Managing Influenza Outbreaks in Long-Term Acute Care Facilities: Best Practices

Long-term acute care facilities, encompassing nursing homes and skilled nursing facilities, serve a vulnerable population unable to live independently. These settings are particularly susceptible to infectious disease outbreaks, with influenza posing a significant threat due to its potential for rapid spread and severe complications among residents. Preventing and managing influenza outbreaks in these facilities requires a comprehensive, multi-faceted approach. This guide outlines best practices for long-term acute care facilities to effectively manage influenza, ensuring resident safety and well-being.

Proactive Measures Before an Outbreak

Prioritizing Influenza Vaccination

Vaccination is the cornerstone of influenza prevention in long-term care settings. Routine annual influenza vaccination for both residents and healthcare personnel is crucial.

Resident Vaccination Strategies

Annual influenza vaccination, ideally with the inactivated influenza vaccine (IIV), should be administered to all residents before the influenza season begins, typically by the end of October. For residents aged 65 years and older, specific enhanced vaccines like high-dose IIV, adjuvanted IIV, or recombinant influenza vaccine are recommended for improved protection. Standard-dose IIV remains a viable option if enhanced vaccines are unavailable. Vaccination efforts should commence in September when vaccines typically become available.

It’s essential to offer vaccination to new residents upon admission, regardless of the time of year. Facilities should have systems in place to document vaccination status, aligning with Centers for Medicare and Medicaid Services (CMS) requirements. CMS mandates that participating nursing homes offer both influenza and pneumococcal vaccines to all residents, documenting acceptance or refusal, unless medically contraindicated. This data is tracked as part of the CMS Minimum Data Set.

Healthcare Personnel Vaccination

The Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) strongly recommend annual influenza vaccination for all healthcare personnel in the United States. This measure protects both staff and vulnerable residents, reducing the risk of transmission within the facility.

Implementing Active Surveillance

Consistent surveillance is vital, especially during periods of community influenza activity. Long-term care facilities should conduct daily active surveillance for respiratory illness among residents, healthcare personnel, and visitors. This heightened surveillance should continue throughout the influenza season.

Individuals exhibiting symptoms of illness should be promptly excluded from the facility to minimize potential spread. It’s important to recognize that older adults and residents with neurological conditions may present with atypical influenza symptoms, such as changes in behavior, and may not always have a fever. Ill residents should be immediately placed on droplet precautions and restricted from group activities to prevent further transmission.

Routine Influenza Testing

Even outside of peak influenza season, testing for influenza is essential when any resident presents with signs and symptoms of acute respiratory illness or influenza-like illness. Prompt testing allows for timely diagnosis and initiation of appropriate management strategies.

Managing Confirmed or Suspected Influenza Outbreaks

An influenza outbreak in a long-term care facility is suspected when two or more residents develop acute respiratory illness within a short period. Confirmation of even a single laboratory-confirmed influenza case should trigger immediate action.

Enhanced Surveillance and Testing Protocols

Upon identifying a suspected or confirmed outbreak, active daily surveillance must be intensified across the entire facility, including all units, residents, staff, and visitors. This enhanced surveillance should continue for at least one week following the identification of the last laboratory-confirmed influenza case.

Molecular assays, including rapid molecular assays and RT-PCR, are the recommended methods for influenza testing due to their high sensitivity. If molecular assays are unavailable and rapid influenza diagnostic tests (RIDTs) or immunofluorescence assays are used, negative results should be confirmed with molecular assays due to the potential for false negatives. Prompt notification of test results to the facility is crucial for timely outbreak management. Public health authorities, both local and state, should be immediately informed of any suspected or confirmed influenza outbreaks, especially if antiviral resistance is suspected.

Implementing Infection Control Measures: Standard and Droplet Precautions

Rigorous infection control measures are paramount during an influenza outbreak. This includes strict adherence to both Standard and Droplet Precautions for all residents with suspected or confirmed influenza.

Standard Precautions

Standard Precautions are fundamental infection control practices that must be consistently applied to all patient care, regardless of suspected or confirmed infection status. These precautions include:

Hand Hygiene: Frequent and thorough hand hygiene with soap and water or alcohol-based hand sanitizer is essential, especially before and after patient contact, after touching potentially contaminated surfaces, and after removing gloves.
Gloves: Wear gloves when anticipating contact with respiratory secretions or contaminated surfaces. Change gloves between resident encounters and perform hand hygiene after glove removal.
Gowns: Wear gowns if there is a risk of clothing contamination with respiratory secretions. Change gowns between resident encounters.

Droplet Precautions

Droplet Precautions are specifically designed to prevent the transmission of pathogens spread through respiratory droplets. These should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while the resident is in the healthcare facility. Droplet Precautions include:

Private Room Placement: Ideally, ill residents should be placed in private rooms. If private rooms are not available, cohorting (grouping together) residents with suspected or confirmed influenza is recommended.
Facemasks: Healthcare personnel should wear a facemask (surgical or procedure mask) upon entering the resident’s room and dispose of it properly upon exiting.
Resident Masking During Transport: If a resident needs to be transported within the facility, have them wear a facemask, if tolerated and feasible.
Communication During Transfers: Clearly communicate the resident’s influenza status to all healthcare personnel involved in transfers to other departments.

These precautions, combined with other measures like resident cohorting, employee and visitor screening, and restricting ill staff and visitors, form a comprehensive infection control strategy. Facilities may extend the duration of Standard and Droplet Precautions based on clinical judgment, particularly for young children or immunocompromised residents who may shed the virus for longer periods. Infection control measures should continue throughout antiviral therapy to minimize transmission, including potential antiviral-resistant strains.

Antiviral Treatment and Chemoprophylaxis

Immediate Antiviral Treatment for Ill Residents

All long-term care facility residents with confirmed or suspected influenza should receive antiviral treatment promptly. Treatment should commence without waiting for laboratory confirmation, especially during an outbreak. Antiviral treatment is most effective when initiated within the first 48 hours of symptom onset but can still be beneficial even when started later, particularly for severely ill individuals or those at high risk of complications.

Recommended antiviral medications include neuraminidase inhibitors (oseltamivir, zanamivir, peramivir) and the cap-dependent endonuclease inhibitor baloxavir marboxil. Amantadine and rimantadine are not recommended due to widespread antiviral resistance. Oseltamivir is available in oral pill and suspension forms, zanamivir is inhaled, peramivir is intravenous, and baloxavir is an oral tablet. Considerations for medication choice include resident ability to use inhalers (zanamivir) and potential drug interactions. Baloxavir is not recommended for severely immunocompromised individuals, pregnant women, or hospitalized patients due to limited data in these populations.

Pre-approved physician orders or expedited processes for obtaining antiviral medication orders are crucial to ensure timely administration during outbreaks.

Antiviral Chemoprophylaxis for Exposed Residents

Antiviral chemoprophylaxis should be initiated for residents in units experiencing an influenza outbreak as soon as an outbreak is declared. This preventative measure is for non-ill residents who may have been exposed to influenza. Oral oseltamivir is the recommended drug for chemoprophylaxis in long-term care settings. Chemoprophylaxis is typically recommended for a minimum of two weeks and should continue for at least 7 days after the last confirmed influenza case on the affected unit. Extending chemoprophylaxis to unaffected units may be considered based on facility-specific factors, such as resident and staff mixing between units.

Chemoprophylaxis for Healthcare Personnel

Antiviral chemoprophylaxis can be considered for unvaccinated healthcare personnel, especially if the outbreak strain is poorly matched by the vaccine or to mitigate staffing shortages. It may also be considered for personnel with contraindications to influenza vaccination. Alternatively, close monitoring and prompt antiviral treatment initiation for healthcare personnel with suspected exposure can be implemented. Newly vaccinated staff may consider chemoprophylaxis for up to two weeks post-vaccination until immunity develops. Live attenuated influenza vaccine (LAIV) should not be given concurrently with antiviral chemoprophylaxis.

Addressing Antiviral Resistance

Be vigilant for potential antiviral drug resistance, particularly in residents who do not respond to treatment or develop influenza while on chemoprophylaxis. In such cases, notify public health authorities promptly. To minimize the spread of antiviral-resistant viruses, reinforce infection prevention and control measures, especially for immunocompromised residents. Residents on chemoprophylaxis who become ill should be switched to treatment dosing.

Additional Transmission Control Measures

Implement these additional measures to further reduce influenza transmission during outbreaks:

Isolate Symptomatic Residents: Keep symptomatic residents in their rooms, restrict them from group activities, and serve meals in their rooms when feasible.
Limit Group Activities: Reduce large group activities and consider room-based meal service facility-wide during widespread outbreaks.
Restrict Admissions and Transfers: Avoid new admissions or transfers to affected units.
Limit Visitation: Restrict visitation, especially by children during community outbreaks, and exclude ill visitors.
Monitor Staff Absences: Track staff absenteeism due to respiratory symptoms and exclude ill staff from work until symptom-free for at least 24 hours.
Restrict Staff Movement: Limit staff movement between affected and unaffected units.
Vaccinate Unvaccinated Individuals: Continue to offer influenza vaccination to unvaccinated residents and staff.

By diligently implementing these comprehensive strategies, long-term acute care facilities can effectively manage influenza outbreaks, protect their vulnerable residents, and maintain a safe environment.

Resources

Influenza Vaccines

CDC. Immunization of Health-Care Personnel. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011:60(RR07);1-45
Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024–25 Influenza Season
Seasonal Influenza Vaccination Resources for Health Professionals
Interim Guidance for Routine and Influenza Immunization Services During the COVID-19 Pandemic

Antiviral Drugs

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza
Influenza Antiviral Medications
Influenza Antiviral Medications: Summary for Clinicians

Influenza Testing

Infection Prevention and Control Measures

Reported Outbreaks in Long-Term Care Facilities

CDC. Outbreaks of 2009 Pandemic Influenza A (H1N1) Among Long-Term Care Facility Residents — Three States, 2009. MMWR 2010:59(03):74-77