Influenza Protocol Guidelines for Transplant and Heart Failure
Centers’ Faculty, Staff and Patients
Activation Date:
11.02.2009
Affected Departments: Emory Transplant Center, Emory Transplant and Heart Failure
Programs, Outpatient Transplant Clinic, and EUH Nursing
Vision Strategy: Patient Care
Protocol Statement: These guidelines were developed to standardize influenza prevention
and treatment across the Emory Transplant Center.
Background: Influenza is a potentially life-threatening infection that occurs primarily during the
winter months. Clinical manifestations of influenza, or flu, include fever, cough, myalgias,
gastrointestinal distress, and fatigue. In a typical year, there are 226,000 hospitalizations and
36,000 deaths related to influenza. Rates of illness and death are generally higher in the very
young (< 2 years), persons > 65 years, and persons with chronic medical conditions, including
those who have received a transplant. Research has demonstrated that vaccination is the most
effective way to reduce morbidity and mortality related to influenza.
Organ Offers from Deceased Donors with Confirmed or Suspected Influenza:
1) Transplant Infectious Diseases should be consulted when accepting organ offers from
deceased donors with confirmed or suspected influenza.
2) Current guidelines regarding acceptance of such offers include:
a. Acceptance of lungs from donors with confirmed or suspected influenza is not
recommended unless the waitlist candidate’s medical urgency warrants
otherwise; and,
b. Acceptance of heart and abdominal organs from donors with confirmed or
suspected influenza should be considered on a case-by-case basis.
3) Prior to acceptance of the organs for a recipient, the transplant candidate must be
informed by the transplanting surgeon of the potential disease transmission risks
including:
a. “Influenza may be transmitted through organ donation.”
b. “Generally, illness caused by influenza is not serious enough to require
hospitalization in transplant recipients. However, some transplant recipients do
require hospitalization.”
c. “A small percentage (0.1% at Emory) of influenza patients have died.”
d. “You will be treated with medication to reduce the risk of getting influenza from
the donor.”
4) Recipients of organs from deceased donors with confirmed or suspected influenza
should have a baseline PCR testing by nasopharyngeal swab for respiratory viruses
ordered with other pre-operative laboratory tests.
Page 1 of 5
5) Regardless of PCR results, transplant recipients of organs from donors with suspected
or confirmed influenza should receive Oseltamivir (Tamiflu) 75 mg twice a day for 10
days post transplant.
6) Post-transplant teaching of these recipients should include the reporting of sore throat
and respiratory symptoms (e.g., cough, rhinorrhea, congestion) to the transplant team.
7) These patients should be monitored on post-transplant follow-up visits for symptoms of
sore throat and respiratory symptoms (e.g., cough, rhinorrhea, congestion) which could
be associated with transmission of donor influenza.
Prevention:
1) All eligible staff should receive the influenza vaccine on an annual basis.
a. The optimal time for administration is between September 1 and December 31.
However, administration at any point during the influenza season (DecemberApril) is likely beneficial to the staff member and to patients in the Emory
Transplant Center.
b. New employees hired during flu season should be vaccinated as soon as
feasible if not already vaccinated.
c. Out of concern for patient safety, staff and faculty who have patient contact are
not currently eligible to receive the FluMist, a live flu vaccine. Staff members who
are not in contact with patients and will not have patient contact for a minimum of
7 days are eligible to receive FluMist.
2) Any staff or faculty with influenza-like symptoms (fever > 100 degrees F and headache,
cough, congestion, sore throat, fatigue, diarrhea, body aches or vomiting) should follow
the following procedures (See attachment 1, Process for Healthcare Workers):
a. If at home, stay home, notify leader and page the nurse practitioner in
Occupational Injury Management at PIC #50464.
b. If at work with influenza-like illness (ILI), notify leader and page the nurse
practitioner in Occupational Injury Management at PIC #50464. Promptly leave
work area and report to the Employee Health/Occupational Injury Management
office for a medical evaluation, treatment and return-to-work instructions.
3) Patient vaccination:
a. Post-transplant patients should only receive injectable influenza vaccine. Family
members and close contacts should also receive the injectable flu vaccine, NOT
FluMist.
b. Patients waitlisted or in the evaluation phase of transplantation, and all heart
failure patients, should be vaccinated annually against influenza.
c. Patients who are at least 3 months post-transplant by September 1 should be
vaccinated against seasonal flu.
d. If possible, patients who will achieve 3 months post-transplant between
September 1 and March 31 should be vaccinated once they have reached the 3
month transplant anniversary.
e. If a patient is transplanted between September 1 and March 31, they may be
vaccinated against influenza at the discretion of the treating physician.
Page 2 of 5
f.
Patients ≥65 years old should receive the high-dose influenza vaccine. For
inpatients, this should be specified in the ‘comments’ section of the order.
4) Hands should be cleaned before and after contact with each patient using alcohol-based
hand cleansers or soap and water.
5) Staff exposed to influenza can be considered for antiviral prophylaxis (See attachment 2,
Occupational Exposure).
Diagnosis: A presumptive diagnosis of influenza can be made in a patient who has fever > 100
degrees F and headache, cough, congestion, sore throat, fatigue, diarrhea, body aches or
vomiting during flu season. Laboratory confirmation can be achieved by performing a
nasopharyngeal swab for respiratory viruses.
Chemoprophylaxis and Treatment:
1) Any patient, regardless of vaccination status but especially if unvaccinated, who has
been exposed to influenza and is within 5 days of exposure should be considered for
antiviral prophylaxis. An exposure is described as a situation in which an individual
without personal protective equipment is at a distance of less than 6 feet of someone
with influenza for duration of greater than 5 minutes. See tables below for medications,
dosage and duration of chemoprophylaxis. The duration may be extended if additional
exposures are identified.
Antiviral medication dosing recommendations for treatment or chemoprophylaxis of
Influenza infection in adult post-transplant patients.
Medication
Oseltamivir (Tamiflu)
[First line agent]
Zanamivir (Relenza)*
Treatment
75 mg capsule twice per day for
10 days
Two 5 mg inhalations (10 mg total)
twice per day for 10 days
100 mg twice per day for 5 days
Chemoprophylaxis
75 mg capsule once per day for
10 days
Two 5 mg inhalations (10 mg total)
once per day for 10 days
Rimantidine
100 mg twice per day (100 mg per
day if > 65 years) for 10 days
* Zanamivir (Relenza) is relatively contraindicated post lung transplant and in patients
with a history of asthma
Antiviral medication dosing recommendations for non-transplant patients and staff:



Medication and dosages are the same as for post-transplant patients (tables above).
Duration of treatment is for 5 days only.
Duration of chemoprophylaxis is for 10 days.
2) Influenza-like illness without fever can likely be handled without an evaluation. Criteria to
warrant an evaluation:
a. Shortness of breath
Page 3 of 5
b. Febrile patients should be evaluated per routine of each program to rule out other
causes of fever.
For further details, see the attached algorithm, Strategy for Off-Site Triage (SORT) for
Adolescents and Adults.
Isolation procedures:
1) See Emory Hospitals Infection Control policies for precautions for patients with
suspected or confirmed influenza. For questions contact the Infection Prevention and
Control Department (2-7156) or see the EHC intranet for updated information
(www.eushc.org). Dependent upon the level of virulence of the actual or anticipated
influenza season, precautions for transplant recipients and heart failure patients may be
increased at the recommendation of Transplant Infectious Diseases.
2) As per Emory Hospitals’ Infection Control policies, for suspected or confirmed influenza
cases, staff, regardless of in-patient or outpatient, should use:
a. Droplet Precautions, requiring the use of masks when entering a room, and
adherence to Standard Precautions. Negative pressure isolation is not needed.
b. The duration of Droplet Precautions will be:
o Until the diagnosis of influenza is excluded or
o For patients with confirmed influenza, until the patient has been on isolation
for > 7 days and has been cleared for by infection control.
3) In-patient precautions for all transplant recipients, ventricular assist device (VAD) and
Class III and IV heart failure:
a. Staff with upper respiratory symptoms (cough, sore throat, rhinorrhea) who have
been cleared to work should wear surgical masks and non-sterile gloves when
entering the patient’s room.
b. For patient safety, patients should be encouraged to limit visitors to immediate
family and close friends.
c. Patients should wear surgical masks when in the hallways and during transport.
d. Whenever feasible staff assignments should be such that staff caring for
suspected or confirmed influenza cases are not assigned to post-transplant,
ventricular assist device (VAD), or Class III or IV heart failure patients.
4) Outpatient precautions:
a. During influenza season, signs will be placed at the front desk alerting patients to
inform the front desk staff of flu-like symptoms. Front desk personnel will ask
patients if they or persons accompanying them have any symptoms suggestive
of a respiratory illness.
b. Patients with influenza-like symptoms should be provided a surgical mask to
wear and be roomed immediately upon notification of the nursing staff.
c. Patients suspected of having influenza should be separated from other patients
in the clinic since flu is transmitted by respiratory droplets. It is preferred,
whenever possible, that patients not be placed in the infusion center with other
patients and their procedures.
Page 4 of 5
d. Contact with other patients should be minimized as much as possible throughout
the clinic visit, including check out and departure.
e. Staff with upper respiratory symptoms (cough, sore throat, rhinorrhea) who have
been cleared to work should wear surgical masks and non-sterile gloves when in
the patient care areas of the clinic.
5) Rooms and equipment used by influenza patients should be cleaned thoroughly with
Oxivir.
References:
American Society for Transplantation, RNA Respiratory Viral Infections in Solid Organ
Transplant Recipients. . American Journal of Transplantation 2009;9 (supplement 4): 166-72.
American Society for Transplantation, Guidelines for vaccination of solid organ transplant
candidates and recipients. American Journal of Transplantation 2009:9 (supplement 4):258-62.
http://www.cdc.gov/flu/
International Society of Heart and Lung Transplantation Advisory Statement on the Implications
of Pandemic Influenza for Thoracic Organ Transplantation, Joint Statement by the International
Society of Heart and Lung Transplantation’s Education Committee and Scientific Council for
Infectious Diseases, May 15, 2009.
American Society of Transplantation (AST) Infectious Diseases Community of Practice /
Transplant Infectious Disease Section of The Transplantation Society (TTS) Guidance On Novel
Influenza A/H1N1* (www.a-s-t.org), September 20, 2009.
OPTN/UNOS Guidance Regarding H1N1 and Implications for Transplantation (www.unos.org),
October 6, 2009.
Approved by: Emory Transplant Center Quality Council
Approval Date:
12.15.2008, 09.04.2009, 10.30.2009, 10.14.2010, 10.17.2012, 09.18.2013
Revision Date(s): 01.15.2009, 09.02.2009, 10.14.2009, 10.30.2009, 10.13.2010
Last Reviewed:
Page 5 of 5
10.07.2014