Prevention and Control of Influenza during a Pandemic for All Healthcare Settings

1

Immunization program

Develop and implement protocols for immunization of all HCWs including pre-placement screening and assessment. This includes assessment of tuberculosis status, offering appropriate immunizations to all HCWs without proof of immunity, including, housekeeping, laundry workers, and workers handling waste. Immunizations includes: hepatitis B; annual influenza (see item 2 below); tetanus booster; measles; mumps; acellular pertussis; pneumococcal; rubella (MMR) and varicella. (See Section VI.1.1.1.).

2

Annual influenza prevention program

Develop and implement annual influenza prevention protocols to include HCWs education, annual immunization and strategies to monitor and improve immunization rates. (See Section VI.1.1.1.).

3

Workplace hazard assessment

Develop and implement a process to evaluate the healthcare workplace to identify potential infectious hazards (and all other health and safety hazards) related to work activities with regular, ongoing inspections and evaluations, and implementation of correction measures. (See Section VI.1.1.2.)

4

Respiratory protection program

Develop and implement a respiratory protection program for use with respirators (N95 or higher filtration), in healthcare organizations where personnel are required to wear respiratory protective equipment. This includes health screening, fit testing/re-testing, and training to all HCWs who may need to wear a respirator for the performance of AGMPs. (See Section V.6.2.4.).

5

Surveillance program - HCWs with symptoms of acute respiratory infections

Establish a process for early identification, containment, investigation and reporting of HCWs with symptoms of acute infections. This includes: policies for HCWs and the self assessment and reporting of acute infection illness to OH; a process for recording HCWs absenteeism due to infection; procedures to manage ill HCWs so they do not expose others in the workplace, and a process to assess whether clusters of ill personnel are associated with outbreaks/clusters of HAIs, including influenza, in patient populations. (See Section VI.3.).

6

IPC professionals

Evaluate and implement appropriate measures to ensure an adequate number of trained Infection Control Practitioners for the size and complexity of the patient population. (See Section VI.1.2.).

7

Surveillance program for Healthcare-associated infections (HAIs)

Develop and implement an HAI surveillance program to track trends and identify and manage outbreaks of respiratory virus infections. This includes a systematic process to assess whether clusters of ill HCWs with respiratory illness can be associated with outbreaks/clusters of HAIs, including influenza, in patient populations. (See Section VI.1.2.).

8

Influenza screening program

Develop and implement methods of early recognition, containment, investigation and reporting of individuals (patients, visitors, etc.) in the healthcare setting with ILI symptoms. (See Section VI.1.2.).

9

Supplies and PPE equipment

Identify measures to obtain and maintain adequate quantities of equipment/products/materials needed for IPC program to prevent exposure to and transmission of respiratory viruses. This includes determining requirements, timely purchases and storage. (See Section V.6.3.).

10

Routine practices and additional precautions (RPAP) program

Develop and implement a RPAP program, with protocols, education and training, to prevent or minimize the transmission of an infectious respiratory agent from an infected source or contaminated environment to a susceptible host. (See Section V.2.).

a) Hand Hygiene

Develop and implement hand hygiene protocols and an ongoing education and training program for HCWs, patients, visitors, etc. in all healthcare organizations. This includes establishing compliance audits and implementation of measures for improving hand hygiene compliance. (See Section V.6.2.6.1.).

b) Personal protective equipment (PPE)

Implement appropriate use of gowns, gloves, eye or facial protection, masks and respirators and establish HCWs PPE compliance audits, with measures for improving PPE compliance. (See Section VI.3.).

c) Infected source controls

Develop and implement a program, including protocols, education and training, to minimize face-to-face contact between infected sources, with ILI symptoms , and susceptible hosts. This includes respiratory hygiene, signage, dispensers for masks and tissues, supplies, use and maintenance of personal protective equipment (PPE), alcohol-based hand rub (ABHR), handling of waste and sharps, and patient immunization. (See Section VI.1.2.).

i) Respiratory hygiene

Develop and implement a respiratory hygiene protocol and an education and training program on source control measures for respiratory hygiene. This includes processes to minimize the generation of and exposure to infectious aerosols created during aerosol-generating medical procedures. (See Section VII.1.5.4.).

ii) Signage

Develop and place signage (in multiple languages) throughout the organization to educate and encourage hand hygiene and respiratory hygiene by all individuals within the healthcare organization. (See Section VII.1.4.).

iii) Dispensers for masks and tissues

Place dispensers for masks and tissues at entrances, point of care, in triage, assessment, waiting and patient-care areas, for easy use by patients, HCWs, visitors, etc. (see Section VI.1.2.). Develop instructional materials for the public for putting on and taking off PPE.

iv) Alcohol-based hand rub (ABHR)

Implement point of care ABHR in all patient-care areas including, triage, assessment, waiting and all other patient-care areas, with the installation of ABHR dispensers. Provide individual bottles of ABHR for use by HCWs where wall/bedside mounted containers are not appropriate. (See Section V.6.2.6.1.).

v) Waste containers

Place closed, hands-free waste containers for use in triage, assessment, waiting and patient-care areas. (See Section V.6.2.6.7.).

vi) Sharps containers

Provide adequate numbers and maintenance of point-of-use sharps containers for use in triage, assessment, and patient-care areas. (See Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care (External link) ).

viii) Patient immunization

Develop processes for offering pneumococcal immunization to high-risk patients in Acute care and long-term care facilities. (See Section VI.1.2.).

d) Engineering and administrative controls

Ensure adequate human and financial resources to support the structural and system changes recommended for engineering and administrative controls, and the availability and use of PPE. This includes sinks for hand washing, spatial separation, heating, ventilation and air conditioning (HVAC) systems, housekeeping, laundry and waste management, cleaning, disinfection and sterilization. (See Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care (External link) ).

i) Hand-wash sinks

Ensure appropriate number of, and conveniently located, dedicated sinks for hand washing, hand soap, hand lotion and single-use paper towels. (See Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care (External link) ).

ii) Spatial separation and spacing

Implement a process to identify patients with acute respiratory infections and implement measure to ensure adherence to appropriate spatial separation requirements to decrease infectious disease exposure for patients and visitors in clinical and waiting areas. (See Section VI.2.2.). This includes,

• ensuring a two metre distance between infected source(s) (or persons ILI symptoms) and any unprotected susceptible host,
• ensuring appropriate physical barriers (e.g., glass/acrylic partitions in entrances to assessment/triage areas), and
• adherence to spatial separation requirements (at least two metres) when designing new healthcare facilities or planning renovations to existing facilities.

iii) HVAC systems

Develop a process/plan for the maintenance and operation of the HVAC system in accordance with available guidelines and regulations. (See Section VI.1.2.).

iv) Housekeeping, laundry, waste management

Develop and implement standards for housekeeping, laundry and waste management, in accordance with available guidelines and regulations. (See Section V.6.2.6.7.).

v) Cleaning, disinfection, sterilization

Develop and implement, along with regular monitoring, standards for cleaning, disinfection and sterilization, in accordance with available guidelines, standards and regulations. (See Section V.2.).

1

IPC/OH Pandemic planning team

Establish a multi-disciplinary team to lead the development and operationalization of the pandemic influenza IPC/OH plan, with defined roles and responsibilities for the preparedness, response, and recovery planning (see Section VI.2.1.). This includes ensuring the integration of the pandemic influenza:

• IPC/OH 's planning team with the organization's pandemic influenza planning team, and
• IPC/OH 's plan with the organization's existing IPC and OH programs.

2

Activities of the planning team

Ensure the requirements of the pandemic influenza IPC/OH plan includes how to review the influenza pandemic plan, the cohorting and transferring/transporting of patients, surveillance, visitation, education and training, immunization, use of antivirals, equipment/supplies, and waste management. (See Section VI.2.1.).

a) How often to review the plan

Develop a process to review the influenza pandemic plan annually and update according to emerging knowledge, legislation, and regulations. (See Section VI.2.1.).

b) Patient accommodation

Develop strategies and structures to accommodate patients with influenza as per Section VI.2.2., to include;

• Use of single rooms for patients with any type of influenza is preferred (i.e., seasonal or pandemic strain),
• Cohort patients with ILI symptoms, when single rooms are not available,
• AGMPs, during the
  • Inter-pandemic period - patients with seasonal influenza do not require isolation rooms for AGMPs,
  • Pandemic period - patients with influenza, caused by the pandemic strain, may utilize airborne infection isolation rooms, however, ensure these rooms are prioritized for patients with known or suspected airborne infections, e.g., TB, measles, varicella, disseminated zoster.

c) Transferring/Transporting patients

Develop a strategy to identify how patients with ILI symptoms should be transferred/transported intra- and inter-facility, as per Section VI.2.3.

d) Surveillance and management of respiratory illness

Develop measures to identify and manage respiratory illness affecting HCWs including, plans to address self identified HCWs at high risk of complications related to influenza, including pregnant HCWs. These individuals should be offered counselling and assessment from an occupational health clinician (or if unavailable, their personal clinician in conjunction with infection prevention and control or public health personnel). These individuals should be provided with counselling and education, including information pertaining to the severe outcomes of influenza, reinforcement of protective measures such as PCRA, appropriate use of PPE, access to treatment and antiviral medication. See Section VI.3. and Part 3 below. (See Section V.3.).

Develop measures to identify and manage respiratory illnesses related to pandemic influenza affecting HCWs. This includes,

· clear case definitions to identify ill and clusters of ill HCWs,

· surveillance methodology and outbreak response directives.

e) Visitation

Develop guidelines and policies to deal with patient visitation during the pandemic waves, as per Section VI.2.3.

f) Education and training

Develop and implement specific pandemic influenza education and skills training for HCWs, including how to do a Point of Care Risk Assessment. (See Check List Part 4, below). (See Section VI.4.).

g) Immunization

Develop protocols on the delivery of pandemic influenza vaccine (when it becomes available) according to the Canadian Pandemic Influenza Plan (see CPIP - Annex D The Canadian Pandemic Influenza Plan for the Health Sector - Annex D) and provincial/territorial/regional or local pandemic influenza vaccine distribution initiatives.

h) Antivirals

Develop protocols on the use and distribution of antiviral medications according to the Canadian Pandemic Influenza Plan (see CPIP-Annex E The Canadian Pandemic Influenza Plan for the Health Sector - Annex E) and provincial/territorial/regional or local pandemic influenza antiviral medication distribution initiatives.

i) Equipment and supplies

Develop strategies/measures for obtaining and maintaining adequate supplies (including stockpiling) of equipment/products/materials needed to prevent exposure to and transmission of pandemic influenza in the healthcare organization. This includes supplies of ABHR, soaps, single-use towels, masks, respirators, eye protection/face shields, gloves, gowns, sharps containers, etc. (See Section V.6.3.).

j) Waste management

Identify measures to handle the anticipated increase in waste generated due to the increased use of single use PPE. (See Section V.6.2.6.7.).

k) Signage

Prepare and place signage (in multiple languages) to educate and inform HCWs, patients and visitors with direction to assessment areas, and instructions regarding respiratory and hand hygiene. (See Section VI.2.1.).

l) Spatial separation

Develop strategies for ensuring appropriate spatial separation between patients with ILI symptoms, those infected with the pandemic influenza virus, and patients without influenza in clinical and waiting areas, in all existing and temporary healthcare settings. (See Section VI.2.2.). This includes predetermining,

• the location of influenza care areas and non-influenza care areas including separate care areas for specialty units (e.g., intensive care areas, coronary care units, maternity units, neonatal units),
• the location of separate assessment areas for patients with ILI symptoms and those without ILI symptoms,
• the location of separate admission holding areas for patients with ILI symptoms and those without ILI symptoms, and
• alternative methods of care delivery for ambulatory care and home care delivery (e.g., prescription renewals over the telephone, telephone triage plans, cancellation of non-urgent appointments, and scheduling block appointments for those with symptoms of influenza).

m) Temporary healthcare settings

Develop a plan for each existing and temporary healthcare setting. The parent organization that is responsible for a temporary setting is also responsible for the planning for that setting. (See Section VI.2.2.3.). Ensure the temporary settings' pandemic influenza IPC/OH plan as outlined below:

• is integrated with the parent organization's pandemic influenza IPC/OH plan,
• includes the planning for and provision of appropriate immunizations of all HCWs in temporary healthcare settings
• is based on published IPC recommendations, and
• is integrated with federal/provincial/territorial/regional pandemic influenza contingency plans.

Self-assessments

Develop and implement an education program for HCWs on influenza self assessment (as per the Influenza Self Assessment Tool in Appendix A) to determine their influenza status and ability to work.

Develop a process to monitor and evaluate the effectiveness and compliance of ongoing HCWs self assessments.

Surveillance

Establish policies and procedures to identify, track, and manage organizational clusters of ill HCWs to include processes, case definitions, surveillance methodology, and outbreak response directives.

Immunity to influenza

Develop and implement a process to identify HCWs who have immunity to influenza. Immunity to influenza may include,

• HCWs who have had laboratory confirmed influenza (during the pandemic) may be considered immune to the influenza pandemic strain, and
• HCWs who have been immunized against the pandemic influenza strain may be considered immune two weeks after vaccination, for purposes of work placement (Refer to Annex D, CPIP The Canadian Pandemic Influenza Plan for the Health Sector - Annex D and the National Advisory Committee on Immunization Canadian Immunization Guide Seventh Edition - 2006).

Develop an immunization education program for HCWs to include,

• information on the HCW who may develop immunity to pandemic influenza strain (as per above),
• the importance of immune HCWs continuing to do daily self assessments for influenza (as per the Influenza Self Assessment Tool in Appendix A, and
• information on why vaccinated individuals should continue to use appropriate PPE to protect against influenza and other respiratory agents.

Staffing shortage

Develop processes to accommodate significant HCWs staffing shortages due to the acquisition of influenza while in the community. This includes criteria for,

• allowing HCWs that have mild influenza (or symptoms consistent with pandemic influenza) to come to work, if they feel well enough, during situations with severe personnel shortages, (Note: in these cases, the HCW should only work with patients with influenza
• evaluating HCWs at high risk of influenza complications and identify safe appropriate work assignments.

Antivirals

Develop protocols on the routine use of antivirals in accordance to Annex E, CPIP The Canadian Pandemic Influenza Plan for the Health Sector - Annex E. This includes:

• not recommending routine use of antiviral prophylaxis, and
• reserving the use of antivirals to treat symptomatic individuals and for outbreak control.

Education and skills training program

Develop and implement an education and skills training program for infection prevention and control related to seasonal and pandemic influenza for all HCWs. This includes the timing, appropriateness, and delivery method.

a) Timing

Education and training should be delivered on an annual basis to all HCWs on all shifts, in all departments, and be intensified when an influenza pandemic is imminent.

b) Appropriate to audience

Education and skills training on pandemic influenza should be appropriate to the audience.

c) Delivery method

A variety of education methods, (e.g., postings in elevators and at entrances, brochures, newsletters, websites, mini education sessions during shift change, use of role play, or other scenarios, etc.) should be used.

Education and skills training content

Develop and implement a comprehensive education and skills training program to include the following content,

• detailed review of the organization's pandemic influenza IPC/OH plan, and how it can be accessed,
• discussion of processes for HCWs at high risk of severe influenza complications due to influenza, to self identify and seek evaluation and counselling,
• provision of information on the importance of, and training regarding influenza self assessments, as per Appendix A,
• provision of information regarding how the application of RPAP measures should minimize or prevent the transmission of all infections, including pandemic influenza. This includes:
  • the use of influenza precautions for all patients with ILI symptoms,
  • review of the appropriate use of PPE when caring for patients with ILI symptoms,
  • strict adherence to hand hygiene practices, and
  • the impact of respiratory hygiene to minimize influenza transmission.
• procedures for accessing immunization for the pandemic strain when vaccine becomes available, as per the CPIP, Annex D The Canadian Pandemic Influenza Plan for the Health Sector - Annex D,
• information on the use of antiviral medications for the purpose of treatment and outbreak response during a pandemic, as per CPIP, Annex E The Canadian Pandemic Influenza Plan for the Health Sector - Annex E,
• information on plans for temporary assessment centres and temporary influenza hospital, as per Section VII.1.,
• information on the rational use of PPE as the pandemic spreads,
• education and training on performing efficient and accurate Point of Care Risk Assessments (PCRAs) before patient contact, (as per Section V.7. and Appendix D)
• information on the novel influenza strain that may lead to an influenza pandemic,
• information on the expected clinical presentation (include clinical presentation of very young children and the frail elderly with influenza and other respiratory tract infections),
• information on the risk posed by the pandemic influenza strain and possible complications for high-risk groups,
• information on the organizations pandemic influenza ORA findings and remedial action taken,
• provision of skills training on performing PCRAs during an influenza pandemic, and
• provision of skills training on how to integrate and apply knowledge acquired from specific PCRAs with knowledge of the organization's available engineering controls and administrative policies and procedures.