1. Influenza Presentation for Health Care Workers 2015-2016 Season

2. Seasonal Influenza –Transmission, symptoms, diagnosis, and treatment The Influenza Vaccine – Components, types available, effectiveness, benefits and side effects Influenza Outbreak Control Measures – Hand hygiene, outbreak signage, PPE, accommodations, patient/resident care equipment, cleaning and disinfection of resident areas Learning Objectives

3. Influenza, commonly known as ‘the flu’ Estimated that 10-20% of Canadians become infected each year Serious, acute respiratory illness that is caused by influenza A or B viruses Symptoms usually last 2-7 days, sometimes longer in the elderly Cough and fatigue can last weeks Influenza is very contagious, you can spread the disease 24 hours before you become symptomatic and for about 5 days after symptom onset The Disease

4. Respiratory Droplet Transmission Droplets are generated when a sick person coughs or sneezes –droplets can travel up to two meters in distance Droplets need to be inhaled by nearby individuals or land on their mouth or nose to transmit the virus Contact Transmission Respiratory droplets can also contaminate surfaces or objects –the flu virus can survive up to 48 hours on hard, non-porous surfaces such as stainless steel If an individual touches a surface or object contaminated with the flu virus and then touches their mouth or nose the virus can be transmitted (CDC, 2013; Public Health Agency of Canada, 2011; WHO, 2010) Modes of Transmission

5. Influenza Symptoms SymptomsFluCold FeverUsually high, sudden onset, lasts 3-4 days *May not be prominent in adults > 65 years Rare HeadacheCommon – can be severeRare Muscle aches and painsCommon – often severeSometimes, Mild Tiredness and weaknessCommon – severe, may last 2-3 weeks Sometimes, Mild Extreme tirednessUsually early onset, can be severe Unusual Runny, stuffy noseCommon SneezingSometimesCommon Sore throatCommon CoughingCommon – can be severeSometimes, Mild to Moderate Gastrointestinal SymptomsSometimesUnusual (Ministry of Health and Long-Term Care, 2015)

6. Influenza Cases over Time

7. 2014-15 Season

8. Age Distribution

9. Morbidity and Mortality Graph retrieved from Public Health Ontario. (2015). What’s new with the flu – the universal influenza vaccination program and influenza vaccines for the 2015-2016 influenza season. Overview and update. http://www.publichealthontario.ca/en/LearningAndDevelopment/Events/Documents/What's_new_with_ flu_Influenza_vaccine_update_Recalla_Warshawsky_2015.pdf

10. Stay home and get plenty of rest Seek medical attention as appropriate Limit your contact with others Wash your hands frequently with soap and water or with alcohol-based hand sanitizer, particularly after coughing or sneezing Ensure you practice respiratory etiquette (cough/sneeze into your sleeve or into a tissue, then wash your hands or use hand sanitizer) (Ministry of Health and Long-Term Care, 2015) Sick with the flu?

11. Nasopharyngeal (NP) Swab –Should be obtained from the most severe and most recently ill residents during the first 4 days of illness Confirming Diagnosis

12. Antiviral treatment for influenza must be started within 48 hours (or less) of onset of symptoms for maximum effectiveness Oseltamivir (Tamiflu) effective against influenza A and B Recommended drug of choice for both prophylaxis and treatment in an influenza outbreak Zanimivir (Relenza) effective against influenza A and B Used when predominant circulating strain is resistant to Tamiflu Treatment

13. Vaccination is the most effective way to prevent influenza and its complications. (NACI Statement 2015-16, pg.7)

14. Seasonal Influenza –Transmission, symptoms, diagnosis, and treatment The Influenza Vaccine – Components, types available, effectiveness, benefits and side effects Influenza Outbreak Control Measures – Hand hygiene, outbreak signage, PPE, accommodations, resident care equipment, cleaning and disinfection of resident areas Learning Objectives

15. Influenza Vaccine Recommendations Evidence has shown that healthy people aged 5-64 years benefit from influenza immunization NACI recommends influenza immunization for all individuals aged 6 months and older without contraindications

16. Graph retrieved from Public Health Agency of Canada. (2015). FluWatch – December 21, 2014 to January 3, 2015 (weeks 52 and 53). http://www.phac-aspc.gc.ca/fluwatch/14-15/w52-53_14/pdf/fw2014-53-eng.pdf Influenza Strain Characterizations 2014-15 N=66

17. Effectiveness: How well the vaccines work in real life In 2014-2015, the H3N2 influenza viruses circulating (new mutations) were mismatched to the H3N2 component of the 2014-2015 influenza vaccine Effectiveness SeasonInfluenza A/H1N1Influenza A/H3N2Influenza BOverall 2009-1093%-- 93% 2010-1159%39%25%37% 2011-1280%51% 59% 2012-1359%41%68%50% 2013-1471%--73% (Yamagata)68% 2014-15---8%-- Graph retrieved from Public Health Ontario. (2015). What’s new with the flu – the universal influenza vaccination program and influenza vaccines for the 2015-2016 influenza season. Overview and update. http://www.publichealthontario.ca/en/LearningAndDevelopment/Events/Documents/What's_new_ with_flu_Influenza_vaccine_update_Recalla_Warshawsky_2015.pdf

18. Repeat Vaccination 17 comparisons found in 10 studies indicated that the general order of vaccine effectiveness, highest to lowest is: Vaccinated in current seasons only Vaccinated in both current and previous season Vaccinated in previous season only, not current Vaccinated in neither reason There is no exclusive conclusion. This data alone is not sufficient to change current vaccine recommendations. “Generally, vaccine effectiveness is highest if vaccinated only in current season, but still better to be vaccinated in both seasons than only previous season.” (PHO, 2015, slide 50) Further study is needed.

19. 2014-15 A/Texas/50/2012 (H3N2) A/California/7/2009(H1N1)pdm09 B/Massachusetts/2/2012 (Yamagata lineage) 2015-16 A/Switzerland/9715293/2013 (H3N2) A/California/7/2009(H1N1)pdm09 B/Phuket/3073/2013 (Yamagata lineage) Components of the Vaccine

20. Nomenclature of the Virus A / California / 7 / 2009 (H1N1) Type Place Where First Isolated Strain Number Year of isolation Subtype of H and N

21. Trivalent & Quadrivalent 2015-2016 A/Switzerland/9715293/2013(H3N 2) A/California/7/2009(H1N1)pdm09 B/Phuket/3073/2013/2013 (Yamagata lineage) B/Brisbane/60/2008 (Victoria lineage) Trivalent (TIV) Quadrivalent (QIV)

22. Contains same formulation as TIV plus additional B strain Two inactivated QIV in Canada: FlulavalTetra TM and Fluzone ® Quadrivalent (neither contains adjuvant) One live attenuated QIV in Canada: Flumist ® Quadrivalent Quadrivalent Influenza Vaccine (QIV)

23. Choice of Influenza Vaccine* GroupVaccine types available for use 6 months to 23 months TIV, TIV-Adjuvanted, QIV 2 years to 17 yearsTIV, QIV, LAIV 18 years to 59 yearsTIV, QIV, LAIV 60 - 64 yearsTIV, QIV >65 yearsTIV, TIV-Adjuvanted, QIV Pregnant womenTIV, QIV Health care workersTIV, QIV * Consult the NACI Statement 2015/16, pgs.13-14 for recommended vaccine in each group.

24. People at high risk of influenza-related complications or hospitalization: Those with chronic health conditions (including morbid obesity) Those living in LTCHs and other chronic care facilities All children 6 months of age to less than 5 years of age and those ≥ 65 years Healthy pregnant women Aboriginal Peoples Who Should Get the Flu Shot

25. People capable of transmitting influenza to those at high risk: Health care and other care providers in facilities and community settings Household members of those at high risk Childcare providers Those who provide essential community services or within closed settings (e.g., crew on a ship) Who Should Get the Flu Shot Cont’d…

26. NACI Statement on Healthcare Providers and Flu vaccine 2015-16 “Transmission of influenza between infected HCWs and their vulnerable patients results in significant morbidity and mortality…HCWs should consider it their responsibility to provide the highest standard of care, which includes annual influenza immunization. In the absence of contraindications, refusal of HCWs to be immunized against influenza implies failure in their duty of care to patients.” pg.22

27. LTCH Staff Vaccination

28. Who Should NOT Get the Flu Shot Anyone who has previously experienced severe lower respiratory symptoms within 24 hours of vaccination Anyone allergic to any component of the vaccine Anyone who had a serious reaction to a previous flu shot Anyone who developed Oculo-respiratory syndrome (ORS) with lower respiratory tract symptoms* Anyone who developed Guillain-Barre syndrome (GBS) within 6 weeks of previous influenza vaccination* Anyone with serious acute illness Egg allergic individuals may be vaccinated against influenza using TIV or QIV however, as with all vaccine administration, immunizers should have necessary equipment to be prepared to respond to a vaccine emergency * Seek medical advice prior to vaccination

29. Protective antibody levels are generally achieved after 2 weeks following immunization: –Response depends on several factors including age, prior exposure to antigens and presence of immune compromising conditions Reduces physician visits, hospitalizations, deaths in high-risk adults Effectiveness of the Flu Shot

30. Agriflu ® – trivalent inactivated vaccine in pre-loaded single-dose syringes Fluviral ® – trivalent inactivated vaccine in multi- dose vial Fluad ® - trivalent inactivated vaccine with adjuvant in pre-loaded single-dose syringes Available Vaccines in York Region

31. Influvac ® - trivalent inactivated vaccine in pre- loaded single-dose syringes FluLaval Tetra ® / Fluzone ® - quadrivalent inactivated vaccine in multidose vial (both), pre- loaded single-dose syringes (Fluzone ® only) Flumist ® - quadrivalent live attenuated vaccine in single-dose sprayer Available Vaccines in York Region Cont’d…

32. Helps protect patients/residents, staff and families associated with hospitals/LTCHs from getting influenza and related complications Reduces time off work (for staff) and decreases visits to the doctor (for everyone) Reduces serious complications associated with the flu Benefits of Getting the Vaccine

33. Soreness at the injection site lasting up to 2 days Fever Muscle aches Most common adverse events following LAIV are nasal congestion and runny nose Serious side effects are very rare. Possible Side Effects from the Flu Shot

34. Common reactions to the flu shot in adults: –Soreness, redness or swelling at the injection site (usually lasts less than 2 days) –Other reactions are usually mild and can include a low grade fever and aches (can last 1-2 days) The most common reactions people have to the flu vaccine are considerably less severe than the actual flu How Come I Don‘t Feel Well After the Flu Shot?

35. They come in contact with other respiratory viruses that cause similar symptoms or a different flu strain not in the vaccine Already exposed to the flu virus prior to vaccination Why do some people still get sick after getting a flu shot?

36. Seasonal Influenza –Transmission, symptoms, diagnosis, and treatment The Influenza Vaccine – Components, types available, effectiveness, benefits and side effects Influenza Outbreak Control Measures – Hand hygiene, outbreak signage, PPE, accommodations, patient/resident care equipment, cleaning and disinfection of resident areas Learning Objectives

37. Hand Hygiene Personal Protective Equipment (PPE) Signage Accommodations Patient/Resident Care Equipment Cleaning and Disinfection of surfaces and equipment Influenza Outbreak Control Measures

38. Hand hygiene plays a very important role in limiting the spread of influenza. Clean Your Hands!!!

39. Hand Hygiene Method #1 Wash with Soap and Water

40. Hand Hygiene Method #2 Use Hand Sanitizer

42. Outbreak Notification Signs To be posted at all facility entrances and affected unit/area (MOHLTC, 2014) Additional Precaution Sign (Droplet & Contact) To be posted at the entrance to the resident’s room or bed space (PHO, 2012) PPE Poster Placement To be posted close to the PPE supplies (e.g., entrance to the resident’s room) (CRICN, July 2013) Hand Hygiene Signage To be posted next to handwashing sinks and hand sanitizer stations Outbreak Signage

43. Routine practices + Droplet & Contact Precautions 1. Surgical mask -to be worn when within 2 meters of a patient/resident with suspected or confirmed influenza -to be changed when it becomes wet or contaminated by secretions (PHO, 2012; Public Health Agency of Canada, 2010) PPE for Influenza

44. 2. Gloves -to be worn when providing direct personal care or will have direct contact with high-touched environmental surfaces -gloves are task-specific and single-use for that task (PHO, 2012; Public Health Agency of Canada, 2010) PPE for Influenza

45. 3. Gown -to be worn when there will be direct contact with the patient/resident or with environmental surfaces/objects in his/her environment (PHO, 2012; Public Health Agency of Canada, 2010) 4. Eye protection -to be worn when within 2 meters of a patient/resident with suspected or confirmed influenza -eye glasses are not an acceptable eye protection (PHO, 2012; Public Health Agency of Canada, 2010) PPE for Influenza

46. The facility must stock sufficient PPE for all staff Staff must have unrestricted access to PPE Inappropriate use of PPE may lead to: –Compromised quality of care provided to the resident –Increased waste and cost –Shortage of PPE → increase of infection rate (PHO, 2012) Additional Points on PPE

47. Accommodations for Residents with Influenza Single room preferred –If room is shared, cohort with appropriate roommates –Ensure privacy curtain is drawn between beds Ill residents are to remain in their room until 5 days after the onset of acute illness or until symptoms have completely resolved (whichever is shorter), as long as it does not cause the resident undue stress or agitation and can be done without applying restraints (Respiratory Outbreak Control Measures – York Region, 2014)

48. Disposable equipment should be used when possible Dedicate equipment to ill resident when possible Shared equipment must be cleaned and disinfected between residents Follow manufacturer’s guidelines on proper cleaning and disinfection procedures for equipment Patient/Resident Care Equipment

49. Cleaning and Disinfection of Environmental Surfaces Use higher level disinfectants in outbreak situations (PHO, 2013) Always follow a two-step process: clean then disinfect (PHO, 2012) Increase frequency of cleaning and disinfection in outbreak affected areas –Pay special attention to frequently touched surfaces such as door handles, bed rails, and light switches (MOHLTC, 2013)

51. The best prevention against the flu is getting the annual flu shot You are protecting yourself, patients/residents, and others by getting your annual flu shot Follow proper hand hygiene practices and wear PPE (when appropriate) to prevent the spread of influenza (and other infections) Stay off work when ill (and seek medical attention) In Summary…

52. Visit our website: www.york.cawww.york.ca Call Public Health: General Questions: –York Region Health Connection: 1-800-361-5653 Vaccine Related Questions: –1-877-464-9675, ext.73452 Additional Information

53. York Region: www.york.ca/flu and www.york.ca/infectionprevention www.york.ca/flu www.york.ca/infectionprevention Ontario Respiratory Virus Bulletin: http://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServ ices/Pages/Ontario-Respiratory-Virus- Bulletin.aspx?_ga=1.147785457.718073401.1442858736 http://www.publichealthontario.ca/en/ServicesAndTools/SurveillanceServ ices/Pages/Ontario-Respiratory-Virus- Bulletin.aspx?_ga=1.147785457.718073401.1442858736 Canadian Flu Watch: http://healthycanadians.gc.ca/diseases- conditions-maladies-affections/disease-maladie/flu- grippe/surveillance/index-eng.php http://healthycanadians.gc.ca/diseases- conditions-maladies-affections/disease-maladie/flu- grippe/surveillance/index-eng.php National Advisory Committee on Immunization (NACI): http://www.phac-aspc.gc.ca/naci-ccni/assets/pdf/flu-2015-grippe-eng.pdf http://www.phac-aspc.gc.ca/naci-ccni/assets/pdf/flu-2015-grippe-eng.pdf Just Clean Your Hands: http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/ JustCleanYourHands/Pages/Just-Clean-Your-Hands.aspx http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/ JustCleanYourHands/Pages/Just-Clean-Your-Hands.aspx