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Influenza The Basics

September 18, 2008Third Year Nursing Students

Bryna Warshawsky, Associate Medical Officer of Health

519-663-5317 ext. 2427; [email protected]

Outline

Influenza background / regular influenza 2007-2008 Influenza Season Difference between:

Regular influenza Avian influenza Pandemic influenza

Influenza vaccine Controlled acts and delegated acts

Informed consent Anaphylaxis management

Needlestick injuries

Influenza Background

Types of Influenza

Influenza A: many different types

Influenza B: two main groups or lineages

Influenza Type A

Neuraminidase

Hemagglutinin

16 Hemagglutinin subtypes

H1, H2, H3 (Humans)

9 Neuraminidase

N1, N2 (Humans)

Influenza Virus

Human types /subtypes:

A -H3N2

A -H1N1

B

Minor changes

Antigenic drift

New vaccines eachyear

All other A subtypes exist mainly inbirds but could potentially infect

people



Regular Influenza

Symptoms of Influenza

Every year betweenDecember and April

Sudden onset of: Fever Cough Runny nose Muscle aches Fatigue Sore throat

Gastro-intestinal symptoms not classic Lasts 2 7 days

Complications of Influenza

Can result in:

Pneumonia in elderly

Worsening of underlying medical conditions

Sinus infections

Ear infections in children

Neurologic problems

Toxic shock syndrome

~ 1,500 to 5,000 deaths / year in Canada

~ 70,000 hospitalizations / year in Canada

Most at Risk for Complications

People with underlying medical problems

Elderly

Infants and young children

Pregnancy second trimester compared tonon-pregnant women

Regular influenza caused by

Influenza A

H3N2

H1N1

Influenza B

All can circulate in one season



Spread of Influenza

Spread by droplet route Direct contact - virus may persist for hours

Time from exposure to disease (incubationperiod):

1 to 3 days

Able to spread (period of communicability):

24 hours before onset

5 days from onset in adults, 7 days in kids

Prevention of Influenza

Vaccine

Antiviral drugs

Infection control

Influenza Vaccine

Most important preventative strategy

Protects against 3 strains of influenza

Developed each year in anticipation ofcirculating strains

Usually right, sometime wrong in predicting -Match

Can take up to 6 months to develop

Antiviral Drugs

Amantadine: Older drug not used any more

Used for Parkinson treatment

Dosing difficult

Side effects

H3N2 strain resistant

Neuraminidase inhibitors: Oseltamivir (Tamiflu) - oral

Zanamivir (Relenza) - inhaled

Antiviral Medications Neuraminidase InhibitorsMechanism of Action

Specifically inhibits the neuraminidaseenzyme on the surface of the virus

Neuraminidase enzyme is needed to allowthe virus to exit the respiratory cells after

infecting and replicating in the cell

Neuraminidase inhibitors block influenzas

ability to leave the cell and spread



Neuraminidase Inhibitors

Treatment Taken within 48 hours of symptom onset

Prevention

Taken while influenza is circulating

Used for residents and unvaccinated staffmembers when there is an outbreak in a longterm care facility

Infection Control

Hand washing

Soap and water

Waterless alcohol hand wash solution

Cover your cough

Avoid touching your face

Stay home if you are ill

Environmental cleaning

Influenza Surveillance

Laboratory reports

School absenteeism

Sentinel physicians

Outbreak monitoring

Febrile respiratory illness monitoring

Health unit reporting

Outbreaks in Long Term CareFacilities

Significant because:

Spread rapidly Frail elderly more at risk for complications

Influenza vaccine not as effective in olderindividuals

Health Unit assists in detecting outbreak and

preventing spread

Contribute Strains

Determine what types of influenza strains arecirculating

Do they match the strain in the vaccine?

Are they resistant to antiviral drugs?

What strains should be used next year?



Pandemic Influenza History

Spanish Flu 1918 killed 40 million

Asian Flu 1957 killed 2 million

Hong Kong Flu 1968 killed 1 million

New influenza strain that spreads aroundthe world and causes significant illness

Spanish Flu A(H1N1) 1918-19

20 to 40 million

deaths

Life Expectancy in US:

Pandemic Influenza History

Spanish Flu 1918

H1N1

40 million deaths

Asian Flu 1957

H2N2

2 million deaths

Hong Kong Flu 1968

H3N2

1 million deaths

Pre-requisites for theStart of a Pandemic

1. A novel virus subtype must emerge to which

the general population has little or no

immunity.

2. The new virus must be able to replicate in

humans and cause serious illness.

3. The new virus must be efficiently transmitted

from one human to another.

Risk of Pandemic Influenza

Since the beginning of this year,all prerequisites for the start of apandemic have been met save one- namely genetic changes in thisvirus that would allow it to achieveefficient human-to-humantransmission.

Stohr, Editorial, NEJM 352; 4; Jan. 26, 2005

Influenza Vaccine



Complicated Production

3 strains in each vaccine Need to choose strains each year

Grown in chick eggs

Chemically disrupted to be less reactogenic splitvaccine

Begins in February to be ready for October

Needs approval / lot releases of regulatory bodies

Influenza Vaccine

Most jurisdictions, high risk programs

Ontario has had a universal program since

2001

Everyone 6 months of age and older

High Risk Program

Those at risk for complications Elderly, underlying medical conditions, 6-23

months, second half of pregnancy

People capable of transmitting infection Health care workers, household, child care

givers

Essential services

Influenza Vaccine Efficacy

70% to 90% effective among persons



Injection

Deltoid if 1 year of age or older Anterolateral thigh if 6 months to < 1year or very

small deltoid in 1 year old

1 inch needle to go IM, unless larger

No need to aspirate / withdraw

Can be given with other vaccines

If more than 2 needles, can be given in the samelimb but at least an inch apart

Adverse Effects

Sore arm Mild fever, muscle aches for 1-2 days

Anaphylactic reaction

Guillain-Barr Syndrome in 1976

Oculorespiratory syndrome 2000-2001

Red eyes, respiratory symptoms, facial swelling

Contraindications

Egg allergy

Allergy to contents:

Thimerosal

Formaldehyde

Neomycin (Vaxigrip)

Triton X-100 (Vaxigrip)

Deoxycholate (Fluviral)

Contraindication

Previous allergic reaction to flu vaccine

Allergic reaction to any vaccine needs

assessment

Infection worse than cold - defer

Severe oculo-respiratory syndrome

Guillain-Barr Syndrome 8 weeks of flu shot

Bleeding disorder / bleeding medication < 6 months of age

Pregnancy and Breastfeeding

Influenza vaccine considered safe inpregnancy

Women in second half of pregnancy high risk

Thimerosal

Very small amounts as a preservative in bothinfluenza vaccines

Controversy in US because of amounts givenin vaccines

Removing if safe alternative exists

Not linked to any abnormalities

Fine in vaccinated infants / pregnant women


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Guillain-Barr Syndrome

Transient paralysis After infection such as campylobacter

Associated with influenza vaccine in 1976

Swine Flu

Uncertain if happens in other season and if itdoes, ~1 / 1,000,000 doses

Managing the Vaccine

Keep it cold 2 80C, never freeze Mark vials when punctured

7 days for Vaxigrip

28 days for Fluviral

Dont pre-draw except small amounts

Controlled Acts andDelegated Acts

Controlled Act 13 controlled act

Physicians can perform 12: Prescribing, dispensing

Nurses can perform 3: Administering a substance by injection or

inhalation

Performing a procedure below the dermis

Putting things into a body orifice

Controlled acts can be delegated

Order vs. Medical Directive

Order:

Specific intervention for a specific client in aspecific time

Medical directive:

Blanket instructions that applies to a range ofclients who meet specific requirements

Medical Directives

Must be written

Name and description of the procedure /

treatment /intervention being ordered;

Specific client clinical conditions and situationalcircumstances that must be met before theprocedure can be implemented;

Clear identification of the contraindications forimplementing the directive;

Name and signature of the NP or physician



Medical Directive

Informed consent

Management of anaphylaxis

Informed Consent

Nature of the treatment; Expected benefits of the treatment;

Material risks and adverse effects of the treatment;

Alternative courses of action; and

Likely consequences of not having the treatment.

All explained in Influenza Vaccine InformationSheet

Allow opportunity to ask questions

Informed Consent

Does not need to be written

We use written consent at our clinic fordocumentation

Age of Consent

No legal age of consent

Must be capable of understanding the

consequences of getting and not getting theintervention

Determined by the health care provider

Will accept the consent of older children andadolescents but prefer joint consent

Substitute Decision Makers

Must be custodial parent or legal guardian

Note from custodial parent or legal guardian

acceptable if can be sure nocontraindications

Talking to custodial parent or legal guardianacceptable - document

Someone must know the medical conditions /

contraindications

Fainting and AnaphylaxisManagement

Prevent faints

Recognize fainters

Prevent injury

Prevent anaphylaxis

Recognize anaphylaxis

Manage anaphylaxis Medical directive, training and equipment



Needle Stick Injuries

Needle Stick Injuries

Have hepatitis B vaccine Know titres

Prevent injuries:

Hold children well

Dont recap

Never put needle down on work station

Be careful going into sharps container

Dont overfill sharps container

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