On March 13, 2021, the Centers for Disease Control and Prevention (CDC) updated their recommended strategies for infection prevention and control considerations for residents of long-term care facilities showing systemic signs and symptoms following COVID-19 vaccination.
Long-term care facilities should have strategies to appropriately evaluate and manage post-vaccination signs and symptoms among their residents. A facility’s approach should balance between the following:
- the risk of unnecessary testing and implementation of Transmission-Based Precautions for residents with only post-vaccination signs and symptoms, and
- inadvertently allowing residents with infectious COVID-19 or another transmissible infectious disease to expose others in the facility.
Per the CDC, systemic signs and symptoms such as fever, fatigue, headache, chills, myalgia, and arthralgia can occur following COVID-19 vaccination. Preliminary data from mRNA COVID-19 vaccine trials indicates that most systemic post-vaccination signs and symptoms are mild to moderate in severity, occur within the first three days of vaccination (the day of vaccination is considered day 1), resolve within 1-2 days of onset, and are more frequent and severe following the second dose and among younger persons compared to those who are older than 55 years of age.
The CDC also notes that the following signs and symptoms alone are not consistent with COVID-19 and should be managed per usual protocols for vaccine-related side effects:
- immediate hypersensitivity reactions (e.g., urticaria, anaphylaxis)
- local symptoms (e.g., pain, swelling, or redness at injection site)
All nursing facilities should be following their Infection Control Plan, which should include the most up-to-date information available about COVID-19. The CDC has suggested approaches to evaluating and managing systemic new-onset post-vaccination signs and symptoms for residents in who received COVID-19 vaccination in the prior 3 days:
- Signs and symptoms unlikely to be from COVID-19 vaccination include any systemic signs and symptoms typical for SARS-CoV-2, such as cough, shortness of breath, rhinorrhea, sore throat, loss of taste or smell, or symptoms of influenza. The CDC suggests evaluation for possible infectious illness, including testing for SRS-CoV-2 and/or other pathogens as appropriate. Pending evaluation, these residents should be placed in a single person room if available and cared for by healthcare personnel wearing all PPE recommended for residents with suspected or confirmed COVID-19 infection. These residents should not be cohorted with residents confirmed to have COVID-19 unless they also are confirmed to have the virus through testing.
- Signs and symptoms that may be from either COVID-19 vaccination, SARS-CoV-2 infection, or another infection include the presence of ANY systemic signs and symptoms (e.g., fever, fatigue, headache, chills, myalgia, arthralgia) that are consistent with post-vaccination, SARS-CoV-2 infection, or another infections illness (e.g., influenza).
Fever in long-term care settings is defined as a single measured temperature of 100.0°F (37.8°C) or higher or repeated temperatures of 99.0°F (37.2°C).
CDC Suggested Approaches:
- Evaluate the resident.
- Restrict the person to their current room (except for medically necessary procedures) and closely monitored until fever, if present, resolves and symptoms improve.
- Healthcare personnel caring for these residents should ideally wear all PPE that is recommended for caring for residents with suspected or confirmed SARS-CoV-2 infection while evaluating the cause of these symptoms.
- If the resident’s symptoms resolve within 2 days, precautions can be discontinued. Fever, if present, should have resolved for at least 24 hours before discontinuing precautions.
- Viral testing for SARS-CoV-2 should be considered for residents if their symptoms are not improving or persist for longer than 2 days.
Residents residing in facilities with active transmission, or who have had prolonged close contact with someone with a positive COVID-19 infection in the prior 14 days, should be tested.
In any situation, positive viral (nucleic acid or antigen) tests for SARS-CoV-2, if performed, should not be attributed to the COVID-19 vaccine, as vaccination does not influence the results of these tests.
A negative SARS-CoV-2 antigen test in a resident with signs and symptoms not typical of those post-vaccination should be confirmed by SARS-CoV-2 nucleic acid amplification test (NAAT). This testing should be conducted if there is active transmission in the facility, if the resident has had prolonged close contact with someone with SARS-CoV-2 infection in the prior 14 days, or if symptoms persist for longer than 2 days. Facilities conducting outbreak testing for SARS-CoV-2 transmission or evaluating residents who have had prolonged close contact with someone with SARS-CoV-2 infection in the previous 14 days should care for residents following all recommended infection control practices, including placement in Transmission-Based Precautions, with use of all recommended personal protective equipment and appropriate testing.
The CDC Post-Vaccine Considerations for Residents Approaches can be accessed here.
The CDC Vaccines & Immunizations Resource can be accessed here.
Compliance Perspective
Issue
As more residents are vaccinated against COVID-19, it is critical that facilities are aware of the differences between a COVID-19 outbreak and post-vaccination signs and symptoms. If a resident does test positive for COVID-19, regardless of their vaccine status, they must be considered having contacted COVID-19, since COVID-19 vaccination does not cause a positive COVID-19 test. If a COVID-19 outbreak is not evaluated immediately, it can have dire consequences.
Discussion Points
- Review the content of your policies and procedures related to COVID-19 and the COVID-19 vaccine to ensure they provide the most recent information that is available. Update these policies as needed.
- Train all staff on the most recent updates to your policies and procedures for COVID-19 and the COVID-19 vaccine. Document that these trainings occurred, and file the signed document in the employee’s education file.
- Periodically audit staff understanding to determine if they are knowledgeable regarding the most recent information on COVID-19 and the COVID-19 vaccine. Ensure that your Infection Preventionist is well versed in differentiating between COVID-19 signs and symptoms, and those experienced by individuals who have received their vaccinations in the last 3 days.
