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October 19, 2021

Dear Nursing and Medical Directors:

Annual seasonal influenza outbreaks in long-term care facilities (LTCF) cause high rates of infection, complications, hospitalizations, and death among LTCF residents. This may be exacerbated during the 2021-2022 flu season due to the concurrent COVID-19 pandemic. Without appropriate diagnostics, these two infections will be indistinguishable. Public Health - Seattle & King County (Public Health) is providing the following information to help you prevent influenza and COVID-19 infections among your residents and staff this flu season. As a reminder, health care facilities in Washington are required by law to report outbreaks and suspected outbreaks of disease to Public Health (WAC 246-100-076). You can find reporting guidelines for LTCFs in the Nursing Home Guidelines Purple Book, 6th Edition.

The following are fundamental components of an effective influenza prevention and control policy. These actions will be more important than ever given the current COVID-19 pandemic and will also help with the control of COVID-19:

  • Ensure COVID-19 vaccination takes place in your facility: All healthcare personnel and volunteers are mandated by the state of Washington to be vaccinated against COVID-19. Ensure your staff have been vaccinated or have appropriate exemption documentation. Establish access to COVID-19 vaccine for all residents in your facility and initiate administration of 3rd dose or booster doses as recommended.

  • Yearly influenza vaccination of residents: The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months and older receive an influenza vaccine by the end of October. In addition, the Centers for Medicare and Medicaid Services require nursing homes participating in their programs to offer all residents influenza and pneumococcal vaccines. Continue to vaccinate newly admitted residents throughout the flu season. High vaccination rates in residents can decrease the likelihood of an outbreak and can decrease hospitalizations and deaths among residents who become infected. People 65 and older can get any flu vaccine approved for use in that age group. However, if available, we recommend using one of the two vaccines designed specifically for people age 65 and older: high-dose flu vaccine and adjuvanted flu vaccine. Both vaccines are associated with a stronger immune response following vaccination. See link under Resources section below. Using standing orders can help ensure adults receive recommended vaccinations. The COVID-19 and Influenza vaccine can be administered together without a waiting period.

  • Yearly influenza vaccination of all health care workers: Health care workers (HCW)* include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the health-care facility, and persons (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, administrative, billing, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from health care workers and patients. Vaccinating staff reduces staff absences for illness during an outbreak. It also minimizes the risk of exposing high-risk residents to influenza. To increase employee vaccination rates, consider offering vaccine on site, paying for vaccine, and providing special in-services for staff. The COVID-19 and Influenza vaccine can be administered together without a waiting period.

  • Restrict staff with respiratory illness or other symptoms of COVID-19 from working. Restrict visitors with respiratory illness or other symptoms of COVID-19 from visiting: Ask all visitors to take appropriate precautions to prevent spreading infections to residents. These include frequent hand washing and wearing facemasks to prevent droplet transmission. All visitors and staff should wear facemasks at all times while in your facility given the concurrent COVID-19 pandemic during this flu season. Staff with symptoms of influenza or respiratory illness should be restricted from working and should remain home until they are fever-free for 24 hours without the use of fever-reducing medications. Staff should also be instructed not to work at other facilities during this time. All staff with symptoms should be tested for COVID-19 as soon as possible and if positive should follow guidance for returning to work provided by CDC.

  • Recognize respiratory illnesses in your facility early: The clinical picture of respiratory infections, including influenza and COVID-19, may vary with age and immune status, making recognition of disease difficult in the elderly. To facilitate prompt identification and testing of patients with respiratory illness, we encourage you to educate your staff about the subtle ways in which influenza or COVID-19 may present in elderly persons (such as anorexia, mental status changes, fever, worsening of chronic respiratory status or congestive heart failure).

  • Have a low threshold for testing for influenza and COVID-19 infection in ill persons. Antigen tests for influenza or COVID-19 may require verification by PCR testing depending on the situation: Rapid antigen tests are not highly sensitive for seasonal influenza especially early in the season. Therefore, a positive test is helpful, but a negative test does not rule out infection. For COVID-19 antigen testing, please refer to CDC guidance on antigen testing in LTCFs.

  • Public Health can provide testing support. For assistance call Public Health at 206-296- 4774.

  • Report to Public Health within 24 hours when either: 1) influenza or COVID-19 is diagnosed in at least one resident/staff, OR 2) more than one resident/staff in the facility or an area of the facility (e.g. separate unit) develops acute respiratory illness during a 72hr period. When an outbreak is suspected, Public Health can assist you in confirming the diagnosis and responding to the outbreak.

How to report a suspected or confirmed outbreak

Please visit to submit your report for influenza, respiratory illness and/or COVID-19 cases using our REDCap reporting system. Should you have questions, please call 206-296-4774 to speak with an investigator.

  • Promptly implement infection control measures for any outbreak of respiratory illness and administration of antiviral medication for treatment or prophylaxis for influenza outbreaks: Antiviral medications must be administered quickly to ill persons to provide optimal clinical benefit (treatment) and to uninfected persons to effectively stop an outbreak (chemoprophylaxis). For outbreak control purposes, consider having orders for antiviral treatment and chemoprophylaxis for influenza as well as testing orders for influenza and COVID-19 prepared in advance. Do not rely on negative rapid antigen-based tests for symptomatic individuals to guide cohorting for COVID-19 or treatment versus prophylaxis for influenza prior to an outbreak, because those tests can sometimes be falsely negative. In a symptomatic individual, negative antigen tests should be confirmed with a PCR based test. For more information on use of antiviral medications for influenza in institutional settings, see link in the Resources section below.

  • Pneumococcal infections also cause high morbidity and mortality in elderly persons. Pneumococcal vaccine should be offered to all residents of LTCFs (unless contraindicated) based on their age, underlying medical conditions and past vaccination history. Pneumococcal vaccine is not administered annually, follow current CDC guidance. CDC recommends pneumococcal polysaccharide (PPSV23) to all adults age 65 years or older. Some patients may choose to also receive pneumococcal conjugate (PCV13). See link in the Resources section below. If you have questions about influenza or other respiratory infection prevention, need assistance evaluating or responding to an outbreak or have suggestions on other ways we can assist you, please contact us at 206-296-4774.

Thank you for your work to protect the health of your residents and staff.


James Lewis, MD, MPH
Medical Epidemiologist – COVID-19 Healthcare Response
Communicable Disease Epidemiology & Immunization Section, Public Health — Seattle & King County

Influenza, Pneumococcal and COVID-19 Resources for Long-Term Care Facilities

*Healthcare Personnel (HCP): HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, volunteer personnel). For this guidance, HCP does not include clinical laboratory personnel. Reference: Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2