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Checklist of Suggested Procedures for Follow-up of Respiratory Disease Outbreaks in Healthcare Facilities

New York State Department of Health - Regional Epidemiology Program

1. When two or more cases of febrile respiratory illness are identified in a healthcare facility, symptomatic patients/residents should be placed on droplet precautions and confined to their rooms or restricted to the affected unit for at least 5 days and until their symptoms have resolved.
2. Notify the NYSDOH Regional Epidemiology Program of the cluster/outbreak by submitting the NYSDOH Nosocomial Report Form via the NORA electronic system on the Health Provider Network (HPN), available at: https://commerce.health.state.ny.us/hpn/infecontrol/forms.html. Clusters/outbreaks also need to be reported by telephone to the local health department (LHD). The medical director or the infection control coordinator may also wish to discuss the situation with their regional NYSDOH or NYCDOHMH epidemiologist. Health department epidemiologists are pleased to offer consultation as soon as an illness cluster is identified.
3. Print out and fill in the NYSDOH Respiratory Illness Line List form, available at http://www.nyhealth.gov/professionals/diseases/reporting/communicable/infection/docs/respiratory_illness_line_list_form.pdf, to record as much information as possible about individual ill patients/residents. Starting and maintaining a line list helps track the progress of an outbreak. Provide the line list to the Regional Epidemiologist with whom you are consulting.
4. Monitor staff absenteeism for respiratory illness. Ensure ill employees do not work until symptoms resolve.
5. Ensure that respiratory specimens are obtained from six to 12 patients/residents with recent (within the past 48 hours) onset of fever and/or symptoms. Nasal aspirate or nasopharyngeal swab specimens are the specimens of choice.
6. Specimens should be submitted to an appropriate hospital or commercial laboratory and tested by both rapid antigen detection and viral culture (because rapid antigen testing is less sensitive than culture, both should be performed for all initial specimens). It is strongly recommended that rapid antigen testing be able to differentiate between influenza types A and B. If a hospital or commercial laboratory is not available, after consultation with the NYSDOH Regional Epidemiologist, a maximum of six specimens may be submitted to the NYSDOH Wadsworth Center virology laboratory for testing.
7. Implement the following control measures:
   • Confine ill patients/residents to their rooms and place them on droplet precautions for at least 5 days and until their symptoms have resolved.
   • Minimize floating of staff.
   • Provide in-service training for staff to reinforce the need to adhere to infection control measures for respiratory outbreaks.
   • Ensure sufficient supplies of hand hygiene materials and surgical or procedure masks are available for patients/residents, staff and visitors.
   • Restrict ill persons from visiting the facility.
   • Ensure that all patient/resident care areas are cleaned more often than usual, especially in the areas where patients/residents are ill.
   • Offer influenza vaccine to unvaccinated patients/residents and staff.
   • Notify receiving facilities of the outbreak when transfers occur.

     Additionally, if one or more specimens test positive for influenza:

     • Re-offer influenza vaccine to unvaccinated patients/residents and staff.*
     • Use neuraminidase inhibitor antiviral medication for treatment and chemoprophylaxis in accordance with current CDC guidelines, available at: http://www.cdc.gov/flu/professionals/antivirals/
     • Give antiviral treatment for five days.
     • Give antiviral prophylaxis for at least 14 days and, if surveillance indicates that new cases of febrile respiratory illness are continuing to occur, continue prophylaxis for an additional seven days after the date of onset of the most recent case of febrile respiratory illness.
     • Place new admissions on antiviral prophylaxis during the outbreak period.
     • Do not admit patients/residents to units where patients/residents are ill.
     • Limit patient/resident movement from the affected unit(s).
     • Notify visitors that influenza is occurring in the facility.
     • Restrict ill persons from visiting the facility.

* In the context of an influenza outbreak, avoid administering live attenuated influenza vaccine (FluMist) to persons who are taking antiviral treatment or prophylaxis. This is because antivirals will interfere with the development of immunity. In such a context, give inactivated influenza vaccine (flu shot) instead of FluMist.