Influenza

1. Influenza Sherri, Michelle, Katie, Carola, and Magdalena

2. Who is Affected by Influenza? • “People 65 years and older are at greater risk of serious complications from the flu compared with young, healthy adults” (CDC, 2012). • “It's estimated that 90 percent of seasonal flu-related deaths and more than 60 percent of seasonal flu-related hospitalizations in the United States each year occur in people 65 years and older” (CDC, 2012).

3. Kent County Statistics • 67 deaths in 2010 from influenza or pneumonia. • 85% of deaths were in population aged 65+. • Influenza/pneumonia was listed as 9th for cause of death in 2010. (Kent County Administration, n.d.)

4. Problem Statement • Adults aged 65 and older in Kent County, Michigan are at risk of hospitalization and death as evidenced by 2010 data revealing that 85% of the deaths in Kent County were related to influenza or pneumonia and occurred in the 65+ population. Statistics also show that 42% of Michigan residents aged 65+ did not receive the flu shot in 2011, which is above the national average. (Kent County Administration, n.d.) (CDC, n.d.)

5. Best Practices for Primary Prevention of Influenza • Maximize health and wellness through strategies that are set in place before illness or injury are present (Harkness & DeMarco, 2012. p. 71). • Influenza vaccination for pre-pathogenic stage • “Vaccines can prevent outbreaks of disease and save lives. When a critical portion of a community is immunized against a contagious disease, most members of the community are protected against that disease because there is little opportunity for an outbreak” (NIH, 2010).

6. Best Practices for Secondary Prevention of Influenza • Minimize impact of disease or injury at “early stage of pathogenesis” (Harkness & DeMarco, 2012, p. 72). • Screening for Influenza A and B at onset of flu symptoms (fever, chills, temperature, nausea/vomiting)

7. Community Change Proposal for Kent County • Proposal to increase the percent of influenza vaccination rates of adults aged 65 and older in Kent County by >15% in the 2013 - 2014 influenza season through education and increased availability of immunizations to prevent hospitalization and death.

8. Resources in the Community • Area Agency on Aging of Western Michigan • “Kent County Health Care Transportation Resource Directory: A resource guide of transit agencies and community programs offering transportation assistance and information” (Kent County Administration, 2013). • Existing Locations for Flu Vaccinations • Kent County Health Department (KCHD) - 5 immunization clinics • 7 hospitals in Kent County • Physician offices, Long Term Care Facilities (LTCF) • Pharmacies, Grocery Stores

9. Partnership Agencies • Department of Health and Human Services (HHS) • Centers for Disease Control and Prevention (CDC) • World Health Organization (WHO) • National Institutes of Health (NIH) (Harkness & DeMarco, 2012)

10. Epidemiologic Model • Focuses on health promotion and disease prevention • Considers modifiable risks of acquiring influenza • Analyzestrends in risk surveillance data • Processes data collection – quantitative morbidity and mortality reports • Determines staging – pre-pathogenic, early pathogenic, and late pathogenic phases of influenza • Establishes relative risk , consistency, exposure, timing, and plausibility • Builds coalitions with partnership agencies (Harkness & DeMarco, 2012, p. 69)

11. Modifiable Risks Vaccination • “Human immune defenses become weaker with age. So influenza can be a very serious disease for people 65 and older” (CDC, 2012). • Influenza – a vaccine-preventable disease • “Influenza outbreaks have been associated with low vaccination rates among health healthcare providers (HCP)”. Immunizing HCP will protect staff, patients, and indirectly reduce disease burden, work absenteeism, and health care costs” (CDC, 2006).

12. Unmodifiable Risks Vaccination Shortage • “Flu cases spike in Kent County - far outpacing last year's tally…Health officials already have confirmed 112 cases - compared with only five cases at this time last year, the Kent County Health Department reported Thursday, Dec. 27” (www.mlive.com). • “Many residents have contacted the health department for vaccinations, reporting that their doctor’s offices and pharmacies have run out of vaccines, health officials said” (www.mlive.com). Virus Composition • “Due to the constantly changing composition of the flu viruses in circulation, the influenza vaccine must be modified each year to match the current viruses” (WHO, 2013).

13. Barriers to Flu Shots • Medical contraindication • Fear of side effects • Inconvenience • Lack of access or transportation • Financial barrier • Perceived ineffectiveness of vaccine • Perceived unlikelihood of contracting influenza • Fear of needles (CDC, 2006)

14. Interventions • WHO - Target population group of adults age 65 and older. • WHY – Disease prevention and health promotion. • Those vaccinated with flu shot are 60% less likely to need treatment for flu by healthcare provider. • WHEN – Annually during flu season (October to March). • Encourage early vaccination. • Reassure that vaccines are monitored by CDC and FDA for safety. • HOW – Remove financial barriers and provide transportation services when applicable. • Determine available insurance for influenza vaccination coverage. • Advise that Medicare Part B covers 100% of flu shots. • “Under the Affordable Care Act, many insurers are required to cover certain preventive services, like the flu vaccine” (HHS, n.d.) (HHS, n.d.)

15. Interventions • WHAT – Flu shot (inactivated flu virus) by injection. Provide helpful and accurate education about influenza. • Teach about influenza disease – viral infection of respiratory tract, types A, B, and C, signs and symptoms, mode of transmission. • Inform about reasons for annual vaccinations related to changing types and strains of flu viruses. • Inform about risk of acquiring influenza for two weeks after flu shot, the time it takes to develop antibodies against disease. • Influenza vaccine contraindicated in severe allergy to chicken eggs, previous reaction to flu shot, moderate to severe illness with fever, history of Guillain-Barre Syndrome. • Teach side effects of flu shot: soreness, headache, fever, swelling at injection site, nausea. (HHS, n.d.)

16. Interventions • WHAT – Cont’d • Advise about severe reactions to flu shot: difficulty breathing, hoarseness, hives, swelling around eyes or lips, high fever, racing heart, weakness. Educate on importance of seeking medical attention immediately. • Teach principles of prevention - infection control and hand hygiene. • WHERE – Existing facilities that offer flu shots (Kent County Health Department’s 5 immunization clinics, hospitals, physician offices, LTCF, pharmacies, grocery stores). • Expand or recruit new locations for immunization clinics – Kent County Community Center, churches, schools. • Schedule and publicize immunization clinics. • Arrange staffing for immunization clinics - Volunteers, translators, and students. • Campaign for health care workers to be immunized to indirectly help meet outcomes. (HHS, n.d.)

17. Influenza Reporting and Data Collection • Michigan Care Improvement Registry (MCIR) records vaccine information provided by the facility administering vaccine. (MCIR, n.d.). • “With MCIR, local health departments have the ability to do population-based immunization level assessments and target their outreach efforts where it's needed” (MCIR, n.d.) • Influenza is a reportable condition required by state law. KCHD is the reporting agency for physicians, labs, infection control departments, daycares, schools, camps, and emergency departments (Kent County Administration, n.d.) • “Kent County Health Department also monitors influenza activity at the state, national, and global levels. Information that is collected in Kent County is reported to the state health department. The data is then forwarded to the CDC” (Kent County Administration, n.d.).

18. Analyzing Trends • “The Epidemiology unit is responsible for conducting effective and timely influenza surveillance in Kent County” (Kent County Administration, n.d.). Circulating flu viruses are monitored for changes. This helps guide actions of the public health officials. (Kent County Administration, n.d.). • “Timely (weekly) surveillance updates will be posted on the Kent county website on the Health Department’s web page” and “clinical signs and symptoms of influenza” (Kent County Administration, n.d.). • Michigan Disease Surveillance System (MDSS) is a web based communicable disease reporting system that records and tracks influenza cases based on reports from health departments, hospitals, and physicians offices. Epidemiologist use this information to track data at a local and state level to find trends in disease outbreak and need for intervention (State of Michigan, n.d.).

19. Tracking the Outcomes Short Term Goals • An increase >15% of adults aged 65+ vaccinated for influenza in Kent County for 2013-2014 influenza season. • Lowered mortality rate related to influenza. • Reduced secondary influenza infections. • Decreased hospitalizations and hospital days related to influenza. Long Term Goal • Meeting the Healthy People 2020 objectives. • Goal – “Increase immunization rates and reduce preventable infectious diseases” (HHS, 2013).

20. Intervention Evaluation • Measure of success will be determined by an increased percentage >15% of Kent County residents aged 65+ receiving the flu shot for 2013-2014 flu season compared to the 2012-2013 flu season. Note: 2012-2013 statistics not yet available. • The anticipated time frame to evaluate effectiveness of interventions will be at the conclusion of the 2013 – 2014 influenza season, and once all of the data has been collected and processed by MDSS. • An interim outcome may include a survey at immunization sites to help determine barriers that prevent the elderly from receiving their flu shots. Other interventions may be adopted to accommodate the target population.

21. THE END Thank you

22. References • Centers for Disease Control and Prevention (CDC). (2013). Key facts about seasonal flu vaccine. Retrieved April 18, 2013, from http://www.cdc.gov/flu/protect/keyfacts.htm • Centers for Disease Control and Prevention (CDC). (2006). Morbidity and mortality weekly report; Influenza vaccination of health-care personnel. Retrieved April 2, 2013, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm • Centers for Disease Control and Prevention (CDC). (n.d.). Prevalence and Trends Data. Retrieved March 1, 2013, from http://apps.nccd.cdc.gov/brfss/list.asp?cat=IM&yr=2011&qkey=83 41&state=All • Centers for Disease Control and Prevention (CDC). (2012).What you should know and do this flu season if you are 65 years and older . Retrieved April 18, 2013 from http://www.cdc.gov/flu/about/disease/65over.htm

23. References • Centers for Medicare & Medicaid Services. (n.d.) Medicare Part B: Medical Insurance. Retrieved on April 18, 2013 from http://www.medicare.gov/coverage/flu-shots.html • Doctor2008. (n.d.). Wash hands 2 [poster]. Retrieved fromhttp://doctor2008.files.wordpress.com/2008/09/wash- hands2.jpg • Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Lippincott Williams & Wilkins. • Kent County Health Department. (2010). 2008 Behavioral Risk Factor Survey. Retrieved February12, 2013, from http://www.accesskent.com/Health/HealthDepartment/Publication s/pdfs/2008BRFS.pdf • Kent County Administration. (2013). Kent County Health Care Transportation Resource Directory. Retrieved April 18, 2013 fromwww.accesskent.com/Health/.../pdfs/Appendix_C_Trans_ Res_Dir.pdf

24. References • Kent County Administration. (n.d.). Monitoring Influenza in Kent County. Retrieved March 1, 2013, from http://www.accesskent.com/Health/CommDisease/Flu/flu_mon itoring.htm • Michigan Care Improvement Registry (MCIR). (n.d.). What’s new with MCIR?. Retrieved April 18, 2013, from http://www.mcir.org/forms/MCIR%20Brochure%20FINAL%202 13-2007.pdf • National Institute of Allergy and Infectious Disease (NIH). (2010, October). Community Immunity (“Herd” Immunity). Retrieved April 11, 2013, from http://www.niaid.nih.gov/topics/pages/communityimmunity.asx • State of Michigan. (2013). Influenza Vaccine Exchange Network. Retrieved from http://www.michigan.gov/mdch/0,1607,7-132- 2940_2955_22779-127415--,00.html • State of Michigan. (n.d.). Michigan Disease Surveillance System (MDSS) Background. Retrieved from http://www.michigan.gov/mdch/0,1607,7-132-2945_5104_31274- 96814--,00.html

25. References Cont’d • The Scarborough Hospital. (2013). Flu poster_ website [poster]. Retrieved from http://tsh.to/pages/Release-Flu-shot-compliance- gets-major-boost • Thoms, S. (2012, January 27). Flu cases spike in Kent County - far outpacing last year's tally. Retrieved March 23, 2013, from http://www.mlive.com/news/grand- rapids/index.ssf/2012/12/flu_cases_spike_in_kent_county.html • Thoms, S. (2013, January 30). Kent County Health Department urges residents to get flu vaccine at Thursday clinic. Retrieved March 23, 2013, from http://www.mlive.com/news/grand- rapids/index.ssf/2013/01/kent_county_health_department_4.html • U.S. Department of Health & Human Services (HHS). (2013). Immunization and infectious diseases. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiv eslist.aspx?topicId=23 • U.S. Department of Health & Human Services (HHS). (n.d.). Vaccination & Vaccine Safety. Retrieved April 13, 2013, from http://www.flu.gov/prevention-vaccination/vaccination/