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

Acute respiratory illness

Acute respiratory illness (ARI) is an illness characterized by any of the two following signs and symptoms:

Suspected respiratory disease outbreak

A suspected respiratory disease outbreak in a LTCF is defined by the Division of Public Health (DPH) as three of 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).

Suspected COVID-19 outbreak

A suspect COVID-19 outbreak in a LTCF is defined by DPH as one or more residents and/or staff (who worked during their infectious period) within a facility who have a case of COVID-19.

Requirements for the timing of reporting, once a disease or condition is recognized or suspected, vary by disease. 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 are described in Wis. Stat. ch. 252 Communicable Diseases. Specific reporting requirements are described in Wis. Admin Code. ch. DHS 145 Control of Communicable Diseases.

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 DPH approval, specimens can be sent to the Wisconsin State Laboratory of Hygiene (WSLH) where testing will be done free of charge.

• Specimens for non-COVID respiratory outbreaks should be collected within five days after the onset of illness and placed in viral transport media to assure optimal test results.
• Specimens for COVID-19 outbreaks should be collected immediately after a resident or staff member develops symptoms, regardless of vaccination status. Testing should be done to establish the extent of the outbreak in both skilled nursing and assisted living facilities.
• If SARS-CoV-2 is identified, facilities should determine a testing approach, either targeted based on contact tracing or a wider approach, per CDC (Centers for Disease Control and Prevention's) LTCF guidance. Nursing homes should follow any testing mandates issued by the Centers for Medicare and Medicaid Services (CMS).
• If specimens will be submitted to the WSLH, include the WSLH lab requisition form. 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, other than as part of state-contracted laboratory services for COVID-19 testing.
• 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 is 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 or participating private or clinical labs.

Order COVID-19 testing supplies and services

Guidance on testing in LTCFs

• Centers for Medicare and Medicaid Services Nursing Home Testing Requirements for SNFs
• CDC Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating
• Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes

Antiviral treatment and prophylaxis during influenza outbreaks

When cases of influenza have been confirmed in a facility, 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.

CDC influenza antiviral recommendations are available on the CDC clinician summary webpage.

COVID-19 therapeutics and treatments

The U.S. Food and Drug administration has issued emergency use authorizations for certain antiviral medications and monoclonal antibodies to treat mild to moderate COVID-19 in individuals at higher risk for severe disease. COVID-19 Treatment Guidelines for health care providers are available from the National Institutes of Health.

Caregivers 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 (such as for COVID-19), including gown, gloves, fit tested N95, and eye protection, such as goggles or face shield.

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

Droplet precautions

Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. In contrast to contact transmission, respiratory droplets carry and transmit infectious pathogens when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances (within 6 feet). Residents on droplet precautions who must be transported outside of their room should wear a surgical mask (if tolerated) and practice respiratory hygiene (cough etiquette).

• Non-COVID-19: Health care personnel should wear a surgical mask for close contact with an ill resident. A respirator is not necessary unless engaging in an aerosol-generating procedure (AGP), such as BIPAP/CPAP procedures. The mask is generally donned immediately prior to room entry.
• COVID-19: Health care personnel should wear surgical masks in all areas of the building for source control aside from when actively eating or drinking. Staff up to date with all COVID-19 vaccine doses may choose to remove source control in a well-defined area that is restricted from resident access (such as a breakroom, all-staff meeting) when the county community transmission level is low to moderate. When the county community transmission level is at substantial to high levels (regardless of whether the facility currently has COVID-19 cases), staff should wear the following as part of CDC guidance for the universal use of personal protective equipment (PPE) during the COVID-19 pandemic:
  • An N95 for all residents during AGPs, and
  • Eye protection for all resident care encounters

Duration of transmission-based precautions: non-COVID-19 respiratory disease outbreaks

Follow CDC guidelines for the specific type and duration of precautions.

• For confirmed or suspected influenza, residents should remain on droplet precautions for seven days after onset of illness or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer.
• For other respiratory illnesses, the resident should remain on appropriate precautions for the duration of illness, defined as 24 hours after resolution of fever without the use of fever-reducing medications and without respiratory symptoms (see ARI symptoms above). Criteria for determining ARI among staff or residents should focus on whether cough is a new or worsening symptom. For discontinuation of droplet or contact precautions, exclude cough as a criterion unless the cough produces purulent sputum. In many cases, a non-infectious post-viral cough may continue for several weeks following resolution of other respiratory symptoms.

Duration of transmission-based precautions: COVID-19 outbreaks

When a resident has confirmed or suspected COVID-19, the resident should remain on standard, airborne, and contact (plus eye protection) precautions at minimum until conditions for discontinuation* are met:

• At least 10 days have passed since onset of symptoms, AND
• At least 24 hours have passed since last fever without the use of fever-reducing medications, AND
• Symptoms (such as cough and shortness of breath) have improved.

*Some individuals with severe illness OR who are severely immunocompromised should be maintained on droplet and contact precautions until at least 10 days and up to 20 days have passed since symptom onset AND at least 24 hours since the last fever with symptom improvement. Use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when Transmission-Based Precautions could be discontinued for moderately to severely immunocompromised patients.

Facilities should continue to follow the latest guidance from federal and state agencies. This includes the use of full PPE for residents with suspected or confirmed COVID-19: gown, gloves, fit tested N95, and eye protection. Aerosol generating procedures (AGP) should take place in an airborne infection isolation room (AIIR), if possible. When AGPs cannot be performed in an AIIR, staff present during the procedure should be limited and the door should remain closed.

Resident room assignments

If possible, any 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.

Non-ill residents should not be confined or restricted to their rooms during a non-COVID-19 outbreak. Outbreaks of COVID-19 may necessitate the cohorting of patients with COVID-19 to a dedicated floor, unit, or wing, with dedicated staff to prevent transmission based on consultation with the facility’s infection prevention personnel.

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

Visitors during COVID-19 outbreaks

A facility with a confirmed or suspected outbreak should follow current CMS visitation requirements for nursing homes and CDC guidance for other LTCFs. All visitors should be screened prior to entry and those who meet quarantine criteria, including those with any symptoms consistent with COVID-19, should not be permitted to enter the facility. 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. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility.

Temporary halting of new admissions during non-COVID-19 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. 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. A pause of new admissions to the facility or the affected unit, wing, or floor may be considered until one week after the illness onset of the last confirmed or suspected case for non-COVID outbreaks.

Temporary halting of new admissions during COVID-19 outbreaks

A newly admitted resident with confirmed COVID-19 infection who have not met the criteria to be discontinued from transmission-based precautions should be placed in a designated COVID-19 unit, regardless of vaccination status. For additional admission/readmission considerations, see guidance from the CDC.

In accordance with CDC guidance, all staff should be screened at the beginning of their shift for all symptoms of COVID-19, close contact with those outside the facility with a SARS-CoV-2 infection, and adherence to source control. Options include (but are not limited to) arrival screening or electronic monitoring systems. Fever is defined as either measured temperature ≥100°F or subjective fever. Exclude and test staff with symptoms and have a plan for those who report close contact with an individual with a SARS-CoV-2.

Exclusion of staff

COVID-19 outbreaks

Staff with confirmed COVID-19 and staff with ARI who are not tested for COVID-19 should be excluded from work until they meet criteria for discontinuation of isolation established by CDC.

Non-COVID-19 respiratory disease outbreaks

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, therapy, or communal dining.

For units closed to new admissions due to an outbreak of COVID-19, unvaccinated residents should be encouraged to remain in their room. Restrict residents (to the extent possible) to their rooms, except for medically necessary purposes. If residents leave their room, they should be encouraged to wear a mask, perform hand hygiene, limit their movement in the facility, and perform physical distancing. Residents up to date with COVID-19 vaccinations and those in the 90-day period post-infection do not need to be restricted to their rooms as indicated in the CDC LTCF guidance for outbreak testing, but should continue to wear source control when outside their rooms.

• CDC: Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating
• CMS: LTCF Testing Requirements

• DHS: ALF Visitation Guidance
• CMS: Visitation Guidance

• CDC: COVID-19 Infection Control for Nursing Home
• CDC: Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes and Long-Term Care Facilities
• CDC: Influenza Infection Control in Healthcare Facilities

• DHS: Immunization
• DHS: Influenza Surveillance
• DHS: Respiratory Diseases
• DHS: COVID-19 Guidance for ALFs and SNFs
• Council of State and Territorial Epidemiologists (CSTE): COVID-19 Outbreak case definition