Infection control: It’s time to get immunized!

Influenza is an acute disease of the respiratory system, and outbreaks of influenza can occur at any time during the year in long-term care.¹ In the United States, complications from infections with the seasonal influenza virus have accounted for approximately 60 percent of influenza-related hospitalizations and 90 percent of influenza-related deaths in patients 65 years of age and older.² The complications most attributed to influenza infections in the elderly include pneumonia, dehydration and worsening chronic conditions.² Of those mentioned, pneumonia is the most debilitating complication, and it can be life-threatening, especially for those living in a long-term care facility.¹

Diagnosing influenza-related pneumonia in residents of long-term care facilities can be difficult. Elders often do not present with typical complaints of fever, chills or pain on inspiration. However, residents may exhibit signs that they have developed increased risks for falls, or they may demonstrate a decrease in functional status or impaired cognition. Therefore, facility staff must be alert to changes in a resident’s behavior and functional status as clues of an infectious process.

Frequently, treatment for pneumonia may require hospitalizations that place a patient at increased risk for further complications such as skin impairments, deconditioning and delirium. Therefore, a key component for reducing the complications associated with influenza is to reduce the risk of becoming infected.

PREDICTING RISK

Several factors may increase the susceptibility of long-term care residents to the spread of influenza and pneumonia. These factors include the disproportionate rate of chronic illnesses in the elderly, decreased immune function, being in close proximity to others that are susceptible, as well as the presence of cognitive and neurological disorders.^2,3

In addition, as an individual gets older, changes may occur in the structure and physiological functioning of his or her respiratory system. The lungs lose elasticity and respiratory muscles weaken. Generally, these changes do not result in severe breathing problems. However, a respiratory infection in addition to chronic illnesses such as chronic obstructive pulmonary disease, heart disease, history of stroke with swallowing problems or impaired nutritional status can tax the respiratory system. Not only are there changes in the respiratory system, but the function of the immune response system decreases resulting in greater risk of pneumonia.

TEAM APPROACHES TO PREVENTION

Prevention of influenza and pneumonia in long-term care residents requires multiple interventions. A primary intervention is an active facility infection control program that promotes infection prevention through data collection, monitoring for trends of infections and education. Identifying and implementing policies promoting the delivery of oral hygiene care for all residents and methods to improve swallowing to minimize the risk of aspiration have been shown to reduce the risk for the development of pneumonia.⁴

Proper hand hygiene by all caregivers, facility staff or family members is acknowledged as the most important preventive activity for infection prevention. Respiratory hygiene and cough etiquette education for residents, staff and caregivers should be emphasized. Using a tissue to cover one’s mouth or nose and the prompt disposal of used tissues, as well as proper hand hygiene after contact with respiratory secretions, minimizes the risk of infection transmission.

The administration of an annual “flu shot” is one of the most important preventive measures to help decrease the risk of becoming infected with the influenza virus.² This vaccine is readily available, and it protects against the three most common flu viruses.² Once immunized, the risks of a person developing influenza-related disabilities, hospitalizations and deaths are lessened.² Therefore, the CDC has recommended that every individual aged 65 and older receive the influenza vaccination to help reduce their risk of acquiring the flu.²

Similarly, the pneumococcal polysaccharide vaccine (PPSV) is another preventive measure that is easily implemented in the long-term care facility. The PPSV protects against 23 types of pneumococcal bacteria within two to three weeks of receiving the injection. However, its effectiveness may be limited in elders or those with some chronic illnesses. But, receiving the vaccine may minimize complications if an individual develops pneumonia.

The CDC recommends that all adults over the age 65 years receive the PPSV.⁵ If a PPSV is received before age 65, a second PPSV is recommended after age 65, but each dose must be separated by minimum of five years. It is important for residents or family members to alert the facility medical staff of the resident’s immunization history, life-threatening reactions to the PPSV or any severe allergies.

It is also imperative that new public policies be established that explore further the issues of inadequate healthcare services, prevention and treatment of influenza, as well as those listed below from the CDC²:

• Practice infection control on a daily basis (hand washing, gloves, etc.).
• Test new residents and those who show any signs of infection.
• Provide influenza vaccinations to long-term care residents and all members of the healthcare team before the flu season begins.

By understanding these factors, healthcare professionals will facilitate a decrease in the associated disability and mortality that is associated with the influenza virus. Therefore, if we can help decrease hospitalizations from influenza-related complication, then patients can remain in their homes and continue to feel independent and empowered.

CONCLUSION

The utilization of a multidisciplinary team for assessment, planning, intervention and evaluation helps bring about positive changes that help to empower both the individual as well as the community. The reduction in the incidence of influenza and pneumonia infections in long-term care residents is a quality-of-life issue. Two effective and safe interventions include the annual influenza vaccine and PPSV. Protect your staff’s family members by discussing the facility’s immunization program with the medical staff and receiving an annual flu vaccine and PPSV as recommended.

Joann Clemons, RN, MSN, specializes in geriatric primary care in Home-Based Primary Care program at the Robley Rx VA Medical Center in Louisville, KY. She can be reached at Joann.Clemons@va.gov.

Katryna McCoy, PhD, FNP-C, is an Assistant Professor at Winston Salem State University specializing in Gerontology, Infectious Diseases and Community Health. She can be reached at mccoyk@wssu.edu.

REFERENCES

1. Montoya A, Mody L. Common infections in nursing homes: A review of current issues and challenges. Aging Health 2011;7(6):889-99.

2. Centers for Disease Control and Prevention. People at high risk of developing flu-related complications. Available at www.cdc.gov/flu/about/disease/high_risk.htm.

3. Flanagan E, Chopra T, Mody L. Infection prevention in alternative health care settings. Infection Disease Clinics of North America2011;25:271-83.

4. Jamshed N, Woods C, Desai S, et al. Pneumonia in the long-term resident. Clinics of Geriatric Medicine 2011;27:117-33.

5. Centers for Disease Control and Prevention. Pneumococcal Polysaccharide Vaccine: Vaccine information sheet. Available at www.cdc.gov/vaccines.