Flu Season in Long-Term Care: Prevention, Vaccination, Symptoms, and Outbreak Response

Influenza, commonly called the flu, is an annual concern for long-term care facilities throughout the United States. Residents of nursing homes and other long-term care settings are at increased risk for serious complications from influenza because many are older adults and/or live with chronic medical conditions or weakened immune systems.

Successful influenza prevention requires more than vaccination alone. The Centers for Disease Control and Prevention (CDC) recommends a comprehensive approach that includes vaccination, surveillance, testing, prompt treatment, appropriate infection prevention and control measures, and rapid outbreak response.

When Is Flu Season?
Influenza activity varies from year to year and from one geographic area to another. In the United States, influenza activity commonly increases during the fall and winter, but facilities should remain prepared throughout the influenza season.
Long-term care facilities should begin preparing before influenza activity increases in their community rather than waiting until residents begin developing symptoms.

Preparation should include:

• Reviewing the facility's influenza prevention and outbreak plan

• Arranging resident vaccination clinics

• Encouraging healthcare personnel vaccination

• Reviewing PPE supplies

• Ensuring access to influenza testing

• Reviewing antiviral treatment procedures

• Educating staff about influenza symptoms

• Reviewing staffing contingency plans

• Reviewing state and local public health reporting requirements

CDC's current nursing home respiratory virus toolkit emphasizes preparation before respiratory virus activity increases and recommends ensuring adequate vaccines, PPE, hand hygiene supplies, and other resources.

When Should Residents Receive the Flu Vaccine?

For the 2026–2027 influenza season, CDC recommends that most people who need only one influenza vaccine dose receive it during September or October, ideally by the end of October. Vaccination should continue after October and throughout the influenza season as long as influenza viruses are circulating and vaccine is available.

Special consideration for older adults

Most nursing home residents are 65 years of age or older. For adults age 65 and older, CDC preferentially recommends one of the following when available: high-dose inactivated influenza vaccine, recombinant influenza vaccine or adjuvanted inactivated influenza vaccine. If one of these preferred vaccines is not available, an age-appropriate influenza vaccine should not be delayed simply to wait for a preferred product.

Facilities should not treat vaccination as a single event. CMS nursing home quality measures include measures related to residents who receive, decline, or have a medical contraindication to seasonal influenza vaccination.

Healthcare personnel play an important role in preventing influenza transmission to vulnerable residents. The CDC recommends annual influenza vaccination for healthcare personnel and others who provide care for or may be exposed to people at increased risk for influenza complications. Facilities should make vaccination convenient and provide education addressing common questions and concerns.

Common influenza symptoms include:

• Fever

• Chills

• Cough

• Sore throat

• Runny or stuffy nose

• Headache

• Muscle or body aches

• Fatigue

• Weakness

However, influenza can present differently in older adults. Older adults, frail residents, and people with certain chronic conditions may have an atypical presentation.

Instead of a classic fever and cough, a resident may develop new or worsening confusion, change in mental status, increased sleepiness, weakness, decreased appetite, decline in functional ability, dizziness, new or worsening cough, nasal congestion, chills, shortness of breath or generalized body aches. A change from the resident's normal baseline should always receive attention.

What Should Staff Do When Influenza Is Suspected?

Facilities should have a clear process that staff understand and can follow. Recognize respiratory symptoms or unexplained changes from baseline. Assess the resident's symptoms, vital signs, clinical status, exposure history, and risk factors. Report symptoms to the provider and clinical leadership promptly. Testing decisions should be based on the clinical situation, facility outbreak status, and applicable guidance. In long-term care settings, even a single suspected case may warrant prompt testing and implementation of infection prevention measures because residents are at high risk for influenza complications. When influenza is suspected or confirmed, residents should be evaluated promptly for antiviral treatment.

CDC recommends immediate antiviral treatment for nursing home residents with confirmed or suspected influenza. Antiviral medications work best when started within the first 48 hours of symptoms, but treatment can still provide benefit after 48 hours in residents who are very ill or at increased risk for complications. Preventing Transmission is paramount.  Implement appropriate infection prevention and control measures based on the clinical situation and current CDC/facility guidance. Ensure continued surveillance for additional cases among residents and healthcare personnel.

Active Surveillance During Flu Season

Long-term care facilities should have a process for identifying new respiratory illness among residents and healthcare personnel.

Surveillance may include reviewing new respiratory symptoms, monitoring changes from baseline, monitoring staff illness, reviewing hospital transfers, tracking positive influenza tests, monitoring respiratory illness clusters and maintaining an outbreak line list when appropriate.

CDC recommends active surveillance to identify additional ill residents and healthcare personnel when respiratory virus transmission is suspected or occurring.

What Is an Influenza Outbreak?

Facilities should follow their applicable public health definitions and reporting requirements.

CDC notes that in long-term care settings, two cases of healthcare-associated laboratory-confirmed influenza occurring within 72 hours on the same ward/unit can meet the criteria for an institutional influenza outbreak.

Importantly, when residents are at high risk for complications, a single suspected influenza case may warrant testing and prompt infection prevention actions.

Facilities should not wait for a large number of residents to become ill before initiating appropriate investigation and control measures.

Responding to an Influenza Outbreak

When influenza transmission is identified, facilities should rapidly implement their outbreak response plan.

Antiviral Prophylaxis During an Outbreak

During an influenza outbreak, antiviral prophylaxis may be recommended for exposed residents, including residents who have already received the seasonal influenza vaccine.

CDC currently recommends antiviral chemoprophylaxis for non-ill residents on affected units when at least two residents become ill within 72 hours of one another and at least one resident has laboratory-confirmed influenza.

For institutional outbreaks, CDC recommends prophylaxis for a minimum of two weeks and continuing for at least one week after the last known case is identified.

Clinical decisions regarding antiviral treatment and prophylaxis should be made by the resident's treating clinician in accordance with current CDC guidance, medication-specific considerations, and facility/public health protocols.

Staff Illness and Staffing Considerations

Healthcare personnel can introduce influenza into a facility and can transmit infection to vulnerable residents and coworkers.

Facilities should have clear policies addressing when ill staff should remain away from work and when staff may return to work. Ensure a contingency staffing plan is prepared prior to flu season.

Facilities should avoid creating a culture in which employees feel pressured to work while experiencing significant respiratory illness.

Communication With Families and Visitors

Families and visitors should receive clear information about influenza prevention. Facilities should encourage visitors who are experiencing respiratory symptoms to postpone non-urgent visits when appropriate.

State and Local Requirements Matter

Although CDC and CMS provide federal guidance applicable to nursing homes nationwide, state and local requirements can differ. Facilities should maintain current information regarding state health department reporting requirements, outbreak definitions, required reporting timelines, required vaccination documentation, state-specific healthcare worker vaccination requirements, state-specific infection prevention requirements and requirements for specific types of long-term care facilities.

CDC specifically notes that reporting requirements and outbreak definitions may vary by pathogen and by state or local health department. Facilities should maintain a current point of contact for their applicable health department.

CDC also maintains comparative information regarding influenza vaccination laws affecting long-term care facilities in different states.

Facility leadership and the infection preventionist should verify current state and local requirements rather than relying solely on a national checklist.