Respiratory Virus Season: Infection Prevention and Control Planning & Response - October 27, 2020
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Respiratory Virus
Season: Infection
Prevention and
Control Planning
& Response
October 27, 2020
October 27, 2020 Respiratory Virus Season Guideline
These guidelines have been developed by the Manitoba Provincial Infection Prevention and Control (IP&C) Team to assist all Service Delivery Organizations (SDOs) in Manitoba in preventing transmission and acquisition of respiratory viral illnesses through the application of principles outlined by health care workers in all health care delivery settings. These guidelines will support infection control professionals, service delivery organizations, and health care providers in developing, implementing and evaluating infection prevention and control (IP&C) policies, procedures and programs to improve the quality and safety of health care and outcomes. They will also assist in standardizing IP&C practices throughout the province. Service delivery organizations (SDOs) are expected to develop policies and procedures based on these guidelines. The information in this guideline was current at the time of development. Scientific knowledge and technology are constantly evolving. Revisions of these guidelines will be necessary as further experience and advances in the field provide new information. Although the guidelines will be updated periodically, professionals are responsible to ensure the most current knowledge and practice is applied for each case. October 27, 2020 Respiratory Virus Season Guideline
Table of Contents Introduction .............................................................................................................................................................. 3 Purpose .................................................................................................................................................................... 3 Principles .................................................................................................................................................................. 3 Definitions/Acronyms ................................................................................................................................................ 4 IP&C Roles and Responsibilities .......................................................................................................................... 7 Process ..................................................................................................................................................................... 7 Challenges Posed by COVID-19 .......................................................................................................................... 8 Respiratory Virus Key Points................................................................................................................................. 8 IP&C Guidelines/Precautionary Measures .......................................................................................................... 0 References ............................................................................................................................................................... 4 Appendix III: Respiratory Virus Season – Immunization Administration for Residents in Long Term Care; Influenza and Pneumococcal Vaccines…………………………………………………………………………………………………………..19 Appendix IV: Provincial Respiratory Virus Illness Season – Respiratory Season Checklist…………………………………………………………………………………………………..………22 October 27, 2020 Respiratory Virus Season Guideline
Date
Version / Issue number
Respiratory Virus Season – Infection Prevention and Control
Guidelines
Introduction
Respiratory virus season causes a strain on the health care system every year. A planned and unified
response is required. Reducing the burden of influenza is particularly important this season to prevent
an increase in health care utilization at the same time as there is a potential resurgence of COVID-19
activity. In its seasonal influenza vaccine statement for 2020-2021, the National Advisory Committee
on Immunization (NACI) advises priority should be given to providing influenza vaccine to persons at
high risk of influenza complications and those capable of transmitting infection to them.
The seasonal influenza immunization campaign provides an opportunity to develop and practice
approaches that may be used for the anticipated COVID-19 immunization program and to ensure
consideration of the diverse needs of population groups based on access to services, social
disadvantage, ethnicity/culture, ability status and other socioeconomic and demographic factors.
Purpose
Provide Infection Prevention and Control (IP&C) guidance for respiratory virus season response at a
provincial level to ensure patients/residents/clients receive the appropriate IP&C management. This
document provides guidance related to respiratory virus management outside of COVID-19. For
COVID-19 specific-guidance, please refer to the Shared Health, Provincial COVID-19 resources for
health-care providers and staff website.
Principles
This guidance is supported by the following principles:
− Multiple viruses contribute to the impact of the annual respiratory season
− Influenza morbidity and mortality can have significant impact on the operations of the health
care system and is a leading infectious cause of death in North America. Annual immunization
with influenza vaccine is the most effective way to prevent or minimize influenza infection or its
complications; influenza vaccine protection wanes over time
− Sites, programs and services operate as one system – sharing resources, balancing their
needs, and coordinating patient/resident/client care. This is required to meet the demands of
the respiratory season, mitigate the various risks that lack of coordination of these services
poses, and to protect public health. Health Care Workers (HCW) with direct
patient/resident/client contact should consider it their responsibility to provide the highest
standard of care, which includes annual influenza vaccination. In the absence of
contraindications, refusal of HCWs who have direct patient/resident/client contact to be
immunized against influenza annually implies failure in their duty of care to
patients/residents/clients
October 27, 2020 Respiratory Virus Season Guideline− Routine Practices and Additional Precautions are required within all healthcare settings (see
MHSAL Routine Practices Additional Precautions Preventing the Transmission of Infection in
Healthcare document), including, but not limited to
o Hand hygiene with alcohol-based hand rub (ABHR) or soap and water
o Cough/respiratory etiquette
o Appropriate personal protective equipment (PPE) such as gown, eye/face protection,
and gloves
− Preventing transmission of respiratory viruses within the health care delivery settings requires a
multi-faceted approach that includes
o Offering immunization to patients/residents/clients and staff who meet the criteria
established by the National Advisory Committee on Immunization (NACI) and Manitoba
Health, Seniors and Active Living (MHSAL)
o Ensuring Infection Prevention and Control measures are implemented to prevent spread
of respiratory viruses
o Ensuring facilities have adequate supplies in the event of an outbreak
o Providing antiviral chemoprophylaxis and/or treatment as appropriate
Definitions/Acronyms
ABHR Alcohol based hand rub
Adenovirus Common seasonal virus in children that causes common cold symptoms. Incubation
period is 1-10 days
AEFI Adverse Event Following Immunization: A reportable AEFI is one which is temporally
associated with an immunizing agent, cannot be attributed to a co-existing condition,
AND meets at least one of the following criteria
− The event is life-threatening, could result in permanent disability, requires
hospitalization or urgent medical attention, or for any other reason is
considered to be of a serious nature, OR
− The event is unusual or unexpected, including, without limitation, an event
that has not been previously identified, or an event that has been previously
identified but is being reported at an increased frequency, OR
− At the time of the report there is nothing in the patient's/resident’s/client’s
medical history, such as a recent disease or illness, or the taking of
medication, that could explain the event
Alternate Decision A third party identified to participate in decision making on behalf of a person who
Maker lacks decision-making capacity concerning immunization. The task of an alternate
decision-maker is to faithfully represent the known preference and/or the interests of
the incapable person. The alternate decision maker may be legally appointed (Public
Trustee, Committee, Advance Health Directive Proxy) or informal (family member,
next of kin)
October 27, 2020 Respiratory Virus Season GuidelineAnaphylaxis An immediate and severe allergic reaction to a substance (e.g., food or drugs).
Symptoms of anaphylaxis include breathing difficulties, loss of consciousness and a
drop in blood pressure. This condition can be fatal and requires immediate medical
attention
ASAP Attendance Support and Assistance Program: The focus of this program is on
improving ability to attend work regularly by addressing any factors affecting
attendance. This program is not disciplinary and is meant as a tool to enable staff to
meet their employment obligation to attend work
Boca Virus Common seasonal virus in children that causes common cold symptoms. Incubation
period is not documented
Cohort Cohort refers to physically separating (e.g., in a separate room or ward/unit) two or
more patients/residents exposed to or infected with the same microorganism from
other patients/residents who have not been exposed to or infected with that
microorganism.
Confirmed Case A lab confirmed case of Influenza A, Influenza B, respiratory syncytial virus (RSV), or
any of the respiratory viruses tested as part of the RSV-16 respiratory multiplex panel
Coronavirus (common Common seasonal virus that causes common cold symptoms. Incubation period is 2-
types; not MERS-CoV, 4 days
SARS or COVID-19)
COVID-19 A specific coronavirus that causes mild to severe illness. Incubation period is
assumed to be up to 14 days
Enterovirus Common virus in children that can cause common cold symptoms. Incubation period
is 3-5 days
Human Common seasonal virus that causes common cold symptoms. Incubation period is 3-
Metapneumovirus 5 days
Herd Immunity When a large percentage of the population is vaccinated in order to prevent the
spread of certain infectious diseases. Even individuals not vaccinated (such as
newborns and those with chronic illnesses) are offered some protection because the
disease has little opportunity to spread within the community. In terms of influenza
immunization, some scientists argue herd immunity is not possible
with influenza (due to ability of the virus to change rapidly), rather a “herd effect” can
be observed when those immunized do not transmit disease to others
Influenza A viral infection of the respiratory system. Symptoms of influenza include acute onset
of fever, cough, sore throat, muscle aches, extreme fatigue and headache. Influenza
is a significant cause of morbidity and mortality, especially in those over the age of
65, immune compromised and/or have a chronic underlying disease. The incubation
period is 1-4 days
Influenza-like Illness Acute/new onset of respiratory illness characterized by:
(ILI) − Fever* and (new) cough, AND one or more of the following symptoms:
o Sore throat
o Joint pain (arthralgia)
o Muscle aches (myalgia)
October 27, 2020 Respiratory Virus Season Guidelineo Severe exhaustion
In children less than 5 years of age, gastrointestinal symptoms (e.g. nausea,
vomiting, diarrhea) may be present. Illness associated with novel influenza viruses
may present with other symptoms. *In clients less than 5 years or greater than or
equal to 65 years old, fever may not be prominent.
Institutional Outbreak Two or more cases of respiratory illness with similar symptoms (including at least one
(Non-COVID) laboratory-confirmed case) occurring within a seven-day period in an
institution/unit/area
ICP Infection Control Professional
IP&C/designate Infection Prevention and Control/designate
Person(s) with responsibility for providing IP&C guidance at the site. This may
include, but not limited to, ICP, unit manager, educator, director of care, IP&C
physicians, or medical officer or health.
LTC Long Term Care
MHSAL Manitoba Health, Seniors, and Active Living
MOH Medical Officer of Health
OH Occupational Health
Parainfluenza Common seasonal virus with common cold symptoms. Incubation period is 2-6 days
Pneumococcal An infection caused by bacteria that can spread easily from one person to another.
Infection The bacteria normally live in fluids of the nose, mouth and throat and many people
carry them without getting sick; however, some people can develop severe disease.
There are more than 90 different types of pneumococcal bacteria that can lead to
infections of the ears, sinuses, lungs (pneumonia), blood (bacteremia) and covering
of the brain (meningitis). Pneumococcal infections may occur following a viral
infection like influenza
Pneumonia Often a secondary bacterial respiratory infection following an acute viral infection
Point of Care Risk An activity where a health care worker (in any health care setting across the
Assessment (PCRA) continuum of care)
1. Evaluates the likelihood of exposure to an infectious agent
a. for a specific interaction
b. with a specific patient
c. in a specific environment (e.g., single room, hallway)
d. under available conditions (e.g., no designated hand hygiene sink)
2. Chooses the appropriate actions or PPE needed to minimize the risk of exposure
for the specific patient/resident/client, other patients/residents/clients in the
environment, the HCW, other staff, visitors or contractors, and so on
PPE Personal Protective Equipment. Personal protective equipment are items worn to
provide a barrier to help prevent potential exposure to infectious disease
PPH Population and Public Health
Probable (Clinical) Patient/resident/client without a lab confirmed result but with clinical presentation of
Case Influenza A, Influenza B, RSV, or one of the other respiratory viruses requiring
additional precautions
October 27, 2020 Respiratory Virus Season GuidelineRespiratory Syncytial Common seasonal virus that causes significant illness in children but can also infect
Virus (RSV) adults. It usually causes common cold symptoms. Incubation period is 2-8 days
Respiratory Virus The following viruses are included in the term respiratory virus:
Influenza A Influenza B
RSV COVID-19
Human Rhinovirus Human Adenovirus
Human Bocavirus Human Coronavirus (229E, NL63, OC43)
Human Enterovirus Human Metapneumovirus
Human Parainfluenza viruses 1,2,3 and 4
Respiratory viruses are a major cause of respiratory illness and are communicable
through Droplet and Contact transmission
Respiratory Virus Respiratory virus season is the season that usually runs from the Fall (~September)
Season until levels of respiratory virus cases returns to baseline again in the Spring
Rhinovirus Common seasonal virus that causes common cold symptoms. Incubation period is 2-
3 days
Seasonal Influenza An acute upper respiratory infection caused by influenza viruses which circulate in all
parts of the world (e.g., influenza A H1N1)
Vulnerable Population Individuals within our populations who are more likely to be impacted and infected by
seasonal respiratory viruses (e.g., very young or very elderly)
IP&C Roles and Responsibilities
− Support sites in the management of respiratory cases
− Monitor, report and interpret respiratory virus impact within sites/settings in a timely way
− Monitor for outbreaks and support sites and programs when these occur
− Participate/be aware of regional and provincial capacity management planning and provincial
Emergency (Disaster) Management planning and response
Process
Identification of Respiratory Season
Using a number of traditional and syndromic indicators, including but not limited to the ED (Emergency
Department) Daily Respiratory Illness Surveillance Report (where available), the Manitoba Health,
Seniors and Active Living Influenza Surveillance Report, the Public Health Agency of Canada, as well
as communication with other programs in the RHA’s, PPH, IP&C and OH monitor and report on the
start of the annual respiratory season. Monitoring includes awareness of the start of the annual
Respiratory Syncytial Virus Prophylaxis program in Manitoba. Once the respiratory season is identified,
testing for multiple respiratory viruses such as influenza, RSV and others becomes more frequent. A
subsequent rise in positive results indicates the start of the season.
IP&C Prevention and Response
IP&C/designate acts as a resource to staff and managers in preparation for immunization and
respiratory virus season preparedness. IP&C/designate coordinates the collection of
October 27, 2020 Respiratory Virus Season Guidelinepatient/resident/client influenza immunization administration data. IP&C/designate monitors and
reports respiratory activity within facilities. IP&C/designate reports all respiratory outbreaks in both LTC
and acute care settings through standardized methods (Canadian Network for Public Health
Intelligence, CNPHI). IP&C/designate offers support and direction for all institutional respiratory
outbreaks. Posters, respiratory outbreak resources and IP&C Highlights can be found here.
Challenges Posed by COVID-19
The COVID-19 pandemic creates a series of challenges for the delivery of the seasonal influenza
immunization program, including
− need for measures to avoid transmission of COVID-19 to staff, volunteers and
patients/residents/clients (many of whom are at increased risk of severe disease from both
influenza and COVID-19)
− availability of personnel to provide immunizations, as staff may be deployed to COVID-19 work
and cautions apply to the involvement of staff or volunteers who are considered to be at high
risk for severe illness from COVID-19
− access to sufficient PPE supplies for vaccinators and other staff
− access to or suitability of usual venues for immunization administration
− risk of a resurgence of COVID-19 activity concurrently with scheduled influenza immunization
delivery
− logistics of providing immunization to the public in a way that maintains social distancing and
other COVID measures
− public fear of exposure to COVID-19 while accessing immunization services
− potentially increased demand for influenza vaccine starting early in the campaign, as seen in the
Southern hemisphere
− confusion between temporal reaction to receipt of immunization and COVID-19 signs and
symptoms
Respiratory Virus Key Points
All Sectors: Acute, LTC, Community
− IP&C management of all respiratory viruses requires implementation of Droplet/Contact
Precautions in addition to Routine Practices. A private room is recommended. Where this is
not possible, cohort based on risk factors, and implement precautions for each
patient/resident/client environment.
− Some side effects experienced following vaccine administration may be confused for COVID-19
symptoms. To manage this
a. Vaccinate according to regular schedule.
b. Monitor for symptoms.
October 27, 2020 Respiratory Virus Season Guidelinec. If symptoms present temporally related to immunization (within 12-24 hours): if not
cough or respiratory symptoms, only monitor, no need to isolate, test for COVID, etc.
d. If other respiratory symptoms or symptoms continue, isolate, collect specimen for
COVID testing.
e. Staff continue to wear universal PPE.
− Influenza - 3 distinct types of seasonal influenza viruses recognized: A, B and C.
o Influenza A viruses are divided into subtypes based on two surface glycoproteins; the
hemagglutinin (H) and the neuraminidase (N). Mutations in the genes encoding the H and
N glycoproteins during replication result in constant emergence of new strains of influenza
A. Both A and B can cause seasonal outbreaks but antigenic variation occurs more slowly
in B viruses.
o Influenza B generally causes milder disease than A and primarily affects children and
older adults. Antigenic variation occurs more slowly in influenza B viruses.
o Influenza C is rarely reported as a cause of human illness and has not been associated
with epidemics
− To prevent transmission of respiratory viruses, physical distancing should be maintained as
much as possible. Physical distancing is a challenge to maintain between staff and the
patient/resident/client so appropriate PPE must be worn according to current recommendations
October 27, 2020 Respiratory Virus Season GuidelineTable: Respiratory Viruses
Symptoms Reservoir and Incubation Period Transmission Period of People at high-risk of Secondary
source of Communicability respiratory virus-related Complications
respiratory complications
viruses
Acute/new onset of Humans are Influenza A & B: Person-to-person Influenza A & B: Adults (including pregnant Pneumonia
respiratory illness only known 1 to 4 days transmission through Probably 1 day before women) and children with (usually
characterized by: reservoir of RSV: large respiratory droplets to 3 to 5 days from the following: bacterial) is the
− Fever* and (new) influenza types 2 to 8 days when infected persons clinical symptom onset Cardiac or pulmonary most frequent
cough, AND one or B and C viruses cough or sneeze is in adults; up to 7 to 10 disorders (including complication.
more of the COVID-19: Current believed to be the primary days in young children bronchopulmonary
following Influenza A may estimates range from transmission route. dysplasia, cystic fibrosis Primary viral
symptoms: infect both 1-14 days with RSV: and asthma) influenza
o Sore throat humans and median estimates of Respiratory secretions Shortly before and pneumonia is
o Joint pain animals 5-6 days between contain the infective until symptoms Diabetes mellitus and other uncommon but
(arthralgia) infection and onset of material. Transmission cease or return to metabolic diseases has a high
o Muscle Humans and clinical symptoms of may also occur through baseline fatality rate.
aches animals have disease direct or indirect contact Cancer, immune
(myalgia) been shown to with respiratory secretions COVID-19: compromising conditions Otitis media,
o Severe be reservoirs Human (e.g., touching surfaces Not well understood; (due to underlying disease particularly in
exhaustion for respiratory Rhinovirus 2 to 3 contaminated with it is assumed no and/or therapy) children
viruses days influenza virus and then longer
In children less than 5 touching the eyes, nose or communicable 10 Renal disease Death
years of age, Human mouth). days after onset of
gastrointestinal Bocavirus: illness, as long as Anemia or
symptoms (e.g. nausea, Unknown Individuals with afebrile and have hemoglobinopathy
vomiting, diarrhea) may asymptomatic infection improved clinically
be present. *In clients Human can transmit virus to Conditions that
less than 5 years or Coronavirus (229E, susceptible individuals Human Rhinovirus: compromise the
greater than or equal to NL63, OC43): (e.g., asymptomatic health Until symptoms management of respiratory
65 years old, fever may 2 to 4 days care worker to patient/ cease or return to secretions and are
not be prominent. resident/ client). Human baseline associated with an
Illness associated with Human respiratory viruses may increased risk of aspiration
novel influenza viruses Enterovirus: persist for hours on solid
may present with other 3 to 5 days surfaces, particularly in Morbid obesity (BMI ≥ 40)
symptoms lower temperatures and
lower humidity
October 27, 2020 Respiratory Virus Season GuidelineSymptoms Reservoir and Incubation Period Transmission Period of People at high-risk of Secondary
source of Communicability respiratory virus-related Complications
respiratory complications
viruses
Human Human Healthy pregnant women
Metapneumo-virus Adenovirus: Shortly • Especially those in
3 to 5 days before and until third trimester, and
symptoms cease or • Women up to four
Human Para- return to baseline weeks post-partum
influenza viruses regardless of how
1,2,3 and 4: 2 to 6 Human Bocavirus: pregnancy ended
days Unknown First Nations, Métis and
Inuit peoples
Human Individuals of any age who
Coronavirus (229E, are residents of long-term
NL63, OC43): Until care facilities
symptoms cease or Individuals greater than 65
return to baseline years of age
All children less than 5
Human Enterovirus: years of age
Until symptoms cease Children and adolescents
or return to baseline (age 6 months to 18 years)
with the following:
Human • Neurologic or
Metapneumovirus: neurodevelopment
Until symptoms cease conditions (including
or return to baseline seizure disorders,
febrile seizures and
Human isolated developmental
Parainfluenza delay)
viruses 1,2,3 and 4: Undergoing treatment for
1 to 3 weeks long periods with
acetylsalicylic acid,
because of the potential
increase of Reye syndrome
associated with influenza
related complications
October 27, 2020 Respiratory Virus Season GuidelineIP&C Guidelines/Precautionary Measures
Across All Sectors
Immunize patients/residents/clients annually against influenza, unless contraindicated.
Conduct screening and active case finding.
Implement Droplet/Contact Precautions immediately when a patient/resident/client presents with an
acute respiratory illness with one or more of the following:
− Fever (may or may not be present)
− New or worsening cough
− Sore throat
− Arthralgia (joint pain)
− Myalgia (muscle pain)
− Runny nose
− Sneezing
− Prostration (extreme physical exhaustion)
Notify IP&C/designate of patients/residents/clients on Additional Precautions/clusters of respiratory
illness in patients/residents/clients.
Collect nasopharyngeal (NP) specimens using flocked swabs or provincially approved swabs as soon
as possible when a respiratory viral illness is suspected. In patients/residents/clients with a
tracheostomy, laryngectomy, etc. a tracheal aspirate may be collected and submitted in viral transport
media, but NP specimen should also be collected.
When indicated, treat with antivirals as rapidly as possible after onset of illness because the benefits of
treatment are much greater within initiation atAccommodation
Minimize exposure of immunocompromised patients/residents/clients to respiratory viruses. See
‘People at high-risk of respiratory virus-related complications’ (table above) for more details.
Encourage visitors and staff to adhere to screening practices that may be in place and stay home when
they have symptoms of an acute respiratory illness.
Acute
Place patients with a high index of suspicion for a respiratory viral illness in a single room preferably
until results are confirmed. Where a single room is not available, ensure appropriate cohorting of
patients:
− Do not cohort patients with a high index of suspicion for, or with, a confirmed respiratory viral
illness with a patient not suspected of having a respiratory viral illness
− If necessary, cohort patients with a high index of suspicion for a respiratory viral illness (results
pending) with another patient with similar presentation
Patients with a low index of suspicion (e.g., absence of fever, cough) do not immediately require
Additional Precautions pending results. Ensure appropriate cohorting of patients:
− Cohort patients with a low index of suspicion for a respiratory viral illness with a patient not
suspected of having a respiratory viral illness, ONLY if the roommate(s) are not at high risk for
acquiring an infection. See ‘People at high-risk of respiratory virus-related complications’ (table
above) for more details
− In outbreak situations, follow outbreak guidance for accommodation
Additional Maternity/Newborn considerations
− Mother is positive for a viral respiratory illness. Measures include
o Rooming in
Droplet/Contact precautions for newborn and mother
Mother/newborn contact is permitted. Mother must wear a medical mask within 2
metres of newborn. Emphasize good hand hygiene and respiratory etiquette
o NICU
Droplet/Contact
Mother is not permitted to go to the NICU. If a newborn of a mother with
suspected or confirmed viral respiratory illness is housed in the nursery instead
of the mother’s room, the mother should not enter the nursery or NICU until 5
days after onset of symptoms and free of respiratory symptoms for 24 hours. For
compassionate reasons, exception may be considered on a case-by-case basis.
This would require advance planning and IP&C approval, including directions for
mother to appropriately use PPE, and assurance this is possible
Symptomatic caregivers or family members should not visit or enter the nursery
or NICU
October 27, 2020 Respiratory Virus Season Guideline− Newborn is positive for a respiratory viral illness. Measures include
o Droplet/Contact precautions for newborn and mother
o Mother/newborn contact is permitted
During outbreak situations, additional precautions and cohorting of newborns may be
required.
LTC
Place residents with a high index of suspicion for a respiratory viral illness on Droplet and Contact
Precautions. A single room is preferred, however when not available:
− In a shared room, roommates and all visitors should be aware of the precautions to follow.
− If possible, close the privacy curtain between beds to minimize opportunities for direct contact,
with heads of beds facing away from each other and at least 2 metres apart
− In multi-bedded resident rooms, two metre spatial separation between beds is recommended to
reduce the opportunities for inadvertent sharing of items between the ill/symptomatic resident
and other residents
− Do not cohort residents with a high index of suspicion for, or with, a confirmed respiratory viral
illness with a resident not suspected of having a respiratory viral illness
Community
Primary Care
Clients shall preferably be placed in a single room or designated space/area. No special air handling
and ventilation are necessary. The door may remain open. The room should have dedicated hand
hygiene products/facilities. In instances where there are not a sufficient number of single rooms or
designated space/area, cohort clients with the same microorganism together. If a single room is not
available and cohorting is not possible, maintain a separation of at least two metres between clients.
Ambulatory/Clinic Setting
Triage client/patient away from waiting area to single room as soon as possible, maintain two-meter
spatial separation. Patient to wear mask for duration of visit and perform hand hygiene. Clean and
disinfect equipment after visit and use dedicated equipment where possible. Perform routine cleaning
and disinfection of high touch surfaces.
Contact clients by telephone if possible 24 hours prior to visit. If client reports respiratory symptoms
determine if the appointment is essential or if it can be rescheduled. Consider virtual visits when
possible.
In Home Health Care/Visits
Where possible, contact client by telephone within 24 hours of initial visit to inquire about symptoms of
respiratory virus and ask clients to inform home care providers if they develop symptoms. At each
October 27, 2020 Respiratory Virus Season Guidelinefollowing visit, staff should inquire about symptoms prior to entry. If symptomatic, determine if visit is
essential. Use Droplet & Contact PPE if clients exhibit respiratory symptoms.
Discontinuation of Precautions for Confirmed or Suspected Respiratory Viral Illness (NON-
COVID)
Acute
Discontinue Droplet/Contact Precautions for confirmed or suspected cases:
− Non-ventilated: after resolution of symptoms
− Ventilated: after clinical improvement
Do NOT discontinue Precautions based on duration of treatment.
Do NOT discontinue Precautions based on negative results.
Patients may have chronic respiratory symptoms and/or a post-viral cough, which do not require
maintenance of precautions.
Resolution of symptoms/clinical improvement may be challenging to assess in the ventilated patient.
Signs of clinical improvement in a ventilated patient/resident/client could include:
− Mechanical ventilation (i.e., ventilator) discontinued
− Afebrile
− Decreased respiratory secretions
− Improved respiratory pressures (clinical judgment of Attending Physician/Respiratory Therapist)
− Improved oxygen saturation levels
If determination of respiratory symptom resolution is unclear (such as in ventilated patients or patients
with a chronic respiratory disease), consult the Infection Control Professional/designate.
LTC
Discontinue Droplet/Contact Precautions for confirmed or suspected cases:
− Non-ventilated: after resolution of symptoms
− Ventilated: after clinical improvement
Do NOT discontinue Precautions based on duration of treatment.
Do NOT discontinue Precautions based on negative results.
Patients may have chronic respiratory symptoms and/or a post-viral cough, which do not require
maintenance of Precautions.
Resolution of symptoms/clinical improvement may be challenging to assess in the ventilated patient.
Signs of clinical improvement in a ventilated patient/resident/client could include:
− Mechanical ventilation (i.e., ventilator) discontinued
− Afebrile
− Decreased respiratory secretions
− Improved respiratory pressures (clinical judgment of Attending Physician/Respiratory Therapist)
− Improved oxygen saturation levels
October 27, 2020 Respiratory Virus Season GuidelineIf determination of respiratory symptom resolution is unclear (such as in ventilated patients or patients with a chronic respiratory disease), consult the Infection Control Professional/designate for your area during working hours or the after hours designate. Community Discontinue precautions when the client is no longer experiencing symptoms of acute respiratory illness. Occupational Health Contact Occupational Health/designate for influenza vaccination, staff assessment and/or concerns. Support Occupational Health in direction for staff to remain home if symptomatic with respiratory symptoms. References Canadian Nurses Association (2012). Influenza Immunization of Registered Nurses. Available at: https://www.cna-aiic.ca/~/media/cna/page-content/pdf-fr/ps_influenza_immunization_for_rns_e.pdf. Government of Canada (2020). Canadian Immunization Guide Evergreen Edition. Available at: https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html. Government of Manitoba (2020). The Child and Family Services Act. Available at: https://web2.gov.mb.ca/laws/statutes/ccsm/c080e.php. Government of Manitoba (2020). The Family Maintenance Act. Available at: https://web2.gov.mb.ca/laws/statutes/ccsm/f020e.php. Government of Manitoba (2020). The Personal Health Information Act. Available at: http://web2.gov.mb.ca/laws/statutes/ccsm/p033-5e.php. Government of Manitoba (2020). The Public Health Act. Available at: https://web2.gov.mb.ca/laws/statutes/ccsm/p210e.php. Healthcare Infection Control Practices Advisory Committee (HICPAC) (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf. October 27, 2020 Respiratory Virus Season Guideline
Manitoba Health, Seniors and Active Living (2013). Cold Chain Protocol Vaccines and Biologics. Available at: https://www.gov.mb.ca/health/publichealth/cdc/protocol/ccp.pdf. Manitoba Health, Seniors and Active Living (2016). Seasonal Influenza Communicable Disease Management Protocol. Available at: https://www.gov.mb.ca/health/publichealth/cdc/protocol/influenza1.pdf. Manitoba Health, Seniors and Active Living (2020). Manitoba’s 2020/21 Seasonal Influenza Immunization Program. Available at: https://www.gov.mb.ca/health/publichealth/cdc/div/manual/docs/msiiipp.pdf Manitoba Health, Seniors and Active Living (2019). Routine Practices and Additional Precautions. Available at: https://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf. Provincial Infectious Diseases Advisory Committee (PIDAC) (2020). Best Practices for Prevention, Surveillance and Infection Control Management of Novel Respiratory Infections in All Health Care Settings 1st Revision. Available at: https://www.publichealthontario.ca/-/media/documents/B/2020/bp- novel-respiratory-infections.pdf?la=en. Provincial Infectious Diseases Advisory Committee (PIDAC) (2012). Routine Practices and Additional Precautions In All Health Care Settings, 3rd edition. Available at: https://www.publichealthontario.ca/- /media/documents/B/2012/bp-rpap-healthcare-settings.pdf?la=en Public Health Agency of Canada (2016). Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings. Available at: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases- conditions/routine-practices-precautions-healthcare-associated-infections/routine-practices- precautions-healthcare-associated-infections-2016-FINAL-eng.pdf. Vancouver Island Health Authority (2017). During Influenza Season: A Checklist for Residential Care Facilities. Available at: https://www.islandhealth.ca/sites/default/files/2018-04/influenza-during- checklist-rescare.pdf. October 27, 2020 Respiratory Virus Season Guideline
Appendix I
Respiratory Virus Season – Informed Consent
The need to obtain informed consent prior to an immunization is based on the principle that a
patient/resident/client is autonomous and has the right to determine what happens or does not happen
to them. Information, comprehension and willingness to participate (voluntariness) are fundamental
elements of the informed consent document.
Definitions
Age of Capacity The Manitoba Health Care Directives Act states, in the absence of evidence to
the contrary, it shall be presumed for the purpose of the Act
(a) that a person who is 16 years of age or more has the capacity to make
health care decisions; and
(b) that a person who is under 16 years of age does not have the capacity to
make health care decisions.
Child in Care A child who is legally in the care of Child & Family Services (CFS) and as such
it is CFS who is the legal guardian and must provide consent. CFS may chose
to consult with the child’s biological parent(s).
Consent Permissions for something to happen or be done.
Exercising one’s own Includes consent to, or refusal to consent to, assessments and/or treatments;
rights consent to, or refusal to consent to the collection, use and disclosure of
personal information and personal health information or other consents as may
be required (i.e., photograph).
Mature Minor A mature minor is an individual, under the age of 18 years, who has the
capacity to fully appreciate the nature and consequences of a proposed health
assessment and/or treatment and can give informed consent. Designation of a
mature minor is not based on age but on capacity to understand.
Minors with capacity If the minor has this capacity, the minor’s consent is both necessary and
who wish to make sufficient. Consent of the parent is not required, nor can it override the minor’s
their own decisions decision.
Non-custodial parent Under The Family Maintenance Act, unless a court order states otherwise, a
non-custodial parent retains the same right as a custodial parent to obtain
personal health information related to their child. This right is limited to
information and does not give the non-custodial parent any right to be
consulted about or participate in making decisions for the child.
Regulated Health Health care provider who is licensed/registered with a professional governing
Professional body, and for whom immunization is within their scope of practice i.e., nurse
(RN or LPN), physician assistant, physician, midwife, nurse practitioner.
October 27, 2020 Respiratory Virus Season GuidelineAppendix I
Substitute Decision A substitute decision maker is an individual appointed by the Vulnerable
Maker Persons' Commissioner to make decisions for a vulnerable person who is
unable to make certain decisions for him or her self.
Temporary Custody A person who has temporary custody of a minor (i.e., foster parent, teacher or
babysitter) has no authority to act as an alternate decision maker unless they
have received written authorization from the parent or legal guardian.
As all vaccine programs are voluntary, confirmation of consent is needed either verbally or in writing
and required documentation on either a Child Immunization Consent Form, Seasonal Immunization
Consent Form, in a patient/resident/client health record, or the Manitoba Health, Seniors an Active
Living Seasonal Influenza and Pneumococcal Vaccine Consent Form.
Informed Consent for patients/residents/clients/alternate decision maker includes the following
i. Disease(s) being prevented
ii. Benefits of vaccination
iii. Risk of not getting immunized (risk of acquiring the disease)
iv. Details regarding vaccine route and schedule
v. Common side effects and their management
vi. Possible serious or severe adverse events, their frequency, how and when to report
vii. Contraindications
viii. Information in the product monograph and/or MHSAL vaccine fact sheet
ix. Immunization documentation in the provincial immunization registry PHIMS
Document consent in appropriate location. This could include
i. Patient/resident/client health record
ii. Immunization form
iii. Child Health Record
Child Health Clinics/Well Child Clinics
Consent may also be implied when a parent/legal guardian makes an appointment for their child on a
voluntary basis. A signed paper consent form is not required. Documentation of verbal consent is
made on the child health record along with direct entry into PHIMS.
October 27, 2020 Respiratory Virus Season GuidelineAppendix I Seasonal Influenza Immunization Clinics Adults Presentation to immunization clinics is voluntary. If not documenting directly into PHIMS, obtain written consent on the Seasonal Influenza Consent Form. If the adult is not competent to consent, obtain consent from the person authorized to provide consent (i.e. proxy, public trustee, alternate decision maker). Minors Parents/legal guardians bring their child to immunization clinics on a voluntary basis. If not documenting directly into PHIMS, obtain written consent from the parent/guardian on the Seasonal Influenza Consent Form. Mature Minors Mature minors can provide informed consent for immunization without a parent/guardian, provided the physician or nurse assesses the client has a full understanding of the risks and benefits of immunization. When not directly documenting into PHIMS, obtain written consent on either the Child Immunization Form or the Seasonal Influenza Consent Form. Child In Care Informed consent must be obtained from the legal guardian of a child in care as per The Child & Family Services Act of Manitoba. It is the foster parents’ responsibility to forward the consent form to their designated social worker to be signed by either the social worker or biological parent. October 27, 2020 Respiratory Virus Season Guideline
Appendix II
Respiratory Virus Season – Laboratory Information
Complete a Cadham Provincial Lab “Supplies Request Form” and fax to the laboratory providing
services to your site.
Facilities/units can complete the required number of nasopharyngeal swabs (as directed), in a time
sensitive manner. Stock, or immediate access to stock, should reflect the ability to do so.
Viral Transport Media (VTM)
− Viral transport media is used to transport nasopharyngeal swabs for the culture of viruses. Only
use this medium for virus isolation
− Shelf life of the viral transport media is
o 3 months at -20⁰C or
o 1 week in the refrigerator
o 1.5 months if re-frozen. If melted during delivery it may be re-frozen
− Check expiry date on viral transport media to ensure media is not outdated
Universal Transport Media (UTM)
− Universal transport media is used mostly where transport and shipping may be
delayed/challenged
− This media is typically pink/red coloured
− Shelf life of the universal transport media is
o Up to 1 year at room temperature and SHOULD NOT be frozen
− Check expiry date on universal transport media to ensure media is not outdated
Nasopharyngeal (NP) Flocked swabs
− NP “flocked swabs” are preferred specimens for respiratory virus detection
o In patients/residents/clients with a tracheostomy, laryngectomy, etc. a tracheal aspirate
may be collected and submitted in VTM, but NP specimen should also be collected
− Request NP swabs at the same time as the VTM
− It may be necessary to use approved swabs other than the “flocked swabs”. This would be
approved, and communication sent out provincially
Collection of Nasopharyngeal swabs
Complete a General Requisition Form for each test request.
Nasopharyngeal swab video available for reference.
October 27, 2020 Respiratory Virus Season GuidelineAppendix II Cadham laboratory phone number for results: 204-945-6123 Ext 4 Standard Operating Procedure below also available at: https://sharedhealthmb.ca/files/covid-19-sop- swab.pdf. October 27, 2020 Respiratory Virus Season Guideline
Appendix II October 27, 2020 Respiratory Virus Season Guideline
Appendix III
Respiratory Virus Season – Immunization Administration for
Residents in Long Term Care; Influenza and Pneumococcal
Vaccines
Annual influenza immunization is the best way to protect against seasonal influenza. Every year,
scientists monitor the global spread of influenza and decide which influenza strains will likely cause the
most illness during the influenza season. Those strains are then put into the influenza vaccine for that
year, so each year the vaccine is different. Vaccination is an effective way to prevent serious illness
and save lives.
All residents of long-term facilities are eligible to receive annual influenza immunization regardless of
age
− Residents who are less than 65 years of age are eligible for Quadrivalent Inactivated Influenza
Vaccine (QIV): an injectable suspension of four different strains (or types of) inactivated Influenza
virus designed to establish immunity when the body responds to the vaccine by creating antibodies
− Residents who are 65 years and older are eligible for Fluzone® High Dose (a high dose influenza
vaccine approved by MHSAL for residents of LTC who are 65 years of age and older. This vaccine
contains four times the amount of influenza virus antigen per strain (60ug vs. 15ug) compared to
the standard inactivated influenza vaccine. This is a trivalent inactivated vaccine (TIV) and
protects against three (2A + 1B) of the influenza strains predicted to be circulating in North America
during the influenza season. Given the burden of Influenza A(H3N2) disease and evidence of
better efficacy in this age group, it is expected that high dose TIV will provide superior protection in
this age group compared with the standard dose influenza vaccine
Order the vaccine directly from the Provincial Distribution Warehouse using the most current Manitoba
Health, Seniors and Active Living (MHSAL) Influenza and Pneumococcal Vaccine Order Form
Prior to the arrival of the vaccine to the long term care facility, prepare an influenza vaccine
administration package for the ward nurses including the following:
− A copy of the MHSAL annual Seasonal Influenza Immunization Program Plan; 2020/21 available
at http://www.manitoba.ca/health/publichealth/cdc/div/manual/docs/msiiipp.pdf
− A copy of the regional Immunization Provider Module if needed
− Several copies of Seasonal Influenza and Pneumococcal Vaccine consent forms (with
addressograph area)
− Several copies of current applicable MHSAL Seasonal Influenza Vaccine Factsheets
o Seasonal Influenza Vaccine
o Pneumococcal Polysaccharide (Pneu-P-23) Vaccine
o MHSAL High Dose Seasonal Influenza Vaccine for Eligible Seniors Aged 65 Years and
October 27, 2020 Respiratory Virus Season GuidelineAppendix III
Older Fact Sheet
− A Quick Reference Guide on the different influenza vaccines available that year, the intended
recipient of each type, and their contraindications and side-effects
− The instructions for ward/unit nurses for vaccine administration
Influenza vaccines are contraindicated in persons who developed an anaphylactic reaction to a
previous dose of Influenza vaccine or to any of the vaccine components (except for egg), or developed
Guillain-Barré Syndrome within six weeks of Influenza vaccination.
Pneumococcal immunization is offered to all residents who meet the criteria as outlined in the Canadian
Immunization Guide/MHSAL.
Immunization providers are responsible for ensuring competency to provide immunizations as required
by their professional licensing body. This includes:
− Knowledge of vaccine preventable disease, benefits and risks of vaccines, and recommended
immunization schedules
− Knowledge of target populations who are at risk for communicable diseases
− Preparing for management of a medical emergency related to the administration of the vaccine
Immunization providers are responsible to ensure they:
− Meet the provincial requirements to provide immunization. Immunization competency education
is available here: https://www.gov.mb.ca/health/publichealth/cdc/div/manual/index.html and
here: https://www.manitoba.ca/health/publichealth/cdc/div/manual/docs/immcomp.pdf
− Follow Routine Practices when administering immunizations
− Documents administration of the immunization in
o Medication Administration Record with the following information
Date and time of administration
Name of the influenza vaccine
Manufacturer and lot number
Vaccination site and route
Provider’s signature
o Integrated Progress Notes if the resident experienced any adverse reactions to the
vaccine.
− Report an adverse event by completing the MHSAL Report of Adverse Events Following
Immunization (AEFI) form and submit to the Medical Officer of Health by telephone and/or email
o Reports the AEFI within seven days of becoming aware of a reportable event
October 27, 2020 Respiratory Virus Season GuidelineAppendix III
o Reports a serious AEFI within one business day: an event that is life-threatening, could
result in permanent disability, requires hospitalization or urgent medical attention, or for
any other reason is considered to be of a serious nature
− Submits documentation of influenza immunizations in a timely fashion for entry into the Public
Health Immunization Monitoring System (PHMIS) database
o Provide direction to all units to remove influenza vaccine from refrigerators at the end of
flu season, when directed by MHSAL
Discard open vials of vaccine in sharps containers
Unopened vials of vaccine
• Facilities using regional pharmacy services: send vaccine to pharmacy
− Facilities that do not use regional pharmacy services: Contact the Provincial Vaccine
Warehouse for return instructions at: (204) 948-1333 Toll-Free: 855-683-3306
Immunization can only be given following informed consent from the resident or their substitute decision
maker.
Consent for influenza vaccination must be obtained annually. Consent for pneumococcal vaccination
must be obtained when the resident meets the criteria.
Follow the contraindication to vaccination criteria as outlined by MHSAL and the product monographs.
Postpone administration of either influenza or pneumococcal vaccine in persons with serious acute
illness until their symptoms have abated. Do not delay because of minor acute illness, with or without
fever. Where hypersensitivity is suspected or allergy not associated with anaphylaxis to vaccine
components, investigation is indicated, which may involve immunization in a controlled setting.
Consultation with an allergist is advised.
Storage and handling of vaccines must comply with MHSAL Cold Chain Protocol.
Equipment and Supplies
− Needle
− Syringe: 1 mL or 3 mL
− Alcohol swabs
− Band aid
− 2x2 gauze
− Vaccine
− Sharps container
October 27, 2020 Respiratory Virus Season GuidelineAppendix III
− Alcohol Based Hand Rub
− Required PPE
− Anaphylaxis kit
October 27, 2020 Respiratory Virus Season GuidelineAppendix IV
Provincial Respiratory Virus Illness Season – Respiratory Season
Checklist
This checklist has been developed to be used as a tool to assist in preparation for the Annual
Respiratory Virus Illness season. Outside of vacation planning, preparation for the season starts no
later than July/August every year. Each section should be reviewed by appropriate stakeholders to
ensure preparedness.
Recommendations are general in nature with a purpose of prompting review and action.
PLANNING AND PREPARING FOR RESPIRATORY SEASON
Review/Update Plans Person(s) Date
Responsible Completed
Review and update respiratory season plans with emphasis on
PPH, IP&C, & OH program components
Review and update surge plans with emphasis on infectious
disease surge and related Policies and Procedures (e.g., mass
fatality, mental health/ psychosocial support)
Review & update Emergency Operations Plan and Over
Capacity Protocols
Ensure processes are in place to communicate information
to staff, physicians, patients/residents/visitors/clients
Plan for increase in pediatric, intensive care unit, geriatric,
and other specific patient/resident populations that may be
disproportionately affected
Ensure effective procedures for expediting admissions and
discharges are in place
Review Incident Command Structure Planning and
Response Guides for Pandemic Influenza
Ensure visible messaging to educate public about where to
receive vaccination (not the Emergency Department), IP&C
measures, when to seek care, and appropriate home care
Ensure there is a process in place for identifying increased
respiratory activity in order to trigger plan activation based
on current guidance
October 27, 2020 Respiratory Virus Season GuidelineAppendix IV
Plan for Capacity Management, Limited Services, and Scarce
Resources
Plan for virtual appointments and review to determine essential
visits
Appropriately schedule Human Resource needs to accommodate
expected respiratory season capacity
Consider vacation planning modifications during holiday season
(i.e., Christmas, New Year’s staffing)
Ensure protocols & processes are in place to prioritize limited
services and scarce resources
Develop plans for allocating scarce resources as approved
by appropriate committee(s) (e.g., ethics)
Plan to implement adjusted staffing patterns, cross
coverage, and practices as allowed by regulation
Identify the flex beds and over capacity beds that can be utilized if
needed
Identify off-servicing opportunities within site/program that can be
utilized if needed
Identify contingency spaces where more beds can be created if
needed
Ensure all staff are aware of Capacity Action Plans and are
prepared to implement
Plan for Equipment, Supplies and Pharmaceuticals
Ensure a supply chain plan and resources are in place to meet
surge (e.g., ventilators, personal protective equipment, hand
hygiene supplies, facial tissues, swabs, transport medium,
disinfectant supplies, central line kits, morgue packs, antivirals,
etc.)
Assess stock/availability of ventilators, other respiratory care
equipment, IV pumps, cardiac monitors, beds
Implement plan to track resources
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