As if protocols in certain states for dealing with nursing home residents returning from holiday leave weren’t complicated enough in terms of corhorting, the impending influenza season and new considerations from the Centers for Disease Control and Prevention (CDC) issued on November 23, 2020 to address co-occurrence of SARS-CoV-2 and influenza will surely up the ante.
CDC advises nursing homes to consider implementing the testing and management protocols when local public health surveillance data and testing data from local health care facilities indicate that both SARS-CoV-2 and influenza are co-circulating. The considerations involve protocols for testing, cohorting, and treating residents as follows:
1. Place Symptomatic Residents in Transmission-based Precautions Using All Recommended Personal Protective Equipment (PPE) Associated with Caring for Residents with SARS-CoV-2 Infection
CDC notes that the symptoms of COVID-19 and influenza can be very similar. The agency advises nursing homes not to place residents with acute illness consistent with COVID-19 or influenza in the dedicated COVID-19 care unit unless they are confirmed by testing to have COVID-19. Rather, such residents should be placed in a single room if available. If a single room is not available, they can remain in their current room, pending the results of testing. They should not be placed in a room with new roommates. Transmission-based precautions should be implemented for these residents.
2. Test Symptomatic Residents for Both SARS-CoV-2 Infection and Influenza
Testing symptomatic residents for both SARS-CoV-2 and influenza is necessary to rule out one or the other. CDC advises facilities to promptly notify the health department of any of the following:
- A suspected or confirmed case of either SARS-CoV-2 or influenza in a resident or staff member.
- A resident with severe respiratory infection resulting in hospitalization or death.
- Three (3) or more residents or staff members with new-onset respiratory symptoms within 72 hours of each other.
CDC advises facilities to obtain respiratory specimens for testing. It recommends multiplex nucleic acid detection assays if available because they can detect both SARS-CoV-2 and Influenza A/B.
If a symptomatic resident tests negative using a point of care antigen test, a nucleic acid detection test should be performed to confirm the results of the antigen test. Any positive test will trigger additional testing under existing guidance.
Like SARS-CoV-2, influenza infection can be detected either with a nucleic acid detection assay or an antigen test. If a symptomatic resident tests negative using a rapid influenza antigen test, a nucleic acid detection assay should be performed to confirm the results of the antigen test.
It is possible for a resident to test negative for both SARS-CoV-2 and influenza. If this is the case, symptomatic residents should be tested for other viral or bacterial pathogens.
3. Cohort Residents Based on Diagnosis
Resident confirmed to be co-infected with SARS-CoV-2 and influenza should be placed in a single room on the COVID-19 unit or housed with other co-infected residents. If this is not possible, CDC recommends that the facility consults with public health authorities to discuss other management options.
Residents with Influenza Only
Residents confirmed to be infected only with influenza should be placed in a single room or cohorted with other residents infected only with influenza. If this is not possible, CDC states that such residents could remain in their current room with measures in place, such as physical barriers and/or anti-viral medication, to reduce the risk of transmission to roommates.
4. Treat Residents According to Diagnosis
The CDC also provides recommendations to clinicians regarding treatment options for residents according to their diagnosis.
By now, most nursing homes have acclimated to the challenges of providing care to vulnerable residents during a pandemic. Yet with COVID-19 cases rising in a second wave in many states and with the traditional start of flu season looming, they will find themselves having to wage a battle on two different fronts at the same time. The greatest challenge for these providers could prove to be logistical in nature as they must allocate sufficient dedicated rooms to house residents needing observation (when they return from holiday leave, for example), residents with confirmed SARS-CoV-2 infection, residents with confirmed influenza, and residents with both SARS-CoV-2 infection and influenza. Only time will tell how that battle will play out.