Infection control guidance for influenza

To prevent the transmission of all respiratory infections in health care settings, implement the following infection control measures at the first point of contact with a potentially infected person.

When you suspect that flu is circulating in your facility

1. Treat ill residents promptly and empirically

Clinical judgment is an important factor in treatment decisions for patients presenting with influenza-like illness. Prompt empiric antiviral treatment with influenza antiviral medications is recommended while results of definitive diagnostic tests are pending, or if diagnostic testing is not possible, for patients with clinically suspected influenza illness who have:

• Illness requiring hospitalization,
• Progressive, severe, or complicated illness, regardless of previous health status, and/or 
• Increased risk for severe disease.

Antiviral treatment, when clinically indicated, should not be delayed pending definitive laboratory confirmation of influenza. Influenza antiviral medications are most effective when initiated within the first two days of illness, but these medications may also provide benefits for severely ill patients when initiated even after two days. Guidance on use of antivirals may change depending upon resistance data.

• See our page on antiviral drug recommendations
• See CDC’s latest recommendations on antiviral use
• See CDC’s Influenza Antiviral Medications: Summary for Clinicians

2. Test promptly for influenza and other causes of febrile respiratory illness

Respiratory specimens should ideally be collected as early as possible (ideally within three days after illness onset, when influenza viral shedding is highest). See information about influenza testing.

3. Isolate and/or cohort ill patients

Restrict staff floating and consider limiting resident activities within the facility. Exclude symptomatic staff and patients until at least 24 hours after they no longer have a fever without the use of fever reducing medications.

4. Immediately report clusters via online report form

See the Influenza/Respiratory Illness Cluster Reporting Form.

 5. Use droplet precautions

Also, use standard precautions when caring for patients with suspected or confirmed seasonal influenza.

6. Conduct daily active surveillance and testing for new illness and cases

Healthcare professionals can use the CDC line list LTC Respiratory Surveillance Line List and Surveillance Outbreak Summary (cdc.gov) as a template for tracking influenza-like illness (ILI) among patients and staff in your facility.

7. Encourage respiratory hygiene, cough etiquette, and hand hygiene

Provide staff reminders or retraining if necessary. Post visual alerts (in appropriate languages) at the entrance to the facility. Posters, brochures, and fact sheets promoting cough etiquette and handwashing in multiple languages are available from the Massachusetts Health Promotion Clearinghouse.

8. Use antiviral agents for outbreak control

Used in conjunction with vaccination and behavioral measures, including droplet precautions and co-horting of ill residents, antiviral agents are a key component of outbreak control in long-term care facilities and other institutional settings.

For more information, please see antiviral drug recommendations.

9. Offer vaccine to unvaccinated staff

Also offer chemoprophylaxis to staff if they care for persons at high risk for complications.

10. Immediately report…

Unusual or unusually severe cases, suspected and confirmed pediatric flu-related deaths, deaths in pregnant people, and suspected cases of novel or variant flu, as described below under “Influenza Reporting.”

Vaccination of residents

• Vaccinate residents against flu when vaccine is available.
  • Vaccinate residents admitted from September through March on admission if prior vaccine is not documented. 
• Ensure that written policies include annual flu vaccination, and COVID vaccines, and pneumococcal vaccines (PCV20 and PCV15), Shingrix, and Tdap vaccination for residents. Also consider shared decision making for RSV vaccination.
  • If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition†, cochlear implant, or cerebrospinal fluid leak.
  • If PCV20 is used, a dose of PPSV23 is NOT indicated.
  • See Pneumococcal Vaccination: Summary of Who and When to Vaccinate for CDC guidance on vaccination options for adults who have previously received a pneumococcal conjugate vaccine.
• Include Vaccine Information Statements (VIS) for PPSV23, PCV15, PCV20, Tdap, shingles vaccine (Shingrix), RSV and flu vaccines in the admission packet. Visit the IAC site for Vaccine Information Statements (VISs) for all vaccines in many languages.
• Obtain consent for vaccination from the resident or family member on admission.
• Implement standing orders to administer flu, COVID, PCV15, PCV20, PPSV23, Shingrix, RSV and Tdap vaccines.
  • Use chart audits to ensure that there is documentation in every chart that the resident has been offered COVID, PPSV23, PCV20, PCV15, Shingrix, Tdap, RSV vaccines and the annual influenza vaccine.
• Consider residents with uncertain immunization histories as NOT immunized and vaccinate accordingly. The benefits of vaccination far outweigh any concerns about revaccination.
• Doses of PCV15 and PPSV23 should be administered in a series and not on the same day. (If given at the same time, or at shorter than the recommended interval, those doses do not need to be repeated.). Other routine vaccines for adults are safe and effective when administered simultaneously in separate syringes at different anatomical sites. 

Vaccination of staff

• Use a systematic approach to vaccination, with checklists, to increase immunization levels:
• Vaccinate all staff against influenza every year.
• Ensure all staff are up to date on COVID-19 vaccinations.
• CDC, the Advisory Committee on Immunization Practices (ACIP), MDPH, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), recommend that all U.S. health care workers get vaccinated annually against influenza and are up to date on COVID-19 vaccinations.
• As a condition of licensure, DPH regulations require health care facilities to offer free-of-charge, annual influenza vaccine to all personnel (full and part-time employees, contracted employees, volunteers, house staff and students), and document receipt of influenza and COVID-19 vaccines administered and declination of immunization.
  • Licensed facilities are also required to report information to DPH documenting compliance with the vaccination requirement, in accordance with reporting and data collection guidelines of the Commissioner (105 CMR).
• Health care workers 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.
• Health care facilities include hospitals, ambulatory surgical centers, dialysis centers, clinics, nursing homes, rest homes, and adult day health programs.
• The long-term care facility and adult day health program regulations are available at the following links:  
  • Licensing of Long Term Care Facilities:105 CMR 150.002(D)(8) (PDF)
  • Licensure of Adult Day Health Programs: 105 CMR 158.030(L)(8)

People with neurological and neuromuscular conditions

Children and adults with neurological and neuromuscular conditions (listed below) are at increased risk of complication from influenza. These conditions can compromise respiratory function, and handling of secretions, and increase the risk of aspiration. We recommend that everyone six months of age and older with these conditions to receive yearly influenza vaccinations.

Congregate housing for those with neurological and neuromuscular conditions

People residing in group housing should receive flu vaccine as soon as it is available. Likewise, staff should also be vaccinated. In addition, when outbreaks of influenza-like illness occur in a group home or day program serving vulnerable populations, healthcare providers should be immediately notified and should consider rapid antiviral treatment of ill individuals, as well as antiviral prophylaxis of individuals who were exposed.

Neurological and neuromuscular conditions at risk

• Disorders of the brain
• Disorders of the spinal cord
• Disorders of the peripheral nerve
• Disorders of the muscle including:
• Cerebral palsy
• Epilepsy (seizure disorders)
• Stroke
• Intellectual disability (mental retardation)
• Moderate–to-severe developmental delay
• Muscular dystrophy
• Spinal cord injury