March 18, 2005
Epi Update Managing Staff:
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
Foege WH., International Journal of Epidemiology 1976; 5:29-37
The Volusia County Health Department was informed on February 18th of an influenza-like illness (ILI) cluster in a nursing home in west Volusia County. The infection control nurse initially reported thirteen individuals suspected with ILI out of 53 individuals residing at the facility. Several staff members were also noted as exhibiting upper respiratory symptoms. The facility is divided into two wings, east and west.
Cases were defined as any resident or staff member with a fever ≥100° F (orally) and cough and/or sore throat between the dates of February 1st – February 28th 2005. Laboratory confirmation of influenza also constituted a case. After developing a line listing, ten residents (AR=19%) met this case definition. No rapid tests were initially preformed. Viral swabs were taken on three ill residents on February 18th and sent to the Jacksonville Department of Health laboratory for confirmation via polymerase chain reaction and isolation. Two of the three swabs were positive for Influenza A and isolation identified the strain as H3N2- Fujian like. One death occurred in the facility during the outbreak. The deceased resident met the case definition and was considered a probable case. Co-morbidity may have been a factor in the mortality since the patient was under palliative care. Pneumonia with respiratory failure was the physician’s final diagnosis and influenza was the noted cause of death.
A questionnaire assessing influenza like illness was distributed to the facility. Staff members that were ill during the month of February were asked to complete and return the questionnaire. Among 77 staff, 21 returned a completed questionnaire. Eleven staff members (AR=14%) were considered to meet the case definition of ILI according to information gathered on the self-reported questionnaire.
were available early in the flu season despite nationwide shortages and
were offered to residents and staff starting September 23, 2004. Resident
vaccinations were administered between the dates of October 3, 2004 and
October 22, 2004. At the time a total of 53 of 57 residents (93%) residing
at the facility received the influenza vaccination. Nine of the ten cases
of ILI (90%) were known to be vaccinated. Among 77 staff members, 50 were
known to have received the influenza vaccine (65%). Six of the eleven ill
staff members (55%) noted that they had received a vaccination. Vaccine
efficacy (the reduction in illness incidence in the immunized groups
compared to the unimmunized groups) was calculated for both residents and
staff. Observed vaccine efficacy for residents was 26.4% and 35% for
staff. These numbers are imprecise and are not statistically significantly
different from zero. Table 1 shows the vaccination and illness status
among residents and staff. Figure 1 shows the distribution of ILI by date
of onset separated for residents and staff.
The cluster of influenza like illness in this long term care facility was associated with the influenza A virus. This cluster occurred during a period of increase in influenza activity within the state and at a time when ILI activity rose above the baseline1. The first probable cases more than likely occurred among unvaccinated staff between the approximate dates of February 1st and February 14th. The period of communicability for adults may be anywhere from 1 day before to five days after clinical onset2. Staff illness and resident illness peaked at about the same time; with ILI presenting in both the east and west wings of the facility, providing evidence of person to person transmission between residents and staff. It is probable that staff may have been the initial source of influenza in the facility. Although some staff did meet the case definition it is possible that another pathogen may have caused their upper respiratory illness. It has been reported in studies of adults sensitivity for clinical definitions of ILI, that include fever and cough, range from 63%-78%3. There also was uncertainty in some staff to recall their illness onset dates.
Control and hygiene practices were in effect at the facility at the time the incident was reported. According to the infection control contact, control guidelines were in effect from February 17th to February 23rd. Cohorting of symptomatic residents to their rooms, suspension of certain common area activities, limitations on visitors and a freeze on admissions were in place for this time period. Droplet precautions and frequent hand washing were advised for staff. Any staff member that presented with fever was to stay away from work per pre-existing standing orders. Antiviral chemoprophylaxis (oseltamivir) was administered to all residents. Also, signs warning of influenza were posted on facility entrances. As a result, influenza diminished within a couple of weeks and no new cases appeared by the end of the month.
The overall percentage of ILI among residents was moderate with 19% meeting the case definition. Despite the national shortage, 93% of residents were known to have received the vaccine early in the season. This met the US Department of Health and Human Service’s Healthy People 2010 goal of 90% vaccine coverage for persons aged ≥65 years. Doubts may arise as to the vaccine’s effectiveness since the virus identified in the outbreak was Influenza A H3N2, Fujian-like; a widely circulating virus and a component of the 2004-2005 vaccine4. The actual effectiveness of the vaccine to prevent flu in older individuals residing in long term care facilities ranges from 30%-40%. More importantly within this population the vaccine is 50%-60% in preventing complications from flu or onset of severe illness like pneumonia. The vaccine is about 80% effective in preventing death5. Illness among staff was also moderate with approximately 14% reportedly meeting the case definition. Again, despite the nationwide vaccine shortage the facility did manage to vaccinate 65% of its employees which exceeded 2003 national coverage estimates of 40.1% among health care workers (CDC, unpublished data, 2005). Among healthy adults aged ≤ 65 years the vaccine is approximately 70%-90% effective in preventing the flu5. As previously noted above, the estimates of vaccine efficacy were not statistically significant. It is possible vaccine efficacy was imprecise due to small numbers of subjects. Vaccine efficacy may also be underestimated due to the possibility that residents and staff were misclassified as to their influenza infection status; some ill persons may not have actually had influenza and some persons that did not meet the case definition were in fact infected with influenza virus. The observed vaccine efficacy in residents is consistent with the published range for the >65 years population, however the observed VE for staff appears to be relatively low. Influenza vaccine remains the primary means of preventing epidemics5.
Conclusions and Recommendations
This particular outbreak incident is an example of influenza as a highly communicable disease that can result in serious morbidity and mortality. Droplets of respiratory secretions are the primary cause of transmission of influenza from person to person. This can occur from person to person contact or through contact with fomites6. Efforts to interrupt the transmission of influenza in long term care facilities rest in staff’s ability to strictly adhere to prevention and control guidelines. During periods of increased ILI activity within a long term care facility, masks should be used by health care professionals as an established component of infection control7. Exclusion of symptomatic staff in addition to frequent hand washing must be reinforced. Many local health departments and the CDC recommend that symptomatic staff be excluded from patient care for a minimum of 72 hours and as long as five days after onset of symptoms8. It is understood that many staff cannot afford to miss work for financial reasons, but it is imperative that exclusion is enforced during flu season. Control and hygiene practices should be extended for two incubation periods after onset of the last symptomatic resident or staff. The typical incubation period for influenza is 1-4 days9.
While the vaccine is the primary option for limiting the effect of influenza, using antiviral drugs is a key component of influenza outbreak control in institutions5. When outbreaks occur in institutions chemoprophylaxis with antivirals should be given to all residents. Also antivirals should be offered to unvaccinated staff, free of charge, from a supply stockpiled for use when outbreaks do occur. Antivirals should be administered to all employees regardless of vaccination status when a variant strain of influenza is identified that is not well matched in the vaccine5. While cost is an issue and oseltamivir can be expensive, amantadine or rimantadine are cheaper alternatives for treatment of Influenza A. Consider acquiring rapid influenza tests for periods of suspected influenza activity. These tests are easy to use (many instances clinical laboratory license is waived) and can be helpful in determining if influenza is present. It is important that during flu season guidelines and precautions are followed. Staff cooperation with control guidelines for influenza in long term care facilities will result in the quicker remediation of the outbreak and lessen the impact of influenza morbidity and mortality.
Florida Department of Health, Bureau of Epidemiology, Influenza website. http://www.doh.state.fl.us/disease_ctrl/epi/htopics/flu/index.htm
Heymann DL, ed. Control of Communicable Diseases Manual. American Public Health Association 2004;18:281-287.
Boivin G, Hardy I, Tellier G, Maziade J. Predicting influenza infections during epidemics with use of a clinical case definition. Clinical Infectious Diseases 2000;31:1166-1169.
CDC influenza website. http://www.cdc.gov/flu/weekly/fluactivity.htm
Harper SA, et al. Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2004;53 (RR-6):1-39.
Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in health care settings. Clinical Infectious Diseases 2003;37:1094-1101.
Vugia D, et al. Experiences with Influenza-Like Illness and Attitudes Regarding Influenza Prevention-United States, 2003-2004 Influenza Season. MMWR 2004;53 (49):1156-1158.
CDC Guidelines and Recommendations. Updated Infection Control Measures for the Prevention and Control of Influenza in Health-Care Facilities. 2005; retrieved from http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilties.htm
Cox NJ, Subbarao K. Influenza. Lancet 1999;354:1277-82.
Andre Ourso is an Epidemic Intelligence Service fellow assigned to the Volusia County Health Department. He can be reached at 386.274.0618.
Nursing homes (NH) and assisted living
facilities (ALF) provide care to a particularly vulnerable segment of the
elderly community. These residents face a variety of health challenges,
which makes the standard of care they receive integral to their quality of
life. The NH/ALF Program in Pinellas County ensures the safety of these
long-term care residents through inspections, disease surveillance, and
the investigation of complaints and outbreaks.
Full Agenda Marks
Bi-Weekly CHD Conference Call
For persons who were unable to participate in the call conducted on March 11, 2005, the following is a brief summary of the discussions which occurred.
Avian Flu Testing. Joann Schulte, DO, announced the bureau web site will host information on avian flu and guidelines for testing and sending test results to the state laboratories. She advised all caregivers to become familiar with the information, as the topic will become increasingly important over the next year or so.
CDC Vessel Sanitation Program. Dr. Dan Chertow described the differences between quarantine stations in Florida and the CDC vessel inspection program at ports throughout the state. The Public Health Service Act gave authority to the CDC to do whatever is necessary to prevent the introduction, transmission or spread of communicable diseases from foreign countries to the US. Under the CDC's Vessel Sanitation Program, cruise ships are required to report gastrointestinal illnesses for each of their trips to the nearest quarantine station or port where the ship will arrive, so the CDC can work quickly with the ship's crew to discern how the outbreak may have originated.
The quarantine program is designed for inspections of animals and animal products, and other public health issues.
2005 Florida Immunization Summit. Phyllis Yambor, Bureau of Immunization, announced the second annual summit hosted by the Central Florida AHEC and the Bureau of Immunization at the Hyatt Airport Hotel in Orlando on April 26-27. Though there is no fee for the summit, early registration and hotel reservations for the special group rate should be made by April 1. Contact Phyllis for further information.
Epi Statewide seminar and poster session. Melanie Black announced a funding source has been located for scholarships for the upcoming seminar, set for May 17-18 at the Lake Mary Marriott in Orlando. Full information will be posted on the bureau Internet site within the week. Melissa Murray stated a deadline of April 15 has been selected for poster abstracts. She reminded those intending to submit posters for the competition to ensure they do so well in advance, and to indicate the category in which they wish to be judged.
Marketing Survey / ER Census. Christie Luce reported a customer service survey has been sent to county health departments and others to assess how well the Bureau of Epidemiology has performed during the past year, and to solicit suggestions that would help us to improve service. The survey is designed to preserve anonymity. She also reported new emergency room census brochures have been printed and are ready for dissemination.
Environmental Health Training. Mitch Stripling, Environmental Health Division, announced a new competency-based training will be offered this spring. Certification will be provided to those who earn scores of 80 or above. The training, pertaining to core competencies for preparedness, is scheduled throughout April and May in each region of the state. To learn more, visit the division website.
CHD Epidemiology Guide. Melanie Black recommended reviewing the newly revised Guide to Disease Surveillance and Investigations. The resource has been thoroughly researched and will be posted to the Epi website as a living document, accompanied by a button enabling readers to submit changes. The version currently posted on the nursing website will be removed.
Jefferson County Influenza Outbreak. Angela Smart outlined aspects of a recent outbreak that occurred at a correctional facility in February. After receiving a call which identified 15 patient cases with influenza-like symptoms who had been isolated, she visited the facility the same day. Most swabs had already been performed. Three tested positive for Shanghai flu. No staff reported illness. Although a number of swabs had to be repeated, the correctional clinic appeared to need no other assistance.
Monroe County Bacterial Meningitis Investigation. Steve Mason reported on a 15 year old male who was transferred to the hospital with niceria meningitis. On March 2, he had flown to Florida with 23 family members for a funeral from La Guardia airport. He experienced sore throat on Day 1. On Day 2, he complained of headache. One Day 3, he suffered stiff neck and vomiting. A spinal tap was performed by ER staff on Day 4. It is estimated he had had close contact with 70 persons. One other family member, a 15 year old male, complained of headache 15 days after onset of symptoms in first patient, but a spinal tap produced a negative result. No other cases have been reported.
Miami-Dade Hepatitis B Investigation. Lydia Sandoval and Roger Sanderson reviewed the past week spent investigating acute cases of Hepatitis B linked to a physician's clinic. Two males, both in their 70s, who had received chelation therapy from the doctor, were later diagnosed with Hepatitis B. An alert staff member at a CHD linked the cases, and Sandoval and Sanderson made a follow-up visit to the physician's treatment room where they observed dangling butterfly needles, vials on coffee tables, poor record keeping, and other evidence of mishandling.
Subsequent to their findings, the physician has signed a voluntary agreement to cease therapy; the team has begun a cohort study with mass mailings to former patients, and a press release advising persons in the area to seek hepatitis testing if they have been treated by the doctor.
The next conference call is scheduled for Friday, March 25 at 10:00 a.m., EDT.
Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.
Summit to be Held
The Bureau of Immunizations, Florida Department of Health and Central Florida Area Health Education Center, Inc. announce the 2005 Florida Statewide Immunization Summit: 85 by '05 - Building Success through Teamwork, to be held April 26-27, 2005 at the Hyatt Regency Airport Hotel in Orlando, Florida.
This meeting will serve as a kickoff to National Infant Immunization Week. Attention will be drawn to the importance of increasing immunization coverage of children ages two and younger, and consist of a variety of sessions on strategies for increasing coverage for young children including best practices from both public and private providers.
Hotel accommodations can be accessed electronically at http://www.immunizeflorida.org/summit2005/index.htm. Mention the Florida Department of Health to identify hotel rooms reserved for the summit and to obtain the special room rate of $99.00. Reservations must be made by April 1, 2005 in order to receive the special room rate. On-line registration can be accessed at http://www.immunizeflorida.org/summit2005/registration.htm. There is no registration fee for this program.
If you have any questions about this meeting, please
contact the Bureau of Immunizations, Florida Department of Health in
Tallahassee at 850.245.4342.
The Bureau of Epidemiology encourages
Epi Update readers to not only register on the EpiCom system at
https://www.epicomfl.net but to sign up for features such as automatic
notification of certain events
contribute appropriate public health observations related
any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication
between the Bureau of Epidemiology and other state medical agencies during emergency situations.
Pete Garner is
administrator of the Bureau of Epidemiology Surveillance Systems
Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.
D'Juan Harris is a GIS
specialist in the Surveillance Systems Section of the Bureau of