Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings

This webpage includes guidance for preventing and controlling acute respiratory illness outbreaks in Wisconsin long-term care facilities (LTCFs). For the purposes of this guidance, LTCFs include skilled nursing facilities (SNFs), community-based residential facilities (CBRFs), and residential care apartment complexes (RCACs).

The information on this webpage was previously located in Bureau of Communicable Diseases (BCD) Memos 2023-04 and 2023-05. These memos went into effect November 1, 2023. Check this webpage frequently, as the content will be updated as guidance for LTCFs changes.

Responding to respiratory disease outbreaks

When an outbreak of acute respiratory illness (ARI), such as COVID-19 or another viral respiratory disease is suspected, timely testing, reporting, and infection control is imperative. Until the cause of an ARI outbreak is determined, facilities should initiate empiric precautions at the most protective level, including gown, gloves, fit tested N95, and eye protection, such as goggles or a face shield.

Questions? Contact us

If you have any questions or concerns, contact the Influenza Surveillance Coordinator at 608-266-5326, or call BCD at 608-267-9003.

Suspected respiratory disease outbreak, including COVID-19

A suspected respiratory disease outbreak in LTCFs and other health care settings are defined by the Division of Public Health (DPH) as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have pneumonia, acute respiratory illness, or laboratory-confirmed viral or bacterial infection (including influenza and COVID-19). For non-LTCF health care settings, only nosocomial cases should be counted.

While this is the definition the Department of Health Services (DHS) is using for COVID-19 and other respiratory outbreaks, CMS (Centers for Medicare & Medicaid Services) is still using the following definition for nursing homes: A single new case of COVID-19 occurs among residents or staff to determine if others have been exposed.

Outbreaks can be closed after two incubation periods have passed with no new cases being identified. For COVID-19 outbreaks, this is 28 days and for all other ARI outbreaks, it is approximately 14 days.

Acute respiratory illness

Acute respiratory illness (ARI) is an illness characterized by any two of the following signs and symptoms that are new or worsening from the resident's normal state:

  • Fever (temperature two degrees above a resident’s established baseline)
  • Cough (productive or nonproductive)
  • Runny nose or nasal congestion
  • Sore throat
  • Muscle aches
  • Shortness of breath or difficulty breathing
  • Low oxygen saturation in the blood (normal levels are between 95 and 100%, but may vary for people with certain medical conditions)

In Wisconsin, confirmed or suspected outbreaks of any disease in health care facilities, including LTCFs, are a Category I Disease, meaning they shall be reported immediately by telephone to the patient's local health officer, or to the local health officer's designee, upon identification.

General reporting requirements are described in Wis. Stat. ch. 252 Communicable Diseases. Specific reporting requirements are described in Wis. Admin Code. ch. DHS 145 Control of Communicable Diseases. More guidance on COVID-19 reporting can be found on the COVID-19: Health Care Providers webpage.

Outbreak line lists

LTCFs are strongly encouraged to maintain and update a line list during an ARI outbreak to organize case information. While LTCFs are no longer required to report these line lists to their local or Tribal health department (LTHD), the Department of Health Services (DHS) recommends that facilities continue to share them with public health as part of shared outbreak response.

When an outbreak of acute respiratory illness is suspected, testing to determine the etiology of the disease is essential to determine the appropriate precautions needed to control the outbreak.

Testing during acute respiratory illness outbreaks

Nasopharyngeal swabs (preferred) or oropharyngeal swabs collected from residents or staff should be sent for multiplex PCR testing. Specimens can be sent to any laboratory that performs multiplex testing or, with prior DPH approval, specimens can be sent to the Wisconsin State Laboratory of Hygiene (WSLH) where testing will be done free of charge. Approval can be requested by contacting the Influenza Surveillance Coordinator.

  • Specimens for acute respiratory outbreaks should be collected immediately after the onset of illness and placed in viral transport media to assure optimal test results. This will help to identify the etiology (cause) of the outbreak.
  • If SARS-CoV-2 is identified, all LTCFs, including nursing homes, should determine a testing approach, either targeted based on contact tracing or a wider approach, per CDC (Centers for Disease Control and Prevention's) guidance.
  • If specimens will be submitted to the WSLH, include the WSLH lab requisition form. Facilities may choose to have clinical specimens tested at a laboratory other than the WSLH, however, fee-exempt testing cannot be offered for tests performed at those laboratories.
  • Due to possible false positive results when using rapid influenza tests, especially when testing occurs during periods of low influenza activity, confirmatory testing of positive rapid test results using RT-PCR or viral culture should be performed.
  • With DPH approval, specimens may also be tested for other respiratory viruses.
  • If test results confirm influenza within a facility, no further testing will be performed on that resident unless they have an atypical presentation of illness or are not responding to treatment.
  • A negative test result does not rule out viral infection or the existence of an outbreak.
  • Testing and supplies are provided for fee-exempt testing through WSLH or participating private or clinical labs.

Guidance on testing in LTCFs

Antiviral treatment and prophylaxis during influenza outbreaks

When cases of influenza have been confirmed in a facility, antiviral prophylaxis should be offered to:

  • All residents regardless of vaccination status.
  • All unvaccinated employees.
  • Those employees vaccinated less than two weeks before the cases were identified.

CDC influenza antiviral recommendations are available on the CDC clinician summary webpage.

COVID-19 therapeutics and treatments

There are several U.S. Food and Drug Administration (FDA)-authorized antiviral medications to treat mild to moderate COVID-19 in individuals at higher risk for severe disease. COVID-19 Treatment Guidelines for health care providers are available from the National Institutes of Health. More information on COVID-19 treatments can be found on the CDC COVID-19 Treatments and Medications webpage.

Health care personnel and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Until the cause(s) of an ARI outbreak is determined, facilities should use the most protective level of precautions.

Transmission-based precautions, such as droplet (PDF), airborne (PDF), and/or contact (PDF) precautions may be recommended, depending on the type of respiratory virus detected. Follow CDC specific guidelines for the specific type and duration of precautions.

Universal source control is no longer required in nursing homes; instead the CDC recommends source control that follows the infection control core practices, while also considering resident characteristics and local respiratory illness data sources. Source control continues to be recommended for individuals who have suspected or confirmed COVID-19 infection or other respiratory infection or those who have close contact with an ill person. View CDC guidance for more on how and when to implement broader source control recommendations.

CDC recommended precautions for common respiratory viruses¹
Respiratory VirusRecommended Precautions
InfluenzaDroplet precautions
COVID-19/SARS-CoV-2Contact² and airborne³ precautions
RSVContact precautions
ParainfluenzaContact precautions
Rhino/EnterovirusDroplet precautions
Seasonal coronavirusContact precautions
Human metapneumovirusContact precautions
AdenovirusDroplet and contact precautions

¹If test results fail to identify an etiologic agent, ill residents should continue to be placed on contact and droplet precautions with an N95.

²Eye protection should be used for suspected or confirmed COVID-19 residents.

³Airborne precautions (such as N95 respirator and, if available, negative airflow rooms) should be used for patients with confirmed or suspected COVID-19.

Duration of transmission-based precautions: non-COVID-19 respiratory disease outbreaks

Follow CDC guidelines for the specific type and duration of precautions.

  • For confirmed or suspected influenza, residents should remain on droplet precautions for seven days after onset of illness or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer.
  • For other respiratory illnesses, the resident should remain on appropriate precautions for the duration of illness, defined as 24 hours after resolution of fever without the use of fever-reducing medications and without respiratory symptoms (see ARI symptoms above). Criteria for determining ARI among staff or residents should focus on whether cough is a new or worsening symptom. For discontinuation of droplet or contact precautions, exclude cough as a criterion unless the cough produces purulent sputum. In many cases, a non-infectious post-viral cough may continue for several weeks following resolution of other respiratory symptoms.

Duration of transmission-based precautions: COVID-19 outbreaks

The duration of transmission-based precautions is dependent on the severity of symptoms and presence of immunocompromising conditions. At minimum, when a resident has confirmed or suspected COVID-19, the resident should remain on standard, airborne, and contact (plus eye protection) precautions until the following conditions for discontinuation* are met:

  • At least 10 days have passed since onset of symptoms, and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (such as cough and shortness of breath) have improved.

*Individuals who remain asymptomatic throughout their infection and who are not moderately to severely immunocompromised should remain on contact precautions until at least 10 days have passed since the date of their first positive viral test. Some individuals with severe illness or who are moderately to severely immunocompromised should remain on contact precautions until at least 10 days and up to 20 days have passed since symptom onset and at least 24 hours since the last fever with symptom improvement. Use of a test-based strategy and (if available) consultation with an infectious disease specialist is recommended to determine when transmission-based precautions could be discontinued for these patients. If symptoms start after a positive test, isolation and precautions should extend for 10 days following symptom onset.

Resident room assignments

If possible, any resident who is ill with symptoms of ARI should stay in a private room. Decisions by medical and administrative staff regarding resident placement should be made on a case-by-case basis. In determining resident placement, consider:

  • Balancing the risk of infection to other residents in the room.
  • The presence of risk factors that increase the likelihood of transmission within the facility.
  • The potential adverse psychological impact on the infected resident.

When a single-resident room is not available, ill residents can be placed in a multi-bedroom following consultation with infection control personnel to assess risks associated with resident placement options (such as cohorting, keeping the resident with an existing roommate). Spatial separation of six feet or more and drawing the curtain between resident beds is especially important for residents in multi-bedrooms.

The LTCF may consider allowing a resident with a cough that is not a suspected or confirmed COVID-19 resident, to leave their room while wearing a surgical mask. This can be reviewed on a case-by-case basis and if the resident’s understanding and compliance with the core principles of infection control will minimize the risk of infection to other residents.

For full details and recommendations for COVID-19 and other respiratory infections, facilities should visit CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic. Facilities may also view the Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities for more information.

In general, facilities should assess risks and develop policies that provide guidance on visitation practices. Guidance and policies developed by facilities should be reinforced at the facility entrance and throughout the facility due to the inherent risks of ARI, including COVID-19, outbreaks among LTCF populations.

Facilities are encouraged to utilize signage that communicates and provides instructions on current infection prevention and control practices being implemented within the facility. Providing a date on the sign can help ensure visitors know that they reflect current practices.

A facility with a confirmed or suspected COVID-19 outbreak should follow current CMS (Centers for Medicare and Medicaid Services) visitation requirements for nursing homes and CDC guidance for other LTCFs. All visitors should be educated upon admission on the type of PPE and other infection prevention principles that should be followed as part of their visit.

Temporary halting of new admissions during respiratory disease outbreaks

Upon recognition of a confirmed or suspected outbreak of respiratory illness, the facility may consider temporarily halting new admissions to the facility in consultation with their LTHD. If the outbreak is confined to a specific unit, wing, or floor, the facility may consider allowing new admissions to other units, wings, or floors not affected by the outbreak as long as they have the staffing, space, and supplies to safely admit residents.

A pause of new admissions to the facility or the affected unit, wing, or floor may be considered, but facilities should facilitate resident admissions and readmissions whenever safely possible.

Facilities should review the latest recommendation on admissions for the outbreak in their facility.

Exclusion of staff

Further recommendations on work restrictions and return to work criteria can be found by visiting CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.

Staff with ARI who are tested and do not have COVID-19 should be excluded from work until at least 24 hours after they no longer have a fever (without the use of fever-reducing medicines such as acetaminophen or ibuprofen). If symptoms, such as cough and sneezing, are still present, staff should wear a surgical mask during resident care activities.

Support and flexibility should be given to staff to encourage them to stay home from work. Try to reduce logistical barriers and financial hardship to the extent possible.

An outbreak of ARI does not require the cancellation of facility-wide resident activities, therapy, or communal dining.

Residents with active ARI should not participate in facility-wide resident activities, therapy, or communal dining.



Last revised July 23, 2024