It’s a New Influenza Season

Every flu season we spend time explaining the reality of the risk vs benefits of flu vaccination to our patients. There is much hype and folklore associated with vaccination, but the facts are clear and should make everyone who’s eligible receive a vaccine. These days, in addition to getting patients to say yes to vaccination, we need to guide them to the right type of vaccine, and we need to educate them about the availability of treatment. It’s a whole new day for influenza care.

While many things have changed in influenza care, some things won’t go away—the excuses remain the same, don’t they? Here are some strategies to break through these barriers.

• “The flu is just a minor stomach upset.” Patients need to learn that influenza is not the minor stomach ailment we call the “stomach flu,” nor is it the common cold, which many people confuse with the flu. True influenza is a serious illness characterized by high fevers, severe muscle aches, and a racking cough. Stomach symptoms are usually not prominent. The flu often lasts for two weeks, which is longer than the seven to 10 days that colds typically last. Remind your patients that the flu is a killer. In the United States alone, every year influenza kills about 36,000 people. So remember to combat flu with the appropriate vaccine rather than worrying about the latest disease scare such as SARS (severe acute respiratory syndrome), anthrax, and bird flu, which altogether have killed fewer than 1,000 people worldwide in the last decade.
• “Twelve years ago the flu shot made me sick.” Minor arm soreness is the only likely side effect. There’s plenty of evidence to prove this, but we don’t expect to convince some folks. We’ve known people who have blamed the shot for any illness or symptom they developed within a month of vaccination. Of course, since it’s given in the fall, and viral illnesses increase in the fall anyway, much of this claimed cause-and-effect is likely a coincidence.
• “Vaccines don’t work—I still got the flu.” Vaccination reduces illness and death from flu so significantly that the government and some insurers are beginning to grade the quality of hospitals and physicians by the percentage of the highest risk patients who are immunized. The flu vaccine is recommended for patients over the age of 50 and for anyone with heart or lung disease, diabetes, cancer, or other immune system weakness. The flu vaccine is now recommended and safe even for pregnant women and children aged six to 23 months. Only individuals allergic to eggs need to avoid flu vaccination, though an FDA-approved egg-free version of the vaccine is available.

The following provides a review of the types of flu vaccines available for patients aged 65 and over.

• “regular” flu shot (trivalent regular dose intramuscular vaccine);
• high-dose flu shot (trivalent high does intramuscular vaccine);
• new four-strain flu shot (quadrivalent intramuscular vaccine); and
• egg-free shot (Flucelvax).

(Note: The nasal spray shot and jet injector device are not approved for those aged 65 and over.)

Keep in mind that there is limited evidence of markedly increased benefit of alternative vaccines over the regular flu vaccine. The type of vaccine a patient receives is less important than receiving the vaccine.

We are learning more about the different types of vaccines. There is evidence that the “high dose” shot leads to a stronger antibody response.

According to the Centers for Disease Control and Prevention (CDC), the high-dose vaccine contains four times the amount of antigen in the regular flu shot and is associated with a stronger immune response following vaccination (ie, higher antibody production).1 Preliminary studies suggest this may translate into greater protection against the flu. For example, one recent study published in The New England Journal of Medicine indicated that the high-dose vaccine was 24.2% more effective in preventing flu in adults aged 65 and older relative to a standard dose flu vaccine. (The confidence interval for this result was 9.7% to 36.5%).1,2

What remains to be learned, however, is whether that leads to fewer people infected with flu. For patients who are at standard risk (ie, those without chronic illnesses such as diabetes, chronic kidney disease, and COPD), the regular flu shot is likely adequate. You may want to consider the high-dose vaccine for patients with increased risk factors. I know I will advise it for most of my elderly patients and especially anyone with chronic illness or chronic stress. Keep in mind any patients who are family caregivers. The chronic stress of that role can increase flu risk.

Another new formulation of vaccine is the quadrivalent vaccine. Each regular flu vaccine is trivalent, or covers three strains of circulating flu viruses. Two A and one B strains are covered in each trivalent vaccine. In a quadrivalent vaccine, four strains, two A and two B strains, are covered. In the elderly, type A strains tend to cause more severe flu, so it is unclear whether this additional coverage will make a difference in their morbidity and/or mortality.

Educate your patients about the existence of antiviral medications and the need to initiate them within 48 hours of flu symptom onset. There is evidence these medications can lessen the severity of the illness and prevent serious complications such as pneumonia.

The following are some key points to keep in mind about treatment. Find full details on the CDC website.3

• Among outpatients, antiviral treatment with a neuraminidase inhibitor is recommended for all patients with suspected or confirmed influenza who are at higher risk for influenza complications because of age or underlying medical conditions.3
• The benefits of antiviral treatment are likely to be greatest if treatment is started as soon as possible after illness onset, and evidence for benefit is strongest in studies in which treatment was started within 48 hours of illness onset. However, treatment is recommended for any person with confirmed or suspected influenza who requires hospitalization, even if the patient presents more than 48 hours after illness onset.3-7
• Patients with influenza are at high risk for such secondary bacterial complications as bacterial pneumonia. Antibacterial therapy plus antiviral treatment are recommended for patients with community-acquired pneumonia when influenza also is suspected. Antibiotic treatment should be directed at likely bacterial pathogens associated with influenza such as S. pneumoniae, S. pyogenes, and S. aureus, including methicillin-resistant Staphylococcus aureus (also known as MRSA), especially for hospitalized patients.3,8,9
• During influenza season, clinicians should consider influenza virus infection as the possible cause of any febrile respiratory illness requiring hospitalization and consider testing for influenza and starting empiric antiviral therapy.3,9
• Treatment also can be considered on the basis of clinical judgment for outpatients with uncomplicated, suspected, or confirmed influenza who are not known to be at increased risk for developing severe or complicated illness if antiviral treatment can be initiated within 48 hours of illness onset.3
• Patients with influenza who present with an uncomplicated febrile illness typically do not require treatment unless they are at higher risk for influenza complications, but early empiric antiviral treatment of these patients might provide benefit, such as a shortened duration of illness. Patients with influenza who are already beginning to recover do not need to start treatment.3

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

References

1. What you should know and do this flu season if you are 65 years and older. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/about/disease/65over.htm. Updated August 17, 2015.

2. DiazGranados CA, Dunning AJ, Kimmel M, et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J Med. 2014;371(7):635-645.

3. Use of antivirals: background and guidance on the use of influenza antiviral agents. Centers for Disease Control and Prevention website. http://www.cdc.gov/flu/professionals/antivirals/antiviral-use-influenza.htm. Updated February 25, 2015.

4. Siston AM, Rasmussen SA, Honein MA, et al. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517-1525.

5. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009–10 season. Centers for Disease Control and Prevention website. http://www.cdc.gov/H1N1flu/recommendations.htm. Updated December 7, 2009.

6. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza, Bautista E, Chotpitayasunondh T, et al. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med. 2010;362(18):1708-1719.

7. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children—diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(8):1003-1032.

8. Hageman JC, Uyeki TM, Francis JS, et al. Severe community-acquired pneumonia due to Staphylococcus aureus, 2003–04 influenza season. Emerg Infect Dis. 2006;12(6):894-899.