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October 2, 2018

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. Public Health - Seattle & King County is providing the following information to help you prevent influenza infection 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 Long Term Care reporting guidelines in the Nursing Home Guidelines Purple Book 6th Edition.

The fundamental components of an effective influenza prevention and control policy in LTCFs are:

  • Yearly influenza vaccination of residents: The Centers for Disease Control and Prevention (CDC) recommends annual influenza vaccination for everyone 6 months and older. 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. Should an outbreak occur, vaccination can decrease hospitalizations and deaths among residents. People 65 and older can get any flu vaccine approved for use in that age group. However, there are two vaccines designed specifically for people age 65 and older: high dose flu vaccine and adjuvant 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.

  • Yearly vaccination of all health care workers and personnel (both medical and non- medical) who have contact with patients: The CDC recommends annual influenza vaccination for both health care workers (HCW) and LTCF employees. Fully vaccinating staff limits disruption due to excessive sick leave 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.

  • Restrict staff with influenza-like illness from working. Discourage visitors with influenza- like illness from visiting: Ask visitors with respiratory symptoms to take appropriate precautions to prevent spreading infections to residents. These include frequent hand washing and wearing facemasks to prevent droplet transmission. Staff with symptoms of influenza or respiratory tract infections 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.

  • Recognize influenza cases in your facility early: The clinical picture of influenza may vary with age and immune status, making recognition of the disease difficult in the elderly. We encourage you to educate your staff about the subtle ways in which influenza may present in elderly persons (such as anorexia, mental status changes, fever, worsening of chronic respiratory status or congestive heart failure) to facilitate prompt testing (See below).
  • Have a low threshold for testing for influenza infection using antigen tests AND influenza cultures (or PCR tests) in ill persons, but DO NOT rely on antigen tests alone for the diagnosis of influenza: 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.

    Public Health provides viral culture kits and laboratory testing at no cost to you. In most instances you can obtain viral culture kits the same day by calling Public Health at 206-296-4774.

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

    Report suspected or confirmed influenza outbreaks within 24 hours by calling 206-296- 4774. In addition to calling, please fax the enclosed report of influenza outbreak form to 206-296-4803.
  • Promptly implement infection control measures and administration of antiviral medication for treatment or prophylaxis of influenza infection during 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 prepared in advance. Do not rely on rapid influenza tests to guide treatment or prophylaxis during an outbreak, because those tests can sometimes be falsely negative. For more information on use of antiviral medications 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. CDC recommends pneumococcal vaccination with PCV13 and PPSV23 to all adults age 65 years or older. See link in the Resources section below.

If you have questions about influenza prevention, need assistance evaluating or responding to an outbreak, or have suggestions on other ways we can assist you, please contact us. Related information can be found at

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


Jeffrey S. Duchin, MD
Health Officer and Chief, Communicable Disease Epidemiology & Immunization Section