Refresher on CDC Infection Prevention Guidance for Nursing Homes

Nursing home members are reminded that on Sept. 10, 2021, the Centers for Disease Control and Prevention (CDC) issued recommendations designed to prevent the spread of SARS-CoV-2 in long term care facilities. The recommendations address the following:

Updated outbreak response guidance to promote use of contact tracing approach. Alternative broad-based approaches to outbreak response at facility-wide or unit level also described;
Updated expanded screening testing recommendations for health care personnel (HCP);
Updated recommendations for quarantine of fully vaccinated residents;
Updated visitation guidance.

Some of what is recommended may not yet have been addressed by the Department of Health (DOH) or may not completely align with current guidance. Members are strongly encouraged to consult with their regional epidemiologist on specific situations. Some of the highlights of the guidance are as follows:

Following a higher-risk exposure, testing and work restriction are recommended for unvaccinated HCP (see table in guidance).

In general, work restriction of asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days and asymptomatic HCP who are fully vaccinated is not necessary unless they develop symptoms, test positive for SARS-CoV-2 infection, or are otherwise directed to do so by the jurisdiction’s public health authority.

Additional considerations following a higher-risk exposure for these HCP (recently recovered and asymptomatic, fully vaccinated) include:

Testing: Fully vaccinated asymptomatic HCP should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately (but not earlier than two days after the exposure) and, if negative, again five to seven days after the exposure. Testing is not recommended for asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days; this is because some people may be non-infectious but have detectable virus from their prior infection during this period (additional information is available here). Criteria for use of post-exposure prophylaxis are described elsewhere.
Source control: Universal use of source control while in the health care facility is recommended for 14 days following their higher-risk exposure, then they may default to routine source control recommendations for HCP.
Circumstances when work restrictions might be recommended:
- Among asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days:
  - HCP who are moderately to severely immunocompromised and might be at increased risk for reinfection. However, data on which specific conditions may lead to higher risk and the magnitude of risk are not available. OR
  - Unvaccinated HCP for whom there is concern that their initial diagnosis of SARS-CoV-2 infection might have been based on a false positive test result (e.g., individual was asymptomatic, antigen test positive, and confirmatory nucleic acid amplification test (NAAT) not performed).
- Among fully vaccinated HCP:
  - HCP who are moderately to severely immunocompromised OR
  - When directed by public health authorities (e.g., during an outbreak where SARS-CoV-2 infections are identified among fully vaccinated HCP)
    - In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of work restriction of fully vaccinated HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction’s public health authority recommends these and additional precautions.

Indoor Visitation During an Outbreak

Facilities should follow guidance from the Centers for Medicare and Medicaid Services (CMS) on visitation.

Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility.
Whether unvaccinated residents are known to be close contacts or are identified as a part of a broad-based outbreak response but not known to be close contacts, indoor visitation should ideally occur only in the resident’s room, and the resident and their visitors should wear well-fitting source control (if tolerated) and physically distance (if possible).
Source control and physical distancing recommendations should also be followed for vaccinated residents.
Outdoor visitation could be allowed, but residents should wear well-fitting source control (if tolerated), maintain physical distancing from others, and not linger in common spaces when moving from their rooms to the outdoors.

Outbreaks – Alternative, Broad-Based Approach

If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility level or group level (e.g., unit, floor, other specific area(s) of the facility).
- Broader approaches might also be required if the facility is directed to do so by the jurisdiction’s public health authority or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission.
Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but not earlier than two days after the exposure, if known) and, if negative, again five to seven days later.
Unvaccinated residents and HCP:
- Unvaccinated residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown. They should not participate in group activities.
- Close contacts, if known, should be managed as described in the Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection section of the guidance.
- For guidance about work restriction for unvaccinated HCP who are identified to have had higher-risk exposures, refer to Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.
Fully vaccinated residents and HCP:
- Fully vaccinated residents should be tested as described in the testing section; they do not need to be restricted to their rooms or cared for by HCP using the full personal protective equipment (PPE) recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction’s public health authority.
- For guidance about work restriction for fully vaccinated HCP who have higher-risk exposures, refer to Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2.
- In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for fully vaccinated residents and work restriction of fully vaccinated HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction’s public health authority recommends these and additional precautions.

Contact: Amy Nelson, anelson@leadingageny.org, 518-867-8383 ext. 146 or Mark Kepner-Clough, mkepner-clough@leadingageny.org, 518-867-8383 ext. 125