October 6, 2008
Influenza Guidelines

Lloyd I. Sederer, M.D., Medical Director, New York State Office of Mental Health and
Gerald M. Engel, R.Ph. Director of Health Services New York State Office of Mental Health

In preparation for the upcoming influenza season the New York State Department of Health (NYSDOH) sent a letter to Adult Healthcare Facilities regarding influenza prevention and control. We offer the following comments and then add their letter.

Vaccination
Remember that vaccination is the most effective means to prevent the flu.
Unvaccinated healthcare workers have been implicated in outbreaks and the spread of influenza in every type of care setting. NYS public health law requires operators of adult care facilities to offer influenza vaccine to all patients and staff.

Vaccination of all children aged 6 months–18 years should begin before or during the 2008–09 influenza season, if feasible. Vaccination of all children aged 5–18 years is a new Advisory Committee on Immunization Practices (ACIP) recommendation. Children and adolescents at high risk for influenza complications should continue to be a focus of vaccination efforts as providers and programs transition to routinely vaccinating all children and adolescents.

The NYSDOH endorses annual influenza vaccination of all healthcare personnel as a standard of care. We know that influenza vaccination campaigns have begun already at most OMH facilities and we are appreciative of this effort. If you have questions, ask your supervisor about how to get a flu shot.

We have received information about creative steps that many facilities are using to improve rates of vaccination. Examples include:

1. Provide information about the benefits of vaccination via multiple sources-posters, email alerts, payday handouts overhead paging, employee health fairs
2. Make vaccination accessible to everyone, on units, on their shifts and in outpatient settings
3. Consider special events, contests, giveaways to trigger interest
4. Consider taking the Joint Commission challenge to increase vaccination acceptance rates www.fluvaccinationchallenge.com

Everyday Preventative Steps
Facilities should be alert for the occurrence of influenza or influenza – like illness as early as October and as late as May. Symptoms include elevated temperature, cough, sore throat, headache, muscle aches and weakness. Employees who display symptoms should not be at work until their symptoms resolve.

There are a number of everyday preventative steps which diminish transmission. These include:

1. Frequent hand hygiene
2. Respiratory hygiene such as covering your cough
3. Reducing contact with others when sick

Use of Antivirals
The 2008 – 2009 trivalent vaccine virus strains are A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens.

Oseltamivir or zanamivir continue to be recommended antivirals for treatment of influenza. Resistance levels to other antiviral medications is higher. Amantadine is no longer considered a first line treatment for influenza prophylaxis. However, in selected cases it can be used particularly for patients needing treatment for parkinsonism (idiopathic or neuroleptic induced).

Further Information

The NYSDOH and the Centers for Disease Control (CDC) have further recommendations. The following sites may be of assistance

New York State Department of Health-Health Advisory: Influenza Prevention and Control 2008-2009
http://www.nyhealth.gov/diseases/communicable/influenza/fact_sheet.htm

Centers For disease Control and Prevention
http://www.cdc.gov/flu/

STATE OF NEW YORK DEPARTMENT OF HEALTH

September 30, 2008

Dear Adult Care Facility Operator:

As you know, influenza affects millions of Americans each year and is most serious in the elderly, very young, and chronically ill. This letter is being provided to you to clarify what is expected of Adult Care Facilities (ACFs) in regard to the prevention and control of influenza among residents and staff. Please use this letter as an explanation of the New York State Department of Health’s (NYSDOH) Influenza Prevention and Control 2008-09 guidelines document that was sent to you electronically on September 25, 2008 via the Department’s Health Alert Network (HAN). The document is posted on the HAN at:
https://commerce.health.state.ny.us/hpn/ctrldocs/alrtview/postings/doc080924_0.pdf  (PDF)

Vaccination
Vaccination is the cornerstone of influenza prevention. The NYSDOH endorses annual influenza vaccination of all healthcare personnel as the standard of care. Article 21-A of the New York State Public Health Law requires operators of ACFs to offer to provide or arrange for influenza vaccine annually to all employees and residents. Article 21-A also requires operators of ACFs to submit an annual survey to the NYSDOH, due on May 1 each year, reporting the number of employees and residents who did and did not receive influenza vaccination during the past influenza season, and the number of residents who have and have not received pneumo-coccal vaccination at any time. Complete information about this law, also known as the Long-Term Care Resident and Employee Immunization Act, and the annual survey, is available on the NYSDOH web site at: http://www.health.state.ny.us/nysdoh/infection/ltc_act/index.htm .

Employees and residents may refuse influenza vaccination for medical or religious reasons, or after being fully informed of the health benefits and risks of such action. Operators should ensure that all residents, or their residents’ families, contact their personal physicians for their annual flu shot. Questions regarding compliance with this Public Health Law should be directed to your NYSDOH Adult Care Facility Regional Program (see list on page 3).

The supply of influenza vaccine is expected to be plentiful this season. Manufacturers have started to distribute the vaccine and will continue to distribute the vaccine over the coming months. Vaccination efforts should be pursued diligently over the next few months and should continue into April 2009, since influenza activity usually continues into the spring months.

Watching for Influenza or Influenza-like Illness
ACF operators should be alert for the occurrence of influenza or influenza-like illness (ILI) among their residents or employees during the “flu season,” which generally occurs during
the winter months but may start as early as October and end as late as April or May. Symptoms of influenza or ILI include elevated temperature, cough or sore throat, headache, muscle aches, and generally feeling weak.

What to Do When Influenza or Influenza-like Illness Occurs
If ILI occurs among residents, operators should notify the personal physician of each ill resident. At the discretion of the personal physician, lab testing may be ordered. If laboratory tests are ordered and prove positive for influenza in one or more residents, the operator should alert the personal physicians of all other residents that influenza infection has been identified in the facility. The physicians may choose to order prophylactic antiviral medication or offer vaccination to help prevent their patient from contracting the virus that is circulating in the facility. For nursing homes, the Centers for Disease Control and Prevention (CDC) and NYSDOH recommend the use of influenza antiviral treatment and chemoprophylaxis when influenza occurs. In ACFs, the choice lies with individual residents’ providers. As in previous seasons, CDC recommends that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States until susceptibility to these antiviral medications has been re-established among circulating influenza A viruses. Thus, neither agent should be used for treatment or prophylaxis during the 2008-09 season. Oseltamivir or zanamivir can be prescribed if antiviral treatment or prophylaxis of influenza is indicated. If ILI occurs among employees, it is critical that they are excluded from work until their symptoms resolve.

Reporting
If your facility has one or more cases of laboratory-confirmed influenza, or has ILI occurring in multiple residents of your facility, you must report this information by telephone to your local health department. A list of local health departments and their telephone numbers is available at: http://www.health.state.ny.us/nysdoh/lhu/map.htm . You must also contact your NYSDOH Adult Care Facility Regional Program (see page 3).

Remember, outbreaks of any illness, not just influenza, must be reported by telephone to your county health department and your NYSDOH Adult Care Facility Regional Program.

Please contact your county health department if you have any questions regarding this letter or recommendations regarding influenza prevention or control.