Viral Respiratory Pathogens Toolkit for Nursing Homes

What to know

  • Preventing the spread of respiratory viruses in nursing homes requires a comprehensive approach that includes not only vaccination, but also testing, treatment, and the prompt implementation of proven infection prevention and control measures.
  • Taken together, these actions can protect residents and staff from respiratory viruses.

Purpose

This toolkit helps nursing home infection preventionists and leadership prepare for and respond when symptoms of respiratory viral infections occur among nursing home residents or healthcare personnel (HCP). While the toolkit is tailored toward nursing homes, the resources and many of the listed actions could be adapted for use in other long-term care settings.

Examples of respiratory viruses for this toolkit

  • SARS-CoV-2 (the virus that causes COVID-19)
  • Influenza
  • RSV

Prepare for respiratory viruses

Vaccinate

  • Provide recommended vaccines to residents and HCP.
  • Recommended vaccines help prevent severe illness, hospitalization, and death from respiratory viruses.
  • Consult with pharmacy and public health partners to ensure access to recommended vaccines for residents and HCP.
  • Provide materials to educate HCP, residents, families, or other visitors about staying up to date with recommended immunizations.
Keep Reading Long-Term Care: Why Get Vaccinated?

Allocate resources

  • Ensure that there are sufficient resources (e.g., personal protective equipment (PPE), alcohol-based hand sanitizer) to fully implement recommended infection prevention and control (IPC) practices.
  • Plan for situations (e.g., multiple symptomatic individuals) that may require increased use of supplies.

Monitor and mask

  • Be aware when levels of respiratory virus spread are increasing in the community. Close communication and collaboration with local and state health authorities can be helpful.
  • When levels in the community are higher, consider recommending visitors and HCP wear a mask when in the facility. At a minimum, consider asking residents wear a mask when outside of their room.
Keep Reading Nursing Home Data Dashboard

Educate

  • Ensure everyone, including HCP, residents, and visitors are aware of recommended IPC practices in the facility. This includes when specific IPC actions are being implemented in response to new infections in the facility or increases in respiratory virus levels in the community by sharing and posting communication materials such as posters, mask graphics and signs.
  • Encourage visitors with respiratory symptoms to delay non-urgent in-person visitation until they are no longer infectious. Following close contact with someone with SARS-CoV-2 infection, visitors should wear a mask while in the facility.

Ventilate

  • In consultation with facility engineers, explore options to improve ventilation delivery and indoor air quality in resident rooms and all shared spaces.

Test and treat

  • Develop plans to provide rapid clinical evaluation and intervention to ensure residents receive timely antiviral treatment and/or prophylaxis when indicated.
    • Ensure access to respiratory viral testing with rapid results (i.e., onsite or send-out testing with results available within 24 hours). Testing results can inform recommended treatment and IPC actions.
    • Establish pharmacy connections to enable the use of any available respiratory virus treatments or prophylaxis.

Respond to first signs or symptoms

  • When an infection due to a respiratory virus is suspected in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility.
  • Nursing home residents, including older adults, those who are medically fragile, and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of respiratory virus infection and may not have fever or respiratory symptoms.
    • Less common symptoms can include new or worsening malaise, headache, new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, or behavior changes.
  • When an infection due to a respiratory virus is suspected in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility.
  • While decisions about testing and treatment, prophylaxis, and the recommended duration of isolation vary depending on the pathogen, IPC strategies, such as placement of the resident in a single-person room, use of a facemask for source control, and physical distancing, are the same regardless of the pathogen.

Prevent spread

Among residents

  • Apply appropriate Transmission-Based Precautions for symptomatic residents based on the suspected cause of their infection.
  • When available, residents can be placed in a single-person room to minimize the risk of spread to roommates. Moving residents to a single room is often not practical (e.g., limited rooms available), and in those situations, residents could remain in their current location.
    • In shared rooms, consider ways to increase ventilation; the use of in-room HEPA air cleaners could also be considered. Use of facemasks at all times by both residents while in the room may also reduce the risk of spread but is often impractical and not routinely recommended.
    • Symptomatic residents should not be placed in a room with a new roommate unless they have both been confirmed to have the same respiratory infection.
    • Roommates of symptomatic residents – who have already been potentially exposed – should not be placed with new roommates, if possible. They should be considered exposed and wear a facemask for source control around others.
  • Residents placed in Transmission-Based Precautions for acute respiratory infection should primarily remain in their rooms except for medically necessary purposes. If they must leave their room, they should practice physical distancing and wear a facemask for source control. The resident should be removed from Transmission-Based Precautions as soon as they are deemed no longer infectious to others.
  • HCP who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved® particulate respirator with N95® filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This PPE can be adjusted once the cause of the infection is identified. Recommendations on PPE for respiratory viruses are available in Appendix A of the 2007 Guideline for Isolation Precautions.

Among healthcare personnel

To discourage working while sick, develop sick leave policies for HCP that are non-punitive, flexible, and consistent with public health guidance and allow HCP with respiratory infections to stay home for the recommended duration of work restriction.

Test

  • Test residents and HCP with new respiratory illness signs or symptoms.
    • Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). At a minimum, testing should include SARS-CoV-2 and influenza viruses with consideration for other causes (e.g., RSV).
    • Multiplex nucleic acid detection assays are ideal to test for both SARS-CoV-2 and influenza viruses to guide antiviral treatment and infection prevention decisions (e.g., decisions about PPE).

Treatment and prophylaxis

  • Provide recommended antiviral treatment for symptomatic residents and post-exposure antiviral prophylaxis to exposed residents when indicated.
  • Symptomatic residents of nursing homes are at increased risk of severe influenza and COVID-19 and should be evaluated for antiviral treatment.
  • Early initiation of antiviral therapy for both COVID-19 and influenza is most beneficial for preventing severe outcomes, and antiviral treatment can be initiated for either or both influenza and COVID-19 based on clinical judgment before test results are available.
  • In most situations, clinical guidance for antiviral treatment of outpatients with acute respiratory illness at higher risk of severe COVID-19 and/or influenza will apply to non-hospitalized residents.

For Influenza

  • CDC recommends antiviral post-exposure prophylaxis with oseltamivir for a minimum of 2 weeks and continuing for at least 7 days after the last known laboratory-confirmed influenza case was identified on affected units.

For COVID-19

  • Provide COVID-19 treatment for residents with mild-to-moderate COVID-19 but be aware of contraindications and potential drug interactions.
Keep Reading Clinical Guidance for Outpatients With Acute Respiratory Illness at Higher Risk of Severe COVID-19 and/or Influenza

Investigate potential spread

  • Perform active surveillance to identify any additional ill residents or HCP using symptom screening and evaluating potential exposures.
Keep Reading Infection Control Guidance: SARS-CoV-2

Control spread

Notify the health department

Notify the local or state public health department when respiratory viral outbreaksA are suspected or confirmed. Once spread is identified in a nursing home, rapid and coordinated action is necessary to prevent further transmission. Health departments have IPC expertise and might also have access to additional testing resources to identify a potential etiology.

In addition to the actions described in the previous section, the following interventions should be considered. Jurisdictions and/or facilities implementing additional measures that impose restrictions on residents (e.g., quarantine, limitations on communal activities) should carefully consider the risks and the benefits to residents to determine whether these time-limited strategies would be appropriate and have a de-escalation plan.

Take initial steps to control spread

  • Offer and reinforce the importance of vaccination in the facility.
  • Consider supplemental measures to improve air circulation and air cleanliness.
  • Implement universal masking for source control on affected units or facility-wide, including for residents around others (e.g., out of their room) and for HCP when in the facility.
  • Continue active surveillance to identify others with respiratory viral illness (e.g., daily or every shift review of symptoms among residents and HCP) and manage people who were exposed or infected (e.g., use of source control, work restriction for HCP, use of Transmission-based Precautions).
  • If transmission is limited to specific units, consider limited quarantine of those units (e.g., restricting those units from group activities or communal dining with residents from other units).
Keep Reading Nursing Home Infection Preventionist Training

Take additional measures if initial interventions fail

  • Consult with the local or state public health department about additional interventions.
  • Consider establishing cohort units for residents with confirmed infections.
    • Dedicate HCP to care for residents in cohort units and
    • Minimize HCP movement from areas of the facility where residents are having illness to areas not affected by the outbreak.
  • Limit group activities and communal dining.
    • Consider limiting the use of communal areas where residents or HCP might congregate over multiple units or facility wide.
  • Consider modifications to indoor visitation policies.
    • Visitors should be counseled about their potential exposure to respiratory infection in the facility.
    • If indoor visitation occurs, visits should ideally occur in the resident's room, and visitors should not linger in other areas of the facility or engage with other residents.
  • Avoid new admissions or transfers into and out of units or wards with infected residents or facility-wide if the outbreak is more widespread.

Resources

Guidance and recommendations

Communication resources

CDC Information on Respiratory Pathogen Vaccination

N95 and NIOSH Approved are certification marks of the U.S. Department of Health and Human Services (HHS) registered in the United States and several international jurisdictions.

Print
Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
  1. Reporting requirements and outbreak definitions may vary by pathogen and by state/local health department. Maintain a point of contact and phone number for your health department and remain aware of notification and reporting requirements within your jurisdiction.