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State of California—Health and Human Services Agency
California Department of Public Health

AFL 21-44
November 19, 2021

Skilled Nursing Facilities

Recommendations for the Prevention and Control of Influenza in California Skilled Nursing Facilities for the 2021-2022 season during the Coronavirus Disease 2019 (COVID-19) Pandemic

All Facilities Letter (AFL) Summary

This AFL provides recommendations to prevent and manage influenza outbreaks in the 2021-2022 season in skilled nursing facilities (SNFs) during the COVID-19 pandemic.

SNF residents are at increased risk for severe disease, hospitalization, and death from infections caused by influenza viruses and the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the virus that causes COVID-19. The ongoing COVID-19 pandemic and the potential for concurrent COVID-19 and influenza outbreaks will complicate the upcoming influenza season. Although the 2020-2021 influenza season was extraordinarily mild, we cannot predict the severity of the 2021-2022 season. Therefore, it is essential for SNFs to optimize all available effective influenza prevention and outbreak control interventions, including influenza vaccination of SNF residents and healthcare personnel (HCP) and prompt initiation of antiviral therapy and chemoprophylaxis when influenza is identified.

On October 5, 2020, the California Department of Public Health (CDPH) issued "Recommendations for the Prevention and Control of Influenza in California SNFs during the COVID-19 Pandemic" (PDF). This document provides recommendations to prevent and manage influenza outbreaks in SNFs in the context of SARS-CoV-2 co-circulation. These recommendations may also apply to other long-term care facilities.

On August 27, 2021 the Centers for Disease Control and Prevention (CDC) posted the "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the ACIP – United States, 2021- 2022 Influenza Season" report. Since there were no major changes in the report that would influence the influenza prevention and management plan for SNFs, CDPH recommends that facilities review  "Recommendations for the Prevention and Control of Influenza in California SNFs during the COVID-19 Pandemic" (PDF), October 5, 2020, to develop and implement an influenza prevention and control plan. The document provides:

  • Similarities and differences between clinically relevant characteristics of influenza viruses and SARS-CoV-2.
  • Recommendations for planning for influenza illness and outbreaks relevant to three groups of individuals: residents, healthcare personnel, and family members/visitors.
  • Recommendations for identifying the presence of an influenza outbreak and implementing the influenza prevention and control plan.

Before influenza begins circulating in the local community, CDPH recommends SNFs be ready with:

  • Sufficient influenza vaccines and standing orders for administration, hand hygiene supplies, personal protective equipment, and antiviral medication orders.
  • Established lines of communication between the SNF and the local health department.
    • Establishing a strong collaborative relationship with the local health department facilitates support in the event of an outbreak, vaccine, or antiviral agent shortage, or if unanticipated events emerge within a given season. 

Additionally, for the 2021-2022 season, CDPH continues to emphasize the following:

  • Follow the local activity of influenza and other respiratory viruses.
  • Access the CDPH "Influenza and other Non-COVID-19 Respiratory Illness Outbreak Quicksheet" (PDF).
  • Ensure influenza vaccination of residents and staff members:
    • Per CDC guidance the influenza vaccine and COVID-19 vaccine may be administered at the same time, but at different anatomical locations.
  • Test for other respiratory viruses when there is a cluster of respiratory infections in the facility and influenza and COVID-19 testing is negative.

Please report influenza outbreaks immediately to your local health department (PDF) and L&C district office.

If you have any questions about this AFL, please contact the CDPH Healthcare-Associated Infections Program at



Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director



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