Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings

Suspected respiratory disease outbreak, including COVID-19

A suspected respiratory disease outbreak in LTCFs and other health care settings is defined as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have pneumonia, acute respiratory illness, or laboratory-confirmed viral or bacterial infection (including influenza and COVID-19). For non-LTCF health care settings, only healthcare-associated cases should be counted.

 For local and Tribal health departments using the Wisconsin Electronic Disease Surveillance System: Outbreaks can be closed after two incubation periods have passed with no new cases being identified. For COVID-19 outbreaks, this is 28 days and for all other ARI outbreaks, it is approximately 14 days.

ARI

ARI is an illness characterized by any two of the following signs and symptoms that are new or worsening from the resident's normal state:

In Wisconsin, confirmed or suspected outbreaks of any disease in health care facilities, including LTCFs, are a Category I Disease, meaning they shall be reported immediately by telephone to the patient's local health officer, or to the local health officer's designee, upon identification.

• General reporting requirements: Wis. Stat. ch. 252 Communicable Diseases.
• Specific reporting requirements: Wis. Admin Code. ch. DHS 145 Control of Communicable Diseases.
• COVID-19 reporting guidance: COVID-19: Health Care Providers webpage.

Outbreak line lists

LTCFs are strongly encouraged to maintain and update a line list during an ARI outbreak to organize case information. While LTCFs are no longer required to report these line lists to their local or Tribal health department, the Department of Health Services (DHS) recommends that facilities continue to share them with public health as part of shared outbreak response.

Facilities may use and adapt the DHS Infection Surveillance Log for Long-Term Care Facilities (Excel) tool to help establish infection surveillance logs for their facility. 

When an outbreak of acute respiratory illness is suspected, testing to determine the etiology of the disease is essential to determine the appropriate precautions needed to control the outbreak.

Testing during acute respiratory illness outbreaks

Nasopharyngeal swabs (preferred) or oropharyngeal swabs collected from residents or staff should be sent for multiplex PCR testing. Specimens can be sent to any laboratory that performs multiplex testing or, with prior DHS Division of Public Health (DPH) approval, specimens can be sent to the Wisconsin State Laboratory of Hygiene (WSLH) where testing will be done free of charge. Approval can be requested by contacting dhsdphbcd@dhs.wisconsin.gov.

• Specimens for acute respiratory outbreaks should be collected as soon as possible after the onset of illness and placed in viral transport media to assure optimal test results. This will help to identify the etiology (cause) of the outbreak.
• If SARS-CoV-2 is identified, all LTCFs, including nursing homes, should determine a testing approach, either targeted based on contact tracing or a wider approach, per CDC (Centers for Disease Control and Prevention's) guidance.
• Upon approval, DPH will notify WSLH of the submission of specimens for testing.
• WLSH will provide the submitter with an Enhance Lab Requisition form by fax or email.
• Facilities may choose to have clinical specimens tested at a laboratory other than the WSLH, however, fee-exempt testing cannot be offered for tests performed at those laboratories.
• Due to possible false positive results when using rapid influenza tests, especially when testing occurs during periods of low influenza activity, confirmatory testing of positive rapid test results using RT-PCR or viral culture should be performed.
• With DPH approval, specimens may also be tested for other respiratory viruses.
• If test results confirm influenza within a facility, no further testing will be performed on that resident unless they have an atypical presentation of illness or are not responding to treatment.
• A negative test result does not rule out viral infection or the existence of an outbreak.
• Testing and supplies are provided for fee-exempt testing through WSLH.

Guidance on testing in LTCFs

• CDC Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating
• CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic

Antiviral treatment and prophylaxis during influenza outbreaks in LTCFs

When cases of influenza have been confirmed in a LTCF, antiviral prophylaxis should be offered to:

• All residents regardless of vaccination status.
• All unvaccinated employees.
• Those employees vaccinated less than two weeks before the cases were identified.

Interim guidance for influenza antiviral treatment and chemoprophylaxis in LTCFs is available on the CDC website.

COVID-19 therapeutics and treatments

There are several U.S. Food and Drug Administration (FDA)-authorized antiviral medications to treat mild to moderate COVID-19 in individuals at higher risk for severe disease. Find more information at the CDC Types of COVID-19 Treatments webpage.

Health care personnel and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Until the cause(s) of an ARI outbreak is determined, facilities should use the most protective level of precautions.

Transmission-based precautions, such as droplet (PDF), airborne (PDF), and/or contact (PDF) precautions may be recommended, depending on the type of respiratory virus detected. Follow CDC specific guidelines for the specific type and duration of precautions.

CDC recommends source control that follows the infection control core practices, while also considering patient and resident characteristics and local respiratory illness data sources. Source control continues to be recommended for individuals who have confirmed respiratory infection. View CDC guidance for more on how and when to implement broader source control recommendations.

¹Based on CDC's Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions

²Airborne preferred (AIIR or negative pressure room), use N95 or higher respiratory protection and eye protection (goggles, face shield). Refer to CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.

LTCF resident room assignments

If possible, any LTCF resident who is ill with symptoms of ARI should stay in a private room. Decisions by medical and administrative staff regarding resident placement should be made on a case-by-case basis. In determining resident placement, consider:

• Balancing the risk of infection to other residents in the room.
• The presence of risk factors that increase the likelihood of transmission within the facility.
• The potential adverse psychological impact on the infected resident.

When a single-resident room is not available, ill residents can be placed in a multi-bedroom following consultation with infection control personnel to assess risks associated with resident placement options (such as cohorting, keeping the resident with an existing roommate). Spatial separation of six feet or more and drawing the curtain between resident beds is especially important for residents in multi-bedrooms.

The LTCF may consider allowing a resident with a cough that is not a suspected or confirmed COVID-19 resident, to leave their room while wearing a surgical mask. This can be reviewed on a case-by-case basis and if the resident’s understanding and compliance with the core principles of infection control will minimize the risk of infection to other residents.

For full details and recommendations for COVID-19 and other respiratory infections, facilities should visit CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic. Facilities may also view the Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities for more information.

In general, facilities should assess risks and develop policies that provide guidance on visitation practices. Guidance and policies developed by facilities should be reinforced at the facility entrance and throughout the facility due to the inherent risks of ARI, including COVID-19, outbreaks among LTCF populations.

Facilities are encouraged to utilize signage that communicates and provides instructions on current infection prevention and control practices being implemented within the facility. Providing a date on the sign can help ensure visitors know that they reflect current practices.

A facility with a confirmed or suspected COVID-19 outbreak should follow current CMS (Centers for Medicare and Medicaid Services) visitation requirements for nursing homes and CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic for other LTCFs. All visitors should be educated upon admission on the type of PPE and other infection prevention principles that should be followed as part of their visit.

Temporary halting of new admissions during respiratory disease outbreaks

Upon recognition of a confirmed or suspected outbreak of respiratory illness, the facility may consider temporarily halting new admissions to the facility in consultation with their LTHD. If the outbreak is confined to a specific unit, wing, or floor, the facility may consider allowing new admissions to other units, wings, or floors not affected by the outbreak as long as they have the staffing, space, and supplies to safely admit residents.

A pause of new admissions to the facility or the affected unit, wing, or floor may be considered, but facilities should facilitate resident admissions and readmissions whenever safely possible.

It is crucial to note that admitting a patient who is currently in their isolation period does not constitute an outbreak. Skilled nursing facilities are well-trained and competent in the use of personal protective equipment (PPE), isolation precautions, and infection control measures. Therefore, a patient's infection status alone should not be a reason to deny admission.

SNFs use comprehensive training and the expertise of staff in managing residents in transmission-based precautions effectively. Admitting COVID-19 or other respiratory pathogen positive patients, when following appropriate protocols, contributes to the overall health care system's ability to provide necessary care for patients that require hospitalization.

Contact a Bureau of Nursing Home Resident Care regional office for additional support.

Exclusion of staff

Further recommendations on work restrictions and return to work criteria can be found by visiting CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.

Staff with ARI who are tested and do not have COVID-19 should be excluded from work until at least 24 hours after they no longer have a fever (without the use of fever-reducing medicines such as acetaminophen or ibuprofen). If symptoms, such as cough and sneezing, are still present, staff should wear a surgical mask during resident care activities.

Support and flexibility should be given to staff to encourage them to stay home from work. Try to reduce logistical barriers and financial hardship to the extent possible.

An outbreak of ARI does not require the cancellation of facility-wide resident activities, therapy, or communal dining.

Residents with active ARI should not participate in facility-wide resident activities, group therapy, or communal dining.

CMS: Visitation Guidance

• CDC: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic
• CDC: Influenza Infection Control in Healthcare Facilities

• DHS: Immunization
• DHS: Influenza Surveillance
• DHS: Respiratory Diseases
• DHS: Respiratory Illness Data
• Council of State and Territorial Epidemiologists (CSTE): COVID-19 Outbreak case definition