Influenza Cases and Outbreaks in LTC and CDC Guidance

Iowa publishes weekly Iowa Respiratory Virus Surveillance Reports. The State continues to experience a high number of Influenza cases. With several viral illness circulating, members may want to begin active daily surveillance for acute respiratory illness among residents, personnel and visitors. 

As a reminder LTC providers should report outbreaks of influenza [email protected].   

All suspected influenza outbreaks are reportable to Iowa HHS. LTC providers should report outbreaks of influenza [email protected].  Providers outside of nursing home settings should report suspected outbreaks to the CADE main office number at (515) 242-5935. 

An influenza outbreak is defined as:   

·      1 laboratory confirmed case along with other cases of respiratory illness in a unit, or 

·      2 laboratory confirmed cases within 72 hours in the same unit. 

CDC resources for health professionals regarding the flu are available at https://www.cdc.gov/flu/professionals/index.htm.  The CDC provides specific guidance for Managing an Influenza Outbreak in LTC and Post-Acute Communities.   

As soon as an influenza outbreak is suspected, LTC providers should begin active surveillance for additional cases.  As a reminder, older adults may manifest atypical signs and symptoms of influenza and may not have fever, so testing is recommended for all ill persons including those who develop acute respiratory illness symptoms after beginning antiviral chemoprophylaxis.  When COVID-19 and influenza are both circulating, residents should be tested for both viruses.  Co-infection of influenza and COVID-19 can occur so a positive of one does not rule the other out.  Once an influenza outbreak has been confirmed, outbreak control measures should be implemented as soon as possible, and active daily surveillance should continue until at least 1 week after the last laboratory confirmed case was identified.    

Outbreak Procedures include: 

• Implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza.  Droplet precautions should be continued for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer.  Standard and droplet precautions should be implemented regardless of antiviral therapy because residents with influenza may continue shedding virus while on antiviral treatment.  [Note that if it is unclear whether the resident has influenza or COVID-19, the resident should be placed on transmission-based precautions and placed in a single room, if possible, pending the results of viral testing.]  As part of Standard Precautions, eye protection should be worn if splashes or sprays are anticipated (e.g., the resident is coughing or sneezing). Because it can be difficult to anticipate potential for coughs and sneezes, facilities might consider having healthcare personnel routinely wear eye protection for the care of residents with influenza. 
• Administer influenza antiviral treatment to ill residents according to current recommendations.  Antiviral treatments work best when started within the first 2 days of symptoms.  In a LTC setting influenza outbreak, empiric antiviral treatment should be given as soon as possible to residents with suspected influenza without waiting for influenza testing results, especially if results will not be available on the day of specimen collection.  Having preapproved orders from physicians or plans to obtain orders for antiviral medications on short notice can substantially expedite administration of antiviral medications.   
• Administer influenza antiviral chemoprophylaxis according to current recommendations.  When an influenza outbreak is determined, the LTC provider should promptly initiate antiviral chemoprophylaxis with oral oseltamivir to all non-ill residents living on the same unit as the resident with laboratory-confirmed influenza (outbreak affected units), regardless of whether they received influenza vaccination during the current season. Consideration may be given for extending antiviral chemoprophylaxis to residents on other unaffected units/areas based upon other factors (e.g., unavoidable mixing of residents or healthcare personnel from affected units and unaffected units).  Use of antiviral drugs for chemoprophylaxis of influenza is a key component of influenza outbreak control in institutions that house residents at higher risk of influenza complications.  

Oseltamivir is the recommended antiviral drug for chemoprophylaxis of influenza in long-term care settings.  CDC recommends antiviral chemoprophylaxis with oseltamivir for a minimum of 2 weeks and continuing for at least 7 days after the last known laboratory-confirmed influenza case was identified on affected units.  [Zanamivir should be used when persons require chemoprophylaxis as a result of exposure to influenza virus strains that are suspected or known to be oseltamivir-resistant.] 

CDC HAN Advisory Guidance when Oseltamivir in limited availability: 

• If not experiencing an influenza outbreak, prioritize oseltamivir for early treatment of influenza in residents of congregate settings who test positive for influenza.  
• If experiencing an outbreak, provide antiviral treatment of suspected influenza in residents.   
• Once diagnosis is confirmed through testing, post-exposure antiviral chemoprophylaxis of exposed residents is recommended.  Because institutional outbreaks can be prolonged, consider using a limited duration treatment dosage (twice daily for 5 days) for post-exposure oseltamivir instead of extended use of oseltamivir chemoprophylaxis (once daily), with ongoing active daily monitoring and influenza testing for all residents with new illness signs and symptoms.  
• If oseltamivir is not available, baloxavir, zanamivir, or peramivir may be used for treatment of influenza.  
• Although baloxavir may be used for treatment, there are no available data on using baloxavir in LTCFs for treatment or post-exposure chemoprophylaxis.  

Consider the following additional measures to reduce transmission among residents and healthcare personnel: 

• Have symptomatic residents stay in their own rooms as much as possible, including restricting them from common activities, and have their meals served in their rooms when possible.  Residents with influenza should be placed in a single room, if available, or housed with other residents with only influenza.   
• Limit the number of large group activities in the facility and consider serving all meals in resident rooms if possible when the outbreak is widespread (involving multiple units of the facility). 
• Avoid new admissions or transfers to wards with symptomatic residents. 
• Limit visitation and exclude ill persons from visiting the facility via posted notices. Consider restricting visitation by children during community outbreaks of influenza. 
• Monitor healthcare personnel absenteeism due to respiratory symptoms and exclude those with influenza-like symptoms from work until at least 24 hours after they no longer have a fever. 
• Restrict healthcare personnel movement from areas of the facility having illness to areas not affected by the outbreak. 
• Administer the current season’s influenza vaccine to unvaccinated residents and healthcare personnel as per current vaccination recommendations.