Duration of Work Exclusion for Influenza
Healthcare workers and patients with influenza should remain off work until they are afebrile for at least 24 hours without the use of fever-reducing medications such as acetaminophen. 1
Work Restriction Guidelines for Healthcare Personnel
The Advisory Committee on Immunization Practices provides clear work restriction criteria for healthcare workers with upper respiratory infections including influenza 1:
- Exclude from duty until afebrile ≥24 hours without using fever-reducing medicines (such as acetaminophen) 1
- Healthcare workers with ongoing respiratory symptoms after the fever resolves should be evaluated by occupational health before returning to patient contact 1
- For workers caring for immunocompromised patients (such as hematopoietic stem cell transplant recipients), consider temporary reassignment or exclusion for 7 days from symptom onset OR until complete resolution of symptoms, whichever is longer 1
- If cough and sneezing persist after returning to work, healthcare personnel should wear a facemask during all patient care activities 1
Special Considerations for High-Risk Patient Care Areas
More stringent criteria apply when healthcare workers provide care in certain high-risk settings 1:
- Intensive care units, nurseries, and organ transplant units require more careful evaluation before allowing symptomatic workers to return 1
- Healthcare workers should remain off work and avoid patient contact entirely if they have symptoms of influenza-like illness 1
Key Clinical Pitfalls
Important caveat: Approximately 38% of hospitalized influenza patients present without fever, particularly elderly patients, those with chronic lung disease, and patients with influenza B 2. These afebrile patients experience:
- Delayed diagnosis and testing 2
- Lower rates of antiviral treatment 2
- Longer hospital stays 2
- Higher mortality rates (3.2% vs 0.6%) 2
Therefore, the absence of fever does not rule out active influenza infection, and clinical judgment regarding work restrictions should consider the full constellation of respiratory symptoms, not fever alone 2.
Practical Implementation
- Minimum exclusion period: 24 hours fever-free without antipyretics 1
- Extended exclusion: 7 days from symptom onset for those caring for immunocompromised patients 1
- Ongoing symptoms: Require occupational health clearance before patient contact 1
- Hand hygiene: Must be reinforced especially before and after each patient contact upon return to work 1