As influenza seasons go, 2015-16 has so far been mild. A few states are now showing up with activity, but the overall activity has not been as significant as previous years. Still, we could be in for a late flu season. Some researchers believe that we have had a good match between vaccine antigens and the current strains, which is particularly good news for patients who have received the high-dose vaccine because recent trials show that when there is a good match year, the effectiveness at preventing cases and complications improves.
In First Monday December 2014, I mentioned the new CDC recommendations for pneumococcal vaccination. Essentially, when a patient comes into our LivingCenter, the admitting nursing staff must find out whether he or she has had the pneumococcal vaccine, when it was given, and whether it was the 23–valent polysaccharide vaccine (PSV23, pneumovax(R)), or the newer conjugate vaccine (PCV13 vaccine, Prevnar 13(R)).
For patients 65 and over or with chronic lung disease or immunicompromise, patients need to have both vaccines.
The original recommendations from November 2014 were a bit confusing, because a gap of six months was needed if the PCV was given first and 12 months if the PPSV was given first. In order to avoid confusion, this has been changed so that regardless of which vaccine was given initially, the other vaccine should be given after 12 months.
There is no physical side effect from giving a vaccine inside of these intervals, but a patient theoretically may get less of a long-lasting antibody response if they are closer together. A patient who has had both vaccines still may require a final PPSV23 if they had their PPSV23 before age 65. This last immunization would come at least one year after the PCV 13 and at least five years since the PPSV23.
Please work with your DNS and attending staff as needed to make sure that your LivingCenter is paying attention to the details and following this CDC recommended process. If you have any questions, feel free to contact me.
Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Weekly, September 4, 2015/64(34); 944-947.
AMDA, the Society for Post-Acute and Long-Term Care Medicine will hold its annual national conference March 17-20 in Orlando, Florida. I encourage you to attend. Each year the conference provides a unique blend of clinical education combined with regulatory and administrative guidance. Attendance of the designated sessions are also an integral part of the process of obtaining AMDA certification in medical direction, the CMD. For more information go to: http://www.paltcmedicine.org/
Golden Living will hold an evening gala for our medical directors, which will be held on Friday night onsite. Golden Living Chief Executive Officer Dr. Neil Kurtz will be at the gala, along with Golden LivingCenters President, Julianne Williams and your Regional Medical Directors. We will award our annual Medical Directors of the Year at that time, and we will have an interactive discussion about the evidence-based choices in medicine. The exact location will be announced when available.
Because Orlando is such an attraction in March, hotels are filling up quickly. If you are thinking of attending, please make arrangements as soon as you can. Please contact Golden Living Head of Medical Director Services, Reene Dux at Maureen.firstname.lastname@example.org or (972)372-6311 if you have any questions.
I look forward to seeing you there!
In 2015 Golden Living took a very proactive step by making high-dose flu vaccine available for patients 65 and over. Large studies have supported this practice in the SNF setting and demonstrated superiority in elders over standard dose vaccine. At the time of this newsletter (January 2016) influenza is not yet widespread in the US. This means that there is still time to encourage anyone who has not yet had their flu shot and has no contraindications to get vaccinated. If you don’t know how successful your LivingCenter has been this fall in vaccination, check with your DNS. It takes about two weeks for antibody levels to rise.
Is it the flu? Do you have an outbreak?
When a suspected influenza case arises in your Living Center, you will want to confirm that this is indeed influenza through testing. Rapid testing is available. It is important to confirm your index cases because decisions regarding influenza outbreak management have significant implications regarding how patients are cared for in your LivingCenter. Also, antiviral treatment and prophylactic medication has associated risk of side effects. Once you have determined that your facility is in the midst of a flu outbreak, it will no longer be necessary to test all suspected cases. In fact, the local department of health may advise against it in order to avoid exhausting diagnostic testing resources. I think it would be wise to say that pending positive test results to treat ILI as actual flu as that is what we advise them to do. I get a lot of reports that say they have five or six people with symptoms but all tested negative. If it looks like the flu they should act accordingly.
The CDC threshold for calling an outbreak is having one confirmed case (by testing) of influenza which occurred in the LivingCenter, in combination with at least one other patient with flu-like illness.
Once an outbreak is determined to have happened, you must assume that influenza-like illness is the flu and address it as such. False negatives may occur, so you should believe a positive influenza test, but you should not be fooled by a negative test in a patient who appears to have the flu. Again, this is the reason why once you have determined that an outbreak is occurring in your Living Center, that widespread testing for influenza is not particularly helpful.
What else should I do in an outbreak?
Work together with your ED, DNS and LivingCenter infection control nurse. There are guidelines on what to do in both the Policy Center and in the Flu Information Site link on the Facilities main page. Some but not all of the listed steps include the need to:
- Notify the local health department, families, and patients
- Postnotices in the Living Center (examples can be found in the Flu Information site)
- Treatsymptomatic patients
- Prophylax –The CDC recommends prophylaxing all residents and staff in an outbreak, but you may decide to modify your decision based upon medication availability, DOH recommendations, and facility layout. If you choose to do this, prophylaxis should continue until a week after the end of the outbreak. If you are considering facility prophylaxis, please feel free to contact our GLC Pharmacy Directors Steve Hord (email@example.com 404-904-7741) or Eric Stratford (firstname.lastname@example.org 919-895-8488) who can assist with obtaining antiviral medication.
- Monitorcases with a “line listing.” Your DNS will report cases to their Field Service Clinical Directors who then report to Melissa Purvis in Plano. During flu season, a weekly outbreak report is circulated based upon these reports. This may serve to warn living centers when outbreaks are nearby.
- Take Infection Control measures
- Isolate – Decide whether to segregate a unit, floor or entire LivingCenter and adjust according to circumstances. Workers in units or hallways with multiple cases should wear masks at all times and be meticulous with hand hygiene.
- Effective isolation is vital in order to avoid a prolonged outbreak. Patientswith active influenza or influenza-like illness should be confined to their rooms when possible. They should be on droplet precautions. If cohorting is possible and practical, then that should be considered as well. Curtains should be drawn between patients with influenza and their roommates. Healthcare workers with the flu or influenza-like illness should stay at home. They should receive antiviral medications if possible and be encouraged to consult with their physician. Because some of our workers in the LivingCenters have limited healthcare resources and may take quite a bit of time to get to their own physicians or the emergency room, the CDC recommends prophylaxis of all workers without contraindications. When the Medical Director provides prescriptions for antiviral treatment, it greatly increases the chance that staff will receive prophylaxis and start it in a timely fashion.
- Ramp up cleaning efforts
- Begin wearing masks
- Consider adding additional hand-sanitizer stations
Patients with the flu should be treated if possible. It is advisable to begin treatment with antiviral medication upon suspicion, rather than waiting for confirmation before initiating treatment. Studies have estimated that neuramidase inhibitors such as oseltamivir (Tamiflu®) can be as effective as 70-90 percent. Patients treated tend to have less severe symptoms, a shorter duration and less chance of complications such as pneumonia and death. Because most treatment is supportive aside from antiviral medications, you should be able to care for the vast majority of patients with the flu in the LivingCenter. As always, the decision to transfer a patient to the hospital is up to the clinical judgment of the attending physician and must be individualized.
The CDC recommends antiviral treatment as soon as possible for residents of nursing homes and ideally patients should be started within 48 hours of onset of symptoms. Treatment initiated after this period of time is up to the discretion of the physician. There is still evidence of effectiveness when treatment is initiated up to four or five days following onset. Usual treatment duration is five days. Longer periods of treatment could be considered for critically ill or immunocompromised patients.
Oseltamivir (Tamiflu®) – Flu treatment options remain the same as last year. Due to amantidine resistance and its side effects in the elderly, the mainstay of antiviral treatment are the neuramidase inhibitors, and the one most appropriate for SNF use is oseltamivir (TamifluÒ). Oseltamivir is an oral agent, which also may be administered via enteral tube. Treatment and prophylaxis dosing is outlined in the table below. Keep in mind that mental status changes are one potential side-effect of this class of medication.
Zanamivir (RelenzaÒ)is an inhaled powder but is contraindicated in persons with underlying lung disease such as COPD or asthma. Zanamivir is also not recommended in patients with severe influenza.If you are considering zamamivir treatment, please discuss with your consultant pharmacist.
Oseltamivir dosing guidelines
|Oseltamivir (TamifluÒ) dosing:||Cr Clest|
|>60 mL/min||60-30 mL/min||<30 to 10 mL/min||< 10 mL/min
on hemodialysis (HD)
on peritoneal dialysis (PD)
|75 mg BID||30 mg BID||30 mg Daily||30 mg following each HD tx||30 mg immediately following exchange|
(2 weeks and up to 1 wk following end of outbreak)
|75 mg Daily||30 mg Daily||30 mg every other day||30 mg after every other HD Tx||30 mg weekly, immediately following exchange|
Oseltamivir is not recommended for patients in End-stage renal disease (ESRD) who are not on any form of dialysis.
Helpful Resources You may also contact me or your regional medical director if you have any questions.
CDC Surveillance site
CDC LTC Toolkit
Specific LTC guidance for health professionals
- Antiviral Drugs for Seasonal Influenza, Med Lett Drugs Ther. 2015 Dec 21;57(1484):169-71
- CDC, Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities