Influenza 2013 - 2014

1. Influenza 2013 - 2014 Gregory Gahm, MD

2. Epidemiology How significant is influenza - really?

3. Influenza Epidemiology Average annual Influenza-attributable deaths in US:36,000 – 48,000 • Good / Bad / Average years • >90% of deaths in a normal year are in those >65 • Increased cardiopulmonary disease and deaths

4. The Influenza Virus “H” (Hemagglutinin) RNA Strand (Carries all information necessary to infect someone) “N” (Neuraminidase)

5. Getting Infected… A Cough or Sneeze by an infected person leaves Flu viruses floating on water droplets in the air The virus is inhaled by the unsuspecting victim… …where it finds a home in the Oro– or Nasopharynx

6. Viral Replication Respiratory Tract Cell Hemagglutinin on Virus finds, binds to, and fuses with cell membrane Flu RNA migrates to Nucleus Viral RNA is released into Cytoplasm Flu RNA Nucleus DNA

7. Viral Replication Viral RNA uses host to initiate Transcription Process Viral Proteins & Genes are Replicated… Influenza RNA Genes …and Released into Cytoplasm Nucleus

8. Viral Replication Viral Proteins reassemble and add a shell to form new virions Nucleus Respiratory Tract Cell

9. Viral Replication Neuraminidase opens cell membrane to release new virions Virions migrate to cell surface Respiratory Tract Cell Off to find the next respiratory tract cells to infect!

10. Multiplication & Migration of the Virus Exposure / Initial Infection (Time 0) Replication: 24 - 48 Hours Time when Neuraminidase Inhibitors can have an effect Symptoms Begin 48 Hours Migration to Lungs

11. Preventive Medicine

12. How do I stay healthy? The best way to prevent flu is to GET VACCINATED!!! - unless: • You’ve had a documented serious reaction to a previous dose • You’ve had Guillain-Barre associated with the vaccine Few Side Effects • Most common →redness, soreness or swelling at injection site (Bravo! for your immune system!) • Less common → fever and body aches • Egg allergy is not a contraindication – esp with a new recombinant vaccine made without any eggs used in the process

13. Recipe for Making a Flu Vaccine AKA: Why you can’t get the flu from the vaccine

14. Making a Vaccine – Step 1Inoculate eggs with the virus

15. Making a Vaccine – Step 2Incubate until egg is full of live virus

16. Making a Vaccine – Step 3Separate virus from egg, discard egg 

17. Making a Vaccine – Step 4Thoroughly KILL virus(chemically, multiple times)

18. Making a Vaccine – Step 5Chop KILLED virus into small pieces

19. Making a Vaccine – Step 6Discard the killed RNA(the part that causesdisease… remember?) 

20. Making a Vaccine – Step 7Put remaining viral shell pieces with Hs & Ns into vaccine

21. Benefits of being vaccinated The ACIP recommends Universal Vaccination (everyone >6 months old) For NH residents the vaccine reduces the risk of: • Hospitalization by 50% • Pneumonia by 60% • Death and complications related to flu by 75-80% In kids / young adults, it is 70-90% effective in preventing flu (also keeps them from spreading it to sibs, parents and our patients)

22. Flu Vaccines for 2013-14 Viral Strains • A/California/7/2009 (H1N1) • A/Victoria/361/2011 (H3N2) • B/Massachusetts/2/2012 • +/- B/Brisbane/60/2008 Vaccines Available • LAIV (FluMist; 2 – 49 yo) – Quadrivalent • Tri - & Quadri - valentinactivated vaccine (IM) • High Dose Fluzone (over 65) • Intradermal Fluzone (ages 18-64) • RIV3 = Recombinant, egg-free vaccine for persons 18 – 49 yo

23. High Dose Fluzone • For ages >65 only • Contains 4X the antigen for each of the 3 viral strains • Only 20-25% of frail elderly (NH pts) develop protective antibodies with the normal seasonal vaccine • Non-serious adverse events were more frequent • Pain at injection site Headache • Muscle aches Low-grade fever • Redness / swelling at injection site Malaise • Serious adverse event rates were equivalent

24. How do I stay healthy? • Avoid close contact with people who are sick • Stay home when you are sick • Cover mouth & nose when coughing / sneezing • Cover mouth & nose when someone else coughs or sneezes! • Wash your hands and practice other good, common sense health habits • VENTILATE!Open doors & windows on nice days!

25. Clinical Medicine Influenza Recognition and Treatment

26. Influenza • A Respiratory Virus • NOT the ‘stomach’ flu • Spread by coughing and sneezing

27. Symptoms… AKA…How do you know if a patient has the flu? • 2 Major Symptoms: • Sudden onset ofHIGH Fever and/or a Nonproductive Cough • LTCFs: watch for multiple cases in a short period of time Other common symptoms: • Muscle aches – often profound • Sore throat or nasal congestion • Headache • Confusion or Delirium

28. Rapid Testing • Problems with collecting / sending swabs • Misses H1N1

29. Antiviral Treatment • If you think someone has the flu: • Involve the provider as soon as there are symptoms! • Meds only work if started <48 hours from start of symptoms • When in doubt, start treatment – STAT – based on clinical judgment • STAY HOME or cohort sick patients in LTCFs! • Plenty of rest, fluids, nutrition • Treat muscle aches / fever with NSAIDs, ASA, Tylenol • Cough / lethargy can last 2 – 3 weeks depending on frailty • Infectious from 1-2 days beforesymptoms start until 1-2 days after coughing stops

30. CDPHE Mandatory Vaccination in LTC General Provisions Healthcare entities and workers have a shared responsibility to prevent spread of infection and avoid causing harm to their patients or residents by taking reasonable precautions to prevent the transmission of vaccine-preventable diseases. Vaccine programs are, therefore, an essential part of infection prevention and control for slowing or stopping the transmission of seasonal influenza viruses from adversely affecting those individuals who are most susceptible.

31. Definitions Employee: any person who performs a service for wages or remuneration, including students, trainees, persons who have individual contracts with the healthcare entity, physicians with staff privileges and allied health professionals with privileges. Does not include volunteers or persons who provide services through a contractual arrangement between the licensee and a separate organization, association or other healthcare entity.

32. Definitions Healthcare Worker: any person, working in a facility who has the potential for exposure to patients, residents or consumers of the entity and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or air. Includes, but is not limited to physicians, nurses, CNAs, therapists, techs, EMTs, dental personnel, pharmacists, lab personnel, students, trainees, contractual personnel, and persons not directly involved in patient care (eg, clerical, dietary, housekeeping, laundry, security, maintenance, billing and chaplains)

33. Definitions Influenza Season: November 1 through March 31 Proof of Immunization: A written statement from a licensed healthcare provider who has administered a flu vaccine to a healthcare worker

34. Vaccination Targets to be Exempt from Masks % of Employees Vaccinated by Dec 31 2012 60% 2013 75% 2014 90%

35. Other Requirements to be Exempt from Masks • Have defined procedures to prevent spread of flu from unvaccinated workers • Maintain documentation for 3 years • Report vaccination to CDPHE by March 31 • Provide vaccine for each healthcare worker • Have a written policy regarding vaccination of your healthcare workers that addresses: • Proof of immunization, or • A signed medical exemption • Maintain proof of annual immunization for employees • Inform other healthcare workers who provide services on the premises that you have these policies, require them to be immunized or wear a mask, and you can provide the mask.

36. Masks Each healthcare worker without proof of immunization must wear a surgical or procedure mask during flu season when in direct contact with patients and in common areas.