Respiratory Outbreaks in Long-Term Care Facilities and Retirement Homes

To report an outbreak during regular business hours, or for more information, call 613-580-2424 ext. 26325.  Evenings, weekends or holidays, call 3-1-1 and ask to speak with the Public Health Inspector on-call.

Respiratory outbreaks occur in long-term care homes and retirement homes throughout the year. Such outbreaks can lead to substantial morbidity and mortality and are disruptive and costly. Long-term care and retirement homes often have elderly residents who may have chronic illnesses which weaken their immune systems, putting them more at risk of developing severe illness and complications. Infections also can be more easily transmitted in institutional environments, thus increasing the importance of early implementation of control measures. Early detection and timely implementation of outbreak control measures is essential to prevent further transmission of the infection to others, thereby reducing the length and impact of an outbreak.

The following resources can be used for the detection, management and implementation of such control measures for respiratory outbreaks in long-term care and retirement homes. 

To report an outbreak during regular business hours, or for more information, call 613-580-6744 ext. 26325, or in the evening, on weekends or holidays, call 3-1-1 and ask to speak with the Public Health Inspector on-call.

Activities in long term care and retirement homes during an outbreak

It is important for long-term care homes and retirement homes to assess and modify activities during the course of enteric and respiratory outbreaks to reduce the risk of transmission of infection amongst residents and staff. Each outbreak is unique and the Ottawa Public Health (OPH) investigator assigned to the outbreak will assist you with outbreak management and activity assessment.

Do all activities have to be cancelled during an outbreak?
No, but some activities may have to be cancelled. You should review your list of planned or scheduled activities to assess whether they can continue based on the likelihood that they can cause disease transmission and, if necessary, modify activities to minimize the risks. 
What criteria need to be considered when assessing whether an activity can continue during an outbreak?

You need to consider the following when assessing if an activity can continue during an outbreak:

  • Outbreak status (newly declared or close to termination)
  • Type of facility
  • Type of outbreak (respiratory or enteric)
  • Areas affected by the outbreak (number of units/floors affected or facility-wide)
  • Type of activity and likelihood of transmission through sharing of objects, air space or touching common surfaces
  • Likely source of exposure to illness (food, environmental surfaces, ill staff, visitors, etc.)
  • Effectiveness of outbreak control measures in place
  • Type of agent(s) identified
  • Number of residents and staff affected and requiring modified activities
  • Health status of residents affected
Do third party services such as physiotherapy, foot care, dental care, etc. have to be cancelled during an outbreak?
Third party services do not always have to be cancelled during an outbreak. Criteria to be considered include the status of the outbreak, types of services being provided, areas of the facility affected by the outbreak (facility-wide, floors, or units), and the health status of individuals receiving the service. Third party service providers must adhere to the outbreak control measures at the affected facility if providing service to residents during an outbreak.
Who can participate in activities during an outbreak?

Well residents (those who are not exhibiting any symptoms) may participate in activities that are considered low-risk for transmission of infection. 

Ill residents should be placed on isolation and must not participate in group activities until they are taken off precautions and are well enough to participate.

One-on-one activities can be provided to ill residents if they are feeling well enough to participate. Any items used during the activity should remain in the ill resident's room or be cleaned and disinfected after use or discarded. Ill residents should be encouraged to remain on their units within the home.

Well staff and volunteers can assist with activities as long as they wear appropriate personal protective equipment (PPE) and practice good hand hygiene.

Where can activities for well residents take place during an outbreak?

Activities can take place on unaffected floors and units.  Only well residents can participate in these activities.

Events scheduled to take place outside the facility should be rescheduled if the outbreak is facility-wide. If well residents participate in off-site activities, high-touch surfaces in the vehicles used to transport them should be cleaned and disinfected after each trip.

What are some examples of individual activities for those who are isolated but feeling well enough to participate?
Activities that include items that can be easily disinfected or discarded following the interaction can take place within the resident's room.
What are some examples of group activities that can be offered for well residents during an outbreak?

Activities that do not involve sharing of objects can continue for well residents, such as, but not limited to, religious gatherings, choirs, sing-a-longs, movies, crafts, group discussions, and trivia games.  Factors to be addressed include seating arrangements (e.g. distance between residents and position of residents) and enhanced cleaning of areas where activities take place. Activities involving shared items that cannot be easily disinfected between residents will likely have to be modified during an outbreak. Examples of activities that may have to be modified or cancelled include: visiting entertainers, bingo, card games, baking, board games, bean bag toss, fitness classes and physiotherapy. 

Food provided during an activity should be served to each resident individually.  Buffet or self service options for food are not recommended.  Provide alcohol-based hand rub for residents to use prior to and after eating.  Residents should not be participating in food preparation during an outbreak.

Does the dining room have to be closed during an outbreak?
No. Eating in the dining room does not count as an activity.  Some facilities may re-locate dining of ill residents to an affected floor if they have the capacity to do so.  During an outbreak, hand hygiene should be performed by all residents prior to entering the dining room.  Tray service is to be provided to ill residents who are isolated in their rooms.

Please contact the OPH outbreak investigator assigned to the outbreak at your facility if you have any questions at 613-580-6744 or visit OttawaPublicHealth.ca

Family and visitor information during an outbreak

Outbreaks of illness sometimes occur in health care facilities and can be a stressful time for families and staff. Outbreaks are most often caused by common viruses that produce symptoms of gastroenteritis, such as nausea, vomiting and diarrhea, or respiratory illness, such as fever, cough and sore throat. These viruses are generally spread from person to person, or by touching contaminated surfaces, objects or equipment and then touching your eyes, mouth or nose or handling food or drink. For the health and well-being of everyone, it is important to implement measures to control the spread of infection as soon as possible.

Ways you can help stop the spread of illness:

  • Do not visit if you are ill
  • Follow the outbreak and infection control measures recommended
  • Limit your visit to your family or friend, as much as possible
  • If you are visiting an ill family member of friend, please check with the staff prior to entering his or her room
  • Clean your hands often with liquid soap and running water or alcohol-based hand sanitizer
  • Clean your hands
    • When entering the facility and before leaving
    • Before entering and after leaving a resident's room
    • Before eating or assisting your family or friend with his/her meals
    • After going to the washroom or blowing your nose
    • Get immunized against influenza every year

Washing your hands

  1. Wet hands under running water
  2. Apply liquid soap
  3. Lather and rub hands for at least 15 seconds
  4. Rinse hands
  5. Towel or air dry hands
  6. Turn taps off with a towel or your sleeve

Cleaning Your Hands with a Hand Sanitizer

  1. Place a quarter-size drop of alcohol- based hand sanitizer in your palm
  2. Rub hands together, palm to palm
  3. Rub back of each hand with palm and fingers of the other hand
  4. Rub around each thumb
  5. Rub fingertips of each hand back and forth in the other hand
  6. Rub until your hands are dry (at least 15 seconds)
Hand hygiene resources

Learn more about preventing the spread of germs in the below resources prepared by OPH.

The information below is available in other formats. Contact Ottawa Public Health at 613-580-6744 to request the document in an accessible format.

How to collect a Nasopharyngeal (NP) swab

The laboratory requires high numbers of organisms to culture successfully for respiratory viruses such as Respiratory Syncytial Virus (RSV), Influenza A, Influenza B or Parainfluenza.

  • The best time to take an NP swab is within 24-48 hours of symptom onset.
  • A properly executed NP swab will yield high numbers of organisms

How do I swab?

  1. Insert the dry swab through one nostril straight back (NOT upwards), along the floor of the nasal passage until you reach the posterior wall of the nasopharynxEncourage the resident to blow his or her nose to clear nasal passage. 
    If the resident is unable to perform this task wipe the nares with a cotton tip swab or tissue.
  2. Label the vial with the resident's name, date of birth and time collected.
  3. Perform hand hygiene. Put on a mask, eye protection and gloves.
  4. With the person's head in a neutral position,
    • Insert the dry swab through one nostril straight back (NOT upwards), along the floor of the nasal passage until you reach the posterior wall of the nasopharynx - generally one half the distance from the corner of the nose to the front of the ear (about 4 to 6 cm or 1.6 - 2.5 inches)
    • Rotate the swab gently then leave in place a few seconds
    • Carefully remove the swab without touching the sides of the nostril
  5. Open the transport vial and place the swab in the transportation medium.
  6. Break the swab at the scored line and recap.
  7. Place the specimen in the big inner pocket of the plastic biohazard bag provided.
  8. Remove your gloves and perform hand hygiene; remove your mask and perform hand hygiene.
  9. Complete the requisition form and place it in the small outer pocket of the plastic biohazard bag.
  10. Place the entire plastic biohazard bag in a separate clean paper bag or zip-lock bag.
  11. Refrigerate the specimen.
  12. Perform hand hygiene.
  13. Call Ottawa Public Health at 613-580-6744, ext 26325 for NP specimen pickup and delivery to the laboratory.

Do not send with your regular lab courier

Identifying and reporting a respiratory outbreak in long term care and retirement homes

Assess if you have a respiratory outbreak

A suspect respiratory outbreak exists when you have:

  • Two cases of acute respiratory infections (ARI) occurring within 48 hours with any common epidemiological link (e.g., unit, floor);

OR

  • One laboratory-confirmed case of influenza

A confirmed respiratory infection outbreak exists when you have:

  • Two cases of ARI within 48 hours with any common epidemiological link (e.g., unit, floor), at least one of which must be laboratory-confirmed;

OR

  • Three cases of ARI (laboratory confirmation not necessary) occurring within 48 hours with any common epidemiological link (e.g., unit, floor);

Case definition:

Clinically compatible signs and symptoms in individuals who are part of an outbreak include, but are not limited to, the following:

  • Upper respiratory tract illness (e.g., common cold, pharyngitis);
  • runny nose or sneezing;
  • Stuffy nose (i.e., congestion);
  • Sore throat or hoarseness or difficulty swallowing;
  • Dry cough;
  • Swollen or tender glands in the neck (i.e., cervical lymphadenopathy);
  • Fever/abnormal temperature for the resident/patient may be present, but is not required;
  • Tiredness (i.e., malaise);
  • Muscle aches (i.e., myalgia);
  • Loss of appetite;
  • Headache; and
  • Chills.

If yes, report to Ottawa Public Health

Notify Ottawa Public Health (OPH) at 613-580-2424, ext 26325 from 8:30 am to 4:30 pm or 
3-1-1 outside regular business hours, on weekends or statutory holidays

When a respiratory outbreak is confirmed by OPH, fax the Respiratory Outbreak Line Listing to OPH at 613-580-9649 on a daily basis, until the outbreak is declared over by OPH.

Identify pathogen

  • Collect nasopharyngeal (NP) swabs from symptomatic residents within 48 hours of symptom onset or as directed by OPH
  • Ensure samples have 2 resident identifiers on the sample bottle and requisition (for example, name and date of birth)
  • Ensure samples are kept refrigerated
  • Call OPH to pick up and deliver the samples to the laboratory

Implement outbreak control measures immediately

  • Do not wait for confirmation of pathogen involved
  • Isolate ill residents (5 days or until symptom free)
  • Exclude ill staff (5 days or until symptom free)
  • Wear appropriate personal protective equipment (PPE) when providing care to ill residents
  • Ensure adequate and frequent hand washing
  • Notify internal and external partners of outbreak (including volunteers)
  • Ensure staff within the facility are aware of the outbreak
  • Post signs at the facility entrances and affected units
  • Enhance environmental cleaning and disinfection (at least twice daily)
  • Modify activities on affected units as appropriate
  • Discuss any transfers or new admissions of residents with OPH
  • Keep visitors and volunteers to a minimum
  • Ensure active surveillance for new cases and report all new cases on the daily line listing to OPH

Termination of a respiratory outbreak

Upon consultation with OPH, respiratory outbreaks can be declared over if there is no new case eight days after the onset of symptoms of the last case

An outbreak may be terminated earlier in consultation with OPH

Respiratory outbreak line listing for residents

Respiratory outbreak line listing for residents [PDF 58 kb]

Fax daily to: 613-580-9649

Respiratory outbreak line listing for staff

Respiratory outbreak line listing for staff [PDF 55 kb]

Fax daily to: 613-580-9649

Outbreak signage

If possible, print the signs in colour and post, facing outwards, at the main entrance and all other public entrances. 

We are experiencing an outbreak [PDF 138 kb]

Antiviral Recommendations for Residents and Staff during a Confirmed Influenza Outbreak

There are currently two antiviral drugs that are licensed in Canada for the treatment and prophylaxis of influenza A and B, including oseltamivir (Tamiflu) and zanamivir (Ralenza). These medications are neuraminidase inhibitors which work by blocking the exit of the influenza virus from the respiratory cells, therefore preventing further replication of the virus. For this reason, when using antivirals for the treatment of influenza, it is important that they are initiated as soon as possible within 48 hours of symptom onset.

Ottawa Public Health (OPH) recommends oseltamivir as the drug of choice for both treatment and prophylaxis of residents in long-term care homes (LTCHs) for the following reasons:

  • The use of Zanamivir has not been proven effective for prophylaxis of influenza in the LTCH setting
  • Elderly individuals may have difficulty inhaling zanamivir
  • Zanamivir is not recommended for treatment or prophylaxis of Influenza in individuals with underlying respiratory conditions such as chronic obstructive pulmonary disease or asthma due to the risk of bronchospasm
  • Reimbursement for zanamivir for residents occurs only when the predominant strain is resistant to oseltamivir

Management of staff

It is important for staff to be advised upon hire about the influenza policy of the facility and/or their collective agreement, and the options available to them in the event of an influenza outbreak if they are not immunized for any reason.

When an influenza outbreak occurs, staff must obtain prescriptions for antiviral medication from their own health care provider and are responsible for their own antiviral-related expenses, unless they have coverage through a company or private health insurance plan. They are not eligible for prescription drug coverage under any circumstances from the Ontario Drug Program (ODP). Only under very specific circumstances, immunized health care workers may be eligible for reimbursement through the High Intensity Needs Fund (HINF).

During a laboratory-confirmed influenza outbreak, when the circulating strain is not well-matched by the vaccine, antiviral prophylaxis should be offered to all staff, regardless of vaccination status, until the outbreak is declared over, based on consultation with OPH.

Immunized Staff

  • Staff immunized ≥ 2 weeks prior to outbreak declaration, whether with an inactivated or live attenuated influenza vaccine (LAIV), have no  work restrictions, provided they are feeling well
  • Staff immunized ≤ 2 weeks with inactivated influenza vaccine prior to outbreak declaration, should take antiviral prophylaxis until immunity is reached or until the outbreak is declared over, whichever is shorter
  • Staff immunized ≤ 2 weeks with LAIV (Flumist) should not receive antiviral treatment or prophylaxis for at least 2 weeks after receipt of LAIV, unless medically indicated, so that the antiviral agents do not kill the replicating virus from the administered vaccine. If antiviral agents are administered within this time frame, revaccination should take place immediately with an inactivated influenza vaccine

Unimmunized Staff

  • Unimmunized staff should be offered vaccine and take antiviral prophylaxis until immunity is reached or until the outbreak is declared over, whichever is shorter
  • Unimmunized staff who refuse to be immunized must take  antiviral prophylaxis until the outbreak is declared over; staff may work with residents as soon as they start antiviral prophylaxis
  • Staff accepting to be immunized, but refusing antiviral medication, should NOT be permitted to work in the outbreak-affected area for a two week period. Prior to being reassigned to another unit, they must be asymptomatic for 72 hours (3 days)
  • Flumist is a vaccine option in Ontario that is only publicly funded for children from 2-17 years of age. If a staff member or resident chooses to be immunized with Flumist privately, it is recommended that LAIV (Flumist) not be administered until 48 hours after antiviral treatment or prophylaxis for influenza is stopped

Management of residents

Prophylaxis

  • During a laboratory-confirmed influenza outbreak, antiviral prophylaxis should be offered to all residents in the outbreak-affected area who are NOT already ill with influenza, regardless of immunization status, until the outbreak is declared over
  • If respiratory symptoms develop in a resident while on prophylaxis, the dose should be switched to a treatment dose for five days or until symptom free whichever is shorter

Treatment

Once an outbreak has been laboratory-confirmed as influenza, additional laboratory confirmation of new cases is not required to begin treatment of residents who meet case definition. It is important that:

  • Antiviral treatment of ill residents who meet case definition is started as soon as possible, and within 48 hours of symptom onset
  • Ill residents remain in their rooms for the duration of the antiviral treatment, which should be a total of five days

Circumstances that may Affect Decisions regarding Use of Antiviral Medication

  • If the resident meets case definition and has been symptomatic for MORE than 48 hours and antiviral treatment has NOT been started, use Appendix A for making decisions about the use of antivirals
  • If the outbreak is ongoing when the five-day treatment course ends AND the resident did NOT have lab-confirmed influenza (either the resident was never tested or had a negative influenza lab result), the resident should be switched to a prophylactic dose until the outbreak is declared over. This is recommended in case of a potential outbreak caused by more than one agent (See Appendix B)

When Antiviral Medications Do Not Control the Outbreak

If new cases continue to appear 72 to 96 hours after the start of antivirals, consider the following:

  • The new cases could be caused by another organism
  • There could be compliance/adherence issues
  • Resistance to the antiviral medications may have developed in the circulating strain

In the event that the outbreak is not controlled with antiviral use:

  • Consult with the OPH Outbreak Management team to determine if the antiviral agents should be continued
Recommended dosage for prophylaxis and treatment of influenza with Tamiflu for adults

Kidney function/Creatinine Clearance

Prophylaxis is given until the outbreak is declared over

Treatment for 5 days

With no known renal disease OR With renal disease and creatinine clearance >60mL/min

 

75 mg once daily

75 mg twice daily

With known renal disease and creatinine clearance of >30-60mL/min

 

75 mg on alternate days OR 30 mg once daily

75 mg once daily OR 30 mg suspension twice daily OR 30 mg capsule twice daily

With known renal disease and creatinine clearance of 10- 30 mL/min

 

30 mg every other day

 

30 mg orally once daily

Residents with renal failure (<10 mL/min)

 

No data

Single dose of 75 mg for the duration of the illness

Dialysis residents: Low-Flux HD

30 mg orally after every alternate hemodialysis session (initial dose can be started between sessions)

 

30 mg orally after every hemodialysis session (initial dose can be started between sessions)

Dialysis residents: High -Flux HD

 

No data

75 mg after each dialysis session

Dialysis residents: CAPD dialysis

30 mg orally once weekly

Administered prior to the start of dialysis

A single dose of 30 mg orally administered prior to the start of dialysis

 

Dialysis residents: CRRT high-flux dialysis

No data

30 mg daily or 75 mg every second day

 

References:

Appendix A: Influenza Outbreak antiviral treatment recommendations if treatment is not initiated within 48 hours of symptom onset

Diagram 1: Influenza Outbreak antiviral treatment recommendations if treatment is not initiated within 48 hours of symptom onset

Influenza Outbreak antiviral treatment recommendations if treatment is not initiated within 48 hours of symptom onset

  • Resident meets outbreak case definition
  • Was antiviral treatment initiated within 48 hours of symptom onset? (NO)
  • Is the resident clinically improving?
    • NO
      Provide antiviral treatment
    • YES
      Consider antiviral therapy for individuals in high risk groups*, or individuals with moderate, severe or complicated illness

* Note: please see AMMI Influenza guidelines (as current) for a definition of high-risk groups

Appendix B: Influenza Outbreak antiviral prophylaxis recommendations for Line- listed cases after completion of treatment with antiviral medication

Diagram 2: Influenza Outbreak antiviral prophylaxis recommendations for Line- listed cases after completion of treatment with antiviral medication

Influenza Outbreak antiviral prophylaxis recommendations for Line- listed cases after completion of treatment with antiviral medication

Is the outbreak still ongoing?

  • NO
    No further action required
  • YES
    • Are antivirals still being used for prophylaxis in residents on the line-listed residents' unit?

      • YES
        • Did the line-listed resident have laboratory confirmed influenza?
          • YES
            Do not provide prophylaxis. The resident would now have immunity to the influenza virus that is causing the outbreak.
          • NO
            Start on a prophylaxis dose until the outbreak is declared over.  This is a precaution in case there is an outbreak with more than one pathogen and the line-listed resident may have previously been infected with a non-influenza pathogen. 

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