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.

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

Topics: Articles , Clinical , Facility management