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

AFL 18-08
January 10, 2018

Congregate Living Health Facilities
Intermediate Care Facilities (ICF)
ICF/Developmentally Disabled (DD)
ICF/DD – Continuous Nursing
ICF/DD – Habilitative
ICF/DD – Nursing
Skilled Nursing Facilities

Influenza Outbreaks in Long-Term Care Facilities (LTCFs)

All Facilities Letter (AFL) Summary

This AFL notifies the health care community that influenza outbreaks may affect health care facilities this flu season and reiterates guidance on prevention and control of influenza in LTCFs.

Influenza activity is high and rapidly increasing in California. Influenza outbreaks can have broad impact across the continuum of care when LTCFs do not accept new admissions or readmissions of residents who were hospitalized for influenza. LTCFs should be prepared to provide care safely without putting residents at risk during influenza season.

Infection control measures for LTCF residents with suspected or confirmed influenza include standard and droplet precautions. Implementation of droplet precautions in LTCF includes (but is not limited to):

  • Placement of ill residents in a private room. If a private room is not available, residents suspected of having influenza can be cohorted with one another.
  • Spatial separation of > 3 feet and drawing the curtain between beds for residents housed in multi-bed rooms.
  • Health care workers wear a facemask (e.g., surgical or procedure mask) upon entering the resident’s room, and remove the facemask when leaving the resident’s room and dispose of it in a waste container.
  • If resident movement or transport is necessary, the resident wears a facemask (e.g., surgical or procedure mask), if possible.
  • Communication of information about residents with suspected, probable, or confirmed influenza to appropriate health care personnel before transferring them to other departments or facilities.

Additional measures to reduce transmission risk include having symptomatic residents stay in their own rooms as much as possible, including restriction from common activities and having all their meals served in their room. Employees and visitors should be screened for illness. Ill health care personnel should be furloughed and ill visitors discouraged from entering the facility. 

Centers for Disease Control and Prevention (CDC) infection control guidance for influenza recommends droplet precautions be continued for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a health care facility. CDC also recommends, "patients under droplet precautions should be discharged from medical care when clinically appropriate, not based on the period of potential virus shedding or recommended duration of droplet precautions." LTCFs should develop plans to be able to implement droplet precautions if necessary for returning residents who were hospitalized with influenza and are clinically ready for discharge from the acute care setting. 

Refer to the CDC guidelines and recommendations entitled "Prevention Strategies for Seasonal Influenza in Healthcare Settings." 

If a facility is experiencing an influenza outbreak, CDC recommendations include:

  • Daily active surveillance.
  • Standard and droplet precautions for all residents with suspected or confirmed influenza.
  • Prompt initiation of antiviral treatment and chemoprophylaxis in accordance with guidelines.
  • Avoiding new admissions or transfers to units with symptomatic residents.

CDPH also recommends LTCFs ensure new or returning residents do not have acute respiratory illness and admit them only to unaffected units of the facility. A returning resident who was hospitalized with influenza and is clinically appropriate for discharge from the acute care setting is past the acute phase of illness but may still need to be on droplet precautions. 

LTCFs should consult with their local health department (LHD) to determine strategies for limiting new admissions during an influenza outbreak while maintaining capacity to safely care for other residents. The duration of limitations on new admissions should be determined on a case-by-case basis in consultation with the LHD. Considerations may include appropriate implementation of control measures including chemoprophylaxis of non-ill residents and the identification of no additional cases during active surveillance. Prolonged closures to all new admissions might not be necessary if transmission appears to be controlled and there are unaffected units available where newly admitted residents could be placed. 

Refer to the CDC guidelines and recommendations entitled "Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities," and CDPH "Recommendations for the Prevention and Control of Influenza – California Long-Term Care Facilities" (PDF). 





Original signed by Jean Iacino

Jean Iacino
Deputy Director

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