INFLUENZA (The Flu) What Nurses Should Know Felissa R. Lashley, RN, PhD, FAAN, FACMG Professor,...

INFLUENZA (The Flu)INFLUENZA (The Flu)What Nurses Should KnowWhat Nurses Should Know

Felissa R. Lashley, RN, PhD, FAAN, FACMGFelissa R. Lashley, RN, PhD, FAAN, FACMGProfessor, College of Nursing, andProfessor, College of Nursing, and

Interim Director, Nursing Center for Bioterrorism and Infectious Disease Interim Director, Nursing Center for Bioterrorism and Infectious Disease Preparedness, College of NursingPreparedness, College of Nursing

Rutgers, The State University of New JerseyRutgers, The State University of New Jersey

This module is designed to highlight important information about influenza. The influenza virus, in This module is designed to highlight important information about influenza. The influenza virus, in addition to being the cause of influenza, an important infectious disease, is also considered to be a addition to being the cause of influenza, an important infectious disease, is also considered to be a potential agent for bioterrorism and is considered as a possible Category C bioterrorism agent by the potential agent for bioterrorism and is considered as a possible Category C bioterrorism agent by the Centers for Disease Control and Prevention (CDC). This module was supported in part by USDHHS, Centers for Disease Control and Prevention (CDC). This module was supported in part by USDHHS, HRSA Grant No. T01HP01407. HRSA Grant No. T01HP01407.

Some General PointsSome General Points

The influenza virus is considered to have The influenza virus is considered to have the potential for use as an agent for the potential for use as an agent for bioterrorism, most probably by altering it to bioterrorism, most probably by altering it to a mutated form with greater virulence, a mutated form with greater virulence, infectivity, more efficient human-to-human infectivity, more efficient human-to-human transmission, and antiviral resistance.transmission, and antiviral resistance.

CDC considers it to be a Category C agent CDC considers it to be a Category C agent under others.under others.

Some General Points cont.Some General Points cont. This module is arranged as follows: etiology, This module is arranged as follows: etiology,

epidemiology, transmission, incubation period, epidemiology, transmission, incubation period, overall clinical illness picture, clinical overall clinical illness picture, clinical manifestations, clinical differentiation between manifestations, clinical differentiation between the common cold and flu, complications, the common cold and flu, complications, diagnosis, treatment, management including diagnosis, treatment, management including infection control measures and patient/staff infection control measures and patient/staff education, and prophylaxis and vaccination.education, and prophylaxis and vaccination.

Avian influenza is considered at the end of the Avian influenza is considered at the end of the content before the case studies.content before the case studies.

Case studies, test questions and information Case studies, test questions and information sources appear at the end of the module.sources appear at the end of the module.

ObjectivesObjectives

At the conclusion of this module, the At the conclusion of this module, the

participant should be able to:participant should be able to: Identify the viruses that can cause influenzaIdentify the viruses that can cause influenza Describe signs and symptoms commonly Describe signs and symptoms commonly

associated with influenzaassociated with influenza Identify the major complications of influenzaIdentify the major complications of influenza Describe symptoms that can help differentiate Describe symptoms that can help differentiate

between upper respiratory infection and between upper respiratory infection and influenzainfluenza

Objectives cont.Objectives cont.

Identify antiviral agents in current use for Identify antiviral agents in current use for prevention of influenzaprevention of influenza

Identify antiviral agents in current use for Identify antiviral agents in current use for treatment of influenzatreatment of influenza

Name the groups for whom flu vaccination Name the groups for whom flu vaccination is recommendedis recommended

Describe what is meant by avian influenzaDescribe what is meant by avian influenza

EtiologyEtiology

Influenza viruses types A, B, & C infect humansInfluenza viruses types A, B, & C infect humans Influenza types A & B can cause widespread Influenza types A & B can cause widespread

outbreaksoutbreaks Influenza type A tends to be the most severeInfluenza type A tends to be the most severe Influenza A virus types have most potential for Influenza A virus types have most potential for

use as bioterrorism weaponuse as bioterrorism weapon Influenza viruses are RNA viruses classified in Influenza viruses are RNA viruses classified in

Orthomyxoviridae familyOrthomyxoviridae family Can mutate and cross species barrier such as Can mutate and cross species barrier such as

fowl to humansfowl to humans

Etiology cont.Etiology cont. Influenza subtypes are referred to by their hemagglutinin Influenza subtypes are referred to by their hemagglutinin

(H) and neuraminidase subtypes (N) which are surface (H) and neuraminidase subtypes (N) which are surface glycoproteins of the virusglycoproteins of the virus

Examples: Avian influenza virus subtypes A H5N1 and H9N2 Examples: Avian influenza virus subtypes A H5N1 and H9N2 which appeared recently in Hong Kong and other areaswhich appeared recently in Hong Kong and other areas

Influenza viruses have the ability to develop antigenic Influenza viruses have the ability to develop antigenic variants through viral mutation. Persons develop variants through viral mutation. Persons develop antibodies to specific variants which may not confer antibodies to specific variants which may not confer protection against another. This helps explain why there protection against another. This helps explain why there are seasonal epidemics and provides the basis for are seasonal epidemics and provides the basis for understanding the rationale for what strains of the virus understanding the rationale for what strains of the virus will be used each year in vaccine production.will be used each year in vaccine production.

EpidemiologyEpidemiology

Worldwide distributionWorldwide distribution Outbreaks usually occur suddenlyOutbreaks usually occur suddenly Flu spreads through communities resulting Flu spreads through communities resulting

in an epidemic. Cases tend to peak after in an epidemic. Cases tend to peak after about 3 weeks and begin to subside after about 3 weeks and begin to subside after another 3-4 weeksanother 3-4 weeks

Epidemiology cont.Epidemiology cont.-2-2

Have been several great Have been several great influenza pandemics:influenza pandemics: 1918-19 “Spanish” flu1918-19 “Spanish” flu

Caused 20-40 million deaths Caused 20-40 million deaths worldwideworldwide

A large proportion of these A large proportion of these deaths was in healthy adults 15 deaths was in healthy adults 15 to 35 years of ageto 35 years of age

1957 “Asian” flu1957 “Asian” flu 1968 “Hong Kong” flu1968 “Hong Kong” flu 1977 H1N1 influenza A virus 1977 H1N1 influenza A virus

subtype, “Russian” flusubtype, “Russian” flu

Epidemiology cont.Epidemiology cont.-3-3

Peak season is November through MarchPeak season is November through March Each year about 10 to 20% of Americans Each year about 10 to 20% of Americans

develop influenzadevelop influenza In the US, approximately 100,000 people In the US, approximately 100,000 people

are hospitalized with influenza each year, are hospitalized with influenza each year, and about 36,000 dieand about 36,000 die

TransmissionTransmission

Major transmission route is through airborne Major transmission route is through airborne large respiratory droplets with particles larger large respiratory droplets with particles larger than 5 microns (μ) in diameter that are expelled than 5 microns (μ) in diameter that are expelled from the respiratory tract of an infected person from the respiratory tract of an infected person when they cough or sneezewhen they cough or sneeze

Direct contact with fomites (inanimate objects) Direct contact with fomites (inanimate objects) contaminated with infected droplets or contaminated with infected droplets or secretions and then touching ones nose or secretions and then touching ones nose or mouthmouth

Transmission from infected birds, poultry or pigs Transmission from infected birds, poultry or pigs (less common) (less common)

Incubation PeriodIncubation Period

1 to 4 days with average of 2 days1 to 4 days with average of 2 days Adults are infectious from day before Adults are infectious from day before

symptoms begin through about 5 days symptoms begin through about 5 days after onset; children can be infectious for after onset; children can be infectious for 10 or more days after onset and those 10 or more days after onset and those who are immunosuppressed can shed who are immunosuppressed can shed virus for weeks or even months.virus for weeks or even months.

Overall Clinical Illness PictureOverall Clinical Illness Picture Influenza infection can run a spectrum from Influenza infection can run a spectrum from

asymptomatic or mild illness through fulminant primary asymptomatic or mild illness through fulminant primary viral pneumoniaviral pneumonia

For most uncomplicated cases, influenza resolves For most uncomplicated cases, influenza resolves spontaneously in a few days but cough and malaise often spontaneously in a few days but cough and malaise often last 2 weeks or morelast 2 weeks or more

Major clinical pictures:Major clinical pictures: RhinotracheobronchitisRhinotracheobronchitis Primary viral pneumoniaPrimary viral pneumonia Respiratory viral infection followed by secondary bacterial Respiratory viral infection followed by secondary bacterial

pneumoniapneumonia There is no “stomach” flu - these manifestations are from other There is no “stomach” flu - these manifestations are from other

disordersdisorders

Major influences on clinical illness Major influences on clinical illness development and complications of influenzadevelopment and complications of influenza

AgeAge - elderly (over 65 years of age) and young children particularly - elderly (over 65 years of age) and young children particularly younger than 5 years of age and especially those 6 to 23 months younger than 5 years of age and especially those 6 to 23 months are particularly vulnerableare particularly vulnerable

Presence of other chronic underlying illnessesPresence of other chronic underlying illnesses such as chronic such as chronic cardiac or pulmonary diseasecardiac or pulmonary disease

Compromised immune statusCompromised immune status such as from immunosuppressive such as from immunosuppressive drugs, or conditions such as malnutrition or pregnancydrugs, or conditions such as malnutrition or pregnancy

Lack of access to health careLack of access to health care Crowded living conditionsCrowded living conditions that facilitate transfer of respiratory that facilitate transfer of respiratory

pathogens that can include congregate and institutional settings pathogens that can include congregate and institutional settings especially if precautions such as respiratory hygiene dn cough especially if precautions such as respiratory hygiene dn cough ettiquette are not observedettiquette are not observed

Health care workers may be at higher riskHealth care workers may be at higher risk for transmission for transmission

Clinical ManifestationsClinical Manifestations Abrupt onset of constitutional Abrupt onset of constitutional

and respiratory symptomsand respiratory symptoms Fever, duration typically 1 to 5 Fever, duration typically 1 to 5

days, with an average of 3 days, with an average of 3 days and peak within 12 hours days and peak within 12 hours after symptoms. Typical after symptoms. Typical temperatures are 38 to 40 deg. temperatures are 38 to 40 deg. C.C.

MyalgiaMyalgia HeadacheHeadache ChillsChills Cough, usually unproductiveCough, usually unproductive Sore throatSore throat

MalaiseMalaise RhinitisRhinitis May have eye tearing, burning, May have eye tearing, burning,

photophobia or eye painphotophobia or eye pain Children may have otitis media Children may have otitis media

and nausea and vomiting as and nausea and vomiting as wellwell as febrile convulsions as febrile convulsions in addition to other symptomsin addition to other symptoms

Elderly persons may present Elderly persons may present with minimal respiratory with minimal respiratory symptoms but show lassitude, symptoms but show lassitude, high fever and confusionhigh fever and confusion

Respiratory symptoms may Respiratory symptoms may increase as fever decreasesincrease as fever decreases

Clinical Differentiation Between the Common Cold Clinical Differentiation Between the Common Cold

and the Fluand the Flu (see Table 1 at end of module)(see Table 1 at end of module)

The following symptoms The following symptoms are more commonly seen are more commonly seen in influenza rather than in influenza rather than the common cold:the common cold:

High fever lasting 3 to 4 High fever lasting 3 to 4 daysdays

HeadacheHeadache Myalgia Myalgia Fatigue and weaknessFatigue and weakness Extreme exhaustionExtreme exhaustion Severe chest discomfort Severe chest discomfort

and coughand cough

The following symptoms The following symptoms are more commonly seen are more commonly seen in the common cold in the common cold rather than influenza:rather than influenza:

Stuffy nose is commonStuffy nose is common Sneezing is commonSneezing is common Cough is generally mild to Cough is generally mild to

moderatemoderate Symptoms such as fever, Symptoms such as fever,

headache, aches and headache, aches and pains and exhaustion are pains and exhaustion are rare in those with colds.rare in those with colds.

Complications may be respiratory Complications may be respiratory or non-respiratory or bothor non-respiratory or both

Major respiratory complications includeMajor respiratory complications include:: Primary viral pneumoniaPrimary viral pneumonia

Occurs most frequently in elderly or persons with Occurs most frequently in elderly or persons with cardiopulmonary diseasecardiopulmonary disease

Can occur in healthy immunocompetent persons or pregnant Can occur in healthy immunocompetent persons or pregnant womenwomen

Usually develops rapidly, within 1 day or onset of illnessUsually develops rapidly, within 1 day or onset of illness Symptoms include rapidly progressing fever, tachypnea, Symptoms include rapidly progressing fever, tachypnea,

tachycardia, cyanosis and hypotensiontachycardia, cyanosis and hypotension Signs include bilateral crepitant rales on chest examination, Signs include bilateral crepitant rales on chest examination,

chest x-rays showing nonconsolidating pulmonary infiltrates, but chest x-rays showing nonconsolidating pulmonary infiltrates, but sometimes areas of consolidation, blood gas studies show sometimes areas of consolidation, blood gas studies show hypoxemia, blood counts may show leukocytosis with a left shifthypoxemia, blood counts may show leukocytosis with a left shift

Mortality is high, and extensive fibrosis and interstitial Mortality is high, and extensive fibrosis and interstitial inflammation may developinflammation may develop

Complications cont.Complications cont.-2-2

Secondary bacterial pneumoniaSecondary bacterial pneumonia Occurs most frequently in elderly or persons with Occurs most frequently in elderly or persons with

pulmonary diseasepulmonary disease Typical course of influenza illness seems to be Typical course of influenza illness seems to be

improving but fever with shaking chills returns, improving but fever with shaking chills returns, pleuritic-type chest pain, productive cough with bloody pleuritic-type chest pain, productive cough with bloody or purulent sputumor purulent sputum

Signs include local areas of lung consolidation on Signs include local areas of lung consolidation on chest X-ray, sputum culture and Gram stain may chest X-ray, sputum culture and Gram stain may reveal predominance of bacterial pathogen, most reveal predominance of bacterial pathogen, most commonly commonly StreptococcusStreptococcus pneumoniaepneumoniae, , StaphylococcusStaphylococcus aureusaureus, , HaemophilusHaemophilus influenzaeinfluenzae, or , or MoraxellaMoraxella catarrhaliscatarrhalis

Mortality can approach 7%Mortality can approach 7%


Combined bacterial-viral pneumoniaCombined bacterial-viral pneumonia Coinfection can yield varying symptoms which Coinfection can yield varying symptoms which

may be like primary viral pneumonia at firstmay be like primary viral pneumonia at first Coinfection with Coinfection with S.S. aureusaureus may carry a may carry a

particularly high mortality rateparticularly high mortality rate Exacerbation of chronic pulmonary Exacerbation of chronic pulmonary

disease such as asthma or in persons disease such as asthma or in persons with cystic fibrosiswith cystic fibrosis


Major non-respiratory complications include:Major non-respiratory complications include:

Cardiac complications particularly electrocardiographic Cardiac complications particularly electrocardiographic abnormalities and myocarditis abnormalities and myocarditis

Central nervous system complications such as seizures, especially Central nervous system complications such as seizures, especially in children, and acute encephalitis in children, and acute encephalitis

Reye’s syndrome, a neurologic and metabolic disorder occuring Reye’s syndrome, a neurologic and metabolic disorder occuring mainly in children and adolescents from 2 to 16 years of age. It mainly in children and adolescents from 2 to 16 years of age. It appears more closely associated with influenza B than influenza A appears more closely associated with influenza B than influenza A and has a mortality rate of 10% to 40%. Not prescribing aspirin for and has a mortality rate of 10% to 40%. Not prescribing aspirin for patients, especially children and adolescents with viral infections patients, especially children and adolescents with viral infections has decreased the incidence of Reye’s syndrome.has decreased the incidence of Reye’s syndrome.

Myositis may occur primarily in children and particularly after Myositis may occur primarily in children and particularly after influenza B along with myoglobinuria and rhabdomyolysis leading to influenza B along with myoglobinuria and rhabdomyolysis leading to acute renal failure.acute renal failure.

DiagnosisDiagnosis Important to make diagnosis as quickly as possibleImportant to make diagnosis as quickly as possible Facilitated by community surveillance knowledge about Facilitated by community surveillance knowledge about

influenza outbreak patterns in the communityinfluenza outbreak patterns in the community May be made on basis of clinical signs and symptoms May be made on basis of clinical signs and symptoms

along with knowledge about influenza patterns in the along with knowledge about influenza patterns in the community. Thus in the setting of a confirmed influenza community. Thus in the setting of a confirmed influenza outbreak in a given community, persons who are not outbreak in a given community, persons who are not residents of institutions and who have muscle aches, residents of institutions and who have muscle aches, fever and two respiratory symptoms probably have fever and two respiratory symptoms probably have influenza according to Shorman & Moorman, (2003). influenza according to Shorman & Moorman, (2003).

Diagnosis cont.Diagnosis cont.

Laboratory diagnostic methods include:Laboratory diagnostic methods include: Viral culture (need expert technicians and Viral culture (need expert technicians and

time but excellent specificity and time but excellent specificity and sensitivity), reverse transcriptase sensitivity), reverse transcriptase polymerase chain reaction (labor-polymerase chain reaction (labor-intensive, costly but quick with excellent intensive, costly but quick with excellent specificity and sensitivity), serology, rapid specificity and sensitivity), serology, rapid antigen testing, and immunofluroescence antigen testing, and immunofluroescence assays.assays.

Treatment Treatment (this is not comprehensive and is not (this is not comprehensive and is not meant as recommendations)meant as recommendations)

Certain antiviral agents may be usedCertain antiviral agents may be used Newer antiviral agents include zanamivir and oseltamivir (Tamiflu). Both are Newer antiviral agents include zanamivir and oseltamivir (Tamiflu). Both are

effective against influenza A and influenza B. These also need to be effective against influenza A and influenza B. These also need to be administered within the first 48 hours of symptoms. Both are category C administered within the first 48 hours of symptoms. Both are category C agents in pregnancy and there is a risk for adverse effects in those with agents in pregnancy and there is a risk for adverse effects in those with underlying respiratory disease. It is administered via oral inhalation. underlying respiratory disease. It is administered via oral inhalation. Oseltamivir may result in nausea and vomiting side effects so needs to be Oseltamivir may result in nausea and vomiting side effects so needs to be taken with food. It is administered orally. Transient neuropsychiatric events taken with food. It is administered orally. Transient neuropsychiatric events have been described in adolescents and some adults taking oseltamivir. have been described in adolescents and some adults taking oseltamivir. These two agents were the only ones licensed for flu prevention and These two agents were the only ones licensed for flu prevention and treatment in 2008.treatment in 2008.

Management including Infection Management including Infection Control MeasuresControl Measures

Management includes:Management includes: Symptomatic treatment such as encouraging Symptomatic treatment such as encouraging

fluids and rest; the treatment of symptoms with fluids and rest; the treatment of symptoms with over-the-counter medications but not aspirin in over-the-counter medications but not aspirin in children or adolescentschildren or adolescents

Comfort measuresComfort measures Specific management approaches depend upon Specific management approaches depend upon

symptoms, complications and characteristics symptoms, complications and characteristics and condition of the individual patientand condition of the individual patient

Management including Infection Management including Infection Control Measures cont.Control Measures cont.-2-2

Infection Control MeasuresInfection Control Measures Appropriate prophylaxis and immunization is an important part and is Appropriate prophylaxis and immunization is an important part and is

discussed belowdiscussed below Respiratory hygiene and cough etiquette programs are now a part of Respiratory hygiene and cough etiquette programs are now a part of

standard precautionsstandard precautions Initiate at first point of contact with even a potentially infected personInitiate at first point of contact with even a potentially infected person Includes education which may be visual and\or verbal at an appropriate Includes education which may be visual and\or verbal at an appropriate

educational level with cultural considerations of patients and the people who educational level with cultural considerations of patients and the people who accompany them accompany them

Should include informing personnel if they have any symptoms of respiratory Should include informing personnel if they have any symptoms of respiratory infection, having tissues provided to patients and visitors, throw tissues away infection, having tissues provided to patients and visitors, throw tissues away after use in proper container, instructing them to cover their mouth and nose after use in proper container, instructing them to cover their mouth and nose when coughing or sneezing, providing alcohol based hand rubbing dispensers when coughing or sneezing, providing alcohol based hand rubbing dispensers and supplies for handwashing and educating patients and staff in their use, and supplies for handwashing and educating patients and staff in their use, encourage handwashing after coughing or sneezing, offering masks to persons encourage handwashing after coughing or sneezing, offering masks to persons who are coughing, encouraging coughing persons to sit at least 3 feet away from who are coughing, encouraging coughing persons to sit at least 3 feet away from others, instruct patients and providers not to touch eyes, nose or mouth and have others, instruct patients and providers not to touch eyes, nose or mouth and have health care personnel observe Droplet Precautions in addition to Standard health care personnel observe Droplet Precautions in addition to Standard Precautions. Health care workers should use standard precautions with all Precautions. Health care workers should use standard precautions with all patients.patients.


Infection Control Measures cont.Infection Control Measures cont. Standard Precautions are detailed in a Standard Precautions are detailed in a

separate moduleseparate module Droplet Precautions are detailed in a Droplet Precautions are detailed in a

separate moduleseparate module


Persons with respiratory infection symptoms should not visit Persons with respiratory infection symptoms should not visit patientspatients

Health care workers with respiratory infection symptoms should Health care workers with respiratory infection symptoms should be excluded from work for the duration of the illnessbe excluded from work for the duration of the illness

In health care settings, influenza testing should be done early In health care settings, influenza testing should be done early in the outbreak to obtain the type and subtype of virus in the outbreak to obtain the type and subtype of virus responsibleresponsible

Droplet Precautions with suspected or confirmed influenza Droplet Precautions with suspected or confirmed influenza should be implemented and authority to do so should be should be implemented and authority to do so should be decided with nursing staff inclusiondecided with nursing staff inclusion

As detailed further under Droplet Precautions, suspected or As detailed further under Droplet Precautions, suspected or confirmed influenza patients should be separated from confirmed influenza patients should be separated from asymptomatic patients asymptomatic patients


Health care staff movement between units and buildings Health care staff movement between units and buildings should be restrictedshould be restricted

In a setting or unit with influenza, patients without influenza In a setting or unit with influenza, patients without influenza should receive influenza antiviral prophylaxis unless should receive influenza antiviral prophylaxis unless contraindicatedcontraindicated

Influenza antiviral therapy should be administered to those Influenza antiviral therapy should be administered to those who are acutely ill with influenza within 48 hours of onset of who are acutely ill with influenza within 48 hours of onset of illness unless contraindicatedillness unless contraindicated

Current inactivated influenza vaccine should be administered Current inactivated influenza vaccine should be administered to unvaccinated patients and health care personnel if not to unvaccinated patients and health care personnel if not contraindicatedcontraindicated

Influenza antirviral prophylaxis should be offered to Influenza antirviral prophylaxis should be offered to unvaccinated personnel for who it is not contraindicated and unvaccinated personnel for who it is not contraindicated and who work in the affected unit or who are caring for high-risk who work in the affected unit or who are caring for high-risk patientspatients


Limit or eliminate elective medical and surgical Limit or eliminate elective medical and surgical admissions and restrict cardiovascular and admissions and restrict cardiovascular and pulmonary surgery to emergency cases only pulmonary surgery to emergency cases only when influenza outbreaks especially those when influenza outbreaks especially those characterized by high attack rates and severe characterized by high attack rates and severe illness, occur in the community or acute care illness, occur in the community or acute care facilityfacility

Recommendations for peri-and post-partum Recommendations for peri-and post-partum settings may be found at settings may be found at http://www.cdc.gov/flu/professionals/peripostpartumguid.htm

Prophylaxis and VaccinationProphylaxis and Vaccination

Antiviral agents may be used for prophylaxis, Antiviral agents may be used for prophylaxis,

often in combination with the flu vaccine in an often in combination with the flu vaccine in an

outbreak situationoutbreak situation Drugs used most often in the U.S. for prevention Drugs used most often in the U.S. for prevention

of flu are zanamivir and oseltamivir and are used of flu are zanamivir and oseltamivir and are used particularly for those at high risk for particularly for those at high risk for complications from the flu or to prevent a person complications from the flu or to prevent a person in close proximity from passing the flu to a high in close proximity from passing the flu to a high risk personrisk person

Prophylaxis and Vaccination Prophylaxis and Vaccination cont.cont.-2-2

Influenza vaccineInfluenza vaccine Current vaccines are inactivated influenza vacine Current vaccines are inactivated influenza vacine

administered by injection (Fluzone) and live attenuated, administered by injection (Fluzone) and live attenuated, intranasal vaccine (FluMist)intranasal vaccine (FluMist)

In late July, 2008, the Advisory Committee in In late July, 2008, the Advisory Committee in Immunization Practices (ACIP) issued their updated Immunization Practices (ACIP) issued their updated recommendations on prevention and control of influenza. recommendations on prevention and control of influenza. The entire document is in Morbidity and Mortality The entire document is in Morbidity and Mortality Weekly Reports, Recommendations and Reports, 57 Weekly Reports, Recommendations and Reports, 57 (early release) , 1-60, July 17, 2008(early release) , 1-60, July 17, 2008

Prophylaxis and Vaccination cont.Prophylaxis and Vaccination cont.-3-3

Recommendations for 2008-2009 Influenza season are given Recommendations for 2008-2009 Influenza season are given belowbelow

It is recommended that all children aged 5-18 years old receive It is recommended that all children aged 5-18 years old receive vaccination .vaccination .

Children younger that 6 months should not be vaccinated.Children younger that 6 months should not be vaccinated. Children and adolescents at higher risk for influenza complication Children and adolescents at higher risk for influenza complication

are those:are those: aged 6 months – 4 years;aged 6 months – 4 years; who have chronic pulmonary (including asthma), cardiovascular (except who have chronic pulmonary (including asthma), cardiovascular (except

hypertension), renal, hepatic, hematological or metabolic disorders (including hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus);diabetes mellitus);

who are immunosuppressed (including immuno-suppresion caused my who are immunosuppressed (including immuno-suppresion caused my dedications or by human immunodeficiency virus);dedications or by human immunodeficiency virus);

who have any condition (e.g., cognitive dysfuction, spinal cord injuries, seizure who have any condition (e.g., cognitive dysfuction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for function or the handling of respiratory secretions or that can increase the risk for aspiration;aspiration;

who are receiving long-term aspirin therapy who therefore might be at risk for who are receiving long-term aspirin therapy who therefore might be at risk for experiencing Reye syndrome after influenza virus infection;experiencing Reye syndrome after influenza virus infection;

who are residents of chronic-care facilities; and,who are residents of chronic-care facilities; and, who will be pregnant during the influenza season.who will be pregnant during the influenza season.Source: CDC, MMWR 57, 2008 pg 2Source: CDC, MMWR 57, 2008 pg 2

Prophylaxis and Vaccination cont.Prophylaxis and Vaccination cont.-4-4

For adults for the 2008-2009 flu season recommendations are For adults for the 2008-2009 flu season recommendations are for any adult and for and for all adults in the following groups for any adult and for and for all adults in the following groups because of higher risk:because of higher risk:•Persons aged >= 50 years;Persons aged >= 50 years;•Women who will be pregnant during the influenza season;Women who will be pregnant during the influenza season;•Persons who have chronic pulmonary (including asthma), cardiovascular (except Persons who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus);mellitus);•Persons who have immunosuppressions (including immunosuppression caused by Persons who have immunosuppressions (including immunosuppression caused by medications or by human immunodeficiency virus);medications or by human immunodeficiency virus);•Persons who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure Persons who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the disorders, or other neuromuscular disorders) that can compromise respiratory function or the handlig of respiratory secretions or that can increase the risk for aspiration;handlig of respiratory secretions or that can increase the risk for aspiration;•Residents of nursing homes and other chronic-care facilities;Residents of nursing homes and other chronic-care facilities;•Health-care personnel;Health-care personnel;•Household contracts and caregivers of children aged <5 years and adults aged >= 50 years, Household contracts and caregivers of children aged <5 years and adults aged >= 50 years, with particular emphasis on vaccinating contracts of children aged <6 months; and,with particular emphasis on vaccinating contracts of children aged <6 months; and,•Households contracts and caregivers of persons with medical conditions that put them athigh Households contracts and caregivers of persons with medical conditions that put them athigh risk for severe complication from influenza.risk for severe complication from influenza.Source: CDC, MMWR 57, 2008 pg 2

Nasal Spray VaccineNasal Spray Vaccine Live, attenuated vaccine administered by nasal Live, attenuated vaccine administered by nasal

sprayspray Option for those healthy people ages 2 to 49 Option for those healthy people ages 2 to 49

years oldyears old Option for health care workers who take care of Option for health care workers who take care of

sick persons or care for babies under 6 months sick persons or care for babies under 6 months of age and who are healthy between 2 and 49 of age and who are healthy between 2 and 49 years of ageyears of age

Not to be used in pregnancyNot to be used in pregnancy Not to be used by those who care for or live with Not to be used by those who care for or live with

someone with a compromised immune system someone with a compromised immune system or children less than 2 years of ageor children less than 2 years of age

Table 1. Is It a Cold or the Flu?Table 1. Is It a Cold or the Flu?Source: National Institute of Allergy and Infectious DiseasesSource: National Institute of Allergy and Infectious Diseases

SymptomsSymptoms ColdCold FluFlu

FeverFever RareRare Characteristic; high (102-104 Characteristic; high (102-104 deg. F): lasts 3-4 daysdeg. F): lasts 3-4 days

HeadacheHeadache RareRare ProminentProminent

General Aches, PainsGeneral Aches, Pains SlightSlight Usual; often severeUsual; often severe

Fatigue, WeaknessFatigue, Weakness Quite mildQuite mild Can last up to 2-3 weeksCan last up to 2-3 weeks

Extreme ExhaustionExtreme Exhaustion NeverNever Early and prominentEarly and prominent

Stuffy NoseStuffy Nose CommonCommon SometimesSometimes

SneezingSneezing UsualUsual SometimesSometimes

Sore ThroatSore Throat CommonCommon SometimesSometimes

Chest Discomfort, CoughChest Discomfort, Cough Mild to moderate, Mild to moderate, hacking coughhacking cough

Common; can become Common; can become severesevere

Special Notes on Avian InfluenzaSpecial Notes on Avian Influenza

Avian influenza viruses refers to those that are carried by Avian influenza viruses refers to those that are carried by birds, usually wild birds that when infected, shed virus in birds, usually wild birds that when infected, shed virus in saliva, nasal secretions and feces. Birds or fowl become saliva, nasal secretions and feces. Birds or fowl become infected when they come into contact with secretions or infected when they come into contact with secretions or excretions from infected birds most often through fecal-excretions from infected birds most often through fecal-oral transmission. Transmission also occurs through oral transmission. Transmission also occurs through contact with surfaces or materials such as feed, water, contact with surfaces or materials such as feed, water, cages or dirt that are contaminated with the virus. cages or dirt that are contaminated with the virus. Contaminated cages, for example, can carry the virus Contaminated cages, for example, can carry the virus from one place to another.from one place to another.

Avian influenza viruses vary in their degree of Avian influenza viruses vary in their degree of pathogenicitypathogenicity

""Hong KongHong Kong"" Flu Flu

First documented direct transmission of an avian influenza First documented direct transmission of an avian influenza (influenza A) virus (H5N1) to humans occurred in 1997 (influenza A) virus (H5N1) to humans occurred in 1997 in Hong Kongin Hong Kong

Severe respiratory disease occurred in 18 healthy young Severe respiratory disease occurred in 18 healthy young adults and children and 6 diedadults and children and 6 died

The outbreak was controlled by slaughter of the poultry The outbreak was controlled by slaughter of the poultry population. More than 1.2 million chickens and 0.3 population. More than 1.2 million chickens and 0.3 million other poultry were killed and imports of chickens million other poultry were killed and imports of chickens from Hong Kong and China were banned by other from Hong Kong and China were banned by other countries. Quarantine and depopulation or culling of countries. Quarantine and depopulation or culling of birds are common ways of control for the outbreakbirds are common ways of control for the outbreak

""Hong KongHong Kong"" Flu Flu-2-2

Live poultry markets were source of the avian Live poultry markets were source of the avian influenza virus strain H5N1 in this outbreak. In influenza virus strain H5N1 in this outbreak. In both influenza and SARS, the so-called “wet-both influenza and SARS, the so-called “wet-markets” have been implicated as sources. This markets” have been implicated as sources. This illustrates a cultural influence on emergence of illustrates a cultural influence on emergence of infectious diseases since the preference of infectious diseases since the preference of many Asian people for buying fresh foods at many Asian people for buying fresh foods at these markets have resulted in an increase in these markets have resulted in an increase in these types of markets. In New York City, these these types of markets. In New York City, these increased in number from 44 in 1994 to 80 in increased in number from 44 in 1994 to 80 in 2002.2002.

Additional Recent Avian Flu Additional Recent Avian Flu OutbreaksOutbreaks

In 1999, avian influenza viruses, H9N2, In 1999, avian influenza viruses, H9N2, were isolated in Hong Kong from children were isolated in Hong Kong from children with mild influenzawith mild influenza

In 2003, the avian influenza virus strain, In 2003, the avian influenza virus strain, H5N1, again emerged in 2 family H5N1, again emerged in 2 family members in Hong Kong after traveling in members in Hong Kong after traveling in China. One died.China. One died.

Additional Recent Avian Flu Additional Recent Avian Flu OutbreaksOutbreaks-2-2

In 2003, the avian influenza virus strain H7N7 In 2003, the avian influenza virus strain H7N7 occurred in poultry farms in the Netherlands, occurred in poultry farms in the Netherlands, spreading to Germany and Belgium. Infection, spreading to Germany and Belgium. Infection, mainly conjunctivitis occurred in 83 humans with mainly conjunctivitis occurred in 83 humans with 1 death. The outbreak was controlled by 1 death. The outbreak was controlled by destroying over 30 million domestic poultrydestroying over 30 million domestic poultry

In 2003, the avian influenza virus, H9N2 was In 2003, the avian influenza virus, H9N2 was identified in a child in Hong Kong with influenza identified in a child in Hong Kong with influenza who recoveredwho recovered


In 2003, an outbreak of avian influenza virus, In 2003, an outbreak of avian influenza virus, H5N1, occurred in South Korea, and in 2004 H5N1, occurred in South Korea, and in 2004 emerged in Vietnam and Thailand. Human emerged in Vietnam and Thailand. Human cases presented with severe respiratory cases presented with severe respiratory infection and out of 23 known and confirmed infection and out of 23 known and confirmed cases, 18 died. Many countries banned the cases, 18 died. Many countries banned the import of poultry products from the Asian import of poultry products from the Asian countries affected. Other countries in which countries affected. Other countries in which poultry were infected included Japan, Laos, poultry were infected included Japan, Laos, China, Cambodia, and Indonesia.China, Cambodia, and Indonesia.


In 2004, an outbreak of avian influenza, H7N7 In 2004, an outbreak of avian influenza, H7N7 occurred in British Columbia, Canada. Infection occurred in British Columbia, Canada. Infection has been reported in 5 humans whose major has been reported in 5 humans whose major illness was conjunctivitis.illness was conjunctivitis.

In 2004-2005, east Asia again saw an outbreak In 2004-2005, east Asia again saw an outbreak of H5N1, particularly in Thailand, Cambodia, and of H5N1, particularly in Thailand, Cambodia, and Vietnam.Vietnam.

By June 19, 2008, there were 385 reported By June 19, 2008, there were 385 reported human cases of avian flu and 243 reported human cases of avian flu and 243 reported deaths.deaths.

Concern about pandemic flu has resulted in Concern about pandemic flu has resulted in global efforts at prevention.global efforts at prevention.

Documented human-to-human transmission of H5N1 Documented human-to-human transmission of H5N1 has been noted but is limited. Of concern is that the has been noted but is limited. Of concern is that the

virus could mutate to allow sustained person-to-virus could mutate to allow sustained person-to-person transmission.person transmission.

Transmission includes:Transmission includes: Direct exposure to Direct exposure to

infected birds/poultryinfected birds/poultry Exposure to surfaces Exposure to surfaces

contaminated with contaminated with infected bird/poultry infected bird/poultry excretions, mostly excretions, mostly through fecal-oral through fecal-oral transmissiontransmission

Rare human-to-human Rare human-to-human transmissiontransmission

SymptomsSymptoms Fever, over 38 deg. C or Fever, over 38 deg. C or

100.4 deg. F100.4 deg. F Shortness of breathShortness of breath CoughCough DiarrheaDiarrhea

Suspecting Avian Influenza (H5N1)Suspecting Avian Influenza (H5N1)

Laboratory testing should be prompted for a hospitalized Laboratory testing should be prompted for a hospitalized or ambulatory patient with or ambulatory patient with

temperature over 38 deg. C AND temperature over 38 deg. C AND with any one or more of the above symptoms AND with any one or more of the above symptoms AND a history of contact with domestic poultry such as a visit to a a history of contact with domestic poultry such as a visit to a

poultry farm or bird marketpoultry farm or bird market Laboratory testing should be prompted for hospitalized Laboratory testing should be prompted for hospitalized

patients patients with radiologically confirmed acute respiratory distress with radiologically confirmed acute respiratory distress

syndrome, pneumonia or other severe respiratory illness for syndrome, pneumonia or other severe respiratory illness for which an alternate diagnosis has not been established ANDwhich an alternate diagnosis has not been established AND

history of travel to an area with documented H5N1 avian history of travel to an area with documented H5N1 avian influenza within 10 days of the beginnings of symptoms.influenza within 10 days of the beginnings of symptoms.

Isolation PrecautionsIsolation Precautions

For hospitalized patients who have or are For hospitalized patients who have or are suspected of having avian influenza A suspected of having avian influenza A (H5N1), isolation precautions are same as (H5N1), isolation precautions are same as for severe acute respiratory syndrome for severe acute respiratory syndrome (SARS). These include:(SARS). These include: Careful hand hygiene before and after all Careful hand hygiene before and after all

patient contactpatient contact Use gloves and gown for all patient contactUse gloves and gown for all patient contact Wear eye protection when within 3 feet (and Wear eye protection when within 3 feet (and

perhaps 6 feet) of the patientperhaps 6 feet) of the patient

Isolation PrecautionsIsolation Precautions-2-2

Place patient in an airborne infection isolation room (AIIR).Place patient in an airborne infection isolation room (AIIR). When entering the patientWhen entering the patient''s room, use a fit tested respirator at s room, use a fit tested respirator at

least as protective as an N95 filtering-facepiece respirator least as protective as an N95 filtering-facepiece respirator approved by the National Institute for Occupational Health and approved by the National Institute for Occupational Health and Safety (NIOSH)Safety (NIOSH)

Outpatients or hospitalized patients discharged in less than 14 Outpatients or hospitalized patients discharged in less than 14 days should be isolated in the home setting on the basis of days should be isolated in the home setting on the basis of principles for home isolation of SARS patientsprinciples for home isolation of SARS patients

These precautions should be continued for 14 days after These precautions should be continued for 14 days after onset of symptoms until an alternative diagnosis is onset of symptoms until an alternative diagnosis is established or diagnostic test results indicate that the established or diagnostic test results indicate that the patient is not infected with inflenza A virus (CDC, 2004). patient is not infected with inflenza A virus (CDC, 2004). Also see: Also see: http://www.cdc.gov/flu/avian/index.htm, and , and http://www.cdc.gov/ncidod/dhgp/pdf/isolation2007.pdf

INFLUENZA (The Flu) What Nurses Should Know Felissa R. Lashley, RN, PhD, FAAN, FACMG Professor,...

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Transcript of INFLUENZA (The Flu) What Nurses Should Know Felissa R. Lashley, RN, PhD, FAAN, FACMG Professor,...