Preventing and Controlling ARI Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Nursing Care

This guidance is for skilled nursing facilities (SNF) and other long-term care facilities (LTCFs) providing skilled nursing care. This includes, but is not limited to, facilities that are licensed under the following Illinois administrative codes:

• PART 300 Skilled Nursing and Intermediate Care Facilities
• PART 340 Illinois Veterans' Homes
  
• PART 390 Long-term care for under age 22
  

Other long-term care facilities that provide skilled nursing care, intermediate nursing care, or other health care, should follow this and Centers for Disease Control and Prevention (CDC) guidance for health care settings when health care is administered. This includes some facilities licensed under Part 350 Intermediate Care for the Developmentally Disabled. Facilities that provide a spectrum of care (e.g., skilled nursing, assisted living, and independent living) should follow the appropriate guidance for each setting. Personnel who serve across settings should be held to the most conservative guidance. Health care providers should follow guidance for health care personnel across all setting types.

This guidance replaces previous COVID-19 disease-specific guidance. It is based on the CDC’s guidance for the control of respiratory illnesses, including COVID-19, influenza, and other respiratory illnesses, in health care settings. See the links to the CDC and other resources for additional details. Contact your local health department or IDPH’s designated Regional Infection Control Coordinator for your region if you have questions or need assistance responding to an outbreak in your facility. Check this webpage frequently, as the content will be updated as guidance for SNF changes.

Acute respiratory illness (ARI) is an illness characterized by any two of the following signs and symptoms that are new or worsening from the resident's normal state:

• Fever (greater than 100°F/37.8°C or more than two degrees above a resident’s established baseline)
• Cough (productive or nonproductive)
  
• Runny nose or nasal congestion
  
• Sore throat
  
• Muscle aches
  
• Shortness of breath or difficulty breathing, which may manifest as increased fatigue
  
• Low oxygen saturation in the blood (normal levels are between 95 and 100%, but may vary for people with certain medical conditions)
  

When a single case of acute respiratory illness (ARI), such as COVID-19 or another viral respiratory disease, is suspected, timely testing and infection control are imperative. Until the cause of an ARI case or outbreak is determined, facilities should initiate empiric precautions at the most protective level, including gowns, gloves, fit-tested N95 respirators, and eye protection, such as goggles or a face shield. A single case should prompt investigation to determine if others have been exposed.

Outbreaks must be reported if they meet the following criteria:

Three or more residents and/or staff in a facility who, within 72 hours of each other, have:

• acute respiratory illness (ARI) and/or
• positive point-of-care test (as available) or laboratory-positive test for a single virus*
  

-AND-

• at least one of the cases is a resident

*Outbreaks should not be reported to ORS if there are multiple etiologies that do not meet the outbreak definition separately. However, facilities must act on even a single case of acute respiratory illness or positive test.

After 14 days without additional cases, respiratory outbreaks can be finalized and considered over. If additional cases are identified after 14 days have passed, a new outbreak should be reported.

*See outbreak definition. Acute respiratory illness outbreaks include those due to COVID-19, influenza, RSV, and other respiratory pathogens.

Note: There may be a need to report cases and/or outbreaks to multiple entities. Reporting to one does NOT satisfy the need to report to the others.

Effective February 27, 2024, individual cases of COVID-19 detected by POC testing conducted by a long-term care facility do not need to be routinely reported unless the infection results in ICU admission or death in a child <18years of age. Test results may be requested by an LHD in an outbreak. Tests conducted by a laboratory shall report positive results via ELR.

COVID-19, influenza, RSV, and other viral respiratory illnesses all have similar and overlapping symptoms. 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 and, if indicated, to implement timely treatment and chemoprophylaxis.

All facilities should have access to appropriate point-of-care testing and/or lab-based testing to meet the testing needs of their residents and staff for outbreak mitigation.

• Specimens for acute respiratory outbreaks should be collected immediately after the onset of illness to identify the etiology (cause) of the illness and outbreak.
• If SARS-CoV-2 is identified, all LTCFs, including nursing homes, should determine a testing approach, either targeted based on contact tracing or a wider strategy, per CDC guidance (see Perform SARS-CoV-2 Viral Testing).
  
• A negative test result does not rule out viral infection or the existence of an outbreak. Empiric precautions should be implemented when symptoms are first identified and continued, even if testing fails to identify an etiologic agent. See the recommended precautions chart.

Test any resident with symptoms of COVID-19 or influenza for both viruses.

• This can be accomplished with a POC (point-of-care) COVID/Flu A&B rapid antigen test or a lab-based PCR panel. Facilities should determine the method with the greatest feasibility and expediency.
• If POC assays for COVID-19 and flu are negative, follow-up PCR testing should be conducted.
  
• Consider sending a multiplex broad respiratory PCR panel if COVID-19 and flu are both negative on POC testing. POC testing may be negative due to the inherently lower sensitivity of antigen testing; however, it may also be negative due to another virus that is circulating. If either COVID-19 or flu is known to be circulating in the facility, only a COVID-19/Flu PCR panel may be needed for confirmatory or follow-up testing.
  
• If COVID-19 and flu are negative by PCR, a subset of isolates should be sent for a multiplex broad respiratory PCR panel. Specimens can be sent to any laboratory that performs multiplex testing or, with prior health department approval, specimens can be sent to the Illinois Department of Public Health, where testing will be done free of charge.
  

• CDC Testing and Management Considerations for Nursing Home Residents with Acute Respiratory Illness Symptoms when SARS-CoV-2 and Influenza Viruses are Co-circulating
• Infection Control Guidance: SARS-CoV-2
• Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long-Term Care Facilities: 2008 Update by the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic (oup.com)
• How to obtain a CLIA Certificate (cms.gov)
  
• How to Apply for a CLIA Certificate, Including International Laboratories | CMS
  

Provide recommended treatment and prophylaxis to infected and exposed residents when indicated.

Provide antiviral treatment immediately for all residents who have confirmed or suspected influenza. Antiviral treatment works best when started within the first two days after symptoms. However, these medications can still help when given after 48 hours to those who are very sick, have progressive illness, or are at higher risk for complications of influenza.

When influenza has been confirmed in a facility, offer antiviral prophylaxis within 48 of exposure to:

• All residents on units or wards with influenza cases, regardless of vaccination status. Consider extending antiviral chemoprophylaxis to other units if there is an unavoidable mixing of residents and/or health care personnel across units.
• All unvaccinated employees.
  
• Those employees vaccinated less than two weeks before the cases were identified.
  

See the guidance for additional chemoprophylaxis recommendations.

Provide COVID-19 treatment for eligible residents with mild-to-moderate COVID-19 with one or more risk factors for severe COVID-19. Be aware of potential drug interactions. Treatment must be started as soon as possible and within five days of symptom onset to be effective.

There are no widely available antiviral treatments available for other seasonal respiratory viruses (e.g., RSV, Parainfluenza, Human Metapneumovirus, Respiratory Adenovirus, Rhino/Enterovirus). For other respiratory viruses such as measles and varicella, see guidance specific to those viruses.

Health care personnel (HCP) 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.

Transmission-based precautions, such as droplet (PDF), airborne (PDF), and/or contact (PDF) precautions may be recommended, depending on the type of respiratory virus detected. The table “Recommended precautions for common respiratory viruses” provides a pragmatic approach to transmission-based precautions recommended by IDPH. At a minimum, facilities should follow the CDC guidelines for the specific type and duration of precautions.

The CDC recommends source control (masking) that follows the infection control core practices, while also considering resident symptoms and local respiratory illness data sources. Source control continues to be recommended for individuals who have suspected or confirmed COVID-19 infection or other respiratory infection or those who have close contact with an ill person. HCP and visitors should wear source control when Community Levels are High for respiratory illnesses. View CDC guidance for more on how and when to implement broader masking (source control) recommendations.

Residents who are 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-bed room following consultation with facility infection control personnel to assess risks associated with resident placement options (such as cohorting and keeping the resident with an existing roommate). Spatial separation of 6 feet or more and drawing the curtain between resident beds is especially important for residents in multi-bed rooms.

Whether a private room or a multi-bed room, the door should remain closed if resident status and safety permit. Consider opportunities to improve ventilation, such as opening a window if the weather is appropriate, placing a portable air scrubber in the room, and turning on bathroom exhaust fans.

Follow CDC guidance on quarantine and isolation. Consider the risks and benefits of individual residents for room placement, including other pathogens of consequence that may prohibit cohorting (e.g., C auris, CPO, etc.).

For full details and recommendations for COVID-19 and other respiratory infections, facilities should visit the CDC’s Infection Control Guidance :SARS-CoV-2. Facilities may also view the Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities for more information.

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

Facilities are encouraged to utilize signage that communicates and provides instructions on current infection prevention and control practices being implemented within the facility. Providing a date on the sign can help ensure visitors know that they reflect current practices.

A facility with a confirmed or suspected COVID-19 outbreak should follow current CMS (Centers for Medicare and Medicaid Services) visitation requirements for nursing homes and CDC guidance for other LTCFs. All visitors should be educated upon admission on the type of PPE and other infection prevention principles that should be followed during their visit.

Upon recognition of a confirmed or suspected outbreak of respiratory illness, the facility may consider temporarily halting new admissions to the facility in consultation with their LHD. 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 as long as they have the staffing, space, and supplies to safely admit residents. A pause of new admissions to the facility or the affected unit, wing, or floor may be considered, but facilities should facilitate resident admissions and readmissions whenever safely possible. Facilities should review the latest recommendations on admissions for the outbreak in their facility.

Staff should be given support and flexibility to encourage them to stay home from work. To the extent possible, logistical barriers and financial hardship should be reduced.

HCP with mild to moderate illness who are not moderately to severely immunocompromised can return to work after the following criteria have been met:

• at least seven days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and
• at least 24 hours have passed since the last fever without the use of fever-reducing medications, and
  
• symptoms (e.g., cough, shortness of breath) have improved.
  

*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day five and again 48 hours later

Further recommendations on work restrictions and return to work criteria for asymptomatic, severely/critically ill, and immunocompromised individuals can be found by visiting CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.

Staff with ARI who are tested and do not have COVID-19 should be excluded from work until they have been fever-free for a minimum of 24 hours without the use of fever-reducing medicines, such as acetaminophen or ibuprofen. Staff should wear a well-fitting mask for at least five days upon return to work. The mask should always be worn, whether in patient care or staff-only areas. If other symptoms, such as cough and sneezing, persist, consider staff reassignment. A consult with a health care provider may be warranted for those with ongoing respiratory symptoms.

If an outbreak is limited to specific units within a health care facility, consider limiting potential interactions between residents on outbreak-impacted units and other residents. For example, have residents on outbreak-impacted units eat and do activities in their unit rather than going to a communal dining or activity room where residents from non-impacted units will be present. When possible, maintain physical distancing of at least 6 feet and maintain a reduced capacity in the space. Increase ventilation measures.

If initial interventions fail, limit group activities and communal dining. Consider limiting the use of communal areas where residents or HCPs might congregate across multiple units or the facility.

Residents with active ARI should not participate in facility-wide resident activities, therapy, or communal dining.

• CMS Visitation Guidance
• Infection Control Guidance: SARS-CoV-2 | COVID-19 | CDC
• CDC Influenza Infection Control in Healthcare Facilities
• Viral Respiratory Pathogens Toolkit for Nursing Homes | LTCFs | CDC