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State of California—Health and Human Services Agency
California Department of Public Health

AFL 08-33
November 3, 2008

Skilled Nursing Facilities (SNF)
General Acute Care Hospitals (GACH)
Acute Psychiatric Hospitals (APH)
Specialty Hospitals (SH)
Intermediate Care Facilities (ICF)
Intermediate Care Facilities-Developmental Disabled (ICF/DD)
Intermediate Care Facilities-Developmental Disabled-Habilitative (ICF/DD-H)
Intermediate Care Facilities-Developmental Disabled-Nursing (ICF/DD-N)
Correctional Treatment Centers (CTC)
Congregate Living Health Facilities (CLHF)
Department of Social Services

Recommendations for the Prevention and Control of Influenza in California Long-Term Care Facilities

​Attached is the Recommendations for the Prevention and Control of Influenza in California Long-Term Care Facilities, revised for the 2008-2009 influenza season. While there are no major changes from the 2007-2008 recommendations, we continue to attempt to improve them. We would appreciate any feedback, particularly when the guide is used to manage an outbreak.

Influenza outbreaks occur during the winter months, and as a result, about 2,000 Californians die each year. Influenza is a particularly serious problem in nursing homes where residents are at high risk of developing serious complications or dying due to their age and health problems. Once influenza virus enters a nursing home, it can spread rapidly. During nursing home outbreaks more than half of the residents can become infected, and some require hospitalization or die. Serious illness and death in otherwise healthy healthcare workers, while rare, can also occur. Severe pneumonia due to Staphylococcus aureus and methicillin Staphylococcus aureus (MRSA) following influenza in previously healthy persons is of increasing concern.

The influenza vaccine supply this year is anticipated to be sufficient. All healthcare workers should be vaccinated against influenza annually. This is particularly important in long-term care facilities, where the efficacy of influenza vaccination for elderly residents is reduced, and the primary protection against influenza is vaccination of staff.

Facilities are strongly encouraged to provide vaccine to healthcare workers by using approaches that maximize immunization rates. Please encourage your staff to get vaccinated against the flu and do all that you can to ensure that they do.

Many major organizations recommend that employers be required to offer annual healthcare worker influenza vaccination free of charge, and that employees be required to sign a declination form if they do not wish to be vaccinated. Pursuant to Health and Safety Code §1288.7 by July 1, 2007, the department shall require that each general acute care hospital, in accordance with the Centers for Disease Control guidelines, take all of the following actions:

(a) Annually offer onsite influenza vaccinations, if available, to all hospital employees at no cost to the employee. Each general acute care hospital shall require its employees to be vaccinated, or if the employee elects not to be vaccinated, to declare in writing that he or she has declined the vaccination.
(b) Institute respiratory hygiene and cough etiquette protocols, develop and implement procedures for the isolation of patients with influenza, and adopt a seasonal influenza plan.
(c) Revise an existing or develop a new disaster plan that includes a pandemic influenza component. The plan shall also document any actual or recommended collaboration with local, regional, and state public health agencies or officials in the event of an influenza pandemic.

The proposed California Division of Occupational Safety and Health (Cal/OSHA) Aerosol Transmissible Diseases Standard ( would make the provision of influenza vaccine and use of a declination form mandatory in all health care facilities.

The California Immunization Coalition (CIC), a non-profit, public-private partnership dedicated to achieving and maintaining full immunization protection for all Californians to promote health and prevent serious illness, has collected tools for implementing an influenza immunization program in long-term care facilities. The tools can be downloaded at

California regulations require that any outbreak of illness in a healthcare facility be reported to both the local health department and the Department of Public Health Licensing and Certification district office. During outbreaks of respiratory illness, the Department of Public Health can provide assistance in: (1) laboratory testing to determine the cause (outbreaks of respiratory illness may be caused by pathogens other than influenza); (2) providing recommendations for measures to control the outbreak; and (3) determining the need for influenza antiviral medications and/or additional influenza vaccine.

The Department of Public Health encourages facility staff to review these advisory recommendations. Influenza vaccine is available for purchase from a number of providers; if you need help identifying a provider contact your local health department.

Questions regarding outbreak control should be referred to your local health department. Written comments about the information contained in these recommendations should be sent to Dr. Jon Rosenberg, California Department of Public Health, Division of Communicable Disease Control, 850 Marina Bay Parkway, Richmond, CA 94804 or



Original Signed by Kathleen Billingsley

Kathleen Billingsley
Deputy Director


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