key: cord-331520-o9e4qqn4
authors: Kistler, Christine E.; Jump, Robin L.P.; Sloane, Philip D.; Zimmerman, Sheryl
title: The Winter Respiratory Viral Season During the COVID-19 Pandemic
date: 2020-10-26
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.10.030
sha: 
doc_id: 331520
cord_uid: o9e4qqn4

The winter respiratory virus season always poses challenges for long-term care settings; this winter, SARS-CoV-2 will compound the usual viral infection challenges. This special article discusses unique considerations that COVID-19 brings to the health and well-being of residents and staff in nursing homes and other long-term care settings this winter. Specific topics include preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and treatment of suspected respiratory infection. Policy-relevant issues are discussed, including whether to mandate influenza immunization for staff, the availability and use of personal protective equipment, supporting staff if they become ill, and the distribution of a COVID-19 vaccine when it becomes available. Research is applicable in all of these areas, including regarding the use of emerging electronic decision support tools. If there is a positive side to this year’s winter respiratory virus season, it is that staff, residents, family members, and clinicians will be especially vigilant about potential infection.

spread farther and linger longer as the temperature falls, cooler weather brings a seasonal rise of several communicable respiratory infections; in addition, heated indoor spaces encourage closer physical contact and dry mucosal surfaces, leaving individuals more susceptible to 20 increased air particles. 1 Until this year, influenza has been the most feared seasonal virus, as it 21 causes 12,000 to 56,000 deaths in the U.S. each year. 2 This winter will be different, of course, due to the pandemic caused by the SARS-CoV-2 virus, which has already claimed the lives of 23 over 1 million people worldwide. In the U.S., more than 75% of those deaths are in people 65 24 years of age and older. 3 

Before the COVID-19 pandemic, influenza was the most concerning viral respiratory infection 27 for nursing home (NH) residents, with outbreaks requiring both treatment and prophylaxis, and 28 even causing some buildings to close to outsiders for brief periods of time. 4 However, influenza 29 is not the only respiratory virus that abounds in the community and frequents NHs in winter.

Others, such as parainfluenza, rhinovirus, adenovirus, metapneumovirus, other coronaviruses, 31 and especially respiratory syncytial virus (RSV), may also cause outbreaks. 5 Other than 32 influenza, there are not yet vaccines or effective antiviral therapies for these infections. Making 33 matters worse, in addition to these viral infections as a cause of pneumonia, they contribute to 34 exacerbations of chronic obstructive pulmonary disease, and, in the case of influenza, may 35 predispose individuals to secondary bacterial infections and cardiac morbidity. 6 ,7 36 37 The winter respiratory virus season always poses challenges for NHs and assisted living 38 communities. Overlaying the usual viral infection challenges this winter will be SARS-CoV-2. In 39 this special article, we discuss unique challenges that COVID-19 will bring to the health and 40 well-being of residents and staff in long-term care settings this winter. Specific topics include 41 preventing the spread of respiratory viruses, promoting immunization, and the diagnosis and 42 treatment of suspected respiratory infection. We also address several issues related to staff, 43 including whether or not to mandate influenza immunization, availability and use of personal 44 protective equipment (PPE), absenteeism, presenteeism (coming to work despite illness), work 45 release for illness, and paid leave. In addition, we discuss strategies to help mitigate these 46 challenges, some important differences between NHs and assisted living relevant to infection and COVID-19, and conclude with a brief consideration of a future SARS-CoV-2 vaccine.

Preventing the Spread of Respiratory Viruses 50 51 Fortunately, we know more about COVID-19 than we did last spring when it first appeared. We 52 know that it spreads primarily via droplets, and less commonly through fomite transmission and 53 aerosolization. 8 However, the influence of heating systems that recirculate air on increasing the 54 aerosol spread of SARS-CoV-2 is not yet clear. We know that masks and other PPE prevent the 55 spread of SARS-CoV-2, 9 and because inadequate PPE has demonstrably increased the death 56 toll in NHs, it will be critical to have access to ample supplies this winter. 10 It also will be 57 necessary to have protocols for universal screening; to require that all persons wear face 58 coverings and practice physical distancing; to test staff and residents for purposes of screening 59 and when an outbreak is identified; and to isolate persons with a viral exposure or positive test.

If other respiratory viruses circulate widely as is typical in winter, NHs and assisted living 62 communities will need to have a workable plan for addressing new symptoms among residents, 

In addition to influenza and pneumococcal vaccines for residents, the Advisory Committee on 101 Immunization Practices recommends that all NH employees receive an annual influenza 102 vaccination, including those who do not have direct patient care responsibilities. 16 However, whereas hospitals have mandatory vaccination policies, most NHs do not. 17 Consequently, only 104 two-thirds of NH staff were vaccinated in 2017-2018. Mandatory vaccination policies increase 105 influenza vaccination rates to nearly 100%, 18 and AMDA's Infection Advisory Committee 106 recommends that all NHs adopt a similar mandatory vaccination policy. 16 The success of these 107 policies relies on staff education, incentives, and making the vaccine readily accessible. In 108 relation to education, the Centers for Disease Control and Prevention (CDC) provide numerous 109 resources, as do state and local health departments. In terms of incentives, NH leadership 110 might consider paid leave or other benefits to workers who receive a vaccination. Regarding 111 accessibility, NH leadership may need to work with their local health department and health care 112 system to provide free access to the vaccine, preferably on site and across all shifts, to promote begins with recognizing symptoms of an acute infection, followed by recognition of respiratory tract involvement. Then, clinicians are alerted to a change in condition; they conduct a diagnostic evaluation, initiate supportive care, and consider whether bacterial pathogens are pneumonia. 21 Further complicating matters, a study of adults with community-acquired 127 pneumonia suggested that viruses may be responsible for 23% of cases, with bacteria identified 128 in only 11% of cases; no pathogen was identified in the majority of cases. 22 Among NH 129 residents, pneumonia carries with it a case fatality rate of at least 25%, 23 

The specific test used to diagnose COVID-19 infections may vary depending on the types of 163 tests available, the time required to obtain the results, and the sensitivity and specificity of the 164 results. 30 In general, polymerase chain reaction (PCR) based tests, which detect viral 165 ribonucleic acid from a nasopharyngeal swab, are the most sensitive and specific. Test results the results. Antigen-based tests are largely point-of-care tests with samples collected from the purposes, a negative antigen test should be confirmed with a negative PCR test.

As NHs continue to grapple with the COVID-19 pandemic, these diagnostic tests are also being tested for COVID-19 at least weekly until there a two week period transpires without screening tests, whereas the frequency of staff screening depends on whether there are cases 

In addition to diagnostic testing for respiratory viral pathogens, several cutting-edge health 192 information technology and testing strategies may improve the diagnosis and management of 193 winter respiratory illnesses in NH residents.

• For pneumonia, evidence strongly suggests that electronic decision support may improve 195 clinician decision making. 33 Integrating clinical decision support in the electronic health 196 record improves evidence-based infection-related decisions. 34 The REDUCE trial 197 demonstrated that incorporating a pneumonia evaluation decision tool into the electronic 198 health record reduced antibiotic use for adults in outpatient care. 35 

Our research also found that NH residents receive an average of one prescription every three 229 months. 43 At any one time, over 10% of NH residents are taking antibiotics, and up to 75% of 230 these antibiotics are inappropriately prescribed. [44] [45] [46] Because constitutional symptoms often 231 promote inappropriate antibiotic prescribing, they present an opportunity for quality of care 232 assessment. 47 Consistent with CMS' focus on antibiotic stewardship over the last years, 48 available; and continually monitoring the PPE supply. 60 Earlier in the pandemic, approximately 20% of NHs reported having less than a one week supply of masks and gowns, and over 15% 266 reported staffing shortages; 61 recent data suggest that NHs have not closed the PPE gap. 62 shortages, as reports indicate that staff shortages persist as well. 51 Plans must include preparing for potential loss of staff due to illness or exposure to COVID-19. Based on CDC employees or more, and provided broad exemptions to employers of emergency responders and health care workers. Although the House has passed revisions of the act to remove these 

Being mindful of challenges and implementing mitigation efforts for both residents and staff may 286 lessen the toll the winter respiratory viral season will take on long-term care residents. Indeed, 287 many experts are predicting that social distancing for COVID-19 will result in a mild influenza 288 season.

It is unknown whether a SARS-CoV-2 vaccine will become available this winter. If so, important 291 questions include adverse effects of the vaccine and whether it will have immunogenicity for 292 chronically ill older adults. Current evidence suggests that mRNA vaccines appear safe and 293 immunogenic in older populations, 64 but whether such is the case remains a significant concern.

294 The question about cost was recently answered, as the U.S. government announced plans to 295 provide and administer COVID-19 vaccines to long-term care residents across the country with 296 no out-of-pocket costs. 65 Although specific plans for distribution of vaccines is unknown, NH and 297 assisted living residents should receive priority. Immunizing staff will further protect this 298 vulnerable population but must affordable and accessible. Due to public concerns about vaccine 299 safety and anti-vaccination resistance, public health efforts to promote the widespread uptake of 300 an effective vaccine should start in each NH and long-term care community as soon as a 301 vaccine appears imminent, to prepare staff and residents for the coming vaccination drives in 302 the spring and summer. 66 

Implications for Practice, Policy, and Research

The winter respiratory virus season always poses challenges for long-term care settings, and 307 those challenges will be exacerbated with the second wave of COVID-19; as such, they present 308 numerous implications for practice, policy, and research. As summarized in this paper, practice 309 must focus on preventing the spread of respiratory viruses, promoting immunization, and the 

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