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Infection Prevention & Control Guidelines for the Management of

Influenza and Respiratory Viral Illness

CDHB Infection Prevention & Control Service Updated May 2018

CHDB Infection Prevention & Control Intranet Guideline Influenza & Respiratory Viral Illness Guidelines

Ref: 238898 Authorised By: CDHB Infection Prevention & Control Committee of 15 v4.Issue Date: 05-04-18

Table of Contents

1. Purpose ........................................................................................................ 3 2. Scope ............................................................................................................ 3 3. Respiratory Hygiene / Cough Etiquette ......................................................... 3 4. Definition of Influenza like Illness .................................................................. 3

5. Laboratory Testing for Influenza like Illness .................................................. 4 6. Seasonal Influenza ....................................................................................... 4

6.1 General Information ........................................................................................... 4

6.2 IPC Measures for Influenza (all clinical areas) ................................................... 4

7. Other Respiratory Viral Illness (Influenza–like illness - ILI) ........................... 6

7.1 General Information ........................................................................................... 6

7.2 IPC Measures for Other Respiratory Viral Illness in general wards ................... 7

7.2 IPC Measures for Other Respiratory Viral Illness in high risk areas for vulnerable patients .................................................................................................... 7

8. Antiviral chemotherapy ................................................................................. 8 9. Management of staff exposure ..................................................................... 9 10. Outbreaks ..................................................................................................... 9

11. Surveillance .................................................................................................. 9 12. References ................................................................................................... 9

Appendix A. Inpatient Influenza Flowchart .............................................................. 11

Appendix B. Management of Respiratory Viral Illness Flowchart ............................ 12

Appendix C. Laboratory Instructions for Respiratory Viral Testing .......................... 13 Appendix D. Patient Information Sheet ................................................................... 14



Infection Prevention & Control Influenza & Respiratory Viral Illness Guidelines

These guidelines describe the infection prevention and control (IPC) measures which must be taken to minimise transmission of influenza and other respiratory viral illnesses within CDHB healthcare facilities. The IPC measures for the management of influenza differ from other respiratory viruses and therefore these guidelines describe these in separate sections.

1. Purpose

Provide guidance to staff on the precautions and other measures necessary to minimise the risk of transmission of influenza and other respiratory viral illnesses.

2. Scope

All staff involved in the care of patients with possible or confirmed influenza or other respiratory viral illness.

3. Respiratory Hygiene / Cough Etiquette

Respiratory hygiene must be practised at all times. Educate patients in the importance of respiratory hygiene.

Cover your mouth and nose with a tissue when coughing or sneezing Use in the nearest waste receptacle to dispose of the tissue after use Perform hand hygiene

Staff who have signs and symptoms of respiratory illness must NOT ..

Care for patients for 72 hours after onset of symptoms

Should stay off work for at least 24 hours after resolution of fever (without the use of fever-reducing medicine.)

4. Definition of Influenza like Illness

Acute upper respiratory tract infection characterised by abrupt onset and two of the following:

fever, chills, headache, myalgia

Children and elderly patients may not present with classical symptoms

Elderly may only present with cough symptoms and/or confusion without a fever

Influenza presents in infancy and childhood as a wide variety of clinical syndromes including vomiting and diarrhoea.



5. Laboratory Testing for Influenza like Illness

All inpatients or those admitted with a diagnosis of suspected influenza should have respiratory viral swabs taken. Refer to Appendix C or the Influenza Instructions for Respiratory Viral Testing

6. Seasonal Influenza

6.1 General Information

Influenza viruses are spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a person).

Transmission via large-particle droplets requires close contact between source and recipient persons, as larger droplets generally travel only a short distance (1 metre or less) through the air.

Contact with respiratory-droplet contaminated surfaces is another possible source of transmission.

Airborne transmission (via small-particle residue [5μm or less] of evaporated droplets that might remain suspended in the air for long periods of time) is also thought to be possible particularly during and after aerosol generating activities, although data supporting airborne transmission is limited.

The typical incubation period for influenza is 1–4 days (average: 2 days).

Adults can be infectious from the day before symptoms begin until approximately 7 days after illness onset.

Young children might shed the virus several days before illness onset, and children can be infectious for 10 days or more after onset of symptoms.

Severely immune-compromised persons can shed virus for weeks or months.

Patients may be transferred or discharged to other care facilities including long term care with appropriate infection prevention and control measures in place. The CDHB IPC community liaison team is available for advice and/or to facilitate discharges to the long term care sector.

6.2 IPC Measures for Influenza (all clinical areas)

Patient Management All patients with suspected or confirmed influenza must be cared for with Standard and Droplet Precautions

A nasopharyngeal swab must be taken for respiratory viral PCR testing.

Hand hygiene is performed as per The 5 Moments for Hand Hygiene. Either alcohol-based hand rub or liquid soap and water may be used for hand hygiene.

A surgical mask should be worn when entering the patient’s room/bedspace. Remove the mask when leaving the patient’s room and dispose of the mask into hazardous waste. Perform hand hygiene.

Aprons and gloves are worn if required as part of Standard Precautions e.g. risk of direct hand or body exposure to blood or body fluids. If worn, gloves and aprons are changed between each patient.

In a cohort situation, staff may wear a mask when caring for more than one patient unless the mask becomes wet when it must be changed.

http://www.labnet.health.nz/resources/file/microbiology-virology/Influenza_Instructions_for_Respiratory_Viral_Testing_22-08

http://cdhbdepartments/corporate/documentmanagement/CDHB%20Libraries/Policies%20and%20procedures,%20guidelines,%20protocols,%20staff%20information%20etc/Influenza-Instructions-for-Respiratory-Viral-Testing.pdf



If patient movement or transport is necessary, have the patient wear a surgical mask if possible.

Provide the patient with a Patient Influenza Information fact sheet (Appendix D)

Patient to use a dedicated shower or patient to shower last prior to cleaning.

Patients to use dedicated toilet facilities where possible.

Do not use nebulisers in multibed rooms. If required, nebulisers can be used in a single room with the door closed whilst in use. An N95 mask must be worn by the HCW while in the room.

HCWs must wear a N95 mask (particulate respirator) for high-risk aerosol generating procedures.

High risk aerosol generating procedures:

- intubation/extubation - Suctioning - cough inducing procedures - bronchoscopy - respiratory autopsy or surgery involving high speed devices - CPR

Bed Management (Patient Placement) Refer also Appendix A –flow chart

Patient with suspected or confirmed influenza to be nursed in a single room o Where there are no single rooms available, patient may be nursed in a multi-

bed room with privacy curtains drawn between bed heads (1 metre) if there is no additional risk to the patient management

o Patient must not receive nebulisers in a multi-bed room

Multiple suspected or confirmed influenza patients may be cohorted together but privacy curtains must still be drawn between bed heads (1 metre) to prevent cross infection of different influenza strains.

A Droplet Precautions sign must be used and be visible

Duration of Precautions for Confirmed Influenza

Patients who have been prescribed anti-viral treatment (Tamiflu) shall remain in Droplet Precautions for 72 hours from commencement of treatment.

Maintain Droplet Precautions for 5 days after commencing treatment for children aged 5 years and under and other patient groups who may have a low immune response e.g. critical care patients.

Precautions should be continued greater than these times while the patient remains symptomatic.

For those not given anti-viral treatment maintain Droplet Precautions for seven days from onset of illness.

NB: Non-symptomatic patients (Contacts) prescribed prophylactic Tamiflu do not require isolation or Droplet Precautions unless they become symptomatic

Management of Contacts



A ‘Contact’ is any patient who is exposed to a suspected or confirmed influenza case prior to the use of Droplet Precautions. This is typically other patients who have been sharing the same multi-bed room with a suspected or confirmed influenza patient

Contacts do NOT require Droplet Precautions or isolation unless they subsequently develop signs and symptoms of influenza, even if prescribed prophylactic Tamiflu

If the index case is confirmed positive, contacts should be assessed by their clinical team and if deemed clinically indicated prescribed prophylactic Tamiflu (Appendix A).

The multi-bed room shall remain open to further admissions. However avoid admitting those patients from the following vulnerable groups

o those with chronic respiratory conditions o pregnant women, especially those in 2nd or 3rd trimester o the morbidly obese o those with immunosuppressive conditions e.g. cancer, transplant,

immunosuppressive medication or HIV o those with other chronic illnesses such as cardiac disease, diabetes

mellitus, chronic metabolic diseases, renal failure, chronic liver disease, chronic neurological disease

Refer ‘Management of healthcare workers’ for non-immunised staff contacts

Cleaning

Full terminal cleaning is not required following discharge of a suspected or confirmed influenza patient but staff undertaking a routine discharge clean should ensure the following environmental surfaces and touch points are addressed:

o Bed mattress, frame and rails o All horizontal surfaces including locker and bed table o Frequently touched fixtures e.g. handles, call bells, knobs and rails

Bed space curtains/screens do not require changing unless visibly soiled or the patient was nursed in Contact Precautions

Visitor restrictions and information

It is recommended the following people do not visit: o Infants (under 1 year). o Visitors with Influenza-like symptoms. o Pregnant women o Others susceptible to infection

Visitors are required to wash their hands or use alcohol-based hand rub prior to leaving the room at the end of the visit.

Visitors are not required to wear masks however social distancing should be advised (1-2 metre separation).

7. Other Respiratory Viral Illness (Influenza–like illness - ILI)

7.1 General Information

ILI may be caused by a number of viruses other than the influenza viruses

A swab sent for respiratory viral testing will be tested for up to 16 different viruses



In the healthcare setting, the principal mode of transmission of other respiratory viruses is via the healthcare worker’s hands, following contact with the patient and their environment

The use of hand hygiene and respiratory hygiene / cough etiquette will limit the transmission of ILI in general wards and departments

It is important to use Standard and Droplet Precautions for all patients until influenza is confirmed or ruled out. For laboratory or clinically confirmed influenza refer to 6.2 ‘Infection Prevention and Control Measures for Influenza’.

If the viral laboratory testing is negative for influenza but positive for another respiratory virus, implement IPC measures described in this document for either general wards or high risk clinical areas

7.2 IPC Measures for Other Respiratory Viral Illness in general wards

Standard Precautions are used for all respiratory viral illnesses in the general

wards, with the exception of Influenza.

The use of Standard Precautions, including respiratory etiquette and good hand hygiene will limit the transmission of other respiratory viruses in general wards and departments.

Wear a surgical /droplet mask when in close contact with a patient coughing or sneezing as part of Standard Precautions, to prevent contact with respiratory droplets on the face.

If the patient is being nursed in a multi bed room and has significant respiratory

symptoms, such as coughing and sneezing, protect other patients in adjacent beds

by drawing the privacy curtains half way between bed heads (1 metre).

As with all respiratory illnesses, education and encouragement to the patient about

respiratory etiquette is important to limit the spread of the virus in the environment.

7.2 IPC Measures for Other Respiratory Viral Illness in high risk areas for vulnerable patients

In patients from vulnerable groups all respiratory viruses may cause severe

disease, therefore requiring a different approach than the general population

Use Contact and Droplet Precautions for patients in vulnerable groups who are

being investigated for a respiratory viral illness until a laboratory result is obtained.

Refer to section 6 for IPC measures for influenza

Refer to the table on Page 8 for a list of other respiratory viral disease and the IPC

measures required

Prolonged shedding with respiratory viruses can occur in immunocompromised

individuals. Therefore it is not recommended that re-testing of patients is used as

an indicator to remove the patient from isolation. Please consider the patient’s

symptoms or lack of symptoms as an indicator and consult the IPC Service if any

queries.

Vulnerable groups of patients include:

o those with chronic respiratory conditions

o pregnant women, especially those in 2nd or 3rd trimester



o the morbidly obese

o those with immunosuppressive conditions e.g. cancer, transplant,

immunosuppressive medication or HIV

The wards and departments specifically caring for vulnerable groups of patients are:

o Intensive Care Unit

o Neonatal Intensive Care Unit

o Bone Marrow Transplant Unit

o Children’s Haematology Oncology Centre

o Paediatric inpatient wards

o Ward 25

o Ward 26

o Burwood Spinal Unit

o Care of the Elderly wards

8. Antiviral chemotherapy

Antiviral drugs are only available for influenza viruses. Tamiflu (Oseltamivir) is prescribed via the hospital pharmacy

Tamiflu:

Virus name Isolation requirements Personal Protective Equipment (PPE) required

Influenza A and B Droplet Precautions Surgical/procedural mask

RSV (Respiratory Syncytial virus)

Contact Precautions Apron/gown and gloves (consider a mask as part of Standard Precautions)

Parainfluenza virus (1-4 ) Contact Precautions Apron/gown and gloves (consider a mask as part of Standard Precautions)

Human Metapneumovirus (HMPV)

Contact Precautions Apron/gown and gloves (consider a mask as part of Standard Precautions)

Rhinovirus Droplet Precautions Surgical/procedural mask

Adenovirus (respiratory) Contact & Droplet Precautions

Apron/gown and gloves Surgical/procedural mask

Enterovirus (respiratory) Contact Precautions Apron or Gown and Gloves

Mycoplasma pneumoniae Droplet Precautions Surgical/procedural mask

Bocavirus Contact Precautions Apron/gown and gloves

Parechovirus Contact Precautions Apron/gown and gloves

Coronavirus Contact Precautions Apron/gown and gloves



o is an important line of defence in the prevention of seasonal influenza. o can be used either to treat influenza or prevent influenza (prophylaxis). o as a prophylaxis should be considered for exposed patient contacts of

confirmed influenza cases. o should not be considered a substitute for influenza vaccination.

Tamiflu is prescribed as follows: o 75mgs BD for 5 days for treatment of influenza cases o 75mgs daily for 10 days for prophylaxis o Refer to the Pink Book for other dosage requirements e.g. renal impairment

9. Management of staff exposure

Seasonal influenza vaccination for healthcare workers is the internationally recognised best practice for protection of patients and staff against influenza. These are offered free of charge each year throughout the CDHB during the annual staff vaccination campaign

Staff are advised to NOT self-diagnose by sending a viral swab to the laboratory

Unvaccinated staff members who are exposed to influenza should contact their GP for further advice.

10. Outbreaks

If influenza or other respiratory virus outbreak is suspected, the following measures should be taken to limit transmission:

Contact the Infection Prevention & Control Service

Restrict staff movement from areas of the facility having outbreaks

Implement Outbreak Response as per Outbreak Management Guideline (refer CDHB IPC policy) Infection Prevention Control Manual

11. Surveillance

Surveillance of inpatients with influenza and other significant respiratory viruses is undertaken by the Infection Prevention & Control Service.

12. References

NZ Ministry of Health Influenza.

National Influenza Strategy Group (NISG), Accessed at: www.influenza.org.nz .

CDHB Infection Prevention & Control Policies and Procedures

CDHB Intranet, Infection Control website

Satinderpal K et al. Influenza in the Older Adult-Indications for the use of vaccine and antiviral therapy. Geriatrics Jan 2001; 56 (1).

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm

Muthuri et al. (2014). Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data.

http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-Policies/Infection-Prevention-Control-Manual/Pages/default.aspx

http://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/influenza

http://www.influenza.org.nz/

http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-Policies/Infection-Prevention-Control-Manual/Pages/default.aspx

http://cdhbintranet/hospitalsupportandlabs/microbiology/SitePages/Home.aspx

http://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm



Authorised by the CDHB Infection Control Committee Date: 9th June 2014 Version 2-May 2015 Minor changes to wording Reported respiratory viruses and isolation requirements for vulnerable groups table updated Version 3 May 2016 Changes to Occupational Health section Addition of two more vulnerable groups Version 4 April 2018 Minor changes to wording Version 5 May 2018 Minor changes to wording


Appendix A. Inpatient Influenza Flowchart

Patient bed space placed in Droplet Precautions

(Blue Sign)

Bed privacy curtains pulled between bed heads (1 metre) to minimise droplet spread from coughing to adjacent patients

Dedicated shower OR patient to shower last

Dedicated toilet where possible

Patient to wear surgical mask when mobilising to shower or toilet

Nebulisers MUST NOT be used in multi-bed room


Contacts are patients exposed to the case (in the same room for more than 1 hour) prior to implementation of Droplet Precautions

Contacts do NOT require isolation precautions unless they become symptomatic

Contacts to be prescribed prophylactic Tamiflu as per clinical team assessment if Index case confirmed positive for Influenza

Suspected or Confirmed Influenza Patient

Patient should be placed in single room

(IP&C Policy)

Single room not available

(nursed in multi-bed room)

Single room available

(Preferred option)

Droplet Precautions

(Blue Sign)

Prescribed anti-viral treatment

NO YES

Droplet Precautions for 7

days after onset of illness

Multiple case (suspected or confirmed) may be cohorted in a multi bed room.

The period of viral shedding may be extended in immune compromised and/or ICU patients

Refer also IP&C Guideline ‘Flow Chart for Use of Nebulisers’

All suspected cases to have a

nasopharyngeal swab sent for Respiratory PCR testing

Refer to Appendix B for the management of patients with other respiratory viral illnesses.

Cough and sneeze etiquette/respiratory hygiene to be observed at all times. Educate patients in the importance of respiratory hygiene.

Appendix A Inpatient Influenza Flowchart - Management for Seasonal Suspected or Confirmed Influenza Patient

Authorised By: CDHB Infection Prevention & Control Committee Page 1 of 1 Issue Date: April 2014

CHDB Infection Prevention and Control Intranet Guideline Influenza and other Respiratory Virus Guidelines 2014

Droplet Precautions for 72hrs

following start of Tx

(Children ≤ 5 years for 5 days)


Appendix B. Management of Respiratory Viral Illness Flowchart

Appendix B Management for Suspected or Confirmed Respiratory Viral Illness

All suspected cases to have a

nasopharyngeal swab sent for Respiratory PCR testing

Refer to Appendix A for the management of patients with influenza

Cough and sneeze etiquette/respiratory hygiene to be observed at all times. Educate patients in the importance of respiratory and hand hygiene.

Suspected or Confirmed Respiratory Viral

Illness

Patient should be placed in Droplet Precautions until viral testing results are obtained

Single Room (IPC Policy)

If no single bed available Refer Appendix A for bed space isolation precautions

Other Respiratory Virus

Influenza Confirmed – refer

Appendix A

Patient in Vulnerable Clinical

Area

Standard Precautions

Vulnerable Clinical Areas


Contacts do NOT require isolation precautions

unless they become symptomatic

Patient not in Vulnerable

Clinical Area ICU NICU BMTU CHOC Paediatric Inpatient Wards Ward 25, 26 Burwood spinal Unit Care of the Elderly wards

Contact/Droplet Precautions(See Table Page 8, Section 7.2)


Appendix C. Laboratory Instructions for Respiratory Viral Testing


Appendix D. Patient Information Sheet

(Available on IPC Intranet site)

http://cdhbintranet/hospitalsupportandlabs/microbiology/SitePages/Patient%20Information.aspx

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