Preventing and Controlling Acute Respiratory Illness Outbreaks in (Non-Health Care) Community Congregate Settings

This guidance is intended for community congregate settings. Community congregate settings are non-health care settings and include long-term care facilities (excluding nursing homes) whose staff provide non-skilled personal care* similar to that provided by family members in the home (e.g., many assisted living, and group homes) and shelters. This includes, but is not limited to, facilities that are licensed under the following Illinois administrative codes:

• PART 295 ASSISTED LIVING AND SHARED HOUSING ESTABLISHMENT CODE
• PART 330 SHELTERED CARE FACILITIES CODE
• PART 370 COMMUNITY LIVING FACILITIES CODE
• PART 380 SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
• PART 385 SUPPORTIVE RESIDENCES LICENSING CODE

Facilities licensed under Part 350 Intermediate Care for the Developmentally Disabled that do not provide skilled care may follow this Community Congregate Setting guidance. Facilities licensed under Part 350 that provide skilled care should follow guidance for health care settings. Facilities that provide a spectrum of care (e.g., skilled nursing, assisted living, and independent living) should follow the appropriate guidance for each setting; personnel who serve across settings should be held to the most conservative guidance. Health care providers should follow guidance for health care personnel across all setting types.

This guidance aligns with the CDC’s Respiratory Virus Guidance for the general community, first issued in March 2024. At that time, previous COVID-19-specific guidance for assisted living facilities was rescinded. More about the reasoning for the new guidance is described here. The guidance is simpler and less prescriptive, and it does not include specific recommendations for all the decisions community congregate care facilities need to make to prevent respiratory illness. This guidance supplements the key elements described in the CDC Respiratory Virus Guidance. Guidance for health care settings remains unchanged. Guidance for skilled nursing facilities, based on the CDC’s guidance for health care settings, can be found here. While these considerations are specific to the care of residents residing in skilled nursing facilities, some practices could be adapted in other Community Congregate Care settings (e.g., assisted living communities).

Visiting or shared health care personnel who enter the setting to provide health care to one or more residents (e.g., physical therapy, wound care, intravenous injections, or catheter care provided by home health agency nurses) should follow the health care recommendations for control of COVID-19 and other respiratory viruses. In addition, if staff in a residential care setting are providing in-person services for a resident with SARS-CoV-2 infection, they should be familiar with recommended infection prevention and control (IPC) practices to protect themselves and others from potential exposures, including hand hygiene, personal protective equipment, and cleaning and disinfection practices outlined in the health care guidance.

For community congregate settings, where testing access may be limited, COVID-19 reporting is incorporated into the existing ARI symptom-based protocol. This approach supports the early identification and management of potential outbreaks through symptom monitoring, thus eliminating the delay of laboratory confirmation.

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 (greater than 100°F/37.8°C or more than 2 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, which may manifest as increased fatigue
• Low oxygen saturation in the blood (normal levels are between 95% and 100%, but may vary for people with certain medical conditions)

Outbreaks must be reported if they meet the following criteria:

**See outbreak definition. Acute respiratory illness outbreaks include those due to COVID-19, influenza, RSV, and other viral respiratory illnesses.

Note: There may be a need to report cases and/or outbreaks to multiple entities. Reporting to one does NOT satisfy the need to report to the others.

Effective February 27, 2024, individual cases of COVID-19 detected by POC testing conducted by a non-health care congregate setting do not need to be routinely reported unless the infection results in ICU admission or death of a child <18 years of age. An LHD may request test results in an outbreak. Tests conducted by a laboratory shall report positive results via ELR.

Residents should be counseled about Core Prevention Strategies for all individuals to protect themselves and others, including recommendations for source control if they are immunocompromised or at high risk for severe disease.

Stay up to date with immunizations

Immunizations are the best way to protect against serious illness and death caused by COVID-19, flu, and RSV. Continue to offer vaccinations onsite and strongly encourage individuals to stay up to date with their recommended vaccinations. A client’s vaccination status is not a reasonable criterion for determining eligibility for housing or services. Encourage staff members to get vaccinated and consider hosting staff vaccination events or promoting policies that facilitate staff vaccination.

Practice good hygiene, including handwashing, covering coughs and sneezes, and cleaning frequently touched surfaces

Facilities should regularly clean frequently touched surfaces and objects such as door handles, stair rails, elevator buttons, touchpads, and restroom fixtures. They should also clean and disinfect surfaces when they are visibly dirty or areas where people have been ill.

Additional resources:

• CDC - When and How to Clean and Disinfect a Facility

Take steps for cleaner air

Increasing ventilation is one of the most effective ways to reduce the transmission of viruses spread through the air. Maximizing ventilation is particularly important in areas designated for isolating persons with respiratory viruses.

• Maximize airflow and filtration within the facility’s HVAC system to improve air quality.
• Ensure your building’s HVAC system is in good working order and frequently inspected. HVAC systems can be optimized by installing a MERV 13 filter and ensuring a minimum of five air changes per hour (ACH).
• Create directional airflow from clean areas (i.e., the corridor) to less clean areas (i.e., sick client rooms) so that infectious particles do not spread within the facility and are, if possible, exhausted directly to the outdoors.
• When mechanical filtration cannot be improved enough to meet targets or in rooms with more crowding, portable air cleaners (“HEPA air filters”) should be considered. Portable air cleaners must be appropriately sized for the area where they are deployed and oriented so that air is exhausted upwards without blowing air from one person to another.
• Improve natural ventilation (i.e., open windows when weather permits). Limit box fan use.
• Decrease indoor occupancy in areas where outdoor ventilation cannot be increased.

Additional resources:

• CDC - Ventilation Mitigation Strategies
• CDC - Improving Ventilation in Your Home

Use precautions to prevent spread

If you have respiratory virus symptoms that aren't better explained by another cause, stay home and away from others (including people you live with who are not sick).

Seek health care promptly for testing and/or treatment if you have risk factors for severe illness.

Respiratory viruses are causing a lot of illness in your community, including when:

• Respiratory illness activity is moderate, high, or very high in Illinois.
• As directed by the local or state health department, based on local data or community trends (via SIREN or other direct communication).
• Facilities may also choose to implement broader use of source control (masking) at their discretion. This may be in response to local data, awareness of outbreaks in other facilities/community settings, or for other reasons established by the facility. Some facilities may implement masking throughout the viral respiratory season (based on historic viral respiratory trends or observed trends).

You or those around you have risk factors for severe illness:

• Older adults are at highest risk of getting very sick from COVID-19. More than 81% of COVID-19 deaths occur in people over age 65. The number of deaths among people over age 65 is 97 times higher than among people ages 18-29 years.
• Certain underlying medical conditions increase the risk of severe illness due to COVID-19, flu, and other respiratory illnesses. The risk of severe illness increases as the number of underlying medical conditions increases.

You or those around you were recently exposed, are sick, or are recovering, including when:

• There is an outbreak in your facility.
• An individual within the facility was recently exposed, is sick, or recovering.

Masks (source control)

• Provide free, high-quality masks to your residents, workforce, and visitors in times of higher respiratory viral spread.
• Masking is recommended for individuals residing, visiting, or working in an area of the facility experiencing an outbreak of respiratory infection (in addition to masking for individuals with suspect or confirmed ARI).

Physical distancing

• Avoid crowding in communal spaces.
• Consider postponing, rescheduling, or canceling communal activities, including meals served in dining rooms.
• Provide employees with paid time off and flexible telework policies to support workers in staying home if sick.

Tests

• Have tests on hand and/or a plan for testing residents quickly for respiratory pathogens.
• Provide employees with paid time off to seek testing for respiratory viruses.

Regardless of outbreak status, facilities should be prepared to accept and isolate individuals onsite who have COVID-19 or another respiratory virus. When a resident/patient/sheltered person has symptoms or tests positive for an acute respiratory illness at intake or during their stay, they need to be kept away from others for the duration of their isolation period. Contact your local health department if you have questions about preparing for or mitigating an outbreak.

• With ARI, symptoms should be masked, placed immediately in a separate space, and tested for COVID-19. If they test negative, continue to keep them away from others and retest in two days. Consider testing for influenza during high community flu transmission periods, or if flu has been detected in the facility.
• Test symptomatic close contacts of a COVID-19 case.
• In the case of a large or uncontrolled outbreak of COVID-19, consider using an expanded testing strategy similar to that used in health care settings. For example, test all staff and residents every 3-7 days until no new cases are identified for at least 14 days.

• With ARI symptoms (due to COVID-19, flu, other etiology, or etiology unknown) should be masked and excluded from work until completing isolation (“staying home when sick,” see below).
• Consider testing for COVID-19, influenza, and/or other circulating respiratory pathogens. If they test negative and still have symptoms, consider continuing self-isolation and retesting in two days.
• Staff may be eligible for free at-home COVID-19 tests. Availability is not guaranteed year-round.

• With ARI symptoms staff should follow health care guidance.
  • COVID-19 Infection Prevention Guidance for Health Care Personnel
  • Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities

All residents with symptoms of ARI, who test positive for, or who a health care provider diagnoses with COVID-19, flu, or other viral respiratory illness should be kept away from others.

• Isolation may end after Day 5 if all the following criteria are met (Day 1 is the first full day after symptoms developed. If no symptoms develop, Day 1 is the first full day after testing positive):
  • No fever for 24 hours without use of fever-reducing medications.
  • No symptoms or symptoms are mild and improving.
  • For COVID-19, an antigen test can help you know how likely you are to spread the virus. A positive test tends to mean it is more likely that you can spread the virus to others.
  • Residents and staff may resume normal activities Day 1-5 if they can comply with added precautions, including:
    • Masking (individuals should wear a well-fitting mask when around other people indoors. More about masking can be found here)
    • Physical distancing (avoid being near someone who has respiratory virus symptoms and avoid crowded areas where you may be unable to maintain physical distance).
• See CDC’s Preventing Spread of Respiratory Viruses When You’re Sick for examples of isolation periods based on the timeline of symptoms.

• If possible, ideally, residents with ARI should be placed in a private room for the duration of isolation.
• If isolation resources are limited, residents may be cohorted together if they have a confirmed diagnosis of the same illness. Provide a separate bathroom or ensure a shared restroom can be effectively cleaned after use.
• If there is no isolation space available, residents should wear a well-fitting mask for the duration of symptoms until they are fever-free for 24 hours WITHOUT fever-reducing medications and then stay masked for five additional days. If a designated space for isolation is unavailable, reduce transmission within the facility by ensuring an ample supply of surgical masks or respirators, optimizing ventilation in the infected individual’s area, and maximizing the physical distance between infected patients and others. Ill residents should wear a well-fitting mask for the duration of symptoms until they are fever-free for 24 hours WITHOUT fever-reducing medications and then stay masked for five additional days.

Additional resources:

• CDC - Preventing Spread of Respiratory Viruses When You're Sick

***In facilities with a spectrum of care, this pertains to staff working only in the assisted living/community congregate areas. All shared staff who also work in the skilled nursing units, including dietary and environmental services staff, should follow the guidance for skilled nursing facilities.

All non-health care staff who have symptoms of ARI, who test positive for, or who a health care provider diagnoses with COVID-19, flu, or other viral respiratory illness should be excluded from work, in accordance with CDC recommendations, until:

• Symptoms are getting better overall

AND

• they have been fever-free (without the use of fever-reducing medications) for at least 24 hours

Upon returning, they should take additional precautions, including wearing a well-fitting mask, for an additional five days. For examples, see Preventing the Spread of Respiratory Viruses When You're Sick.

• Refer to COVID-19 Infection Prevention Guidance for Health Care Personnel for staff in health care areas that test positive for or are diagnosed by a health care provider with COVID-19.
• See Health Care Settings and Health Care Personnel for influenza and other ARI pathogens.

• Share educational materials about respiratory virus treatment options:
  • Flu
  • COVID-19
• Plan for access to treatment for residents in advance of when it might be needed (e.g., from an onsite health care provider, residents personal health care provider, etc.)
  • See the HHS COVID-19 and Flu Treatments Locator for community treatment options.
• Influenza chemoprophylaxis: Individuals over 65, those with certain underlying medical conditions, and those who live in nursing homes and other long-term care facilities are at increased risk of serious complications from influenza. Residents of assisted living and other long-term care facilities should be offered chemoprophylaxis according to the CDC’s recommendations: Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities. Chemoprophylaxis may be considered in other community congregate settings depending on the nature of the outbreak and resident and facility factors.
• Provide employees with paid time off to seek treatment for a respiratory virus, as needed.