Dear Nursing and Medical Directors:

I am writing with information on how Public Health - Seattle & King County can work with you to protect your patients’ health for the upcoming influenza season. Substantial influenza-related morbidity and mortality among residents of Long Term Care Facilities (LTCFs) continues to occur each year. Attack rates of influenza A in LTCFs often range from 20 to 40 percent, and case-fatality rates range from 5 to 55 percent. Twenty-two percent of LTCF residents who contract influenza during outbreaks either develop complications severe enough to require hospitalization, or die.

The fundamental components of an effective influenza prevention and control policy in long term care facilities are:

• Yearly influenza vaccination of residents: The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination all persons aged >65 years and residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions. Since October 2005, the Centers for Medicare and Medicaid Services has required nursing homes participating in the Medicare and Medicaid programs to offer all residents influenza and pneumococcal vaccines. The use of standing orders programs might help ensure the administration of recommended vaccinations for adults.
  
  
• Yearly vaccination of all health care workers and personnel (both medical and non-medical) who have contact with patients: The CDC recommends annual influenza vaccination for both health care workers (HCW) and other employees of assisted living and other residences for persons in groups at high risk for complications of influenza. Influenza can be transmitted from patient-to-patient, from visitor-to-patient, from patient-to-staff, and from staff-to-patient. In two separate studies (see Carman and Potter, below) in geriatric long-term care facilities, patient mortality was significantly lower in those sites where HCW were routinely vaccinated against influenza compared to sites where routine vaccination was not offered (10% vs. 17% in the study by Carman, and 14% vs. 22% in the Potter study). Increased rates of HCW vaccination also correspond with a significant decrease in the incidence of healthcare-associated influenza.
  
  
• Restricting staff with influenza-like illness from working, and discouraging visitors with influenza-like illness from visiting: Persons with respiratory symptoms of any kind should be informed of appropriate precautions to prevent spread of respiratory infections to residents. These can include frequent hand washing and wearing facemasks when appropriate to prevent droplet transmission.
  
  
• Recognizing influenza early: The clinical picture of influenza may vary with age and immune status, making recognition of the disease difficult in the elderly. We encourage you to educate your staff about the subtle ways in which influenza may present in elderly persons (i.e., anorexia, mental status changes, fever, worsening of chronic respiratory status or congestive heart failure). We also ask that you have a low threshold for obtaining influenza cultures and antigen tests in ill persons. Public Health provides viral culture kits and laboratory testing at no cost to you. In most instances you can obtain viral culture kits the same day by calling the Public Health laboratory at 206-731-8950, weekdays from 8:00 a.m. to 5:00 p.m.
  
  
• Reporting outbreaks of influenza to Public Health: Health care facilities in Washington are required by law to report outbreaks and suspected outbreaks of disease to Public Health (WAC 246-100-076). Please report suspected or confirmed influenza outbreaks within 24 hours by calling 206-296-4774 or by faxing the enclosed influenza surveillance report form to 206-296-4803. When an outbreak of influenza is suspected, Public Health can assist you in confirming the diagnosis and responding to the outbreak.
  
  
• Prompt implementation of infection control measures and administration of antiviral medication for treatment or prophylaxis of influenza infection during outbreaks. Outbreak control measures should be promptly implemented and outbreaks should be reported to Public Health in the event of either of the following: 1) influenza is diagnosed in at least one resident, or 2) more than one resident in the facility or an area of the facility (e.g. separate unit) develop acute febrile illness during a 1-week period. Antiviral medications must be provided quickly to effectively stop an outbreak; therefore please consider having orders for these medications in advance. A reference we recommend is “Prevention of Influenza in Long Term Care Facilities” by Bradley et al, published in Infection Control & Hospital Epidemiology (1999; 20: 629-37).

Pneumococcal infections also cause high morbidity and mortality in elderly persons. In order to prevent severe pneumococcal illness, pneumococcal vaccine should be offered to all residents of LTCFs unless contraindicated. Although usually given once in a lifetime, revaccination is indicated in certain individuals. It is safe to administer pneumococcal vaccine to a person who is unsure whether he/she has received this vaccine in the past.

Long term care providers should also report outbreaks of gastroenteritis, or any cluster of illness thought to be food borne to public health. Please call Public health at 206-296-4774 as soon as you suspect a cluster or outbreak is occurring.

Sincerely,

Jeffrey S. Duchin, MD

Chief, Communicable Disease Control, Epidemiology & Immunization Section, Public Health – Seattle & King County

References ad Resources:

• Carman WF, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomized controlled trial. Lancet 2000; 55:93-7.
  
• Potter J, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis1997; 175:1-6.
  
• Talbot TR et al. SHEA Position Paper: Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages, Infect Control Hospital Epidemiol (in press).
  
• CDC. Prevention and Control of Influenza. Recommendations of the Advisory Committee on immunization Practices (ACIP), 2005.
  
• Additional information from the CDC Prevention on prevention and control of influenza