Notes From Infection Control
Influenza (flu)
Preparation and Recommendations
Sept, 2013
Respiratory Virus Shedding in a Cohort of On-Duty Healthcare Workers
Undergoing Prospective Surveillance
Esbenshade JC, Edwards KM, Esbenshade AJ, et al
Infect Control Hosp Epidemiol. 2013;34:373-378
Study Summary
Two recent publications serve as yet another reminder that
healthcare workers (HCWs) should avoid patient care duties
when feeling ill.
Esbenshade and colleagues performed prospective biweekly
surveillance to assess influenza and other respiratory virus
shedding in a cohort of hospital-based HCWs between November
2009 and April 2010. During the 20-week study period, 1404
nasal swab specimens were collected from 159 physicians,
nurses, and ancillary staff working in patient care areas.
Multiplex respiratory virus polymerase chain reaction was also
performed on 119 specimens from 83 ill HCWs and 200
specimens from 106 randomly selected asymptomatic HCWs.
Forty-two specimens were positive: 35 (29.4%) obtained from ill
HCWs and 7 (3.5%) from asymptomatic HCWs. Human
rhinovirus was the most commonly identified virus (n = 33),
followed by coronavirus and parainfluenza virus (n = 4 each) and
human metapneumovirus (n = 1). No influenza was detected,
which was believed to be related to the atypical influenza season
in 2009-2010 as well as the high level of vaccination among
participants (74.2%).
Multivariate analysis demonstrated that viral shedding was
strongly associated with report of any symptoms (odds ratio
[OR],13.06; 95% confidence interval [CI], 5.45-31.28; P < .001)
and less strongly associated with younger age (OR 0.96; 95% CI,
0.92-0.99; P = .23). In a postsurveillance survey, 46% of study
participants reported working with an influenza-like illness.
Table 1. Comparison of Seasonal and Novel / Pandemic Influenza (FLU)
Seasonal Flu
Novel / Pandemic Flu
Cause
Know circulating flu viruses
A novel virus
Transmission
Infectious Period
Large droplet and fomites
 Adults: 1 day prior to
symptom onset; 5 days
post illness
 Children: 10 days
 Immune-compromised
shed for weeks to months
 Annual vaccination
 Respiratory hygiene
 Antivirals for treatment and
prophylaxis (however, viral
strains are becoming
resistant)
Winter seasons in the Northern
and Southern Hemispheres
Large droplets and fomites
 Unknown
 Likely similar to
seasonal flu, but
unknown
Prevention & Treatment
When occur and how
spread?
Who seriously affected?
How many affected?
 Elderly
 Young children
 Chronic conditions
In US (varies each season), on
average:
 36,000 deaths
 200,000 hospitalizations



Unknown
No vaccine currently
exists
Antiviral effectiveness is
unknown
Indications
Since no previous exposure,
humans will have little or no
pre-existing immunity
Complicates the use of
quarantine, isolation and
masks for protection.

Availability and
effectiveness of
antivirals fro pandemic
flu is uncertain
Unknown
Year-round without warning
Rapid worldwide spread
Everyone including the young
and healthy
Most important differentiating
factor
In US:
 89,000 – 207,000
deaths
 314,000 – 734,000
hospitalizations
Can have devastating impact
on hospitals, funeral homes,
etc.
Could greatly impact
community infrastructure
Adopted from Los Angeles County Dept of Public Health Pandemic Influenza Preparedness and Response Planning Guidelines.
STOPPING THE SPREAD OF INFLUENZA-LIKE ILLNESS
How influenza-like illness is spread
Illnesses like the flu (influenza) and colds are caused by viruses that infect the nose, throat, and lungs. The flu and
colds usually spread from person to person when an infected person coughs or sneezes.
How to help stop the spread





Cover your mouth and nose when you sneeze or cough
Clean your hands often
Avoid touching your eyes, nose or mouth
Stay home when you are sick and check with a health care provider when needed
Practice other good health habits.
Cover your mouth and nose when you sneeze or cough
Cough or sneeze into a tissue and then throw it away. Cover your cough or sneeze if you do not have a tissue.
Then, clean your hands, and do so every time you cough or sneeze.
Table 2. Respiratory Hygiene/Cough Etiquette
Concern
To contain respiratory secretions, all persons with
signs and symptoms of a respiratory infection,
regardless of presumed cause, should be instructed
to:
Healthcare facilities should ensure the availability of
materials for adhering to respiratory hygiene/cough
etiquette in waiting areas for patients and visitors:
Recommendations








Cover the nose/mouth when coughing or sneezing.
Use tissues to contain respiratory secretions.
Dispose of tissues in the nearest waste receptacle after use.
Perform hand hygiene after contact with respiratory secretions
and contaminated objects/materials.
Provide tissues and no-touch receptacles for used tissue disposal.
Provide conveniently located dispensers of alcohol-based hand rub.
Provide soap and disposable towels for handwashing where sinks
are available.
Clean your hands often


Soap and warm water - rub your hands vigorously together and scrub all surfaces. Wash for 15 to 20
seconds. It is the soap combined with the scrubbing action that helps dislodge and remove germs.
Alcohol-based sanitizer – rub your hands vigorously together and scrub all surfaces until they are dry.
Stay home when you are sick and check with a health care provider when needed
When you are sick or have flu symptoms, stay home, get plenty of rest, and check with a health care provider as
needed. Your employer may need a doctor’s note for an excused absence. Remember: keeping your distance from
others may protect them from getting sick. Common symptoms of the flu include:
fever (usually high)
extreme tiredness
sore throat
muscle aches
headache
cough
runny or stuffy nose
nausea, vomiting, and diarrhea, (much more common
among children than adults)
Assessing for influenza-like illness (ILI):
An ILI assessment tool should be used for immediate triage of patients or staff, and for accommodation or cohort of patients
prior to further clinical management. This is not intended to be used as a clinical management tool.
Table 3. Influenza-like Illness (ILI) Assessment Tool
ILI is determined by the presence of the three symptoms on the left plus one or more symptoms on the right:
Please check the following:
'Acute onset of respiratory illness
'Fever (>38 C)*
'Cough
and one or more of the following:
□ sore throat
□ arthralgia
□ myalgia or prostration
□ diarrhea**
□ vomiting**
□ abdominal pain*
*May not be present in elderly people
Adapted from http://search.lapublichealth.org/acd/Pandemicflu.htm.
** May be present in children
Summary of Infection Control Recommendations for Care of Patients with
Novel / Pandemic Influenza
Component
Standard Precautions
Hand hygiene
Personal protective equipment
(PPE)
Safe work practices
Patient resuscitation
Soiled patient care equipment
Soiled linen and laundry
Needles and other sharps
Environmental cleaning and
disinfection
Disposal of solid waste
Respiratory hygiene/cough
etiquette
Patient placement / Droplet
Precautions
Patient transport
Aerosol-Generating
Procedures
.
Recommendations
Use in the care of all patients regardless of their diagnosis or presumed infection status. Use
whenever contact with nonintact skin or mucous membranes is anticipated.
Applies to blood, body fluids, secretions, and excretions regardless of whether or not they
contain visible blood.
Perform hand hygiene after touching blood, body fluids, secretions, excretions, and
contaminated items; after removing gloves; and between patient contacts. Hand hygiene
includes both handwashing with either plain or antimicrobial soap and water or use of alcohol
based products (gels, rinses, foams) that contain an emollient and do not require the use of
water. If hands are visibly soiled or contaminated with respiratory secretions, they should be
washed with soap (either non-antimicrobial or antimicrobial) and water. In the absence of
visible soiling of hands, approved alcohol-based products for hand disinfection are preferred
over antimicrobial or plain soap and water because of their superior microbicidal activity,
reduced drying of the skin, and convenience.
Gloves: for touching blood, body fluids, secretions, excretions, and contaminated items; for
touching mucous membranes and nonintact skin.
Gown: during procedures and patient-care activities when contact of clothing/exposed skin
with blood/body fluids, secretions, and excretions is anticipated.
Face/eye protection (e.g., surgical or procedure mask and goggles or a face shield): during
procedures and patient care activities likely to generate splash or spray of blood, body fluids,
secretions, excretions.
Avoid touching eyes, nose, mouth, or exposed skin with contaminated hands (gloved or
ungloved); avoid touching surfaces with contaminated gloves and other PPE that are not
directly related to patient care (e.g., door knobs, keys, light switches).
Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation bag, or other
ventilation devices to prevent contact with mouth and oral secretions.
Handle in a manner that prevents transfer of microorganisms to oneself, others, and
environmental surfaces; wear gloves if visibly contaminated; perform hand hygiene after
handling equipment. Consider dedicating equipment to patient.
Handle in a manner that prevents transfer of microorganisms to oneself, others, and to
environmental surfaces; wear gloves (gown if necessary) when handling and transporting
soiled linen and laundry; and perform hand hygiene.
Use devices with safety features when available; do not recap, bend, break or handmanipulate used needles; if recapping is necessary, use a one-handed scoop technique; place
used sharps in a puncture-resistant container.
Use EPA-registered hospital-approved detergent-disinfectant; follow standard facility
procedures for cleaning and disinfection of environmental surfaces; emphasize
cleaning/disinfection of frequently touched surfaces (e.g., bed rails, phones, lavatory surfaces).
Contain and dispose of solid waste (medical and non-medical) in accordance with facility
procedures and/or local or state regulations; wear gloves when handling waste; wear gloves
when handling waste containers; perform hand hygiene.
Source control measures for persons with symptoms of a respiratory infection; implement at
first point of encounter (e.g., triage/reception areas) within a healthcare setting.
Cover the mouth/nose when sneezing/coughing; use tissues and dispose in no-touch
receptacles; perform hand hygiene after contact with respiratory secretions; wear a mask
(procedure or surgical) if tolerated; sit or stand as far away as possible (more than 3 feet) from
persons who are not ill.
Place patients with influenza in a private room or cohort with other patients with influenza.*
Keep door closed or slightly ajar; and apply droplet precautions to all persons in the room.
*During the early stages of a pandemic, infection with influenza should be laboratoryconfirmed, if possible.
Personal protective equipment - wear a surgical or procedure mask for entry into patient room;
wear other PPE as recommended for standard precautions.
Limit patient movement outside of room to medically necessary purposes; have patient wear a
procedure or surgical mask when outside the room.
During procedures that may generate small particles of respiratory secretions (e.g.,
endotracheal intubation, bronchoscopy, nebulizer treatment, suctioning), healthcare personnel
should wear gloves, gown, face/eye protection, and a fit-tested N95 respirator or other
appropriate particular respirator.