Since the COVID-19 outbreak began, the Fairfax County Health Department has been actively engaged with long-term care facilities to prevent and mitigate the spread of disease within these high-risk settings. Communal living situations, such as skilled nursing facilities and assisted living facilities, are high-risk for spread of COVID-19, as they are for many other respiratory illnesses. The Health Department has a specific role to both prevent and mitigate outbreaks in these settings.
Proactive Health and Safety Actions
The Health Department has established a dedicated team of employees who are focused on investigating and reducing risk in in these congregate care settings. This team includes public health nurses, epidemiologists, environmental health specialists and a physician.
We have contacted all of Fairfax County’s assisted living and skilled nursing facilities and provided education on COVID-19 prevention. This includes specific actions facilities should take with cleaning, visitor policy, staff policy, and residents to enhance infection prevention. Information was also provided about the importance of staff not working in multiple sites and materials were provided to decrease staff movement between facilities.
A public health nurse is also proactively being deployed to all these facilities to provide in-person guidance to reinforce these infection prevention messages and organize respirator fit testing for staff. Follow up visits are also available for fit testing of N-95 respirators, increasing environmental disinfection, and taking COVID-19 specimens for testing.
Responding to a COVID-19 Case
If a single case of COVID-19 is identified in a resident or staff member, the Health Department will investigate and work with the facility to prevent or limit further spread of infection. By the time an infection has been identified at a facility, and before a Health Department visit, others at the facility already may have been exposed and infected; by working with the facility and improving infection prevention the goal is to prevent further disease spread.
An experienced communicable disease public health nurse is assigned to the facility to lead an investigation and provide recommendations. A Rapid Response Team is dispatched to the facility to provide training on appropriate personal protective use, taking nasopharyngeal specimens for lab testing, environmental disinfection, and infection prevention practices. A liaison public health nurse is also assigned to each facility and visits each day to observe infection prevention, make recommendations for improvement and provide support.
As testing capacity has increased, the Health Department has instructed all assisted living and skilled nursing facilities to proactively test any resident who has respiratory symptoms for COVID-19. To help facilitate this, we are training staff on collecting specimens and have conducted tests for symptomatic patients, most at no cost, at the Health Department’s laboratory. Tests can also be conducted by a commercial laboratory.
Point Prevalence Testing
The Health Department added another layer of infection prevention for long term care facilities in accordance with guidance from the Virginia Department of Health and the new availability of testing resources. We have reached out to every skilled nursing facility in Fairfax County to offer Point Prevalence Surveys, which is point in time testing of asymptomatic residents and staff to identify who is infected.
Test results will help facilities identify where to best locate residents who test negative and those who test positive, and how to provide staffing in a way that reduces the risk of infection spreading. This approach, called “cohorting” is used along with other infection control measures such as the use of personal protective equipment by staff, isolation of infected residents, environmental disinfection, and good handwashing by everyone at the facility. Facilities will be prioritized for testing based on the characteristics of their outbreak, the level of risk to residents and staff, and collaboration by the facility. Therefore, we are unable to share when or where testing will take place.
Testing is not a panacea for infection prevention in long-term care facilities; it is one tool that adds to other layered measures. Testing only provides information about infection at one point in time. It also may not detect infection early in its course when the virus may not yet be at a level sufficient to be detected by the test. At all of these facilities, we continue to test those who develop illness and to reach out to facilities with COVID-19 positive cases who have not completed Point Prevalence Surveys.
In addition to these tests offered by the Health Department, facilities have tested residents and/or staff on their own using commercial labs and the University of Virginia laboratory.
While the Health Department is working intensively with facilities to prevent COVID-19 infections, additional residents may become ill despite the infection prevention measures being taken. Because there may be a week or more between the time someone is exposed and when that person becomes ill, the virus already may have spread before the heightened infection prevention measures were implemented. Prevention is an ongoing process and we continue to collaborate with facilities to make progress on all fronts to reduce the risk for residents.
Why are these places at greater risk?
Assisted living facilities and skilled nursing facilities are considered high-risk for potential disease outbreaks for the following reasons.
- Residents of these facilities have a greater likelihood to have underlying medical conditions, and people with underlying medical conditions, such as lung issues, asthma, diabetes or obesity, are at greater risk for more severe COVID-19 infection.
- Residents of these facilities, by nature of age fall into the high-risk category for contracting severe symptoms of COVID-19.
- Residents in skilled nursing facilities may depend on staff for multiple close interactions such as getting out of bed, assistance with mobility, etc.
- Because of the large number of staff needed to care for residents and community transmission, there is a risk that someone will be infected but not ill and inadvertently bring the virus into the community.
- Staff of these facilities frequently work other jobs and might inadvertently spread disease from one facility to another facility.