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

AFL 23-10
January 18, 2023

Skilled Nursing Facilities

Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities (SNFs) for the 2022-2023 Season during the Coronavirus Disease 2019 (COVID-19) Pandemic

​All Facilities Letter (AFL) Summary

This AFL notifies facilities of an updated version of the guidance document “Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities (SNFs) during the COVID-19 Pandemic" (PDF), which includes minor changes to align with updated infection control guidance for SARS-CoV-2.

​SNF residents are at increased risk for severe disease, hospitalization, and death from infections caused by influenza viruses and SARS-CoV-2, the virus that causes COVID-19. Influenza seasons vary in timing, intensity, and severity from year to year, based on the characteristics of the circulating influenza virus strains, how well the vaccine matches the circulating strains, and other factors. Influenza activity in some locations of the Southern Hemisphere during the 2022 season increased to pre-COVID pandemic (or even higher) levels, which raises the possibility that Northern Hemisphere countries could encounter increased influenza activity this season. The Centers for Disease Control and Prevention (CDC) has reported early increases in seasonal flu activity in most of the country, and influenza activity is increasing in California. With concurrent circulation of influenza, SARS-CoV-2, and respiratory syncytial virus (RSV) in California, there is increased risk of co-infection associated with increased morbidity and mortality. In the United States, the most common influenza strain identified to date has been influenza A(H3N2), which has been associated with severe illness in older people. The currently circulating A(H3N2) strain is genetically and antigenically closely related to this season's vaccine.

Facilities should review the updated "Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities during the COVID-19 Pandemic" (PDF) to ensure readiness for the influenza season. It is essential for SNFs to optimize all effective influenza prevention and outbreak control interventions, including influenza vaccination of SNF residents and healthcare personnel (HCP) and prompt initiation of antiviral therapy and chemoprophylaxis when influenza is identified. SNFs should focus efforts on improving influenza vaccination rates in residents and especially in HCP, which have lagged substantially behind those for HCP in acute care hospitals and ambulatory clinics and have plateaued since 2019-2020. Additionally, for FY2023, reporting of SNF HCP influenza vaccination rates will be required and used to calculate payments via the SNF Value Based Purchasing Program ( (PDF).

The following strategies are especially important during this influenza season:

  • Accelerate the influenza vaccination program, along with administration of the COVID-19 bivalent booster for residents and staff. 
  • Provide adults aged ≥65 years quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4) per the Advisory Committee on Immunization Practices (ACIP) preferential recommendation for the 2022-23 season.
  • Follow weekly influenza and respiratory viral surveillance reports to know conditions in your county.
  • Test symptomatic individuals for influenza and SARS-CoV-2 to inform infection control management and appropriate antiviral treatment. See Appendix C (PDF).
    • COVID-19/Flu A+B multiplex antigen tests are available to SNFs for a one-time distribution via the Medical Health Operational Area Coordinator (MHOAC). Single influenza and COVID-19 tests may also be used.
    • Test for other respiratory viruses when there is a cluster of respiratory infections in the facility and influenza and COVID-19 tests are negative.
  • In the presence of co-infection, antiviral agents active against influenza and against SARS-CoV-2 may be administered concomitantly. Review medications before prescribing to evaluate for possible drug-drug interactions. If any questions, consult a pharmacist.
  • Follow the recommendations for education, planning, and management presented in the CDPH guidance document. Be ready with:
    • Sufficient influenza and SARS-CoV-2 test supplies, vaccines, and standing orders for administration; hand hygiene supplies; personal protective equipment; and antiviral medication orders.
    • Established lines of communication between the SNF and the local health   department to facilitate support in the event of an outbreak, vaccine or antiviral agent shortage, or emergence of unanticipated events.

Report influenza outbreaks immediately to your local health department and Licensing and Certification (L&C) district office.

If you have any questions about this AFL, please contact the CDPH Healthcare-Associated Infections Program at



Original signed by Cassie Dunham

Cassie Dunham

Deputy Director



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