70

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 The cleaning process removes microorganisms primarily by mechanical action but does not destroy those remaining on the object. Do not double dip and ensure saturation of cloth with disinfectant solution 71

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) Low level will kill many common organisms, including influenza

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 In outbreak situations need to increase the disinfection level higher because you don’t know what you are dealing with initially. Again you do not need to wait until an outbreak is declared to increase the level of disinfectant used. When a resident is isolated in their room, a higher level disinfectant can be used and cleaning frequencies of that room should be increased.

Bleach Solutions Low Level - every day (non-outbreak) High Level - outbreak These are excerpts from our new Cleaning & Disinfection Chart that will be posted on our website very shortly. Please access it at www.york.ca

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)

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

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 Wipes should not be used as a routine cleaning/disinfectant tool - it is difficult to attain adequate disinfection contact time using disinfectant wipes. Multiple wipes may be required to attain adequate contact time per manufacturer’s instructions - wipes are expensive! Wipes are good for small items that must be disinfected between residents at the point-of-care (e.g., stethoscope) or for items that cannot be soaked. Wipes must be kept wet and discarded if they become dry.

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 Need to think about where the symptomatic residents are being toileted? If not using the toilet, where is the commode/bedpan being dumped? How is cleaning and disinfection being done/monitored? How are they being dumped? Use products to eliminate dumping (e.g, Hygie, Verna-care) Post signs if necessary to ensure dedicated washroom. Should not be used for HCW hand washing.

Do your environmental cleaning staff use a cleaning checklist for ill resident’s rooms? If you are interested in copies of this checklist it is posted on our website at www.york.ca/infectionprevention

Environmental Cleaning Best Practices Educational Toolkit For more information: ricn@oahpp.ca This toolkit has been designed to support Environmental Services Managers and Infection Control Professionals in providing training to staff regarding effective procedures for environmental cleaning. The program supports the Provincial Infectious Disease Advisory Committee’s (PIDAC) Best Practices document for Environmental Cleaning for Prevention and Control of Infections in all Health Care Settings.  Each section of the toolkit is comprised of a narrated training presentation and additional support materials (there are 6 Modules).   For more information contact: ricn@oahpp.ca or you can access it online at the Public Health Ontario (PHO) website.

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 See page 32 of ‘Control of Gastroenteritis Outbreaks in LTCHs – Control Measures for Residents’, MOHLTC Sept 2011.

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

Administrative Controls

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

Admissions/Transfers 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 Measures may be altered as the outbreak comes under control. Each re-admission has to be assessed in consultation with Public Health. The following should be considered: Outbreak under control Physician approval Appropriate accommodation Adequate staff to care for resident Informed consent obtained

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

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 Group activities should be cancelled on the affected unit or facility depending on the situation – consult with Public Health if needed.

Visitors to LTCH Pamphlet Contains the following information: Hand hygiene Respiratory etiquette Planning a visit to a LTCH Food safety Online at www.york.ca This resources is available on our website in the following languages: English, Chinese, Russian, Italian, Farsi, Tamil

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) Outbreak management – what to expect: staff changes (e.g., cohorting, use of antivirals, etc.), increased use of PPE, isolation carts, increased cleaning and disinfection, changes to routine This education would also include roommates of those in a Retirement Home and any visitors

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

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

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 Control measures include: PPE, cleaning and disinfection, accommodation, staff and volunteer health policy, visitor policy

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 Influenza and pneumococcal (residents only) vaccination rates for staff and residents should be provided to the Public Health Coordinator - package will be sent out to every home in the fall Creatinine clearance should be taken at the beginning of every season for all residents

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 www.york.ca/infectionprevention You will be sent an evaluation via email in the next few days and we would appreciate your feedback on the webinar.

References PIDAC Best Practice Documents: Current PIDAC documents can be downloaded from the following website: http://www.oahpp.ca/resources/pidac-knowledge/ 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: http://www.oahpp.ca/services/documents/specimen-collection-guide/gastro_full_20080301.pdf