As flu season approaches I am wondering what all of you use as criteria for your employees to stay out of work when they have flu symptoms. In our group of hospitals HCW’s with flu symptoms and temperature over 100 degrees need to stay out of work until afebrile without antipyretics for 24 hours. One could debate which specific symptoms, what level of fever, how long they need to stay out, but what I am most interested in is whether fever is a necessary requirement in determining out of work status with flu symptoms.

The Hospital Epidemiologist/ID specialist I work with feels that based on several studies of HCW’s who had positive influenza testing where it was found that under 40% did not have a fever at initial presentation with flu symptoms, fever should not be a necessary finding for removing a HCW from work. In those without fever, it was felt that high levels of viral shedding was present before fever developed. A letter to the editor he wrote to Infection Control and Hospital Epidemiology in July is attached, as well as pasted below.

My ID colleague and I have been asked to discuss with our HAI committee the following suggestions:

(1) Healthcare workers should be evaluated for influenza and other respiratory viral infections with otherwise unexplained onset of respiratory symptoms (eg,cough, rhinorrhea, sore throat, nasal congestion)even in the absence of fever.

(2) Healthcare workers with influenza, and possibly other viral respiratory infections, should be excluded from work even when they have no demonstrable temperature of 37.8°C or higher.(the question remains whether influenza testing will be required, or if we go by constellation of symptoms)

There are clearly many implications of such a policy such as who would make these decisions, would influenza testing be required, who pays for the testing, how long out of work, etc.

As I prepare for my discussion with my HAI committee members, I would like to do some benchmarking from the List to find if anyone utilizes criteria for placing a HCW out of work which don’t require fever.

I have also attached an article from June published in Clinical Infectious Diseases on this subject.

Thanks.

Dana

Dana Sparhawk, MD, MPH

Director, Lifespan Employee and Occupational Health Services

Clinical Assistant Professor, Alpert Medical School, Brown University

Grads Dorm, Rhode Island Hospital

593 Eddy Street

Providence, RI 02903

(401) 444-7412

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letter to the e ditor

Influenza Fever Restrictions for Healthcare

Workers and Pandemic Planning: Time for

Reappraisal

The Centers for Disease Control and Prevention’s thoughtful

guidance entitled Prevention Strategies for Seasonal Influenza

in Healthcare Settings1 states, “Healthcare personnel who

develop fever and respiratory symptoms should be: Excluded

from work until at least 24 hours after they no longer have a

fever.” The guidance further states, “Healthcare personnel who

develop acute respiratory symptoms without fever may still

have influenza infection and should be: Considered for evaluation

by occupational health to determine appropriateness of

contact with patients.” The guidance goes on to state that such

healthcare workers be “Allowed to continue or return to work

unless assigned to care for patients requiring a protective

environment such as hematopoietic stem cell transplant

patients.” Ridgway and colleagues2 found that 20 (49%) of 41

healthcare workers with influenza A did not report a history of

fever or were afebrile when first evaluated for respiratory

symptoms, yet 100% had cough. Yamagishi and colleagues3

found that cough started before fever in 10 (34%) of

29 patients with influenza A; sore throat started before fever in

2 (29%) of the 7 patients. Lau and colleagues4 found that of 26

patients with influenza A and 18 patients with influenza B,

most had temperatures below 37.8°C at the onset of

their symptoms (18 [69%] and 10 [56%], respectively), yet

most had cough (18 [69%] and 14 [78%], respectively) and

rhinorrhea (19 [73%] and 11 [61%], respectively).

The correlation between viral shedding and influenza

symptomatology, as well as the influence of viral shedding on

influenza transmission, are debated issues. However, Lau and

colleagues4 found a strong correlation between influenza viral

shedding and symptoms. Only 14% of patients with influenza

and detectable virus shedding by reverse transcription polymerase

chain reaction were asymptomatic and shedding was

low in such cases. However, peak shedding of influenza A virus

occurred at symptom onset when only 31% of such patients

had a temperature of at least 37.8°C.

These studies involve small numbers of patients but share

the same signal. The lessons learned are as follows: (1) Fever

may be an insensitive identifier for influenza-infected individuals

presenting with cough, rhinorrhea, and other respiratory

symptoms. (2) Maximal viral shedding occurs at the onset of

symptoms, when many influenza-infected individuals are

without fever. (3) Maximal viral shedding at the onset of

respiratory symptoms suggests that the greatest risk of influenza

transmission may in fact occur at that time.

On the basis of these findings, I propose the following

recommendations: (1) Healthcare workers should be evaluated

for influenza and other respiratory viral infections with

otherwise unexplained onset of respiratory symptoms (eg,

cough, rhinorrhea, sore throat, nasal congestion) even in the

absence of fever. (2) Healthcare workers with influenza, and

possibly other viral respiratory infections, should be excluded

from work even when they have no demonstrable temperature

of 37.8°C or higher. (3) Pandemic influenza planners must

review their past guidance on the basis of the fact that many

patients presenting with influenza do not have fever at symptom

onset and may be most contagious at that time. As such,

use of fever at airports and in other scenarios for influenza

screening will not identify considerable numbers of infectious

individuals.

acknowledgments

Financial support. None reported.

Potential conflicts of interest. The author reports no conflicts of interest

relevant to this article.

Leonard A. Mermel, DO, ScM, AM (Hon)

FACP, FIDSA, FSHEA

Affiliations: Division of Infectious Diseases, Rhode Island Hospital, and

Department of Medicine, Warren Alpert Medical School of Brown

University, Providence, Rhode Island.

Address correspondence to Leonard Mermel, DO, Department of

Epidemiology and Infection Control, Rhode Island Hospital, 593 Eddy St,

Providence, RI 02903 (lmermel@lifespan.org).

Infect. Control Hosp. Epidemiol. 2015;00(0):1–1

reserved. 0899-823X/2015/0000-0. DOI: 10.1017/ice.2015.173

references

1. Centers for Disease Control and Prevention (CDC). Prevention

strategies for seasonal influenza in healthcare settings. CDC

website. http://www.cdc.gov/flu/professionals/infectioncontrol/

healthcaresettings.htm. Updated January 9, 2013. Accessed July 5,

2015.

2. Ridgway JP, Bartlett AH, Garcia-Houchins S, et al. Influenza

among afebrile and vaccinated healthcare workers. Clin Infect Dis

2015;60:1591–1595.

3. Yamagishi T, Matsui T, Nakamura N, et al. Onset and duration of

symptoms and timing of disease transmission of 2009 influenza A

(H1N1) in an outbreak in Fukuoka, Japan, June 2009. Jpn J Infect

Dis 2010;63:327–331.

4. Lau LL, Cowling BJ, Fang VJ, et al. Viral shedding and clinical

illness in naturally acquired influenza virus infections. J Infect Dis

2010;201:1509–1516.

infection control & hospital epidemiology