Influenza 2018

Last week’s cold front and this morning’s pumpkin spice latte means one thing for medical professionals, flu season. Each year we dip a toe into the season leery of what may come and how well the vaccine will cover the most vulnerable. We mentally prepare for a rush of patients seeking vaccines last minute, wavering parents, students with requirements, elderly, pulmonary patients, special needs children and those who dismiss the need for vaccines.

Flu-icky

While manufacturers mass-produce vaccines, we look to Australia for an update. Yes, the land down under has a flu season prior to the United States that correlates closely. This year has been mild for Australians, with few people taking sick time and reduced person to person transmission. Influenza

A was detected in 83% of cases with the A(H1N1) strain being predominant at 58% and A(H3N2) accounting for 24%, 18% influenza B with 17% influenza B Yamagata and less than 1% A(H1N1) and A(H3N2) co-infections. 55 deaths were reported to be related to influenza, 75% related to Influenza A, however, the accuracy of this varies as reporting influenza is not required. The vaccine was 68% effective against all strains of influenza providing a positive outlook compared to last flu season.

1.Are we ready this year?

Last year 80,000 people died from Influenza, I know you remember watching local news stories about children dying and parents pleading for increased vaccination. This was difficult for healthcare workers in every capacity. Doctors, nurse practitioners, nurses, paramedics, and respiratory therapists have urged vulnerable populations to vaccinate early citing last year’s severity. Hopefully, we are ready.

2.Back to Basics

Time for a brief review of influenza, including types, strains, and transmission. Influenza is categorized as type A, B, C and D. Type A and B are the most prevalent, C causes minor illness in people and D is found on cattle. Strains relate to the surface proteins found on influenza, hemagglutinin (H) and neuraminidase (N) with 18 and 11 strains respectively, hence H1N1 strain. The influenza B virus has two strains B/Yamagata and B/Victoria.

Influenza spreads via droplets when an infected patient sneezes, coughs or talks, and those droplets land inside the mucus membranes of someone within 6 feet. Transmission can also occur when someone uses a surface that has influenza droplets and then rubs their eyes or places a finger in their mouth. Once someone becomes infected they start to transmit the virus to others before any physical symptoms appear at day 5 to 7.

The risk of contracting influenza is higher for those who work in the healthcare industry. The risk of having severe influenza or complications is elevated in the following populations:

  • Age < 2 and >65
  • Pregnant women, including 2 weeks postpartum
  • Long term care facility patients

Patients with the following medical conditions are at an elevated risk. This is only enhanced when a patient falls into one of the above populations and has a condition listed below.

  • Asthma
  • CVA
  • COPD
  • Metabolic disorders
  • Heart Disease
  • Diabetes
  • Immunocompromised
  • Obese
  • Liver or Kidney disease

3.Kids and Influenza

Children under the age of 5 are at higher risk of contracting influenza and having a severe case of influenza, while children under 2 and less than 6 months carry the highest risk respectively. Day care, schools and children centric facilities are petri dishes during flu season. The people who care for children are also at high risk for contracting and spreading flu.

4.An Ounce of Prevention is Worth a Pound of Cure

Prevention is the best medicine, yet vaccination rates in the United States remain flat. The mechanisms and systems controlling this are beyond the scope of this article, however as providers, promoting awareness of influenza and prevention techniques is essential. Vaccine technology has improved and this season more options are available to everyone. The following are recommendations from the CDC, first some terminology.

IIV – Inactivated Influenza Vaccine

RIV – Recombinant Influenza Vaccine

RIV4 – Quadrivalent Recombinant Influenza Vaccine

LAIV – Live Attenuated Influenza Vaccine

LAIV4 – Quadrivalent Live Attenuated Influenza Vaccine

Trivalent or IIV3 – Trivalent Inactivated Influenza Vaccine

Quadrivalent vaccines protect against four strains, H1N1, H3N2, B/Victoria and B/Yamagata this season. Trivalent vaccines protect against three H1N1, H3N2 and B/Victoria.

Vaccine Type Vaccine Age Group Grown in Eggs
Quadrivalent IIV4s Fluarix Quadrivalent months

FluLaval Quadrivalent

Fluzone Quadrivalent

 > 6 Months Yes
Quadrivalent IIV4s Afluria Quadrivalent >3 yrs and 18-64 with jet injector Yes
Quadrivalent IIV4s Flucelvax Quadrivalent >4 yrs No
Quadrivalent RIV4 Flublok Quadrivalent >18 yrs Recombinant
Quadrivalent LAIV4 Flumist 2-49 Yes
Trivalent IIV3 Afluria Seqirus >3 yrs No
Trivalent IIV3 Fluad Seqirus, Fluzone High Dose >65 yrs No

5.Who gets what?

Patient Type Recommendation
HealthCare workers and those who live with elderly or young children Annual Vaccination
Age 6 months to 8 years old IIV4 products or LAIV4 0.2ml intranasal for children > 2
Pregnancy IIV or RIV4 may be used. LAIV4 should not be used during pregnancy
Immunocompromised patients LAIV4 not be used for immunocompromised persons 
Age > 65 Fluzone High-Dose (HD-IIV3)
Egg Allergy IIV, RIV4, or LAIV4

6.Treatment and Prevention

Patients who are diagnosed with influenza or require prophylaxis have more options this year. The first group of medications are neuraminidase inhibitors and these protect and treat flu A and B. These include oseltamivir phosphate (Tamiflu), zanamivir (Relenza) and peramivir (Rapivab). A new drug baloxavir (Xofluza) is a RNA transcription inhibitor.

Prophylaxis is warranted in patients who are exposed and present in <48 hours. Patients who present after 48 hours since contact with an influenza-positive patient are treated at the discretion of the provider. An outbreak in a institution (Hospital/LTAC/SNF etc..) warrants prophylaxis treatment of everyone who can tolerate one of the medications below.

Medication Route Indications Age Notes
oseltamivir phosphate (Tamiflu), PO Treatment   Prophylaxis >14 days

>3 months

 Can cause nausea, vomiting and neuropsychiatric events
zanamivir (Relenza) Inhaled Treatment Prophylaxis >7 yrs

> 5 yrs

 Can cause nausea, vomiting, bronchospasm and neuropsychiatric events. Avoid in COPD/Asthma/ILD
peramivir (Rapivab) Intravenous Treatment >2 yrs Can cause diarrhea and neuropsychiatric events
baloxavir (Xofluza) PO Treatment >12 yrs Can cause diarrhea and bronchitis

7.End of Shift

Influenza will affect millions of Americans this year and thousands will succumb. Preparation, vaccination, prophylaxis and hygiene are four pillars of reducing the impact of influenza this season. Armed with information nurses, nurse practitioners, respiratory therapist, paramedics and doctors can lead the charge in prevention and treatment. Now that you have digested an update on the flu season, we hope that you stay healthy until spring and of course avoid the flu!

8.References

Australian Government Department of Health. (2018). Australian Influenza Surveillance Report. Retrieved from: http://www.health.gov.au/

Centers for Disease Control and Prevention. (2018). Influenza. Retrieved from: https://www.cdc.gov/flu/professionals/index.htm

Author:

Jake Weinstein DNP ACNP CCRN CFRN
Chief Nursing Officer
MedEdNow, LLC

Looking for CPR or other Nurse CE Courses?    Take a look at our course library