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Influenza Facts and the Healthcare Worker


Academic year: 2021

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Online Course:www.dentalcare.com/en-US/dental-education/continuing-education/ce446/ce446.aspx

Disclaimer:Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

Every dental team member must take necessary precautions to avoid illness, maintain a safe office environment for both the dental team and its patients, and keep current on new strains of influenza and other respiratory illnesses. Dental offices should implement a program for screening patients for aerosol transmitted diseases (ATD). Understanding the risks and how to deal with them can avoid panic, illness and even death.

Conflict of Interest Disclosure Statement

• The author reports no conflicts of interest associated with this work.


This course is part of the home-study library of the American Dental Assistants Association. To learn more about the ADAA and to receive a FREE e-membership visit: www.dentalassistant.org


The Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp

Wilhemina Leeuw, MS, CDA

Continuing Education Units: 1 hour


Approved PACE Program Provider

The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to 7/31/2017. Provider ID# 211886


Your patient is sneezing and coughing. A coworker is complaining of feeling “dead tired”, has a headache, cough, and feels hot. Exactly how should dental offices deal with these situations? Public health leaders in most countries continue to launch full efforts educating people to recognize and control the spread of respiratory infections. Dental professionals play a vital role in strategies to keep respiratory illness out of the dental office.

Dental healthcare workers will undoubtedly be exposed to seasonal strains of influenza. Every dental team member must take necessary precautions to avoid illness, maintain a safe office environment for both the dental team and its patients, and keep current on new strains of influenza and other respiratory illnesses. Dental offices should implement a program for screening patients for aerosol transmitted diseases (ATD). Understanding the risks and how to deal with them can avoid panic, illness and even death.

Learning Objectives

Upon completion of this course, the dental professional should be able to:

• Understand influenza epidemics and pandemics. • Know how influenza is transmitted.

• Recognize signs and symptoms of influenza.

• Take appropriate precautions against influenza exposure and transmission. • Screen patients for influenza and other transmissible respiratory infections. • Be aware of vaccinations and antiviral medications.

Course Contents

• Glossary

• Background

How Influenza Replicates: RNA Genetic Mutation

• Types of Influenza

• Influenza Epidemics and Pandemics Novel Viruses

Recent Flu Pandemic Pandemic Phases • Transmission

• Clinical Signs and Symptoms of Influenza and Severe Influenza-related Complications • Precautions Against Influenza

• Screening Patients for Flu and Other Transmissible Respiratory Infections • Sample Script for Screening Patients • Vaccinations

• Antiviral Medications • Conclusion

• Appendix A • Appendix B

• Course Test Preview • References

• About the Authors


adjuvant – A drug or agent added to

another drug or agent to enhance its medical effectiveness.

aerosol transmissible diseases (ATD) – Diseases transmitted by airborne infectious particles smaller than droplets that may remain suspended for periods of time - even days. antigenic – Capable of causing the production of an antibody.

antigenic drift – Occurring in both influenza A and B, this involves an accumulation of variations, allowing the virus to mutate making it easier for them to spread through a partially immune population.


antigenic shift – A sudden change resulting from the recombination of two virus strains; associated with pandemics due to lack of immunity.

asymptomatic – Condition without symptoms. ATD screening – Identification of potential ATD cases through readily observable signs and the self-report of patients to determine the appropriateness of treating the patient at that time; screening should be performed prior to treatment.

avian flu – A subtype of influenza type A that was identified in 2003 and continues to infect birds; this subtype has the potential to cause a human pandemic if it mutates to a form that can be transmitted easily between humans.

CDC – Centers for Disease Control (www.cdc.gov).

cilia – A microscopic hair-like process extending from a cell.

droplets – Respiratory and oral particles larger than 5 microns in diameter generated by coughing, sneezing, talking or by splatter-producing procedures, such as dentistry. febrile – Pertaining to a fever; symptoms of a fever.

flu – Commonly used term for influenza. HPAI – Highly Pathogenic Avian Influenza. influenza – Acute respiratory viral illness characterized by fever, headache, myalgia (muscle aches), exhaustion, sore throat and cough; some patients suffer nausea, vomiting and diarrhea; symptoms usually last about 7 days, but may last much longer, and may be confused with other illnesses; complications include acute viral pneumonia, secondary bacterial pneumonia and sometimes death.

influenza epidemic – Widespread, rapid transmission of influenza infection throughout a population.

influenza pandemic – Worldwide spread of a new (novel) subtype or one that has not

circulated among humans for a long time; may cause severe infection, illness and death because of its virulence and because people have little or no immunity to the pathogen.

NIH – National Institutes of Health (www.nih.gov). novel influenza – “New” influenza virus to which people have little or no natural immunity.

pathogen – Agent that causes disease.

Respiratory Hygiene/Cough Etiquette in Health Care Settings – CDC, November 4, 2004, hereby incorporated by reference for the sole purpose of establishing requirements for source control procedures.

RNA – Ribonucleic Acid

standard precautions – Term used in infection control to identify a standard of care in which all blood or any other body fluid, excretion, or secretion (except sweat), non-intact skin or mucous membranes, regardless of whether they contain blood, are treated as infectious.

WHO – World Health Organization (www.who.int/en).


Influenza, more commonly called “the flu,” spreads rapidly through populations each year during colder months bringing seasonal flu. Flu season usually begins in the fall and peaks in the months of January and February. However, there have been times with the flu has started as early as October and ended as late as May. Approximately 5% – 20 % of the U.S. population contracts the flu each year. If a virus is similar to previous strains, people may be partially immune and the severity of seasonal flu symptoms may be reduced. When a “novel” virus appears (one that is new, and to which people have little or no natural immunity), it spreads quickly. 2009 H1N1 was a novel virus and spread rapidly throughout the world, which caused the 2009 flu pandemic and made control of respiratory illness a top priority.

When the general public refers to the “the flu,” they are often under the impression that this is just one type of virus. However, several flu strains are usually active during a season. For instance, the


CDC has antigenically characterized 83 influenza viruses, including 62 2009 influenza A (H1N1) viruses, 20 influenza A (H3N2) viruses, and one influenza B virus, collected since October 1, 2013.

How Influenza Replicates: RNA Genetic Mutation

Influenza RNA contains eight segments that change by genetic mutation or reassortment during viral replication. Antigenic drift refers to small point mutations that occur with successive replication, resulting in viral subtypes with some new characteristics. Slight mutations result in strains that people have partial immunity to through previous exposure or vaccinations. If the mutations give rise to viral subtypes that are not similar to previous strains, the virus is likely to spread rapidly. Antigenic shift is a major and abrupt genetic reassortment resulting in new (novel) variants, or subtypes. These new variants are potentially very dangerous because they are often completely unrecognized by host immune systems. For this reason they are able to infect large numbers of animals and/or humans and spread rapidly, leading to epidemics or pandemics.

Types of Influenza

Viral subtypes are identified and named by their surface antigens hemagglutinin (H) and neuraminidase (N). There are three types of influenza:

Type A is the most diverse and infects humans and many animals, including ducks, chickens, pigs, whales, horses and seals. While certain subtypes are found in specific animal hosts, birds are hosts to all subtypes of influenza A and are a repeated source of new flu pathogens. Type A is likely to undergo an antigenic shift if two or more subtypes infect a single host; an occurrence that has caused both epidemics and pandemics.

Type B influenza infects only humans,

primarily children, and generally causes milder symptoms than type A. Type B is known to cause seasonal outbreaks and epidemics, but not pandemics.

Type C influenza is common in swine, but rarely seen in humans.

Influenza Epidemics and Pandemics

It is important to know the difference between an influenza epidemic and pandemic. An epidemic is caused when an infectious disease or condition affects many people at the same time within a geographic area. A pandemic is when an infectious disease or condition is affecting people at the same time in many different parts of the world.

Novel Viruses

When Influenza types A and/or B circulate annually, they may cause epidemics. Every ten to forty years, however, new or “novel” viruses emerge and circle the globe causing a pandemic. All known influenza pandemics have resulted from influenza A variants undergoing antigenic shift, creating a new virus that spread between humans.

The earliest recognized pandemic of avian flu occurred in 1580 and there have been 31 since then. In 1918-1919, the Spanish influenza A (H1N1) pandemic started in Kansas and spread worldwide through United States military troops and steamship travel. In less than 5 months, 21 million people died. The pandemic claimed 500,000 U.S. lives and killed 50 million worldwide (two percent of those infected died). In 1957-1958, the Asian Flu A(H2N2) caused 70,000 American deaths, and the 1968-1969 Hong Kong Flu A (H3N2) caused 34,000 American deaths. Typically, an avian flu virus first infects pigs then humans. The Hong Kong strain may have jumped directly from birds to humans. In 2001, influenza A (H1N2) emerged and spread globally. It most likely resulted from genetic reassortment of A (H1N1) and A (H3N2) when both viruses were present in one host.

In 2004 a deadly avian flu (Highly Pathogenic Avian Influenza A - H5N2) spread globally in birds and was detected in a flock of Texas chickens. According to the Centers for Disease Control (CDC), this was the first outbreak of HPAI (H5N2) in twenty years. No transmission to humans was reported.

Recent Flu Pandemic

The well-known 1918 “Spanish Flu” pandemic was caused by an H1N1 virus: the ancestor of


all later human-adapted seasonal and pandemic species. During the 1918 pandemic, that flu strain was transmitted to pigs and it has been evolving in swine since then. The 2009 H1N1 strain (first called “swine flu”) was created when two common Swine Influenza Type A H1N1 viruses (that infect pigs and sometimes humans who are in contact with pigs) mixed with human flu and bird flu. The pigs were exposed to all four Type A (two swine, one human and one bird) viruses causing a dramatically different new strain of influenza with the ability to spread between humans. Many people had little or no immunity to 2009 H1N1 accounting for high rates of transmission.

As of January 2010, the World Health

Organization (WHO) regions reported that more than 209 countries had confirmed cases of 2009 H1N1 influenza virus, including at least 14,142 deaths. This total was believed to be an underestimation of total cases in the world since many countries only use specific tests to confirm diagnosis on many persons with severe illness and/or high risk conditions, and many cases are not reported if the patient does not seek medical care. As of June, 2012, the mortality rate estimated between 151,700 and 575,400 people. A large number of these deaths occurred in Southeast Asia and Africa where access to treatment was limited.

Concern about the high transmissibility of the flu combined with high susceptibility of the world population has resulted in heightened global efforts to inform and vaccinate the public. It is important to remember, however, that flu viruses may mutate and become more virulent, and

that every year in late fall and winter, 5-20% of the U.S. population is infected with a flu virus. Approximately 226,000 of those infected are hospitalized, and about 36,000 infections result in death. Regardless of the type of virus, influenza is a serious matter.

Pandemic Phases

The WHO identifies six phases of pandemic alert to help health officials plan and activate resources (Table 1).

The 2009 H1N1 was a Phase 6 pandemic but the severity of the pandemic was moderate as of September, 2009. This means that most people recovered from the infection without the need for hospitalization or medical care. However, the WHO was concerned about current patterns of serious cases and deaths that were occurring primarily among young persons, including the previously healthy and those with pre-existing medical conditions or pregnancy. Public health leaders recommended a conservative approach to preventative precautions, implementing respiratory precautions in addition to droplet precautions for known or suspected ATD cases.


Influenza is transmitted primarily through one of three ways:

1. airborne large-particle respiratory droplets (5 microns or larger) from sneezing (Figure 1) or coughing in close proximity (6 feet or closer) to another person,

2. smaller aerosols traveling greater distances, or 3. contact with respiratory-droplet contaminated

surfaces. Inhalation, direct personal contact Table 1. Pandemic Phases


severely ill or dying from both seasonal and novel flu viruses:

• Children less than 5 years old • Pregnant women

• Children and adolescents aged 6 months - 18 years, who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection

• Adults and children who have chronic pulmonary, cardiovascular, hepatic,

hematological, neurologic, neuromuscular or metabolic disorders

• Adults and children who have immunosuppression

• Persons aged 50 years or older

• Residents of nursing homes and other chronic-care facilities

Clinical Signs and Symptoms of

Influenza and Severe Influenza-related


Influenza viral infections can cause a wide range of symptoms, including fever, cough, sore throat, body aches, headache, chills and fatigue (Table 2). Symptoms typically have a sudden onset and patients feel markedly worse than those with the common cold. Some people have reported diarrhea and vomiting associated with influenza. Seasonal flu viruses can vary in severity from mild to severe with the possibilities of pneumonia, respiratory failure and death. Sometimes bacterial infections may occur at the same time as or after infection with influenza viruses and lead to pneumonias, ear infections or sinus infections.

Precautions Against Influenza

Basic precautions recommended by the CDC for all people include:

• Covering the nose and mouth with a tissue when coughing or sneezing.

• Wash hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub.

• Avoid touching the eyes, nose or mouth. Germs spread this way.

• Try to avoid close contact with sick people. If sick with flu-like illness, CDC recommends staying home for at least 24 hours after your and touching eyes, nose or mouth with

contaminated objects or hands are the most likely routes of flu transmission.

Like other respiratory viruses, influenza viruses attach to ciliated epithelial cells lining the respiratory tract where they penetrate and replicate. Common cold viruses (such as rhinovirus) are heat sensitive and only infect the upper respiratory tract. However, in addition to upper respiratory tissues influenza can also penetrate tissue in warmer, deeper areas such as the trachea, bronchi and lungs leading to more severe symptoms.

The incubation period for influenza is estimated at 1-4 days. An infected person can transmit the virus 1 day before symptoms develop, and at least 7 days after onset. Children may be infectious earlier before symptoms start, and remain contagious for longer after onset. Both symptomatic and asymptomatic people spread the infection, so high-risk susceptible people should consider avoiding crowded areas and close contact during times and in locations of influenza occurrence.

About half of the country may be at higher risk of serious illness from novel viruses. The following people have the highest risk of becoming


Table 2. Signs and Symptoms of Influenza

Table 3. Severe Influenza-related Complications Requiring Emergency Treatment

fever is gone except to get medical care or for other necessities (The fever should be gone without the use of a fever-reducing medicine.). Keep away from others as much as possible to keep from making others sick.

This includes hospitals and healthcare facilities treating patients with influenza. Many hospitals have restricted visitation to flu patients and have created rules limiting any minors under the age of 18 from any hospital visitation.

Other important actions that can be taken: • Follow public health advice regarding school

closures, avoiding crowds and other social distancing measures.

• Be prepared in case of illness the need to stay home for approximately 1 week; have a supply of over-the-counter medicines, alcohol-based hand rubs (for when soap and water are not available), tissues and other related items will eliminate the need to make trips out in public while sick and contagious.


again. Vital signs to assess temperature, respirations, and blood pressure can be

documented with every visit as part of the patient seating and examination process. Provisions should be made to allow for prompt isolation and assessment of symptomatic patients. [Note: ALWAYS protect patient privacy during screening. Written screening forms may be most appropriate.]

Sample Script for Screening Patients

A hierarchy of control measures should be applied to prevent transmission of influenza in all health care settings. Elimination of potential exposures is very important (e.g., deferral of ill patients and source control by masking coughing individuals).

Specific Recommendations for Dental Health Care

• Use patient-reminder calls to identify patients reporting influenza-like illness and reschedule non-urgent visits until 24 hours after the patient is free of fever, without the use of fever-reducing medicine.

• Identify patients with influenza-like illness at check-in; offer a facemask or tissues to symptomatic patients; follow respiratory hygiene/cough etiquette (see Appendix A); For dental healthcare workers, standard

precautions reduce the risk of exposure to most contact and respiratory pathogens that are likely to be encountered. However, additional precautions are recommended for controlling highly contagious diseases, especially those that may become airborne. Prior to the 2009 H1N1 pandemic, healthcare personnel were instructed to observe Droplet Precautions (i.e., wearing a surgical or procedure mask with eye protection for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present.

Studies on influenza transmission show that airborne (inhalation) transmission is one of the potential routes of transmission. CDC recommends a more conservative approach

in dealing with ATD’s during a pandemic. All

healthcare personnel should wear a fit-tested disposable N95 respirator surgical mask

(Figure 2) or better when they enter the rooms of patients in isolation with confirmed, suspected, or probable ATD such as influenza. Personal protective equipment (PPE) including specialized respiratory protection (fit-tested disposable N95 NIOSH respirators or better), gloves, gowns, and eye protection and other strategies such as innovative triage processes, handwashing, disinfection, vaccination, antiviral drug use, written program, training, and special building construction and operation to contain and control room air flow. Unless dental facilities are specially equipped to comply with these safety requirements, they should avoid treating patients with ATD symptoms. Healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.

Screening Patients for Flu and Other

Transmissible Respiratory Infections

Infection control starts before the patient arrives at the front office. When a patient is called for appointment confirmation they should be screened for febrile respiratory illness to prevent transmission of an aerosolized transmissible disease.

When the patient arrives, and while protecting their privacy rights, they should be screened

Figure 2. N95 NIOSH respirator mask.


[Note: Adapted from OSAP script: http://www.cdc. gov/oralhealth/infectioncontrol/pdf/2009_prevent_ h1n1.pdf]


Vaccinations are the highest priority for prevention of illness and should be administered if available and not contraindicated. The severity of seasonal flu epidemics depends on the symptoms, transmissibility of the viruses and

susceptibility of the population. Scientists attempt to predict how influenza genes will mutate and/ or re-combine as they replicate. Each year vaccines are produced to fight the expected epidemics. Sometimes the vaccines are very effective and other times the viruses mutate and spread differently than scientists predicted, rendering the vaccines less effective. Because flu viruses are usually similar to previous strains, many people have at least partial immunity due to either previous illnesses or vaccines. Due to the increased awareness of the flu and possible pandemics, more healthcare workers (HCW) are receiving flu vaccinations. In the 2007-2008 flu season, vaccinations of HCW reached 47.6%. In the 2011-2012 season, it jumped significantly to reach 62.4% overall in HCW.

Most people are advised to get vaccinated against seasonal influenza, but physicians exclude those people who are allergic to eggs, children under six months old and others who may have complications from the vaccine. Vaccines are available in injection form and a nasal spray. The flu shots contain inactivated fragments of killed influenza and will not cause the flu to manifest. The nasal spray (live attenuated influenza vaccine, or LAIV) is made using a weakened live flu virus. Pregnant women, young children and people with compromised immune systems cannot receive the nasal spray and should receive the injection. The CDC prioritizes who should be vaccinated if vaccines are available in extremely limited and reschedule non-urgent care. Separate

ill patients from others whenever possible if evaluating for urgent care.

Symptoms of Influenza

Persons with influenza may have some or all of these symptoms:

• fever* • cough • sore throat

• runny or stuffy nose • body aches

• headache • chills • fatigue

• sometimes diarrhea and vomiting

*It’s important to note that not everyone with influenza will have

a fever.

• Urgent dental treatment can be performed without the use of an airborne infection isolation (AII) room because transmission of influenza is thought not to occur over longer distances through the air, such as from one patient room to another.

• Use a treatment room with a closed door, if available. If not, use one that is farthest from other patients and personnel.

• Wear recommended PPE before entering the treatment room.

Dental health care personnel should wear a NIOSH fit-tested, disposable N95 respirator when entering the patient room and when performing dental procedures on patients with suspected or confirmed influenza.

Personal protective equipment (PPE) for exposures that cannot otherwise be eliminated or controlled. Additional PPE includes gloves, protective eyewear, and protective clothing (e.g., gowns).

If N95 respirators and/or fit-testing is not available despite reasonable attempts to obtain, the dental office should transition to a prioritized use mode (i.e., non-fit-tested disposable N95 respirators or surgical facemasks can be considered as a lower level of protection for personnel at lower risk of exposure or lower risk of complication from influenza until fit-tested N95 respirators are available).

• As customary, minimize spray and spatter (e.g., use a dental dam and high-volume evacuator).


infection from a common cold, because antiviral medication taken within the first 2 days of

sickness is recommended. The dosage is usually prescribed for 5 days and must be taken as directed. Some side effects have been noted, which are much like having the flu itself; nausea, vomiting, dizziness, runny nose, etc.

Antiviral medications are a second line of defense as a treatment. Even with the availability of these medications, the best defense is to receive the influenza vaccination.


Influenza is an acute respiratory illness that returns every year in a new form. The 2009– 2010 flu season brought a new threat to the world because 2009 H1N1 was a novel virus, to which virtually everyone was susceptible. The 1918 “Spanish Flu” H1N1 virus caused a devastating pandemic when no antiviral medications and no vaccinations were available. The 2009 H1N1 was derived from the 1918 virus and is highly transmissible with a severity similar to seasonal flu. Clinical signs and symptoms of influenza are fever, headache, muscle aches, exhaustion, cough, respiratory symptoms and possibly vomiting and/or diarrhea.

The most important strategy to prevent illness is vaccination. World health organizations urge everyone who is eligible to receive a vaccination. Dental offices should employ Respiratory

Hygiene/Cough Etiquette (see Appendix B) and screen patients for respiratory symptoms and aerosol transmissible diseases. Symptomatic patients should not be treated, and dental healthcare workers with symptoms should not report to work. People in high risk categories may experience severe cases of influenza and quantities: pregnant women, people who live

with or care for children younger than 6 months of age, healthcare and emergency medical services personnel, persons between the ages of 6 months through 24 years and people ages 25 through 64 years who are at higher risk for flu viruses because of chronic health disorders or compromised immune systems. Once demand for vaccinations for the prioritized groups has been met at the local level, programs and providers begin vaccinating everyone from the ages of 25 through 64 years. Current studies indicate that the risk for infection among persons age 65 or older is less than the risk for younger age groups. However, once vaccine demand among younger age groups is met programs and providers will offer vaccination to people 65 or older (see http://www.flu.gov/prevention-vaccination/vaccination/#).

Antiviral Medications

There are prescribed medications from a healthcare provider that can be used to treat influenza. This medicine comes in the form of pills, liquid, or inhaled powder. Those who are very ill with the flu, or those who have a greater chance of additional, serious complications are candidates for this medicine. Most otherwise-healthy people with the flu do not need to be treated with antiviral medication.

Two antiviral medications: oseltamivir (Tamiflu®), and zanamivir (Relenza®) are available for those suffering from the flu. Tamiflu is available in pill or liquid and Relenza is a powder that is inhaled. Because it must be inhaled, Relenza is not recommended for people with breathing problems like asthma or chronic obstructive pulmonary disease (COPD).

When taken properly, these medicines can shorten and lessen the symptom time by 1-2 days and can also aid in the prevention of additional complications like pneumonia. For some higher risk patients, the medication can mean the difference between having milder symptoms to a hospital stay. Children and pregnant women can receive these antiviral medicines. Unfortunately, there are a few flu strains that have developed a resistance to oseltamivir.

Physicians should be consulted if the flu is suspected. It is important to distinguish a flu


The following link offers short Public Service Announcements (PSAs) from the CDC that could be played for your patients:

http://www.cdc.gov/flu/freeresources/media-psa.htm should be vaccinated early, protected from

exposure and seek immediate medical attention if they become ill. Informed, trained and motivated dental healthcare workers are an important part

of the healthcare community’s effort to overcome

any type of seasonal influenza.

Stop the spread of germs that can make you and others sick!

You may be asked to put on a facemask to protect others.

If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.

Wash hands often with soap and warm water for 20 seconds. If soap and water are not available, use an alcohol-based hand rub.

Cover your mouth and nose with a tissue when you cough or sneeze. Put your used tissue in the waste basket.



Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to:


1. A ____________ influenza virus is one in which people have little or no natural immunity.

a. novel b. pandemic c. endemic d. swine

2. Dental offices should screen patients _______________.

a. to identify those with bloodborne diseases

b. before the appointment while seated in the receptions area c. prior to treatment, while protecting their privacy

d. to prevent transmission of aerosol transmissible diseases e. C and D

3. A symptom of influenza in older children and adults typically includes a fever of __________.

a. 97.6° F b. 98.4° F c. 99.8°F

d. 101.1° F or more e. No fever associated.

4. _______________ correctly describes influenza.

a. Influenza never changes significantly, but people’s susceptibility changes yearly, requiring new flu


b. Antigenic shift refers to small point mutations that occur with successive replication

c. New variants or subtypes of influenza are potentially dangerous if they are unrecognized by immune systems

d. B and C

5. The incubation period for the flu is estimated at ____________.

a. 24 hours b. 1-4 days c. 5-6 days d. under 48 hours

6. Vaccinations among healthcare workers has ____________.

a. increased b. decreased c. remained steady

7. A basic precaution to prevent the contraction of the flu is _______________.

a. washing hands often with soap and water b. avoid touching the eyes and nose

c. avoid contact with those known to be sick d. All of the above.


8. The 2009 H1N1 Influenza was a Phase 5 pandemic. In a Phase 5, a virus is spreading in at least one country in addition to those in one WHO region.

a. Both statements are true.

b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false.

9. Symptoms of seasonal flu may include _______________.

a. sudden fever b. muscle aches c. sore throat

d. sinus congestion, cough d. All of the above.

10. Personal protective equipment necessary for dental healthcare workers to prevent acquiring or transmitting the flu is _______________.

a. gloves and safety glasses

b. gloves, safety glasses, N95 mask, and gown c. gloves

d. only an N95 particle mask

11. Current studies indicate that the risk for infection among persons age 65 or older is ____________ the risk for younger age groups.

a. greater than b. equal to c. less than

12. An epidemic is caused when an infectious disease affects many people at the same time within a geographic area. A pandemic is caused when an infectious disease affects people at the same time in many different parts of the world.

a. Both statements are true.

b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false.

13. Populations most susceptible to novel viruses are _______________.

a. elderly adults over 65 years b. children less than 5 years old c. adults aged 30 to 45 years old

d. those who just received the injected vaccine

14. Flu-related symptoms requiring emergency attention include _______________.

a. troubled breathing b. persistent vomiting c. dehydration d. All of the above.


15. The severity of seasonal flu epidemics depends on the symptoms, transmissibility of the viruses and susceptibility of the population. Only symptomatic people spread the infection so it can be detected and prevented easily.

a. Both statements are true.

b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false.



1. [No references cited.]

Additional Reading

• FLU.gov. Interim Public Health Guidance for the Use of Facemasks and Respirators in Non-Occupational Community Settings during an Influenza Pandemic. May 2007.

• California OSHA, Title 8, Chapter 4, Section 5199 Excerpts.

• Health.com. Can’t Stop Coughing? 8 Causes of Chronic Cough. Accessed 7/7/2009.

• Centers for Disease Control and Prevention. H1N1 Flu. Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. July 2010.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). Interim Guidance for the Use of Masks to Control Influenza Transmission. August 2009.

• Centers for Disease Control and Prevention. H1N1 Flu. Questions & Answers - Vaccine against 2009 H1N1 Influenza Virus. August 2009.

• Graham B, Heymann DL, Editor. Control of Communicable Diseases Manual. 18th Ed. 2004. Influenza, 281-287.

• Molinari JA, Harte JA, Cottone JA. Cottone’s practical infection control in dentistry. 3rd Ed. Chapter

4: Upper Respiratory Tract Infections, 45-62.

• Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

• Centers for Disease Control and Prevention. Droplet Precautions, In: 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

• NIH News. Dynasty: Influenza Virus in 1918 and Today, June 29, 2009 News Release. U.S. Dept of Health and Human Services.

• OSAP.org. Early Identification and Deferral of Patients with Flu-Like Symptoms – Suggested Script for Front Office Staff. [Article no longer available].

• NIH News. Early Results: In Children, 2009 H1N1 Influenza Vaccine Works Like Seasonal Flu Vaccine.

• Kohn WG, Collins AS, Cleveland JL, Harte JA, et al. Guidelines for infection control in dental health-care settings--2003. MMWR Recomm Rep. 2003 Dec 19;52(RR-17):1-61.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). What You Should Know About Flu Antiviral Drugs. Accessed 11/5/2013.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). Situation Update: Summary of Weekly FluView. Accessed 11/5/2013.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). First Global Estimates of 2009 H1N1 Pandemic Mortality Released by CDC-Led Collaboration. Accessed 4/17/2013. • Centers for Disease Control and Prevention. H1N1 Flu. Interim Guidance on Infection Control

Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel. July 2010.

• Centers for Disease Control and Prevention. H1N1 Flu. 2009 H1N1 Flu: International Situation Update. Accessed 8/17/2009.

• http://www.monofacto.com/facts/dictionary?PCR+test. [Web site no longer available].

• World Health Organization. Global Alert and Response (GAR). Pandemic (H1N1) 2009 - update 84. January 2010. Accessed 4/17/2013.

• Miller CH, Palenik CJ. Infection Control and Management of Hazardous Materials for the Dental Team, 3rd Ed. Chapter 9, Immunization, Influenza. 151-153.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). Influenza Vaccination Information for Health Care Workers.


• Centers for Disease Control and Prevention. H1N1 Flu. Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season. Accessed 5/6/2009.

• Novel Influenza A (H1N1) Virus, Resources for Dental Professionals (5.12.09).

• Protocol for Managing Dental Patients with Confirmed or Suspected Respiratory Infection. [Article no longer available].

• Institute of Medicine of the National Academies. Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A: A Letter Report. September 2009.

• FLU.gov. Seasonal Flu. Accessed 4/22/2013.

• CNNhealth.com. Study: Face masks seem to protect against flu. August 2009.

• Centers for Disease Control and Prevention. H1N1 Flu (Swine Flu): Information for Concerned Parents and Caregivers. Accessed 4/29/2009.

• Centers for Disease Control and Prevention. Avian Influenza (Flu). Transmission of Influenza A Viruses Between Animals and People.

• NIH News. Early Results: In Children, 2009 H1N1 Influenza Vaccine Works Like Seasonal Flu Vaccine.

• Centers for Disease Control and Prevention. Seasonal Influenza (Flu). What You Should Know About Flu Antiviral Drugs. Accessed 4/22/2013.

• World Health Organization. Global Alert and Response (GAR). WHO guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses. February 2010. • World Health Organization. Influenza. Current WHO global phase of pandemic alert: Avian Influenza


• FLU.gov. About Pandemics. Accessed 9/9/2009.

Suggested Sites for Office Reference Materials

• Centers for Disease Control – Seasonal Flu http://www.cdc.gov/flu/references.htm

• Respiratory Hygiene/Cough Etiquette in Healthcare Settings http://www.cdc.gov/niosh/nas/RDRP/appendices/chapter6/a6-90.pdf • World Health Organization – How to Hand Wash


About the Author

Wilhemina Leeuw, MS, CDA

Wilhemina Leeuw is a Clinical Assistant Professor of Dental Education at Indiana University Purdue University, Fort Wayne. A DANB Certified Dental Assistant since 1985, she worked in private practice over twelve years before beginning her teaching career in the Dental Assisting Program at IPFW. She is very

active in her local and Indiana state dental assisting organizations. Prof. Leeuw’s educational background includes dental assisting - both clinical and office management, and she received her Master’s degree

in Organizational Leadership and Supervision. She is also the Continuing Education Coordinator for the American Dental Assistants Association.


Figure 1.  Airborne transmission from sneezing.
Table 2.  Signs and Symptoms of Influenza
Figure 2.  N95 NIOSH respirator mask.


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