Guidelines for preventing respiratory illness in older adults aged 60 years and above living in long-term care

March 28, 2020

Patricia Rios, Amruta Radhakrishnan, Sonia M. Thomas, Nazia Darvesh, Sharon E. Straus, Andrea C. Tricco

This work was supported through the Canadian Institutes of Health Research (CIHR) through the Strategy for Patient Oriented-Research (SPOR) Evidence Alliance and commissioned by the Infection Prevention & Control, Health Emergency Programme, World Health Organization. We have prepared a summary of our report on behalf of the Oxford COVID-19 Evidence Service Team

Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences
University of Oxford
Li Ka Shing Research Institute, Knowledge Translation Program, St. Michael’s Hospital

Correspondence to Andrea.Tricco@unityhealth.to

VERDICT
The recommendations from current guidelines overall seem to support environmental measures for infection prevention and antiviral chemoprophylaxis for infection management as the most appropriate first-line response to viral respiratory illness in long-term care. However, these recommendations should be viewed with caution as it is unclear how many of these guidelines are based on the best available evidence due to their poor overall quality.

BACKGROUND
The Infection Prevention & Control of the World Health Organization (WHO) Health Emergency Programme commissioned a review on preventing and managing COVID-19 in older adults aged 60 years and above living in long-term care facilities. The overall objective of this rapid review of clinical practice guidelines was to identify infection protection and control measures for adults aged 60 years and older in long-term care settings. In order to focus the research question to increase feasibility, we proposed the following key research questions:

1. What are the infection prevention and control practices/measures for preventing or reducing respiratory viruses (including coronavirus and influenza) in older adults aged 60 years and above living in long-term care?
2. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness and severe comorbidities or frailty differ than those without such severe comorbidities/frailty?
3. How do infection prevention and control practices differ for adults aged 60 years and above living in long-term care with respiratory illness from low- and middle-income economy countries (LMIC) differ than those living in high-income economy countries and do differences exist across different cultural contexts?

CURRENT EVIDENCE
Preventing respiratory illness in long-term care facilities:

Two or more clinical practice guidelines recommended the following: hand hygiene^1,3,4-13,16 (n=13), wearing personal protective equipment^{2-11,13,14,16} (n=13), social distancing/isolation^2-8,10-14,16 (n=13), disinfecting surfaces^3-9,11-14,16 (n=12), droplet precautions^3-6,8-14,16 (n=12), surveillance and evaluation^{2,4-6,9-11,13-16} (n=11), conducting diagnostic testing to confirm suspected respiratory illness^{1-4,6,9-12,14} (n=10), policies and procedures for visitors^{3-6,8-11,14,16} (n=9), respiratory hygiene/cough etiquette^2-6,9-12,16 (n=9), policies and procedures for staff and/or residents^{1-4,6,9-11,13} (n=9), providing supplies^{3-6,9-11,13,16} (n=9), education of staff and/or residents^{3-6,9,11,13,14} (n=8), increasing communication^2-4,6,10,16 (n=6), consulting or notifying health professionals^5-7,9,10,16 (n=6), appropriate ventilation practices^3,13 (n=2), and cohorting equipment^7,16 (n=2). One clinical practice guideline each recommended appropriate air ventilation³ or smoking cessation¹.

Managing respiratory illness in long-term care facilities:

Ten clinical practice guidelines^{2,4,6,10-12,14-17} recommended the use of antivirals for prophylaxis of staff and/or residents and one¹⁷ recommended early mobilization of residents.

Summary of Clinical Practice Guideline recommendations

EMERGING EVIDENCE IN COVID-19
Two guidelines, published by the CDC⁵ and the Ontario Ministry of Health⁹ respectively, provided recommendations specific to COVID-19 that included:

• restricting visitors and enforcing sick leave policies for health care providers
• screening all visitors and staff entering a facility
• educating residents, personnel, and visitors about COVID-19 infection control
• educate and train healthcare providers to adhere to infection control measures including hand hygiene and proper use of personal protective equipment
• provide appropriate supplies for infection prevention and control
• encourage respiratory hygiene and cough etiquette
• proper environmental cleaning and disinfection
• evaluate and monitor residents and enforce restrictions on resident movement when necessary
• reporting suspected cases of COVID-19 to local public health authorities for testing and assessment

CONCLUSIONS

• The most commonly recommended prevention strategies across the clinical practice guidelines were hand hygiene, wearing personal protective equipment, social distancing/isolation, disinfecting surfaces, droplet precautions, surveillance and evaluation, conducting diagnostic testing to confirm suspected respiratory illness, policies and procedures for visitors, policies and procedures for staff, and respiratory hygiene/cough etiquette
• For managing respiratory illness in long-term care facilities, the majority of the clinical practice guidelines recommended antivirals for prophylaxis of staff and/or residents
• Most of the clinical practice guidelines failed to address multiple AGREE-II items, suggesting that they are most likely based on expert opinion.

medrxiv.rog pre-print link: https://www.medrxiv.org/content/10.1101/2020.03.19.20039180v1

End.

Disclaimer:  the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and social Care. The views are not a substitute for professional medical advice.

SEARCH TERMS
Comprehensive literature searches addressing all research questions were developed by an experienced librarian for MEDLINE, EMBASE, the Cochrane Library, as well as online guideline repositories (e.g., guidelines.ecri.org, joulecma.ca/cpg, www.guidelinecentral.com).

Funding Statement: This work was funded by the Canadian Institutes of Health Research (CIHR) through the Strategy for Patient Oriented-Research (SPOR) Evidence Alliance

REFERENCES

1. Alberta Medical Association (AMA). Guideline for The Diagnosis and Management of Nursing Home Acquired Pneumonia (NHAP). 2008. Available from: http://hpcconnection.ca/wp-content/uploads/2014/07/NHAP_Guidelines.pdf
2. Aoki FY, Allen UD, Stiver HG, Laverdière M, Skowronski D, Evans GA. Guidance for practitioners on the use of antiviral drugs to control influenza outbreaks in long-term care facilities in Canada, 2014-2015 season. Can J Infect Dis Med Microbiol. 2015 Jan-Feb;26(1):e1-4.
3. Burdsall et al. (2017). A Unit Guide to Infection Prevention for Long-term Care Staff, 2017. Available from: https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
4. Buynder et al. (2017). Communicable Diseases Network Australia. Guidelines for the prevention, control and public health management of influenza outbreaks in residential care facilities in Australia. Canberra: The Network. 2017.Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/27BE697A7FBF5AB5CA257BF0001D3AC8/$File/RCF_Guidelines.pdf
5. Center for Disease Control (CDC). Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes. 2019. Available from: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html
6. California Department of Public Health (CDPH). Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities (SNF). 2018. Available from: https://www.sfcdcp.org/wp-content/uploads/2018/01/RecommendationsForThePreventionAndControlOfInfluenza_FINAL.pdf
7. Protecting against infectious disease transmission during equipment maintenance: lessons from the 2003 SARS outbreak. Health Devices 2020 Feb 18. Available from: https://www.ecri.org/components/HDJournal/Pages/Equipment-Maintenance-Lessons-from-2003-SARS-Outbreak.aspx
8. Manitoba Health, Seniors and Active Living. Routine practices and additional precautions for preventing the transmission of infection in health care. 2019. Available from: https://www.gov.mb.ca/health/publichealth/cdc/docs/ipc/rpap.pdf
9. Ministry of Health (MOH). Novel Coronavirus (COVID-19) Fact Guidance for Long-Term Care, 2020. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_long_term_care_guidance.pdf
10. Ministry of Health and Long-term Care of Ontario (MOHLTC). Control of Respiratory Infection Outbreaks in Long-Term Care Homes, 2018. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/reference/RESP_Infectn_ctrl_guide_LTC_2018_en.pdf
11. Public Health Agency of Canada (PHAC). Guidance: Infection Prevention and Control Measures for Healthcare Workers in Acute Care and Long-term Care Settings, 2010. Available from: https://www.canada.ca/en/public-health/services/infectious-diseases/nosocomial-occupational-infections/guidance-infection-prevention-control-measures-healthcare-workers-acute-care-long-term-care-settings.html
12. Rüttimann RW, Bonvehí PE, Vilar-Compte D, Isturiz RE, Labarca JA, Vidal EI. Influenza among the elderly in the Americas: a consensus statement. Rev Panam Salud Publica. 2013 Jun;33(6):446-52.
13. Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, Mody L, Nicolle L, Stevenson K. SHEA/APIC guideline: infection prevention and control in the long-term care facility. Infection Control & Hospital Epidemiology. 2008 Sep;29(9):785-814.
14. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar 26;53(RR-3):1-36.
15. Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File Jr TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG. Clinical practice guidelines by the Infectious Diseases Society of America: 2018 update on diagnosis, treatment, chemoprophylaxis, and institutional outbreak management of seasonal influenza. Clinical Infectious Diseases. 2019 Mar 5;68(6):e1-47.
16. Victoria State Government. Respiratory illness in residential and aged care facilities. 2015. Available from: https://www2.health.vic.gov.au/public-health/infectious-diseases/infection-control-guidelines/respiratory-illness-management-in-aged-care-facilities
17. Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Read R, Verheij TJ; Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections–full version. Clin Microbiol Infect. 2011 Nov;17 Suppl 6:E1-59.