Public Health Emergency Preparedness and Response: Non-Pharmaceutical Interventions to Reduce Transmission of Viral Respiratory Infections in Long-Term Care Communities

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends non-pharmaceutical interventions (NPIs) in long-term care (LTC) communities to decrease viral respiratory infection incidence among LTC community residents and staff.

Evidence shows that during a viral respiratory infection outbreak or pandemic, combinations of NPIs can reduce the risk of infection among LTC community residents and staff.

The full CPSTF Finding and Rationale Statement and supporting documents for Public Health Emergency Preparedness and Response: Non-Pharmaceutical Interventions to Reduce Transmission of Viral Respiratory Infections in Long-Term Care Communities are available in The Community Guide Collection on CDC Stacks.

Intervention

LTC communities for adults with disabilities and older adults can adopt NPIs as strategies to prevent, slow, or stop the spread of viral respiratory infections. NPIs may be directed to residents, staff, and visitors and applied at individual, community, and environmental levels.

  • Individual level NPIs may include using personal protective equipment such as gloves and masks, proper hand hygiene, and staff not coming to work when sick
  • Community level NPIs may include testing and screening, physical distancing, visitor restriction, and resident admission or transfer restriction
  • Environmental level NPIs may include cleaning and disinfecting and improving ventilation

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 42 studies (search period from database inception to January 2024). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods and subject matter experts.

Study Characteristics

Studies evaluated interventions implemented in: United States (11 studies); the Netherlands (5 studies); Spain, the United Kingdom (3 studies per location); Canada, Germany (2 studies per location); Belgium, Cyprus, France, Hong Kong, Israel, Sweden, Taiwan (1 study per location).

Studies included: all types of LTC communities (15 studies); nursing homes or skilled nursing facilities only (13 studies); residential LTC communities only (2 studies); LTC communities, unspecified (2 studies).

Studies examined LTC communities serving: older adults (22 studies); older adults and people with dementia (4 studies); adults with disabilities (3 studies); older adults and adults with disabilities (2 studies); older adults, people with dementia, and adults with disabilities (2 studies).

Studies included NPIs implemented in response to: SARS-CoV-2 (28 studies); respiratory illnesses caused by other viruses, including flu or flu-like illnesses (3 studies); pneumonia (2 studies).

NPIs that were implemented in response to outbreaks or pandemics lasted: fewer than three months (14 studies); between three and six months (4 studies); between six and nine months (4 studies).

Studies evaluated the impact of adding NPIs at the: individual level (2 studies); community level (21 studies); environmental level (2 studies); a mix of the different levels (7 studies).

NPIs were implemented based on decisions made at the: LTC community level (13 studies); local or state level (9 studies); national level (11 studies).

Summary of Results

NPIs implemented in LTC communities reduced viral infection in residents and staff by 46% (10 studies). These interventions also decreased hospitalization or ED visits by 57% (5 studies) and mortality due to infection by 33% (3 studies).

LTC communities in the included studies used different combinations of NPIs based on their needs and resources, and it could not be determined which NPI or NPI combination was the most effective.

The review team examined the impact of community level NPIs on residents’ mental health and quality of life during the COVID-19 pandemic. The evidence was inconsistent regarding the effectiveness of these interventions on mental health and quality of life outcomes (8 studies).

Summary of Economic Evidence

A systematic review of economic evidence has not been conducted.

Applicability

The CPSTF finding is applicable in all types of LTC communities with adult residents across the United States. The CPSTF finding is likely applicable to different combinations, types, or levels of NPIs implemented. The finding is mostly based on responses to SARS-CoV-2 but can be applied to infections caused by other respiratory viruses.

Evidence Gaps

  • What is the impact of these interventions on residents’ mental health and quality of life, considering the need for comparative study designs, having U.S.-based studies, and using standardized mental health outcomes?
  • How effective are NPIs in the following settings:
    • Rural LTC communities?
    • LTC communities with high proportion of residents from historically disadvantaged racial and ethnic populations?
    • Residential LTC communities?
    • LTC communities for people with disabilities?
  • Which individual or combinations of NPIs work the best?
  • Remaining questions for research and evaluation identified in this review include:
      • Does intervention effectiveness vary with the following factors?
        • Compliance with NPI
        • Population characteristics such as gender or vaccination status
        • Community characteristics such as size of community, room sharing, staff to resident ratio, staff working in multiple communities
        • Provision of education or support services to allow better implementation of NPIs

Implementation Considerations and Resources

Strategies to alleviate potential harms associated with NPI implementation in LTC communities:

  • Digital technology (e.g., video chats with family and friends) may help reduce social isolation of residents when visitor restriction or physical distancing were implemented (Colas 2022)
  • Small group activities may improve residents’ health, with physical activity to reduce their functional decline, and arts activities and other group programming may help enhance residents’ social engagement (Bethell 2021, Resnick 2021)
  • Regular updates to family caregivers may help mitigate anxiety. Keeping family members and caregivers informed about their loved ones as well as the need for and use of NPIs may help reduce their anxiety (Gallant 2022)

Strategies to ensure timely and clear communication between LTC communities and public health agencies:

  • Effective and regular communication between LTC communities and public health agencies may help to reduce viral transmission and enhance emergency preparedness and outbreak response (Dawson 2021, Jones 2022, Oldfield 2021)
  • Virtual or “just-in-time” education programs for LTC staff may provide rapid and real-time dissemination of NPI best practices (Lingum 2021)

Strategies to support LTC community workforce:

  • Foster supportive community among LTC community workforce to build morale (Navarro-Prados 2022)
  • Provide evidence-based mental health support for staff members (Fisher 2021, Hugelius 2021)
  • Consider having a contingency staffing plan to better manage workloads during any emergency response, especially with the need to incorporate additional NPIs into already busy daily routine (Dawson 2021)
  • Recognize the challenges facing the LTC workforce that’s racially diverse and primarily female. Develop strategies to address issues such as lower pay, the need to hold multiple jobs, and lack of jobs offering paid sick leave, creating barriers to staying home when sick and increasing the risk of infection for themselves and the LTC residents (Dawson 2021, High 2007, Kobayashi 2016, Van Houtven 2020)

Implementation Resources

The following publicly available resources provide guidance on implementing NPIs in LTC communities:

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.