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The world’s attention is now focused on COVID-19, and rightly so, but infectious disease experts have been warning for months that, come fall and winter, another deadly infection will rear its head as well: influenza. The flu is especially dangerous to the elderly, which is why elder care facilities like assisted living centers and nursing homes have been practicing diligent flu protection since long before anyone had heard of the coronavirus.
Such prevention tactics are critical because the numbers are daunting. Somewhere between 12,000 and 79,000 people die of the flu each year, the Centers for Disease Control and Prevention report. Last year, that number was at least 24,000. Tens of millions of people contract the flu between October and May, the traditional flu season, and last year more than 400,000 individuals were hospitalized because of flu.
The risk of severe illness and death goes up with age, as bodies grow frailer and disease-fighting immune systems grow weaker. A CDC study from 2019 found that about 90% of influenza-related deaths and up to 70% of flu-related hospitalizations were in people aged 65 years and older. And those 85 years old and older are two to six times more likely to be hospitalized and die from the flu than adults aged 65 to 74 years.
Elder care facilities therefore must take infection protection seriously – and they always have. “Historically, with flu prevention and contingency planning for early recognitions of an outbreak, we’ve had that forever,” says Dr. Elaine Healy, medical director and vice president of medical affairs at United Hebrew in New Rochelle, a senior living campus in Westchester County, New York.
Such planning “centers around staff training in infection prevention, hygiene, equipment sterilization, identifying sick patients quickly and putting them in isolation,” adds John Mastronardi, executive director of The Nathaniel Witherell, a short-term rehab and skilled nursing care center in Greenwich, Connecticut.
The CDC recommends a five-pronged approach to flu control:
- Surveillance and testing.
- Infection prevention and control.
- Antiviral chemoprophylaxis.
If possible, all residents should receive the influenza vaccine every year, the CDC says. In most flu seasons, the vaccine becomes available to long-term care facilities beginning in September, and should be offered by the end of October, though later vaccination is still warranted if that deadline is missed. If a new patient or resident enters the facility after the vaccination program has ended, he or she should be counselled on vaccination and offered the vaccine as soon as possible.
All health care providers and staff also should be vaccinated annually, the CDC says. “We campaign every year for vaccinations for staff and family members,” says Healy, who reports a response rate of over 95% for her residents and close to 90% for staff.
Surveillance and Testing
If a flu outbreak occurs in the community, staff are encouraged to check on residents often to look for flu symptoms, such as fever, cough, chills and body aches. The CDC also notes that older adults and long-term care residents who are fragile or have neurological or neurocognitive conditions may exhibit “atypical” signs and symptoms of the flu, such as a behavior change, and may not have a fever.
“We also monitor CDC and state Department of Health advisories about flu in the community to be aware when it becomes active,” Healy says.
Lab testing is recommended for any resident who has flu symptoms, and especially when two residents or more develop respiratory illness within 72 hours of each other. If two cases of confirmed influenza occur within 72 hours among residents living in the same housing unit, facilities should begin outbreak control measures as soon as possible.
Prevention and Control
Elder care facilities have long practiced the kind of infection prevention and control protocols that we all now follow in the face of COVID-19, such as frequent hand-washing and wearing face masks. Staff wear masks at all times now, Healy says; it was only done during outbreaks before the coronavirus pandemic.
In addition, providers and staff:
- Wear gloves if they anticipate contact with respiratory secretions or contaminated surfaces.
- Wear a gown if such secretions may contaminate their clothing.
- Change gloves and gowns and wash hands after each visit with a resident.
To control outbreaks, facilities place infected residents in private rooms or group them in a cohort of other ill residents in a private area. These residents’ movements are restricted, and they are excluded from group activities until no longer ill and contagious.
The CDC recommends that all long-term care facility residents who have confirmed or suspected influenza receive antiviral treatment immediately, even before a confirmed lab test, because antiviral treatment works best when started within the first two days of symptoms.
However, antiviral medications may also help when given after 48 hours for patients who are very sick, including those who are hospitalized.
If an outbreak is occurring, all residents on units or wards with influenza cases who may have been exposed to the virus should begin antiviral preventive treatment, known as chemoprophylaxis, whether they received the flu vaccine earlier or not. Even those who do not have symptoms should receive treatment to prevent possible transmission of the virus. The CDC recommends antiviral chemoprophylaxis for at least two weeks and continuing for at least seven days after the last known lab-confirmed case is identified.
Facilities should also consider antiviral chemoprophylaxis for staff and personnel who were not vaccinated.
The CDC also recommends the following to control flu in an elder care setting:
- Limit the number of large-group activities.
- Serve meals in resident rooms if possible during a widespread outbreak.
- Avoid new admissions or transfers to wards with residents exhibiting symptoms.
- Limit visitation. Consider restricting visitation by children if there is a flu outbreak in the community, and encourage other methods, such as phone and video calls.
- Keep tabs on personnel who are absent from work because of respiratory symptoms and encourage those with flu symptoms to stay home until at least 24 hours after they no longer have a fever.
- Restrict personnel movement between areas with illness and those not affected by the outbreak.
Of course, all of this effort is heightened by the presence of COVID-19, and many experts fear the possibility of a “twindemic” of flu and COVID this winter. “The fact that we are all masked at all times, all staff and as many residents as we can get to wear them, I am hoping that alone may lessen the possibility of flu being spread,” Healy says. Indeed, the only potential “benefit” of the COVID outbreak, Mastronardi says, is that “infection prevention has been heightened.”