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Operator: Good afternoon, ladies and gentlemen. Welcome to the Ontario Safety Association for Community and Healthcare prevention and management of influenza conference call. I would now like to turn the meeting over to Ms. Kathryn Nichol. Please go ahead, Ms. Nichol.

Kathryn Nichol: Thank you, Tina. Good afternoon. My name is Kathryn Nichol. I'm a consultant with the Ontario Safety Association for Community and Healthcare of Ontario in the GTA southeast region. On behalf of the Health Care Health and Safety Association, I would like to welcome you all. Today our presentation is prevention and management of influenza. Following our presentation, we invite you to stay on the line for a question-and-answer period. Please note that the question-and-answer period is of a finite time, so as time runs out and your question is not addressed, please stay on the line and the Operator will take your contact information. I will get back to you with the speaker's e-mail address.

Before introducing our speaker, I have a few reminders for the audience. Please eliminate all background noise or discussion during your call as this will affect the audio quality. Please sit close to the microphone if you are conferencing in a large room. Please turn off all cell phones and pagers now, and finally, if your building has a PA system, please turn it down or off if possible. Okay, it's time to get started.

Our speaker today is Dr. Allison McGeer who is a microbiologist and the Director of Infection Control at Mount Sinai Hospital in Toronto. Dr. McGeer completed an Undergraduate and Masters degree in Biochemistry and went on to obtain her Medical degree at the University of Toronto. She specialized in internal medicine and infectious diseases followed by a Fellowship in Hospital Epidemiology at Yale New Haven Hospital. Dr. McGeer is an Associate Professor of Pathobiology and Laboratory Medicine and Public Health Sciences at the University of Toronto. In addition to her position as Director of Infection Control at Mount Sinai, Dr. McGeer is an infection control consultant to Scarborough General Hospital and the Bloorview McMillan Center. She serves as an expert reviewer for many research funding agencies including the Canadian Institute of Health Research, the Ontario Ministry of Health and the Alberta Heritage Foundation. Dr. McGeer also serves on the editorial boards of the Canadian Medical Association Journal, the Canadian Journal of Infectious Diseases and Infection Control and Hospital Epidemiology. Dr. McGeer is an excellent speaker and we are very pleased that she can be with us today. Welcome, Dr. McGeer.

Dr. Allison McGeer: Thank you. Okay, what I'm going to do in the next 45 minutes or so is talk about four things. First of all, give you a brief overview of influenza - and I'm going to apologize for moving fast so that we can get to the really important stuff - and then talk about as health care institutions what we can do to prepare for the influenza season, how to look for influenza and detect outbreaks early and some principles of the investigation and management of influenza outbreaks.

So here with go with influenza. If you look at the third slide, you have to have a lot of respect for the influenza virus. This is an RNA virus, no DNA, it makes exactly 12 proteins and despite that it manages to survive and infect one-sixth of the world's population every year. The other reason this slide is there is to point out to you that the two important proteins from an immunologic perspective are the hemagglutin and neuraminidase which are the things that you can see on that third electromicrograph sticking off the surface of the influenza virus. Those two proteins are responsible for the virus sticking to cells and releasing itself from them but they're also the proteins on the virus that are responsible for our immune response. It's the antibodies of the hemagglutin and the neuraminidase that we make that protects us from re-infection with influenza virus.

I apologize for the fifth slide which doesn't come out very well when you print it, but was mostly to remind me to talk about the fact that influenza virus is an infection of superficial cells of the respiratory tract, and that's got two implications. The first is that even though you get aches and pains and you feel awful with it, it's not a systemic infection, it's only a superficial infection and it is a self-limited infection so that with the exception of bone marrow transplant patients, everybody who gets influenza clears the virus in a matter of days, and the problems that we get into with influenza are in general not related to the influenza itself. They're related to the fact that that infection of the superficial cells kills the layer of superficial cells in your respiratory tract and leaves you with the loss of your major protection against invasion from bacteria and irritation that's associated with asthma, exacerbation for COPD. And the problem that we get into with influenza is not so much related to the virus itself but that the damage it does sets us up for complicating infections and asthma attacks and those are the things that make people seriously ill with influenza.

On the next slide you'll see a summary of the clinical characteristics of influenza. In general, once you're infected with influenza you start to shed the virus probably 12 to 24 hours before you get your first symptom. When you get symptoms you tend to get them quite suddenly. One of the characteristics of influenza as opposed to other respiratory viruses is that instead of having that feeling you sometimes get for a day or so that you're going to come down with something, influenza usually starts instantly. All of a sudden you feel like you've been hit by a truck, okay, and you then get fever and all of the respiratory symptoms as well as malaise, muscle aches, headaches. Those systemic symptoms are not actually caused by the virus, they're caused by your immune response to the virus, by the fact that the virus makes your body produce cytokines that then get distributed systemically and make you feel bad.

In general, by the time you've been sick for 24 or 48 hours, your body already has control over the influenza virus. The number of viruses is dropping rapidly and all of your symptoms are actually due to the immune response. The reason that's important is because we talk about treatment of influenza. Once you're past the 48-hour mark, treatment isn't going to do you any good, it doesn't matter what the treatment is like. When you hit 48 hours, your body is already killing the virus and the symptoms are related to your immune response so starting therapy at that time isn't going to help you at all, you're still going to get better and you won't get better faster because you're already killing virus.

Two other things when you look at this slide. The first is that you'll notice partway down there's a marker that says "cough". One of the other characteristics of influenza is that cough is an early symptom of influenza. With a lot of respiratory viruses, on day five or six you'll start to develop this nagging cough that'll go on. Characteristically with influenza you get the cough earlier on. And so the things that separate influenza from other viruses are sudden onset, how sick you are, how high your fever is, and the early onset of cough.

Having said that, while those are useful clues, the bottom line with clinical symptoms is you cannot distinguish influenza from any other respiratory virus in an individual person. The only way you can tell whether somebody has influenza or some other virus with certainty is to do a nasopharyngeal swab and actually look for the virus. Clinically you can't tell the difference.

On the next slide then is a list of complications of influenza and these in fact are the things that make people seriously ill and kill people after they've had influenza. The next slide, which is a picture of somebody blowing their nose, is a reminder about how influenza is spread. You would think influenza being such a common disease that we would know the details of how influenza is spread and what's really important but the truth of the matter is we don't. We know it is spread by direct contact, so that if I put my hands up to my nose, get secretions on them and touch your face, I can give you influenza. We know that it can be spread by small droplets so that when I talk or cough or sneeze and I have influenza I spread influenza in a space about two or three feet in front of me and people who breathe it in from there or if it drops onto your eyes or your nose from there, you can get influenza. We know that in some circumstances influenza can be spread by the true airborne route, meaning that all you have to do is breathe the air in the same room and you'll get infected.

The relative importance of those three routes remains unclear. There are different studies that show different things, and most of the time we know that influenza is not spread by the airborne route, it's contact and small droplets, but sometimes it is and so when you think about managing and controlling outbreaks you've got to go for stopping transmission by direct contact, stopping transmission by droplet, and when you can, trying to provide the best protection against airborne spread because it might happen occasionally.

Now, there are some interesting things about the epidemiology of influenza that we need to understand in order to understand the approach to outbreaks and the first of these is that human influenza virus only infects humans and there's no carrier state, and that means the virus must continue to infect people in order to survive. Influenza viruses are able to do that through two mechanisms. Remember I said that it's the antibodies, the hemagglutin and neuraminidase, that protect you? If influenza viruses couldn't change their hemagglutin and neuraminidase, over three or four years everybody in the world would get infected with influenza, everybody would be immune and influenza would die out, gone, finished.

Influenza gets around this problem by mutating the hemagglutin and neuraminidase proteins by slowly changing them over time and as they change them over time they manage to evade our immune system often not well enough to make us really sick if we've been exposed to something similar before, but enough to make us infected and to allow us to spread the virus. And that's slow change. One base pair in the DNA of the influenza virus allows influenza viruses to move from one to another and, when there's enough change, people will get sick. The World Health Organization has rules about how much is enough change to call it a new strain. So, in '97/'98 we had the first of a strain of influenza called A-Sydney 0597, isolated in Sydney, Australia and that changed over time to two strains, an A Panama and A New Caledonia. They're related to Sydney but different enough that we can get infected.

The second thing that influenza viruses do is shown on that next slide that has pigs and ducks and people and it's labeled "genetic re-assortment". Influenza A viruses also have the ability to have sex with influenza A viruses from birds and pigs and when they do that, okay, remember that the RNA in an influenza virus that comes in eight segments and imagine that you pick a bird influenza virus and a human influenza virus and you shuffle the segments and then sort them out into eight segments each and see what comes up. Most of the time what you get is a virus that does infect birds, pigs or humans and nothing bad happens. But every once in a while if you do it often enough you come up with a new strain, completely different from what humans have seen before because it's mostly got pig and bird proteins in it. The new strain can infect humans and when that happens you get what is called a pandemic. What happens in a pandemic is you have a completely new human strain of influenza A, nobody in the world has any antibodies to related strains because it's brand new and a lot of people get sick and people get more sick because they don't have any leftover protection from related strains.

Pandemics are such impressive events in the world that we've actually been tracking them since the 1600s, and what we know is that they come in general all around the world within a year and they occur at the shortest timeframe every eight years and at the longest timeframe every 40 years. The reason that everybody's been nervous about pandemics is because we're overdue for a pandemic. The last pandemic was in '67/'68 and there ought to be one coming soon, and when it comes of course none of us will have any immunity and we'll be really dependent on detecting it early and getting a vaccine out quickly so that people won't get really sick with it, and of course all of us are still a little nervous that we don't know yet enough about influenza to be able to predict early on whether it's going to be a mild pandemic, like the '67/'68 one, or a really bad one like the 1918/'19 one.

However, let's get back now to yearly influenza. Count on the fact that the federal government and a bunch of people in the province are working on pandemic planning and will do a good job when it comes, and come back to dealing with it every year. Although we think of influenza as a non-significant illness in general, it is in fact highly significant. If you just look at the numbers on the next slide, every year about one in six Canadians will be infected with influenza, about one in 100 people over the age of 65 will be hospitalized because of influenza, and somewhere between, depending on the year, 1,500 and 7,000 people will die. That makes influenza the single most common infectious disease cause of death in Canada. It's a little surprising to most of us. About one-third of all acute febrile ear infections are due to influenza and a very large number of work days lost accrue to influenza.

Okay. Now, the last thing about influenza before we talk about influenza outbreaks and long-term care is on these weird slides that are unlabelled and have different shades of gray, and they are to point out to you that if you're going to be worried about influenza and detecting outbreaks in institutions, you need to know about three seasons. So let's take the first slide. You see on the bottom of it there's a fairly steady line that say goes up to I think four on the Y axis where you see intermediate gray lines, and that represents the ongoing respiratory infections that occur all year. It's not nearly as common to get colds in the Summer as Winter, but it happens, and you see a steady range. And then in the Winter you get in general an increase in respiratory virus infections, adenoviruses, paraflu, rhinoviruses, respiratory superficial viruses and those numbers tend to go up in October and stay up over the Winter and tail off through April and May and then be gone for the Summer. And then layered on top of that you get influenza.

What's really interesting about the influenza season in the northern hemisphere, okay, different from the tropics, is that influenza comes reliably in the Winter but it's not all Winter, it doesn't spread itself evenly from October to May. It comes usually in a six to eight-week very distinctive season. It can start as early as the beginning of December, can sometimes start as late as the beginning of February, it sometimes stops fairly quickly and sometimes has a tail on it. So here's the 2001/2002 season this year. You can see that it was kind of an average season for respiratory viruses, and that the season started about the middle of January. Most of the influenza activity was actually in February and then it tailed off.

The next graph before that, that has the biggest black bar in December, was something like the '99/2000 season where most of the activity started in the second week of December, really peaked through Christmas and New Years and faded away in January. The third graph you see what happened in the '97/'98 season in Ontario where there wasn't very much other virus activity, and influenza started about the third week of December that year and really peaked so that in January of that year the majority of respiratory illness was due to influenza, a relatively uncommon event. Usually you still have other viruses. And then in the bottom slide from that slide you'll see that the... that's a representation of the 2000/2001 year where we had very little influenza in Canada, really... not in Canada, in Ontario, okay? Almost undetectable, and you really didn't see any distinct influenza season that you could pick off.

The reason that that's important is that when you're looking for influenza in your long-term care facility and your hospital you really need to be conscious of where you are in the influenza season. Respiratory outbreaks [inaudible] season you have to conscious of them, but they're much more likely when influenza is in season so that knowing whether influenza is in your community and where you are in the season is really important - when you're investigating, when you're looking for outbreaks and investigating them.

The other thing that you can learn from the influenza season is that, and just a reminder again about the severity of influenza, influenza is the one disease where you can track the occurrence of influenza by mortality in people, and the last slide on that page labeled "pneumonia and influenza mortality" is the U.S. Sentinel Surveillance System. What they do is they track the percentage of deaths that are due to pneumonia and influenza. Remember that most people die of the complications of influenza, so their death certificate doesn't say influenza on it. And when you do that you can see that there's a solid line in the shape of a sign wave.

That's the model expected deaths, percentages of deaths due to pneumonia and influenza. And then you see the kind of spiky line. That's the real death, that's the real percentage of deaths due to pneumonia and influenza week by week through a number of years on this graph. And where you see that spiky line go up above the curve, all right, you'll notice it doesn't happen every year, like the 2001 year it doesn't go above the curve, the '99/2000 it goes way above. Where it goes above consistently will be where you have influenza activity. So you can actually measure influenza season by this Sentinel Surveillance for mortality and it tells you how important in fact influenza is and how many people die during the Winter season.

Okay. So now let's talk about influenza. All of us are conscious of the fact that influenza outbreaks are very common in long-term care and that you need to worry about them. We have until recently pretty much ignored influenza outbreaks in acute care. But when you look for them, you will find them, and I have just summarized on the next slide some of the outbreaks of influenza in acute care that have been published in the last two or three years. And one of the things that we're finding in Ontario is we started doing surveillance for influenza outbreaks in long-term care in 1992 and 1993 and in that year there were two reported influenza outbreaks in the province. The largest number of reported outbreaks of influenza in the province occurred in the '99/2000 year. There were 338. Now, do not imagine for a moment that that was actually a difference in how many outbreaks there were. We just got good at detecting and labeling things as outbreaks and in fact in the 2000/2001 season, the first season of universal flu vaccine in Ontario, there were only nine institutional outbreaks in the province.

As we pay more attention to influenza in acute care, the number of outbreaks we're detecting in acute care facilities has also risen steadily so that there were very few before the mid-1990s and last year there were 17 in the province. We're going to see that continue to increase as we become more aware of it and more able to control it.

But I want to point out on this slide that when you do get influenza outbreaks it can really be a severe disease. You can see that on the column labeled patient ARs, the attack rate in patients, 26 to 50%. In general, these outbreaks have not reported staff illness but they're frequently there. And when you look down the mortality column you can see that it ranges from very low, three out of 77 patients, to 50 or 60% of patients. My guess would be those are outbreaks in which they didn't detect all the patient cases because it would be unusual to have mortality rates that high, but it certainly drives home the message that influenza in hospitalized patients is a severe disease and one that we need to worry about preventing.

Well, okay, so how do you protect the patients and staff of your institution from influenza? And there are I think four categories of things that you need to be worried about. The first is that you need to minimize the risk that people who are either infected with influenza or who are incubating and shedding influenza but aren't yet sick are entering your facility. The second is that when they do enter your facility you need to know that you've done what you can to reduce the risk of transmission from those cases to patients and staff. You need, when you have knowledge of communal cases, to recognize them and manage them to prevent spread. And when you do have outbreaks, because you will get outbreaks, you need the ability to detect them early and manage them effectively so that they're as small as possible.

Well, how do you minimize the risk of introduction? First and foremost of course is vaccination. And for acute care institutions that means vaccinating long-stay patients. It also means thinking about vaccinating patients likely to return. On our medical wards at Mount Sinai, 70% of patients who are admitted to those wards have had a previous hospital admission in our facility, not any facility but our facility within the last six months, okay? What that means is that when you see patients coming in in September, October and November, the chances are that a significant fraction of them will be back during influenza season and that's a very good reason for making sure that they get vaccinated while they're in your facility. Another good reason - let me tell you, we've been running a patient vaccination campaign at Mount Sinai for three years now and the patients really like it. It's very good public relations. It makes them feel loved and wanted to be offered influenza vaccine in the facility.

Obviously you need to vaccinate staff and everybody else who works in the facility, physicians who come in, volunteers who come in, contractors who come in, people who come up to maintain your computers. Although, as we said, influenza is spread by direct contact, because it's also spread by droplet, people who are in your facility who don't have direct contact with anybody also still pose some risk and the more people you can get vaccinated the better. From that perspective, of course being in Ontario and having the universal flu campaign has been a wonderful thing because it really makes it easy.

You also want to strongly encourage the vaccination of families of your long-stay patients and the visitors. They're in general pretty good about not coming when they're sick but remember that because you shed virus before you get sick, even with the best of intentions people who are not vaccinated may be a risk for the facility and so encouraging a vaccination, and one of the things that really encourages is making it available to them. Those of you who are worried about the legal aspects of vaccinating people who are not your patients or staff, the OHA actually got a legal opinion on it last year which is acceptable, and the long version of which is eight pages long and single spaced, but the short version of which is you can get into trouble if you do do it and you can get into trouble if you don't do it. So I think that with the right programs in place it's a good thing to do.

In terms of what you need to do to get staff vaccinated, I think all of us are a little frustrated about the low vaccination rates of acute care staff and I have no easy solution. There are clearly however, two approaches to what we need to do. The first thing you need is positive reinforcement for people. The belief systems and the example of senior administration and opinion leaders in the hospital is critical and staff need to know that those belief systems are there. There needs to be consistent messaging about vaccination, there needs to be adequate information about benefits and risk. You have to be completely open, but people have to be clear, and perhaps regrettably since you'd think people ought to have the responsibility for it, bribery works, okay?

So honestly, I think most people at Mount Sinai get vaccinated because we offer chocolate with it, but having prizes... partly having prizes is just to remove the barriers, you know it's a pain in the neck to go and get vaccinated. The second message about vaccinating staff is that in addition to providing people positive reinforcement you need to remove barriers, you need to make it easy for people. People mean to get vaccinated but they've got to trek all the way over to Occupational Health and wait 20 minutes. They're much less likely to do it than if you really make it available to people. And so anything you can do to make it easy for people will increase the vaccination rate.

Just a reminder. When you're losing faith and getting tired of bugging staff about getting vaccinated, there are now two large randomized control trials very clearly demonstrating that vaccination of health care workers reduces death in patients, and the first one is the table at the bottom of page 4, a study done by Potter et al in the United Kingdom, and what they did in this study was they randomized chronic care facilities offering vaccine to residents, offering vaccine to staff, offering vaccine to neither or offering vaccine to both. So you have four groups of long-term care facilities and then you can look at the effects of just health care workers or just residents. Now, there wasn't a huge difference in their facilities between... in the vaccinated residents whether or not they offered it, and you can see that they were in fact not able to detect an effect of vaccinating residents on mortality or mortality from pneumonia or lower respiratory tract infections.

Now, we know from other studies that it does work and it does have an effect. Their study just wasn't big enough to detect it. But you can see that even though in the facilities in which they offered vaccine to health care workers, vaccination rates among health care workers were only 40 to 60%. You can see that there was a dramatic effect on all cause mortality and mortality from pneumonia in the patients they took care of. And most of us in fact looked at the study when it was first published and said oh, it can't be that big, you know? And so some colleagues of these went ahead and did a second study and you can see that study, the results of that study shown in the next graph which demonstrates exactly the same thing. On this graph you can see the mortality rate among patients during the Winter season and those facilities that have sort of 12% or less vaccination of staff are facilities that were randomized to not offering vaccine and those with 20% or more are the ones where they did offer vaccine, and you can again see a very substantial effect even though they were only at 40 or 50% vaccination rate. So while we're all going for 100%, you need to have faith that even 40 or 50% is a significant benefit and that the effect size is so large that we must keep working at vaccinating our staff and getting the uptake, and I am.

I think what you need to remember is that getting people to develop preventive habits is a long-term thing. It doesn't happen overnight and I was at a talk about introducing public policy by Ted Beaudoin who said that the first thing that he was involved in was the introduction of seat belts. And those of you who are old enough remember that when seat belts were introduced that everybody knew somebody's brother's cousin's best friend who was only alive because they had been thrown out of the car and weren't wearing their seat belt, and the car manufacturers said that if seat belts became mandatory people would stop driving cars. And where are we, right? We all wear our seat belts now. But it took 20 years to get there and influenza vaccine is going to be like that. It's not going to be an overnight thing. A degree of patience is necessary.

The second thing that seat belts brings up is also that we are going to have to come to terms with whether we're willing to make vaccination mandatory for health care workers. Everybody's temptation is to say that we shouldn't do it, that mandatory is bad, but I need you to take a deep breath and think about why you wear your seat belt. Because most of us wear our seat belts substantially because it'll protect us but also partly because we'll get fined if we don't. And we're going to have a choice with influenza vaccine. Either we're going to make it mandatory so that we know everybody will get it, even if people approve of it and before you can make it mandatory we're going to have to persuade most people that it's a good thing. But if we don't make it mandatory we are going to be left with a fraction of people who don't do it because it's just a pain in the neck and they'll get to it, okay, which is what we do with preventive things. And we as a society are going to need to make a decision about how important this is to our patients.

Okay. So now you've gotten past doing everything you can in the way of vaccination. What are the other things that you can do to minimize the risk of introduction? The first is visitor restriction. Now, you're not going to do that all year but when you are, when influenza season starts you may well want to think about restrictions for ill visitors to keep them out of the facility, and if you're in a small area and have a local paper that you can use or other mechanisms of being in touch with your community, that may be an effective way of keeping ill visitors out. You also want health care workers who have influenza not to work in your facility and this is really difficult because if you send everybody home with the sniffles then nobody will work at all. And of course if everybody's vaccinated, then the chance that they have influenza is very low and you probably don't need to be worried about it. But in the in-between it is not... some hospitals have made workable a plan that says during influenza season, again, okay? So again this is something you want to have a switch for that says once influenza season starts that health care workers report respiratory illness to occupational health, that a rapid screen for influenza is done and that if they have influenza that they don't come into work for the period of time.

Now, you're going to say well, you know, rapid influenza screens are not 100% and all these other things, but remember what we're doing is dealing at a population level with reducing the overall risk. And what that policy will do is it'll pick off the people excreting the highest concentrations of influenza virus because those are the people with the positive tests, and keep them out of your facility for 48 hours. And hospitals that are using this have said that it is workable and they have succeeded through... how it's not one thing but through a combination of things in reducing nosocomial transmission. Okay.

Now, once you've minimized the risk of introduction, you want to make sure that when it does get introduced that you'll minimize the risk of transmission. You know this about … [transcription tape flip] … discussion about minimizing transmission, so hand washing, but the truth of the matter is that if you look at the next slide, the table with impacts on hand hygiene and infections and look at the bottom three studies, there's a fourth one now that I just haven't gotten to add into the slide, that we now in the community and in the army base we have a good demonstration that disinfecting your hands routinely five times a day reduces respiratory illness by 30 to 35%. There's no reason to believe that we don't get the same benefit in hospitals. And that means that the... the hand washing for other things, but alcohol hand wash outside every door in your inpatient... and perhaps a thought about the fact that the beginning of influenza season might be a really good time to do your hand washing in services and your reminders about hand washing.

Now specifically with reducing influenza, the other thing you want to be able to do is to identify infected patients during influenza season and there are two things you need to do that. One is to have rapid testing organized and available in your Emergency Department and staff there trained so that they do the tests on people with respiratory illness who have been admitted, and secondly having a system between the facilities in the area and the public health units about outbreaks so that when people are transferred to you, you know that they're coming from a facility that has an outbreak of influenza and you can put them in isolation. For infected patients you want to make sure that they're on.. I'm sorry, this says droplet, it should say droplet and contact precautions which is a mask and gloves when you're within three feet of the patient, and preferably they should get a private room. This again is that issue of there is a potential for airborne spread, and within a two or four-bed room patients may also get within three or four feet of each other so there is a risk, and if you can do a private room it's obviously a benefit.

Generally, you want three to four days of isolation. The alternative is to stay until their NP swap is negative for influenza but that for most of us is too much lab testing and is probably only necessary for people who are severely immunocompromised or neonates. If you just look at the next slide labeled duration of shedding, you'll see that the sicker and older you are, the longer you shed influenza virus. So that healthy adults shed it for three or four days usually, and as you become older or younger, the extremes of age, you can shed for up to seven days. Neonates [inaudible] can shed three or four weeks and similarly HIV patients, transplant and leukemia patients can shed for many weeks. So those patients you're going to do serial NP swabs until you're convinced they're negative. Most older and chronically ill adults have been ill for two or three days before they come into the hospital with their influenza and so if you say three or four days on top of that you'll generally be at about seven days and it'll be safe to take them out of isolation at that time.

All right. Now what do you do about preparing for outbreaks? Okay. The first thing you need is a set of policies that cover a list of things, okay? First re-offering staff vaccines during outbreaks. Remember that having one outbreak does not protect you from having another outbreak. And secondly, that outbreaks are an opportunity for staff to get their first vaccine and once people have had it once they're much more likely to get it again. So every opportunity you get, including outbreaks to move to ratchet up the number of people who get vaccinated is a good thing. You need to decide ahead of time what antiviral you're going to offer patients and staff and who's going to pay for it and how it's going to be ordered. You do not want to be doing this on a Friday night of a long weekend which is always when outbreaks happen, right?

And you need to have a medical directive for an antiviral order, okay? And long-term care facilities may have a limited number of physicians that can deal with it although you don't want to anyway, but in hospitals you do not want to have to be contacting every physician to get an antiviral order. You want to have a medical directive that says this is the antiviral we're going to use, this is the person who's going to decide, this is the person who's going to write the order so that you can get it down. And in an outbreak, four or six hours makes a difference to how many people get affected and so you really want to do it and you want to make a decision about work restriction for staff so that you can talk to staff about it and everybody knows what the rules are going to be when there's an outbreak. In those circumstances the labor relations board will support you, your staff will support you and you won't get into trouble either during the outbreak or afterwards about how it's going to be.

The second thing about preparation and I've already alluded to it a little bit and that's about communication, okay? All of your staff and your public health department need to know what your policies are going to be and you can talk beforehand to unions about why they're going to be that way. You can't have too much information for staff, patients and visitors and the more information you have for patients and visitors the fewer questions staff are going to get asked. So having a bunch of pamphlets ready to go that you can give to patients and visitors is enormously useful. You want to be able to rapidly identify vaccinated and unvaccinated staff, okay, so that on Friday night after occupational health has gone home and when your infection control practitioner is on holidays somebody's got to be able to decide who can come to work the night shift and who's okay to work in the morning. And you also need to be able to go back. Okay, now that you've got an influenza outbreak, it always started two or three days ago and in my hospital that means at least 15 patients have been discharged and half of them have gone to other institutions, okay, and you really don't want to be exporting your outbreak to other institutions. So you need to have a mechanism that allows you at any time to be able to pick up the phone and say okay, who got discharged and where did they go so that you can protect other institutions that you share patients with.

All right. Now, how do you detect outbreaks when they happen? Okay. Firstly, you obviously want to be watching all the time but you really do want to increase people's threshold when... decrease people's thresholds when the season starts. And so that overall you're going to be looking for acute respiratory illness in patients and clusters of respiratory illness in staff. There's going to be some background in staff respiratory illness. And people are divided about whether you should do it for nosocomial infections, whether you should do NP swabs on everybody who gets a nosocomial respiratory tract infection or whether if you're good enough at detecting them that you can wait until you have two people and then swab those people. I don't think there's a clear answer to that. From my perspective in my hospital the number of nosocomial respiratory tract infections is low enough and my ability to actually get swabs on everybody is not perfect, so that we have a policy that says everybody gets a swab which doesn't quite capture everybody but I think is probably on balance less expensive in the long run than having to deal with outbreaks.

When you get the... there are a bunch of triggers for enhanced surveillance and looking more carefully and the first is one nosocomial patient with influenza, the second is two patients within 72 hours who've got the new onset of hospital-acquired respiratory illness and the third is two or three staff who work together who report acute respiratory illness. In that setting, what you need to be able to do is immediately get NP swabs on staff and patients with illness, relatively easy with patients, a little harder with staff. But you need to know whether that's the season's influenza. The second thing you need to do is look for additional cases. Generally when if you get... sometimes if you really get two acute respiratory cases in patients, there's two acute respiratory in patients, but usually it's three or four actually and almost always there's more staff than you know about because staff are just in the facility all the time and they don't necessarily think to report. So there's usually additional cases that you've missed and this is the time when you need to pick up the phone and tell public relations and senior admin that you've got a potential problem and you're watching it and people need to be ready to kick in and do something about it.

And then you're going to be looking for the next cases to confirm whether or not you have an outbreak and the definition of an outbreak for influenza means you have at least three episodes of acute respiratory illness and remember since most elderly people are vaccinated now that when you start making influenza-like case definitions for them, it doesn't work. Okay, so you have to go for... in fact, in most facilities the case definition is fever and... either fever or a respiratory symptom or any respiratory symptom without other explanation and it's fever without any explanation. If you've got a group of young composite patients, okay, so if you're running... oh, doing hernia operations or knee surgery, okay, where people could tell you about their symptoms and they're young and healthy, then you can afford to go with a more influenza-like illness definition. But on floors that have older medical patients you've just got to go with any respiratory symptom as a case definition.

You want at least two positive tests for influenza because as long as you only have one test, you don't know that the illness is really influenza. You haven't got documentation of transmission. As soon as you've got two positive tests, you know you've transmitted influenza and you need to be moving into place to stop the transmission of influenza. And there are some circumstances where you may go with even no positive tests. One in particular in my experience had an outbreak in a long-term care unit right at the peak of the '97/'98 influenza outbreak. No other respiratory illnesses out there, a bunch of unvaccinated staff who felt really awful, okay, a very acute rapid onset of illness in multiple patients and when we did the NP swabs and sent to the lab the lab said we've run out of rapid tests, we won't be able to do them for you.

In that circumstance your risk of it being influenza is so high that you might even go with it, and certainly there are circumstances where one test when you know it's going outside should make you decide it's an influenza outbreak, but in general you will be able to have a number of tests and remember that the sensitivity of these tests is not perfect, so you want to aim for testing four or five patients knowing that even if they all have influenza only three of them are likely to be positive.

Okay. So now you've got an outbreak. What do you do? The first thing you have to do is you have to figure out what the area of the hospital and the time period that you're talking about, how long as this been going on, when do you think the first case happened and how big is the area. Then you need to think about closing the unit, you need to think about identifying staff and patients who might have taken it to other hospitals, you need to stop transmission on the unit and you need to have set up surveillance so that you know how effective your management has been. Okay. Well, what do I mean about defining areas of the hospital involved?

The experience that we have in long-term care facilities is that containment to a single unit is very difficult in long-term care. Often acute care will be different. Our units tend to be more isolated in acute care but the critical issue, okay, is how many staff you share and how much patient movement there is back and forth. And in teaching hospitals, house staff are a particular problem, okay, they're out there everywhere, they see each other socially and they go to classes together and so it's really hard in teaching hospitals to isolate units. In other hospitals it sometimes can be... if you're going to declare it on a single unit, you need to really be working in enhanced surveillance on other units so that if you have...it has been transmitted to another unit with a respiratory therapist or one of your physicians or any of the other people that go unit to unit that you'll pick it up early and be able to add that unit and control it without getting into trouble.

And you need to go back remember and because you're going to be talking... you've got to define which healthcare workers are exposed and might be incubating disease. You need to know when you think the first case occurred. So you really need to invest some time in looking at patients and staff and trying to decide whether you're going back one day or two days or four days looking for cases.

The next thing you've got to think about doing is whether you're going to close the unit, okay. This is never an easy decision particularly when you have people backed up in Emerg, but what it really means doing is saying what's the safest thing for managing patients. Okay? The first important... is if closing means you're going to send staff to other units in the hospital, don't do it, okay, because it's staff getting ill that's going to get you into trouble with spreading to other units. Okay? Now, and in general closing the unit makes it easier to contain the outbreak, it means it's going to be over sooner, you can stop worrying sooner, and it is the safest thing to do for patients that are not currently on that unit. However, it is also not really good to be running inpatient hospital care in the corridors of your emergency department, okay? So you need to think about how you can do that and if you can't close the unit, okay, what you want to be able to do is start all newly admitted patients on prophylaxis when they come up to the unit protected from influenza. You want to cohort those [inaudible] group of patients on the unit who've been exposed who may get sick, and if you can both physically and by staff separate them from new patients coming in so that new patients in general are cared for by different staff than old patients and they don't share rooms, and that you put those new patients coming up on droplet precaution. That protects, may protect you from them but it also protects them from you so that if staff are going to come down with it these patients won't get sick.

And then worrying about cohorting staff who work on multiple units, so keeping the potentially exposed staff who work on multiple units away from them. So there are ways that you can leave wards open and protect patients but you really need to make a conscious decision that the risks of closing that unit are greater than the risks of keeping it open. Okay. The next thing you need to do is make a list of staff and patients who may have taken the influenza already to other hospitals okay, bad enough dealing with it in your hospital, sending it to others is bad and that means letting other institutions know about recently transferred patients. Preferably their infection control practitioner just because it's more efficient, okay. If I pick up a phone and call an infection control practitioner and say I discharged this patient on this day, they were exposed to influenza from this day to this day, then their infection control practitioner can deal with the whole thing and it just saves you a bunch of trouble.

The second thing you want to do is communicate with unvaccinated staff who worked since the first exposure because they may be starting to get sick and you really want to get them on prophylaxis before they get sick. There's certain groups of people who say that if they didn't get vaccinated that your obligation to protect them is limited. Nonetheless, you want them well and you want them working and the sooner you can get in touch with those staff and get them on prophylaxis whether or not they're going to be working, the more likely you are to protect them from illness and be able to keep them on staff. Okay.

Number four - you need to be able to stop transmission and stopping transmission means droplet and contact precautions for symptomatic patients, private rooms if you can, cohorting symptomatic patients where you can do it, okay. All of this is the best you can do under the circumstances. You want to make sure that if you've got wards that have shared activities that you cancel those shared activities, that you stop transfers off the floor even if you're not... even if you're opening the floor to new admissions. What you don't want is to be sending patients to other floors or to other institutions unless they're going in isolation and people are confident they can handle them. And then you want to think about whether you're going to restrict tests or not. Mostly you don't have to, mostly you could send people down and precaution... but there may be circumstances where you have a large number of people ill where you really want for 48 hours just to make sure that you've stopped the situation and if you're not medically interfering with care then you may want to think about doing that.

Your next challenge, okay, is to classify patients, okay, and this is because you're going to give them antiviral prophylaxis and what you have to do is you have to look at every potentially exposed patient and put them into three categories, okay. Category one is people who have been symptomatic for more than 48 hours. Those people need to be in precautions generally for seven days after the onset of illness if they're elderly and have chronic illnesses, but it's no good giving them treatment, and they obviously don't need prophylaxis, okay. The only thing you need to think about is if you've got to mix something going on or if they just have a fever and you don't know whether it's influenza, you may want to offer them prophylaxis. If you're going to do that, as we'll come back to in a moment, you want to make sure it's Tamovir and not [inaudible]. We'll come back, okay? The second category of patients is patients who have been sick for less than 48 hours and those patients need to be in precautions until seven days after the onset of illness and they need treatment, okay, and the earlier you... treatment is not wonderful for influenza, but it's better than no treatment in terms of reducing the day symptomatic and reducing the risk of complications, and again if you're going to treat you only use a neuraminidase inhibitor for treatment and for hospitalized patients. Functionally that means at the moment also Tamovir. The zanamivir works perfectly well but it's hard to administer to elderly people because it's inhaled. Okay? And then your patients who are not yet ill, you want to get on prophylaxis. And you want to do that fast, okay, because the purpose of this is to get people on this before they're sick.

Now, why am I talking about [inaudible]? Okay. From the acute care hospital perspective there are a number of... our hospital has made the decision that we're only going to be using oseltamivir and here's why. First of all it means we only have to write one policy because amantadine is not effective against influenza B. All right? In the setting where you have influenza B you've got to use oseltamivir. Secondly, it's a single dosage regimen and there's no interactions and you only have to adjust if people have a creatinine clearance of less than 10 mls per minute and even then if you make a mistake it's not serious, okay.

In long-term care facilities you can afford to measure creatinine clearances ahead of time and look at their medications and everything but at acute care facilities the turnover is too high. It takes hours to do that assessment adequately, okay? I once did 45 patients in a long-term care facility. It took me five hours to do it. Okay? Get all their tests. Five hours is not what you want to lose, okay?

Number three, oseltamivir has a very high toxic to therapeutic ratio. Amantadine errors can kill people and the setting of an outbreak on a weekend when staff are sick and patients are sick and everybody's stressed, somebody new in a long-term care facility in Toronto got 10 times the dose. Amantadine comes as a liquid and it's easy to make mistakes with a liquid and you're going to have a bunch of people on a bunch of different doses. Long-term care facility staff tend to be used to that because now that we've all had influenza outbreaks before and you can get good at amantadine with practice. Acute care facility staff don't have practice, okay?

Fourthly, there are relatively few side effects in patient populations. Nausea and vomiting is the common side effect of oseltamivir and it is more common in younger people and women, okay, so that staff get nausea and vomiting from oseltamivir but patients get it much less commonly. And whereas amantadine has a substantial number of generally not serious but relatively annoying side effects, so oseltamivir is easier. And lastly you don't have to worry about resistance, okay. When you treat people with influenza with amantadine there is a risk, very easy for influenza to develop resistance and so you don't ever in a setting of a outbreak if you're using amantadine prophylaxis you don't want to use it for treatment, okay? So one of the options is when you treat patients you give them oseltamivir. When you prophylax patients you give them amantadine. It's a little less expensive but I think from an overall hospital perspective because the time involved to write and calculate amantadine prescriptions and make sure you're doing it right, honestly it's just better to spend the money on oseltamivir.

So if you do decide to use amantadine, there are a bunch of very strict rules about how to use it, okay? You must calculate creatinine clearance based on gender, weight and serum creatinine, okay? I was stunned and amazed to discover how many under-65-year-olds in my facility have low creatinine clearances and were at risk, okay, and so you can't do that. Just worry about over 65, but not under 65. You have to do it for everybody. You have to assess chronic illnesses and medications for interaction and the risk of adverse effects, people who've had recent seizures, people on [inaudible] problems with amantadine and shouldn't be using it. You must not treat symptomatic patients because of the risk of resistance and you shouldn't give as prophylaxis to people who want to prophylax because you're not sure whether the illness might be influenza because if their illness is influenza then you're going to put people at risk of infection and you must watch for neurologic adverse effects when you give it even when you dose it appropriately and carefully and follow the guidelines, you still sometimes get neurologic adverse events and you have to be watching it and ready to stop it.

Okay. Now what are you going to do with staff? Again, you want to classify into vaccinated and unvaccinated. If they're vaccinated they're fine. If they're unvaccinated you've then got to think about whether they've been exposed or not exposed. If they've been exposed you want to get them onto prophylaxis right away before they get sick. If they haven't been exposed you want them to get on prophylaxis when they come into the facilities, you want them started before they have contact but you can wait until they come in to pick up their medications to be able to do that. And you want to make sure that you offer unvaccinated staff vaccine again, as I said before.

Now, people who are unvaccinated and refused prophylaxis. If they are unexposed you can write a policy that allows them to work elsewhere but remember you don't want them up there going into their locker and mucking about off floor where you're having transmission of influenza. If they've been exposed, they can't work anywhere until 96 hours after they've been exposed because the last thing you want is to send them somewhere else in your facility to start an outbreak somewhere else. Okay? It's also important to remember when you're dealing with an outbreak that outbreaks in hospitals occur in a setting of enhanced community activities. If you've got a bunch of staff who are unvaccinated, okay, and you take them and you then load up another unit with unvaccinated staff, what you're going to do is increase the risk of an outbreak on that unit because those unvaccinated staff might get infected in the community and bring it into the hospital. So you need to be a little conscious of shifting the staff around in the hospital.

Generally restricting visitors overall is really based on nursing need. In outbreaks people tend to have a lot of questions and if nursing staff are already overloaded you may want to restrict visitors to reduce the load on nursing staff. But it doesn't really help to restrict visitors other than for that reason. And then finally you need to coordinate with public health about discharges. You want to make sure that people who are going home are aware of their illness and probably that they take oseltamivir when they go home if they've been exposed so that they don't get sick. And then you need to negotiate with other institutions and public health when it's safe to discharge patients. We used to say absolutely the outbreak has to be over. In general most of us... we have bed demands that won't tolerate that and we know now that if transmission has stopped and if people are on prophylaxis that it's safe to transfer them to other institutions, so it ends to be a one on one thing. But you usually don't have to wait until the outbreak is completely over to start freeing up beds and allowing things to function.

And finally then you need to worry about when it's over and in general what you're going for is you can say it's over one full incubation period after the last infectious cases in the facility which is usually that people are infectious for about four days. So in general it's about eight days after the onset of the last case. But again that can change a little bit and you're always of course going for the shortest possible time you can declare it over, traded against the risk of restarting the outbreak if you're wrong. So you need to think about that and try to go for the shortest safe time.

So there you have it. Influenza is very common. We're increasingly recognizing it as a cause of hospital-acquired infection and we know from [inaudible] that investing in prevention and management of outbreaks reduces patient morbidity and is also cost effective because of absenteeism for hospital staff.

Kathryn Nichol: Okay. Thank you, Dr. McGeer. Tina, we're ready now to turn it over to you for questions.

Operator: Thank you. We will now take questions from the phone lines. If you have a question please press 1 on your telephone keypad. If you are using a speakerphone please lift the handset and then press 1. If at any time you wish to cancel your question please press the pound sign. Please press 1 at this time if you have a question. There will be a brief pause while the participants register for questions. Thank you for your patience. Our first question is from Diane Peach. Please go ahead.

Diane Peach: Hello. I'm just wondering, if you have staff that are unvaccinated and they're on prophylaxis either amantadine or Tamiflu, when can they safely come back to work in a long-term care facility?

Dr. Allison McGeer: If they haven't been exposed in the outbreak they can be back any time. You know, some people have rules that say you want to give them two or... to minimize their risk of disease you want to get it to them two or three hours before they start because that makes sure that they have serum levels. But in general the risk is low and the logistics of getting it to them three hours before they start is frequently impossible. So from my perspective for people who haven't been exposed, as long as they start on it, you know, the moment they walk through the door there is an incubation period and they will be adequately protected.

Diane Peach: Great.

Dr. Allison McGeer: Staff who have been exposed and go on prophylaxis, remember that they may be incubating disease and even on prophy... once you, if you start, you know, what we call prophylaxis, when it's really treatment because they've been infected but they're not yet symptomatic, is not 100% effective. So the first thing is that they need to know that if they get any symptoms they, you know, it's do not pass go, do not collect $200, get out of the facility. Okay? And for the first... in general if you're going to get sick you'll get sick in the first 48 hours that you're on prophylaxis. So they need to be specifically warned about that. So now having said that, from my perspective it really... they're a risk for 48 hours. They're a relatively low risk because they're on prophylaxis and I personally am willing... you know, we have evidence that you can control outbreaks and it's not an unreasonable risk to take. But whether they start... you know, so taking their, starting on prophylaxis four hours before they come in is good because then they only have 44 hours to go, okay, and eight hours is better and 24 hours is better than that. But again I have to say I'm a little uncomfortable with this rule about three or four hours because really they continue to be a risk for the 48, only when they're not symptomatic at 48 hours that you can really breathe a sigh of relief and say it's okay with those staff.

Diane Peach: Okay, wonderful. Am I allowed two questions or only one?

Kathryn Nichol: I guess you can have two.

Diane Peach: Okay. What is the risk of the vaccine for pregnant women staff?

Dr. Allison McGeer: The vaccine is absolutely safe for pregnant staff and pregnant staff want it and they want to take it for two reasons, okay? The first is that there's now an American study that demonstrates that women in their second and third trimesters of pregnancy are at significantly higher risk than the general population of hospitalization due to influenza. That's probably a function of the fact that you... it may be a degree of immunosuppression that you get when you're pregnant, it may also be just there's this large thing squashing your lungs, right, and your lungs don't function, but there is evidence that late in pregnancy influenza is bad for you. The second reason is that we also know that infants less than one year of age are at very high risk.

In one American study nearly one in 100 infants under the age of one were hospitalized due to influenza. Okay? We've kind of ignored it but it's there. And in the... so you can vaccinate at six months but for the first three months of life, remember that your protection comes from your mother's antibodies. So being vaccinated against influenza will protect your child from getting sick if your child is born during the influenza season. So people who are pregnant in fact should be vaccinated. In general, I suggest that they wait until they're past 12 weeks, okay, and that's not because it does anything bad but only that if you have a miscarriage you always worry that it was something you did. It doesn't matter what it is, okay, you always worry, and so if people.. I'll gladly vaccinate people at less than 12 weeks because I know it's no risk. But it's also, you know, there's no circumstance in which you can't wait until after 12 weeks when I'm pregnant, right, because you've got two or three months in which you can vaccinate people. And so generally once you get past the high risk of miscarriage then you no longer have to worry about feeling guilty about it.

Diane Peach: Wonderful. Thank you very much.

Operator: Thank you. Our next question is from Donna Kansy [phonetic spelling]. Please go ahead.

Donna Kansy: Hi. My question is your recommendation for the prophylaxis for staff. Is it the amantadine or the Tamiflu?

Dr. Allison McGeer: What we've decided to do in our facility for Prophylaxis for staff is offer people a choice, okay, because amantadine, zanamivir and... in influenza A outbreaks amantadine and oseltamivir and zanamivir are all equally effective and people may have different preferences for side effects okay? Some people don't like taking inhalers. Zanamivir has no side effects but you have to figure out how to take [inaudible] inhaler. Oseltamivir has a 5 or 6% rate of nausea and vomiting. Some people don't mind that, it drives some people crazy. Amantadine you tend to get dry mouth and sometimes insomnia and difficulty concentrating. But they're all equally effective and so I don't have a... you know, there's kind of no reason to prefer it. Now it may be easier to be doing one thing with a group of staff and in that setting I think in general most [inaudible] but you know because people are health care workers and may have different preferences, I'm... we're still going to try to offer people a choice.

Donna Kansy: Hello? Yes, that's fine. Can I ask another question?

Kathryn Nichol: Sure. Go for it.

Donna Kansy: Okay. You talk about the transmission being contact and droplet, but there are circumstances for airborne transmission. What would be those circumstances?

Dr. Allison McGeer: That's an excellent question. I wish we knew, okay? You know, the evidence that it's airborne comes from... the most graphic evidence of airborne comes from an outbreak on an aircraft that landed temporarily in Nome, Alaska, okay, where there was nothing, because of engine trouble, okay? So it was on the tarmac for four hours and a few people got out of the plane and a lady sitting at the front of the plane came down with influenza during that stopover, okay? And then they flew on to wherever they were going and three-quarters of the people on that plane got influenza within the 48 hours after that. This lady did not leave her seat, she clearly didn't have either droplet or contact with most of the people on the plane, but the only people who didn't get sick were the people who got out on the tarmac and walked around for three hours. People who stayed on the plane got sick. That must be true airborne spread. It's very hard to argue with.

Nonetheless, we know that in most circumstance... and the other reason to believe in airborne spread is that occasionally in nursing homes you get these really explosive outbreaks okay where 20 people get sick within 24 hours, okay? Droplet spread just doesn't explain that in most circumstances. You can't explain that on droplet spread. Nonetheless, in most circumstances in hospitals we admit people with influenza, we may or may not get them into precautions. Usually nothing bad happens. And if it were true airborne spread at that rate all the time, we'd be in much worse trouble. So it really remains a mystery. And nobody knows what the circumstances are in which, you know, whether it's very rare and it just has to be, you know, exactly the right combination of something or whether there's an element of it that occurs more commonly.

Donna Kansy: Okay, because in our hospital we've traditionally been using airborne precautions and I'd like to continue with that but are you recommending that that would be okay then?

Dr. Allison McGeer: I think you should... if you have been using airborne precautions and you have enough rooms and they're working, perfect. Okay. Most of us don't have enough airborne rooms, airborne isolation rooms to be able to manage all influenza patients in airborne precaution.

Donna Kansy: We don't have negative pressure rooms by any means but we do keep the door closed, etc., etc. That's about as good as it gets.

Dr. Allison McGeer: Yeah, and I think that's... I mean that's really the reason for wanting people in private rooms and if it's... I'll certainly put people in the negative pressure rooms if they're available. It's just mostly our negative pressure rooms are filled with people with TB and we don't have the opportunity for it, and we don't have good evidence at the moment that airborne precautions significantly increases your protection, okay? Now part of it is we haven't really been looking very carefully at outbreaks and it might actually be true it does, but I think the evidence... and you'll notice that if you... if you read the CDC guidelines the CDC guidelines do not say airborne precautions. They say droplet contact and a private room if possible and that's precisely because it appears that in most circumstances it's not spread by the airborne route.

Donna Kansy: Okay.

Dr. Allison McGeer: Fred Hayden however, who's the guy who knows most about influenza in North America at the moment, will tell you that you really ought to have people in airborne precautions. So you know, I think it's one of those circumstances where you do the best you can. If you can achieve airborne precautions, brilliant. If you can't, private room.

Donna Kansy: Okay.

Dr. Allison McGeer: If you can't do that, cohort.

Donna Kansy: Cohort in droplet then?

Dr. Allison McGeer: Sorry?

Donna Kansy: Cohort in droplet precaution?

Dr. Allison McGeer: Always droplet and contact.

Donna Kansy: Okay. We have cohorted and had airborne precautions signed up simply meaning keep the door closed.

Dr. Allison McGeer: Yeah.

Donna Kansy: [inaudible]

Dr. Allison McGeer: I guess why I'm against calling it airborne precautions when you don't have a negative pressure room because I think it confuses people.

Donna Kansy: Okay.

Dr. Allison McGeer: If you put somebody in airborne precautions when the room isn't negative pressure then they're like to think when they have a TB patient or something that as long as they put them in a private room and close the door it's okay when it's not. So now I think you might...so you know then you get into this real trap because then you could have an influenza precautions, okay, which is private room, close the door, and it's always a trade-off as to what level of specificity, you know, complication versus specificity.

Donna Kansy: Okay.

Dr. Allison McGeer: But I'd be unhappy about calling something airborne precautions when you're not using a negative pressure room.

Donna Kansy: Okay. Thank you.

Operator: Thank you. Our next question is from Janet McLean. Please go ahead.

Janet McLean: Have there been any cases of influenza this year in Ontario?

Dr. Allison McGeer: There have been. There has been two long-term care facility... well, that I know about. There have been two long-term care facility outbreaks, one in Peel Region and one in Perth in the beginning of October and there is currently an outbreak in a private school in York Region and there has been a couple of other isolates. None of that is at the level of... you know, it's like every time you heard an outbreak at the beginning of the season you think well, you know, is this the first swallow that doesn't make a summer or the third swallow that does. So far there's some activity. It's all influenza A, it's all vaccine strain so far. But it's not sufficient that I... you know, I think one of the things that happened was we used to be not very good at detecting outbreaks in long term care and so when you got your first outbreak in long term care that was usually at the beginning of the season. But now that we're really good at detecting them you do the tests... there are some of them kind of all year round and there are always one or two in September and October and every time it happens we kind of hold our breath thinking you know, is this it? But there's not enough activity to say that the season is starting yet but there has been some.

Janet McLean: Thank you.

Operator: Thank you. Our next question is from Danielle Rasalle [phonetic spelling]. Please go ahead.

Danielle Rasalle: Hi. Excellent presentation by the way. My question to you is I'm in a community with home health care, nurses, home support, etc. Where can I find information about establishing policies because often the population of workers that we have have dual employment in outside institutions. And that's difficult to track.

Dr. Allison McGeer: Yeah, it is. And I don't know that there are policies anywhere.

Danielle Rasalle: Okay.

Dr. Allison McGeer: This might be a good time to talk to the Ministry however about thinking about policies for home care. They are interested in the area in general and they've written some ARO policies for home care. And you know now that we've had a couple of years experience with the universal campaign and looking at vaccinating health care workers, they might well be amenable to getting a group together and starting to talk about how to write policies for home health care. I haven't seen any from any other jurisdictions. One of the problems in Ontario is that we're ahead of most other people with influenza and that's a bit of a problem when you're looking for outside help.

Danielle Rasalle: Okay, perfect. A second question: What's the alternative for the people who cannot receive the flu vaccine?

Dr. Allison McGeer: For people who can't take flu vaccine?

Danielle Rasalle: Yes.

Dr. Allison McGeer: The first thing to know is that there are three different flu vaccines licensed in Ontario so that some people who cannot take one can take another and that needs to be assessed. And there's probably going to be a fourth on the market next year. And the second thing then is to look at how high their risk of influenza is because your choices for protecting people who can't be vaccinated from influenza are kind of threefold. The first is to say that you know, a risk is a risk and you'll do sensible things. You'll wash your hands five times a day, you'll make sure that you wash your hands after coming into contact with... avoid close contact with people who are symptomatic, and the mid range which is I guess we're thinking about probably not very sensible is to say you'll do that and if you have a non-exposure to influenza you'll take prophylaxis. I think the problem is that most of the time you're not going to know that.

Danielle Rasalle: M-hm.

Dr. Allison McGeer: So the other option in somebody who's really high risk is to give them prophylaxis for the influenza season so that when you know the season is starting in your area you start on prophylaxis and you continue to take it until influenza is gone. That's about $400 worth of drugs for oseltamivir and about $150 for amantadine and so you really got to be sure that it's worthwhile, but [inaudible] tells you to consider it and you should consider it. The other thing, remember about at risk people who can't take flu vaccine, vaccinating their contacts is more effective than any of those things at protecting them.

Danielle Rasalle: Okay.

Dr. Allison McGeer: If you work in an office that has somebody who's high risk and can't take flu vaccine, all of their co-workers should be vaccinated, their household contacts, other people who have close contact with them is more effective than any of those other things at preventing illness.

Danielle Rasalle: Okay, thank you.

Kathryn Nichol: You know, Dr. McGeer can take one more question.

Operator: Thank you. And we do have one further question from Sally Lloyd. Please go ahead.

Joanne Burt: It's Joanne Burt here from Bowmanville. I would just like to ask with the new sort of pandemic, a re-assortment strain coming, and we're pushing the flu vaccine telling them it's going to protect people, is there not a worry that the people that we convince to take this who then get sick because we face this all the time, now people get sick after... when they've had the flu vaccine, that we're going to really alienate people after this?

Dr. Allison McGeer: I don't think so. I think the risk of people not getting vaccinated now because they get sick after their flu shot is real and we need to do a lot of work educating people about the fact that you can't tell within yourself, you can't tell by measuring your own illness whether the flu vaccine is working or not. We've been working really hard at it in our institution and it's beginning to pay off. People are starting to be able to say that the fact that I got sick this year after my flu shot doesn't mean the flu shot didn't work, okay. That's a... I think we made a... it was probably an unintentional mistake but you know, we screwed up in what we told people about flu vaccine and flu-like illnesses. I think when the pandemic comes it's going to be big enough and obvious enough and different enough that I don't think people will be offended by the fact that... remember, what we're aiming for, right, is we're going to get them to take another vaccine and with luck we're going to have enough warning and the vaccine is going to be made and we'll get at least one dose of the vaccine into people before the first wave of a pandemic hits. And so I don't think in that setting that... I think it'll be easy enough to be clear that the pandemic is different, that we'll be okay. But I think you're absolutely right about the issue now about as we start to vaccinate people the risk of losing people because they get vaccinated one year and they get sick after, it is real, and it’s something that we've got to work really hard at for the next few years if we're going to be able to make this program work well.

Joanne Burt: Thank you.

Operator: Thank you, and at this time there are no further questions registered. I would like to turn the meeting back over to you, Ms. Nichol.

Kathryn Nichol: Thank you, Tina. At this time I'd like to thank Dr. McGeer for taking the time out of her busy schedule to speak to us today. I'm sure we can all agree how valuable it is to get current and expert information from a leading professional in the field. Thank you once again, Dr. McGeer. This concludes our presentation today. But before we end, I would like to remind you that our next teleconference will take place on Tuesday, January the 21st, 2003. Jean Wilson of St. Michael's Hospital will be presenting information on tuberculosis. Please check the December 2002 newsletter or contact Kristyna Kerekes at 416-250-7444, Extension 139, for more information. I thank you for joining us and I wish you a safe day.