​This notice is to alert long-term health care facilities (LTCFs) regarding influenza outbreaks that may affect your communities this flu season and to reiterate the Centers for Disease Control and Prevention (CDC) guidance on prevention and control of influenza in LTCFs.

Nationwide influenza activity is high or widespread this flu season, and influenza is rapidly spreading in California. The California Department of Public Health (CDPH) has already received reports of several influenza outbreaks in LTCFs due to influenza A (H3N2) with complications including hospitalizations and deaths.

CDC recently issued a Health Advisory to emphasize the importance of using antivirals (neuraminidase inhibitors) when indicated for treatment and prevention of influenza, as well as vaccination. This year, it is particularly important to consider early treatment with antivirals in high-risk individuals because the current flu vaccine’s ability to protect against this year’s predominant influenza strain might be reduced.

CDPH urges all LTCFs to take measures that can lessen the effect of a local influenza outbreak on residents, who are at high risk of complications such as pneumonia, hospitalization, and death. The CDC and CDPH recommendations for preventing and controlling influenza in institutional settings, including LTCFs, are summarized below:

• Be vigilant for cases of influenza. Influenza should be suspected in residents or staff with influenza-like illness (ILI), i.e., Mild sore throat, itchy eyes, cough, fever of ≥100°F (37.8°C), muscle aches, headache, fatigue, and a nonproductive cough. Many residents may be unable to report symptoms reliably. Symptoms in elderly persons can be atypical and subtle, such as a change in mental status, a temperature, which may be below normal. Staff with a fever of 100°F or higher should not work.
• Test for influenza in residents with ILI, especially if there is a cluster (two or more cases of ILI within 72 hours). Notify your local health department as soon as possible of a cluster of ILI. The local health department can coordinate prompt influenza testing by reverse-transcriptase polymerase chain reaction (RT-PCR) at a regional public health laboratory; RT-PCR is the best way to confirm the diagnosis of influenza. Rapid Influenza Diagnostic Tests (RIDT) can vary in their sensitivity and specificity compared with RT-PCR or culture. A decision not to treat a resident with an antiviral should not be made on the basis of a negative RIDT test result.
• Vaccinate residents and staff. Despite potentially reduced effectiveness this year, the vaccine can still prevent infection and serious flu-related complications in many people. Be familiar with your local health department’s requirements for use of surgical masks by non-vaccinated healthcare personnel. Complications, especially in unvaccinated long-term care residents, include pneumonia, worsening of chronic health conditions, and dehydration.
• Treat with antivirals all residents with suspected or confirmed influenza. Begin antiviral treatment with a neuraminidase inhibitor (e.g., oral oseltamivir, inhaled zanamivir, parenteral peramivir) as early as possible, ideally within 48 hours. Decisions about starting antiviral treatment should be made regardless of vaccination history and should not wait for laboratory confirmation of influenza. For dosage and additional information, refer to:

CDC - Influenza Antiviral Medications: Summary for Clinicians

To date, circulating strains have been susceptible to neuraminidase inhibitors. There are no current national shortages of antivirals. However, local shortages have been reported for some formulations. LTCFs should notify their local health department of difficulties accessing antiviral supplies.

Adamantanes (rimantadine and amantadine) are not currently recommended for treatment or prevention of influenza because of high levels of resistance among circulating influenza A viruses.

• Start chemoprophylaxis with antivirals for all non-ill facility residents (regardless of vaccination history) when an influenza outbreak has been confirmed in a LTCF (two or more residents with ILI within 72 hours and at least one resident has confirmed influenza). The CDC has additional recommendations on chemoprophylaxis of health care personnel in LTCFs:

CDC - Prevention Strategies for Seasonal Influenza in Healthcare Settings

Antiviral chemoprophylaxis should be administered for a minimum of two weeks, and continue for at least seven days after the last known case of influenza was identified.

• Consider bacterial infections and treat appropriately, if suspected. Antibiotics are not effective against influenza infection, and early diagnosis of influenza can reduce the inappropriate use of antibiotics. However, certain bacterial infections can produce symptoms similar to influenza and bacterial infections can occur as a complication of influenza. In addition, because pneumococcal infections are a serious complication of influenza infection, new pneumococcal vaccine recommendations for adults 65 years of age or older, as well as adults and children at increased risk for invasive pneumococcal disease due to chronic underlying medical conditions should be followed.
• Implement Enhanced Standard Precautions Plus Droplet Recommendations for all residents with suspected or confirmed influenza. Infection control measures include isolation or cohorting of ill residents and screening employees and visitors for illness. For additional guidance refer to:

AFL 10-27 Enhanced Standard Precautions (ESP) for Long-Term Care Facilities

• Reinforce use of other preventive health practices to decrease spread of influenza such as respiratory hygiene, cough etiquette, social distances (e.g., staying home from work when ill, staying away from people who are sick), and hand washing.
• Report all suspected and confirmed outbreaks to the LTCF medical director, local health department, and CDPH Licensing and Certification (L&C) district office.

Please see the attached list of references for more information, and direct questions regarding influenza to your local health department.

Sincerely,

Original signed by Jean Iacino

Jean Iacino
Interim Deputy Director