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.
While manufacturers mass-produce vaccine, 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 then 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 other 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.
- Metabolic disorders
- Heart Disease
- 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
|> 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|
|Trivalent IIV3||Afluria Seqirus||>3 yrs||No|
|Trivalent IIV3||Fluad Seqirus, Fluzone High Dose||>65 yrs||No|
5.Who gets what?
|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.
|oseltamivir phosphate (Tamiflu),||PO||Treatment Prophylaxis||>14 days
|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!
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
Jake Weinstein DNP ACNP CCRN CFRN
Chief Nursing Officer