It never fails — you waited all year for a special holiday party, and the day of the party, you feel chills, a headache, and a scratchy sore throat. Your next thought: Why didn’t I get that flu vaccine?

Each year, individuals, families and communities are affected by seasonal influenza. Although often taken lightly, the “flu” can be a deadly disease. In 2009, the H1N1 flu pandemic was one of the worst in over 40 years and responsible for more than 12,000 deaths in the United States. In 2010, although less severe, the influenza season had substantial negative health effects on every single age group. This flu season, it’s expected that three viruses will find their way to your community: the H1N1 virus, the H3N2 virus, and an influenza B Brisbane-like virus.

The Centers for Disease Control and Prevention (CDC) has established a pre-holiday campaign entitled “The Flu Ends with U,” declaring December 4-10, 2011 as National Influenza Vaccination Week. As nurses we are active participants in the battle against seasonal influenza, organizing vaccination clinics and educating the public about emerging influenza. We quell the public’s fear of global outbreaks by answering questions and reporting facts about the virus, its spread and how to protect and prevent complications. This article focuses primarily on the CDC’s recommendations for vaccination, changes in universal protection — including the new Fluzone intradermal (ID) vaccine — disease symptoms, diagnosis, complications, and the CDC’s “Take 3” strategies for prevention and treatment.

Vaccines for (nearly) everyone

The CDC changed its recommendations for seasonal influenza vaccination. In the past, vaccination efforts have been geared to high-risk persons, including pregnant women, young children, people with chronic health conditions like asthma, diabetes or heart and lung disease, and people 65 years and older. As in the past, high-risk individuals include those living in nursing homes or long-term care facilities as well as healthcare workers.

The CDC now recommends that everyone 6 months and older get a vaccine as soon as it is available. Complications of the flu in infants that are less than 6 months are higher than in any other child age group. This presents a dilemma. Currently, no flu vaccine is available for children younger than 6 months of age. Instead, the CDC warns that parents should protect infants by making sure that members of their household and their caregivers are indeed vaccinated.

Cough, chills, and more

Influenza is a contagious viral disease. For this reason schools and people confined to close living quarters such as those in dormitories and nursing homes, are particularly vulnerable to its spread. Usually, the onset of the flu is sudden. The most common symptoms are:

• Headache, fever, chills
• Scratchy sore throat
• Nasal congestion
• Cough
• Feeling tired, run down
• Vomiting and diarrhea, particularly common in children
• Normal white blood cell count (an elevated WBC could indicate a bacterial infection)

Testing, testing

Differentiating bacterial from viral infection is essential to ensure proper treatment. The symptoms of bacterial and viral illness may overlap but isolating the virus by the use of diagnostic testing is good practice. Diagnostic tests available for influenza include viral culture, serology, rapid antigen testing, polymerase chain reaction (PCR), and immunofluorescence assays. Specimens may be obtained from the throat or nose. In outpatient settings, the use of rapid diagnostic tests can assist in detecting viruses in about 15 minutes.

Complications

The most life-threatening complication of the flu, especially for the elderly, is pneumonia. Pneumonia caused by a virus will produce clear mucus. Bacterial pneumonia presents with thick yellow or green colored mucus.

The cough is also different. Viral pneumonia produces a cough that is be dry or has small amounts of clear mucus, but the cough associated with bacterial pneumonia is productive, with phlegm that can be dark yellow or even green.

The elderly may only have mild or even no temperature elevation, but the possibility of viral pneumonia is great.

Prevention and treatment: Take three!

The CDC has recommended three preventative actions to stop the flu:

1. The sooner the better — get a flu vaccine. December and January are key months!
Individuals who are age 6 months or age and older should get the flu vaccine, especially if they are in high-risk groups. Four forms of the vaccine are now available: three injectable, including the new Fluzone intradermal vaccine, and one in nasal spray form.

• The flu shot (Fluzone) contains inactivated vaccine made of killed virus and is administered intramuscularly in the deltoid muscle. The virus is dead and will not cause the flu but rather assist in development of protective antibodies against the influenza virus. Individuals may experience a localized affect from a sore muscle that can be treated with an over the counter analgesic.
• The flu shot High-Dose (Fluzone High-Dose) is a vaccine designed to target those 65 years and older. As individuals age, the immune system weakens and places the elderly at higher risk of getting influenza. This new vaccine will help boost older people’s immunity.
• The intradermal flu shot (Fluzone Intradermal) is the first influenza vaccine licensed in the United States using a microinjection system for intradermal (ID) delivery of vaccine (see photo below).

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Fluzone Intradermal microdelivery needle system. Photo courtesy of Sanofi Pasteur, reprinted with permission

The vaccine comes in a single-dose, preservative- free (no thimerosal) pre-filled syringe that delivers the vaccine in the dermal layer. This vaccine is indicated for active immunization of persons from 18 to 64 years old. Like the regular flu shot, the intradermal flu shot is composed of inactivated (dead) virus and does not cause the flu. The major advantages are that 40% less antigen is used, and a needle that is 90% smaller than other flu shots is used for ID injection.

• FluMist is the vaccine in nasal spray form. The spray is composed of weakened flu viruses. The spray promotes an immune response in the upper airway passages and the body as well. The CDC reports that vaccination with the nasal-spray flu vaccine is always an option for healthy people from 2 to 49 years of age who are not pregnant. Side effects from FluMist are relatively benign and can include runny nose, headache, sore throat, and cough.

2. Stop the spread

Particularly with the holidays approaching, prevention needs to be emphasized. Nurses are visable public health educators and should teach individuals the following preventative strategies:

• Protect others by covering your mouth when coughing or sneezing.
• Thoroughly and vigorously wash hands with soap and water. If soap and water are not available, use an alcohol-based hand cleanser.
• Avoid touching your eyes, nose, and mouth.
• Try to avoid close contact with sick people.
• If you are sick with a flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of a fever-reducing medicine.)
• While sick, limit contact with others as much as possible to keep from infecting them.

3. Antiviral therapy

Antiviral therapy can help individuals who get the flu. Examples of prescription antiviral drugs include Tamiflu and Relenza. These drugs are approved for prevention or treatment of influenza A or B in patients with symptoms for 2 days or less. Tamiflu is an oral drug taken once a day. Relenza is an oral inhalation and two inhalations twice a day are required. Patients must be at least 7 years old to take this medication. These medications can shorten the period of illness and prevent the complications of pneumonia.

Make a difference

Influenza can be a deadly disease. We have effective new vaccinations, universal criteria for expanded protection, high-dose vaccines for the elderly, and knowledge to keep the public safe. We can make a difference by encouraging patients to get vaccinated early for sure, but we must also promote vaccination throughout the winter months, especially before, during, and after the holiday season.

Sharon Hudacek is professor of nursing at the University of Scranton, Pennsylvania.

Selected references

Children, the flu and the flu vaccine. Center for Disease Control and Prevention. (2011) http://www.cdc.gov/flu/protect/children.htm. Accessed October 30,2011.

CDC Says “Take 3” actions to fight the flu. Center for Disease Control and Prevention. (2011). http://www.cdc.gov/flu/protect/preventing.htm. Accessed October 30, 2011.

FDA Licenses Sanofi Pasteur’s New Influenza Vaccine Delivered by Intradermal Microinjection. Press Release. http://www.sanofipasteur.us/node/1602. Accessed Nov. 14, 2011.

Flu Symptoms & Severity. Center for Disease Control and Prevention (2011). http://www.cdc.gov/flu/about/disease/symptoms.htm” target=”_blank. Accessed Nov. 12, 2011

Fluzone high-dose seasonal influenza vaccine. Center for Disease Control and Prevention. (2011). http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm. Accessed Nov. 1, 2011.

Intradermal Influenza (Flu) Vaccination. Center for Disease Control and Prevention. (2011). http://www.cdc.gov/flu/protect/vaccine/qa_intradermal-vaccine.htm. Accessed Nov. 1, 2011.

Key facts about Influenza (flu) & flu vaccine. Center for Disease Control and Prevention. (2011). http://www.cdc.gov/flu/keyfacts.htm. Accessed Nov. 1, 2011.

Malone MJ. Lower respiratory agents. In: Lewis S, Dirksen SR, Heitkemper MM, Bucher L, & Camera IM. In: Medical Surgical Nursing: Assessment and Management of Clinical Problems. 8th ed. St. Louis, MO: Elsevier –Mosby: 2011: 547-52.

Role of lab diagnosis of influenza. Center for Disease Control and Prevention. (2010) http://www.cdc.gov/flu/professionals/diagnosis/labrole.htm. Accessed Oct. 30, 2011.

Updated CDC estimates of 2009 H1N1 cases and related hospitalizations and deaths from April 2009 – April 10 2010 by Age Group. Center for Disease Control and Prevention.(2010 http://www.cdc.gove/ h1n1flu/ estimates_2009_h1n1.htm. Accessed July 11, 2010.