September 1, 2008 |

Flu season

As flu season approaches, Long-Term Living magazine asked board-certified geriatrician Jonathan Musher, MD, CMD, president of Metropolitan Physicians Practice, Chevy Chase, Maryland, lecturer, long-term care expert, and past president of the American Medical Directors Association (AMDA), to address concerns about seasonal flu inoculations among residents and staff in long-term care facilities. According to the Centers for Disease Control and Prevention (CDC), about 5% to 20% of Americans get the flu each year. More than 200,000 people are hospitalized and about 36,000 people die. Especially at risk are people living in nursing homes; those 50 and older, patients suffering from heart or lung conditions, including asthma; those who have been hospitalized from diabetes, chronic kidney disease, or who have a weakened immune system; people with any condition that can compromise their ability to breath; and any person in close contact with someone in a high-risk group. Dr. Musher spoke with Long-Term Living’s Executive Editor Maureen Hrehocik.

Hrehocik: How is seasonal flu spread?

Dr. Musher: The main way that influenza viruses are spread is from person to person in respiratory droplets of coughs and sneezes. This can happen when droplets from a cough or sneeze of an infected person are propelled through the air and deposited on the mouth or nose of people nearby. Influenza viruses may also be spread when a person touches respiratory droplets on another person or an object and then touches their own mouth or nose (or someone else’s mouth or nose.) This is why hand washing is so important.

Hrehocik: Why does the vaccine change every year?

Dr. Musher: A new strain of flu virus emerges every year. The immunity that is built up from having the flu caused by one virus strain doesn’t always provide protection when a new strain is circulating. That is why the influenza vaccine is updated to include current viruses every year.

Hrehocik: When is the best time for residents and staff to get a seasonal flu shot?

Dr. Musher: It depends on what part of the country you live in, but in general, you should get a flu shot between October 1 and March 31.

Hrehocik: Is the inoculation (shot) better than FluMist (an inhalant)?

Dr. Musher: This is actually a controversial subject as it depends on the age of the recipient as well as the setting. The live attenuated vaccine (FluMist) is considered safe if given to healthy people aged 5 to 59 years, so it would not be appropriate for the average resident of a nursing home. The CDC has recommended the use of live attenuated vaccine for healthcare workers who care for patients in nursing homes. However, there is still an issue with shedding of the live virus in immunocompromised patients and if a healthcare worker has to maintain a certain distance for a certain amount of time after receiving the live attenuated vaccine.

The other issue is one of cost. The estimated cost of the live attenuated vaccine, including the administration fee, is $60 to $70 per dose, about six times the cost of the inactivated flu virus vaccine shot. Since AMDA and other associations and organizations advocate for facilities to pay for employee immunization, using the live attenuated vaccine could be expensive and therefore problematic.

Hrehocik: How important is it for residents of nursing homes to be inoculated against seasonal flu?

Dr. Musher: Since the flu virus can quickly turn into an outbreak in a nursing facility if even just one person has the flu, it is important to set up a system to encourage all residents and employees to be vaccinated. Influenza and pneumococcal disease are major causes of morbidity and mortality in long-term care facilities. Influenza alone kills an average of 36,000 Americans annually. More than 90% of all deaths from influenza occur in the elderly. Residents of long-term care facilities are particularly at risk. Illness rates of up to 60% and fatality rates as high as 55% have been documented as a result of influenza outbreaks in long-term care facilities. Influenza and pneumococcal disease cause more deaths (approximately 40,000 annually) in the United States than all other vaccine-preventable deaths combined. Influenza and pneumonia combined represent the fifth leading cause of death in the elderly; up to 20,000 residents of long-term care facilities succumb to these illnesses every year.

Influenza transmission among residents, family members, other visitors, and healthcare workers is a particular problem in long-term care facilities for two reasons; the close proximity of health care workers and residents and the immunological changes that occur in frail or debilitated individuals, which may prevent them from responding to flu vaccine with protective levels of antibody. That is why it is equally important for all healthcare workers and volunteers to be vaccinated against influenza. Studies have shown that influenza outbreaks in long-term care facilities are associated with low vaccination rates among healthcare workers and that higher levels of vaccination among healthcare workers are associated with a lower incidence of influenza infection. Vaccinating a large percent of the residents and employees of a healthcare facility produces what is called herd immunity (in diseases passed from person to person, it is more difficult to maintain a chain of infection when large numbers of a population are immune. The more immune individuals present in a population, the lower the likelihood that a susceptible person will come into contact with an infected individual) which helps prevent the spread of influenza.

Hrehocik: What if the resident, family member, or staff reject inoculation?

Dr. Musher: Patients and their legal representatives have the right to refuse any and all vaccinations after receiving education about the benefits and potential side effects. However, they should be encouraged to give this some thought as their decision to refuse may affect the safety of the entire nursing home community.

Hrehocik: Is the flu vaccine contraindicated for anyone or any conditions?

Jonathan Musher, MD, CMD

Dr. Musher: Valid medical reasons for withholding vaccine are: presence of fever; moderate or severe acute illness; end stages of a terminal illness; egg allergy; development of neurologic symptoms (e.g., Guillain-Barre Syndrome) within seven weeks of prior dose of influenza vaccine; and a history of problems with the vaccine.

Hrehocik: Are there other benefits for residents and staff from receiving the flu shot other than lessening the likelihood of catching the flu?

Dr. Musher: Knowing you are helping to protect the vulnerable people around you as well as your loved ones should be a benefit. It is important for staff to realize that they will benefit directly from receiving the vaccine. Vaccination will keep them healthier and will enable them to remain functional and productive and to miss less work during the winter months. One study has shown that healthy working adults who receive influenza vaccination have 25% fewer upper respiratory infections, 44% fewer doctor visits, and 43% fewer sick days off than their unvaccinated counterparts. Staff also needs to be aware that if they are vaccinated against the flu, they will be helping to protect their children and other family members from illness.

Hrehocik: Are there other measures staff can take to lessen the likelihood of flu in a long-term care facility?

Dr. Musher: The medical director should assist facility staff in identifying and providing information about the benefits and risks of influenza vaccination. The AMDA and the CDC provide a wealth of materials that can be helpful in fulfilling this requirement. The medical director can play a pivotal role in educating staff about the principles of influenza prevention and assisting in developing a program to ensure maximal participation of staff in the vaccination program, such as providing incentives for staff vaccination.

It is important to prepare a comprehensive plan for resident and staff vaccination, surveillance, treatment, prophylaxis, and infection control. The medical director and director of nursing should review the CDC’s Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), which is updated annually and published on the CDC Web site (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr55e628a1.htm), as well as resources from their state and local public health departments.

Jonathan Musher, MD, CMD, is a board-certified family practitioner and geriatrician. He is a charter certified medical director and past president of AMDA. He has more than 20 years of clinical hands-on medical experience. His expertise spans the spectrum of acute care and long-term care services, from inpatient and ambulatory care through home and hospice care to skilled nursing care. He has published and lectured extensively in the areas of geriatrics, long-term care, and medical direction. He is chair of the AMDA Foundation, a member of the AMDA Public Policy Committee, and was a recent delegate to the White House Conference on Aging. He is also a member of several medical boards and committees including the National Assisted Living Task Force.

To send your comments to Dr. Musher and the editors, e-mail hrehocik0908@iadvanceseniorcare.com.

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What to do in a flu pandemic?

by Maureen Hrehocik, Executive Editor

Two-state study shows LTC facilities woefully unprepared

A new study in the Journal of the American Medical Association (July 23, 2008, Vol. 300 No. 4) suggests nursing homes in two states are woefully unprepared to assist with overflow patients from hospitals should a flu pandemic hit.

The study, “Preparedness for Pandemic Influenza in Nursing Homes: A 2-State Survey,” shows that 52% of the 451 responding nursing homes in Nebraska and Michigan do not have any pandemic plan; 23% had a specific plan; and 24% had a pandemic response incorporated into an overall disaster response plan. Survey authors sought to find if a flu pandemic hit the United States, could nursing homes accommodate overflow flu patients, as well as non-flu-suffering patients if hospitals were inundated? Long-Term Living Executive Editor Maureen Hrehocik spoke with senior author Lona Mody, MD, MSc, assistant professor of internal medicine at the University of Michigan Health System and research scientist, Geriatric Research, Education and Clinical Center at the Veterans Affairs Ann Arbor Healthcare System, about how long-term living facilities can best care for their own residents as well as other hospital patients, should a flu pandemic hit.

Lona Mody, MD, MSc, was senior author on a two-state study assessing nursing homes’ readiness for a flu pandemic

Hrehocik: What is the difference between seasonal flu and pandemic flu?

Dr. Mody: Seasonal influenza is usually due to a known influenza virus strain and is more common. An annual vaccine is available to help prevent severe illness from seasonal influenza. Seasonal flu begins in November and ends around March. The best time to get a seasonal flu vaccine is in October and November. Many hospitals and nursing home residents do get seasonal flu if they are exposed to it and have not been immunized. However, pandemic influenza occurs when there is an emergence of a new influenza strain to which we, as humans, do not have any immunity. It is a different strain than the seasonal influenza strain. Influenza pandemics are, thankfully, rare but recurring events. There were three pandemics during the 20th century. The worst was the Spanish influenza in 1918, which killed an estimated 40 to 50 million people worldwide.

Experts have been closely monitoring a serious strain—H5N1 strain—for over a decade now. This strain has caused serious outbreak in poultry. Since 2003, many human cases have been identified, predominantly in Asian countries. The good news is that so far this virus has not jumped very easily from poultry to humans. Work is ongoing on vaccine development for a new pandemic strain based on this H5N1 strain. There will be a shortage of the vaccine because it must match the exact strain very closely and we do not know the exact strain that is going to cause the pandemic until it is here. Work is ongoing in this area. Older adults residing in nursing homes will not be on the priority list for a pandemic vaccine since it is believed that older adults may not be able to mount adequate immunity. We didn’t study seasonal flu in the survey. However, the reason I got interested in this area (flu pandemics) was the chaos we had during the 2004-2005 seasonal flu vaccine shortage. We conducted a survey of various nursing homes nationally and realized that nursing homes’ experience during an emergency varied. It went from some facilities experiencing no shortage at all to others needing to patch up their supply from three to four different sources after numerous phone calls to different sources ranging from their health department to local businesses. That made me think, ‘What will happen if there is real chaos in a situation such as a pandemic and nursing homes don’t have a plan for it?’ Seasonal flu outbreaks will be more common than pandemic outbreaks.

Hrehocik: How likely is a flu pandemic in 2008-09?

Dr. Mody: Most experts agree it is a matter of time, but it is hard to predict the time and severity. I will say, however, that research is ongoing on the H5N1 strain to counter and prevent a possible pandemic.

Hrehocik: Your study talks about nursing homes being used as “overflow” sites for patients in the case of a pandemic. Isn’t it dangerous to introduce sick people to an already compromised population in a nursing home?

Dr. Mody: Nursing homes can serve as sites for overflow patients. Say, hypothetically, if there was a pandemic influenza outbreak and the hospitals were overwhelmed, hospitals could discharge other non-influenza patients who need less intense care to nursing homes, for example hip replacement patients, osteomyelitis patients, and those needing antibiotics. Nursing homes have an infrastructure similar to hospitals. Many nursing homes can now provide IV fluids, antibiotics, oxygen, and other medications. There’s already a nursing staff, infection control infrastructure, and physician visits. So, theoretically, nursing homes can serve as overflow sites. However, their occupancy rate is already high, so serving as an overflow may require planning and coordination. In the case of discharging influenza pandemic patients into nursing homes, more thought and planning need to occur. In our survey, when we asked nursing homes, ‘Would you be able to accept non-influenza patients?’, about 58% said ‘yes.’ However, only 38% were agreeable to accepting influenza patients that required a low level of care. That number would change in an actual emergency, with nursing homes being more concerned about accepting pandemic influenza patients unless they are prepared for it.

Hrehocik: How should nursing homes prepare for a flu pandemic?

Dr. Mody: Actually, we were pretty happy to see nursing homes have started taking the initial step of having a point person responsible for pandemic planning; especially considering nursing homes have few resources onhand to prepare. Now nursing homes can take this preparation further. They can go to the CDC Web site and download the CDC’s recommendations for pandemic influenza (https://www.pandemic.gov or www.cdc.gov/pandemic). They can also establish contact with their regional pandemic planning coordinators, their local hospitals that may need to feed patients to them, as well as state planning officials. If they need to, they should seek out expertise to help them implement their plan. What our study showed was of the 451 nursing homes that responded to our survey, 45% had infection control professionals in charge of their plan, 21% had executive directors or administrators in charge, and 14% had directors of nursing or safety coordinators in charge.

It is important to have a plan, but it is equally important to exercise those plans and carry out drills. They should also plan for staff shortages which are already a concern. They should expect more staff turnover and staff shortages during an influenza pandemic. They have to be more involved in regional pandemic planning efforts. We need more research and funding in learning how nursing homes adopt numerous recommendations and guidelines and policies that come their way as they continue to provide care for a very vulnerable segment of our population.

Lona Mody, MD, MSc, can be reached at (734) 845-3072 or lonamody@umich.edu.To send your comments to the editors, e-mail 2hrehocik0908@iadvanceseniorcare.com

Sidebar

Infection control precautions are very important in preventing flu outbreaks.

To prevent an outbreak, redouble the emphasis on:

Vaccination of staff and residents
Hand washing hygiene
Respiratory hygiene and cough etiquette
Insist that sick staff members do not come to work
Limit staff floats to or from affected units
Post visual alerts at building entrances and on the doors to infected residents’ rooms
Maintain a minimum 3-ft. separation between an infected patient and other patients and visitors

Long-Term Living 2008 September;57(9):50-55

Topics: Articles , Clinical , Facility management

Flu season

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