Millions of people in the U.S. live in long-term care (LTC) facilities like nursing homes, hospices, and assisted living facilities.1 People aged 65 and older make up the majority of LTC residents and are at the highest risk of complications from the flu because the immune system weakens with age.2

Healthcare worker assisting patient in wheelchair

Many residents of long-term care facilities also have significant health issues or are immunocompromised, which puts them at even greater risk of developing serious and potentially fatal flu complications. Given these facts, it may not come as a surprise that approximately 85% of seasonal flu-related deaths in the U.S. occur in people over age 65.3

Preventing flu outbreaks in LTC facilities is critical, as well as containing the spread of the flu when an outbreak occurs.

Ahead, we’ll look at how long-term care facilities can help prevent and control the spread of flu through measures including but not limited to: staff and resident vaccination, good infection control practices, and active surveillance.

Ensuring healthcare workers receive comprehensive long-term care facility staff training and education on infection control practices is also vital. Using a combination of online healthcare education courses, live demonstrations, and classroom sessions can help ensure that workers have access to the learning method that works best for them.


It’s difficult to estimate the burden of influenza on long-term care facility residents, largely because existing data show that infection rates, complications of the flu, and flu-related deaths can vary significantly, depending on the types and subtypes of the virus in circulation at any given time and other factors, including geographic region and the specific conditions at each LTC facility.4

Nevertheless, we know that flu generally presents a major risk to long-term care residents. A comprehensive review of 206 published infectious outbreaks in long-term care facilities across 19 countries over a 40-year period found the following:4

  • Of 37 different pathogens identified in the review, influenza virus caused the largest number of all outbreaks (49 of 206 outbreaks, or 23%).
  • Of the 49 outbreaks caused by flu, the median attack rate in residents was 33%; rates varied dramatically by facility-in some facilities, the rate was as low as 4%, in others, as high as 94%.
    • The median fatality rate for residents was 6.5%. Fatality rates also varied dramatically by facility, from 0-55%.

Exposure to the flu virus significantly increases a resident’s risk of hospitalization and death from flu-related respiratory problems, compared to unexposed residents. This is true even in facilities where a large percentage of residents have been vaccinated against the flu.4

Patient bed at hospital

Due to America’s aging population — demand for long-term care facilities will only grow in the coming years. The number of Americans over age 65 is projected to grow from around 40 million people in 2010 to 88.5 million in 2050; the number of people age 85 and over will almost triple in the coming decades, from 6.3 million in 2015 to 17.9 million in 2050.1

This means LTC facilities will face even greater challenges in the years ahead in preventing and containing flu outbreaks. Diligent infection prevention and control strategies will be even more important.


There are three types of flu virus known to infect humans: A, B, and C. Types A and B are responsible for nearly all the annual flu epidemics in the U.S.5 Type C also causes flu, but symptoms are much less severe than with types A and B, and type C is not thought to cause epidemics.5

Type A influenza viruses are further broken down into subtypes and strains; type B viruses are further broken down not into subtypes, but into lineages and strains.5

Per the CDC, two types of influenza A (H1N1 and H3N2) and one or two types of influenza B virus (depending on the vaccine) are included in each year’s influenza vaccine.5


Flu transmission occurs via three routes: droplet-larger particles too large to be inhaled into the lungs and which fall quickly to the ground/other surfaces; aerosol-small particles that can remain suspended in the air and are potentially inhalable into the lower respiratory tract; and contact-transfer of infectious particles to the mucous membranes through contaminated objects.


Flu incubation periods are short, typically ranging from one to four days, but it can take as few as three or as many as nine days for an infected person to show symptoms.4 The flu’s short incubation period means the virus can spread rapidly through LTC facilities. Staff should begin isolation and transmission-based precautions as soon as a case of influenza is confirmed or suspected (discussed ahead).


Healthy people may only shed the flu virus for six to seven days, with pre-symptomatic shedding in up to one-third of cases.4 While influenza transmission dynamics have not been studied in people age 65 and older, research has found that immunocompromised patients and those who are hospitalized with severe flu may shed the virus for weeks or even months. Patients with multiple health issues have also been shown to shed the virus for longer and to have a larger viral load.4

Since many LTC residents have comorbidities or are immunocompromised, they may be infectious for prolonged periods, compared to the general population-an important consideration for LTC administrators.

Flu Symptoms

Common flu symptoms include high fever-102 degrees F or greater – body aches, fatigue, sore throat, headache, nausea/vomiting, and in some, a runny/stuffy nose. It’s important for healthcare personnel to know that flu symptoms may be less obvious in long-term care residents-infected residents may not have a fever, or they may have non-specific symptoms or atypical presentation of influenza, such as exacerbation of an underlying condition with no known cause.4


Flu complications are common and dangerous in seniors, especially those with multiple chronic health conditions. Serious complications can include pneumonia, dehydration, inflammation of the heart (myocarditis), inflammation of the brain (encephalitis), multi-organ failure, and death.


Flu prevention requires diligent, year-round adherence to a range of protection measures, including vaccination (residents and staff), surveillance, infection control, testing, antiviral treatment, antiviral chemoprophylaxis, and others.

  • Surveillance/Early Recognition – when there is flu activity in the local community, LTC facilities should conduct daily surveillance among all residents, staff, and visitors. Once a single case of influenza has been confirmed with lab testing, staff should assume there are other cases on site. Surveillance should continue until the end of influenza season and at least one week after the last confirmed case. Administrators should notify local health and state health departments of every suspected or confirmed influenza outbreak occurring at an LTC facility.
  • Infection Control Measures
    • Standard Precautions should be followed, including hand hygiene, wearing gloves while working with potentially infectious material, and using gowns for patient-care activities that involve blood, bodily fluids, or secretions.
  • Droplet/Isolation Precautions – Patients with suspected or confirmed influenza should be placed in a private room or area or, if not possible, grouped with other patients who have the same affliction. LTC staff should wear facemasks when entering the rooms of patients with suspected or confirmed influenza; facemasks should be removed and disposed of properly, followed by hand hygiene. Patients should wear facemasks and follow respiratory hygiene, cough etiquette, and hand hygiene guidelines.
  • Staff Vaccination – the CDC recommends that all health care personnel get vaccinated against influenza to help reduce transmission of the virus, staff illness and absenteeism, and flu-related illness and death, especially for people at increased risk. The CDC reports that higher vaccination rates among healthcare personnel are associated with a lower risk of healthcare facility-associated flu cases. Studies have shown that high rates of staff vaccination in LTC facilities decrease the risk of death due to any cause, especially when both healthcare workers and patients have high vaccination rates.4,6
  • Resident Vaccination – Studies have yielded inconclusive results in terms of how effective influenza vaccination is in protecting residents of long-term care facilities.6 Still, the CDC recommends vaccinating all new and current residents.6 Where possible, all residents should receive trivalent inactivated influenza vaccine (TIV) annually before the flu season begins. 6 Residents admitted after the conclusion of a flu vaccination program should be considered for vaccination on a case-by-case basis.6
  • Manage Visitor Access during Flu Outbreaks – Visitation of patients in isolation for flu should be limited to situations where visits are necessary for the patient’s emotional well-being and care. Visitors with acute respiratory symptoms should be restricted from certain areas-e.g., oncology units, with exceptions made on a case-by-case basis. All visitors should follow posted respiratory hygiene and cough etiquette. Facilities should ensure that visitors have the information and personal protective equipment they need to prevent the spread of the flu.
  • Lab Testing – Even if it’s not flu season, facilities should test for influenza when any resident has signs and symptoms of influenza-like illness, especially if two or more residents develop respiratory illness within 72 hours of each other. Facilities should implement outbreak prevention and control measures as soon as a flu outbreak has been confirmed.
  • Antiviral Treatment -Facilities should immediately administer antiviral treatment to residents and staff who have suspected or confirmed influenza, according to current recommendations.6
  • Antiviral Chemoprophylaxis -Facilities should administer antiviral chemoprophylaxis to all eligible residents as soon as a flu outbreak is confirmed. 6
Medical worker wearing gloves


Healthcare administrators have the responsibility of ensuring that all healthcare personnel receive education and training on preventing the transmission of influenza. Healthcare staff should receive updates about current influenza viruses in circulation, as well as ongoing training and continuing education on infection control practices. Key aspects of an influenza training and education program include:

  • Recognizing influenza signs and symptoms.
  • Understanding flu complications and their risk factors.
  • The importance of infection control practices, including respiratory hygiene and cough etiquette, hand hygiene, the use of personal protective equipment, sick policies and specific work practices that prevent the spread of infection.

Medcom Featured Series: Infection Control in Long-Term Care

Medcom’s healthcare education programs are trusted by nursing homes, hospices, assisted living facilities, adult day care centers, and hospitals across the country. Our Infection Control in Long Term Care courses were developed with nurses, certified nursing assistants, and others who work directly with residents of long-term care facilities in mind. Courses include:

  • Infection Control in Long Term Care: An Introduction
  • Infection Control in Long Term Care: Multidrug-Resistant Organisms
  • Infection Control in Long Term Care: Precautions
  • Infection Control in Long Term Care: Regulatory and Administrative Measures
  • Infection Control in Long Term Care: Safe Work Practices
  • Preventing Blood borne Infection in Long Term Care

Viewers will learn about a broad range of topics, including events that led to the development of improved infection control practices, how the Joint Commission promotes healthcare worker and resident safety, the CDC network used for reporting healthcare-associated infections, the Needlestick Safety and Prevention Act, how to perform proper hand hygiene and fingernail care, how to properly use personal protective equipment (PPE), the key characteristics of different multi-drug-resistant organisms (MDROs), and much more.

Medcom has designated 0.5 contact hours of continuing nursing education credit for each of the courses listed above.

For more information about this series or to set up a free preview, please contact Medcom at 800-541-0253, or email [email protected].

Medical log on laptop


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