[MCOH-EH] Is fever a requirement to remove HCW's with flu symptoms from work?

[Sparhawk, Dana P]

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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Downloaded from http://journals.cambridge.org/ICE, IP address: 101.187.147.10 on 20 Jul 2015
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 at lifespan.org<mailto:lmermel at lifespan.org>).
Infect. Control Hosp. Epidemiol. 2015;00(0):1-1
© 2015 by The Society for Healthcare Epidemiology of America. All rights
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
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