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2013-14 INFLUENZA SEASON PRIMER GREGORY GAHM, MD
12/26/2013



First… A Disclaimer: Emails / advice are from a practitioner with a strong interest in influenza.  
As much as possible, the information provided is evidence-based, though not every situation has 
been thoroughly studied and my opinions sometimes vary from other published guidelines based on 
the fact I am primarily targeting advice to nursing home populations.  Updates will include vaccine
strategies, outbreak preparation, and options to consider when caring for patients, staff and visitors. 
Despite best intentions, perfect answers aren't always available.  Some vaccinated persons – 
especially frail seniors - still get infected and may die from influenza.  Some people who don’t
get vaccinated may be exposed and not get the flu – or at least not show symptoms.

Bottom line - use the advice to the extent you wish and make your own decisions.
 
Attached are the following:

• A one-page worksheet to follow as a guide for recognition, diagnosis, treatment and prophylaxis 
  of influenza
• A simple patient education / information document for patients or their legal representatives 
  from the CDC
• An editorial from Annals about Debunking the Egg Allergy Myth
• A summary of vaccinating persons with egg allergy from Up-To-Date

Overview

Except in immunocompromised persons and many elderly, Influenza is generally a preventable disease – 
if everyone were vaccinated annually as per CDC recommendations.  Unfortunately, too many persons
find excuses for themselves and their kids not to get vaccinated, so these persons become carriers
of the disease and spread it to everyone else. Choosing not to be vaccinated is almost always a 
selfish choice based on unfounded fears and myths that continue to rage despite volumes of evidence 
to dismiss them (e.g., see egg allergy update, below).  The vast majority of healthy kids and adults
respond to the vaccine with protective antibodies.  Unfortunately, only about 1 in 4 elderly living 
in nursing homes develop protective antibodies to standard-dose vaccine (it is likely 2-3 times that 
number with the High–Dose vaccine), pointing out once again why it is so important to vaccinate 
everyone else.

Kids and working-age adults seldom die from influenza, though they are the mobile petri dishes that 
acquire the virus, cultivate it, and then spread it indiscriminately to family, friends, coworkers, 
patients… anyone with whom they come into contact.  Because they often aren’t incapacitated or even 
terribly ill and need or want to go to school or work, they compound the problem by sharing their 
harvest of virions with everyone who comes near them.  Since the virus can circulate in water droplets 
in the air for a prolonged period of time, they don’t even have to cough on others to share it – they 
just cough and leave a trail of contagion behind for others to share later!

Each year, approximately 36,000 persons die of influenza in the US, more than 90% of whom are >65.  
In an average year, 1 in 8 up to 1 in 3 nursing homes report outbreaks.  During an average SNF 
outbreak, 1/3 of the patients and ¼ of the staff develop an influenza-like illness, and more than 
1 in 20 of the infected patients die as a result.  

The financial impact of an outbreak can be enormous.  You can juggle the numbers, but imagine 
these averages applied to a 100-bed facility with an outbreak.  34 residents get Influenza, and 
2 of them die.  One-quarter of the staff are out, for 3-7 days, so you need replacements.  The 
34 ill residents and sick staff likely receive Tamiflu or Relenza, running approximately $100 
per person for a course of treatment.  The other 66 residents and any unvaccinated staff are 
likely placed on Tamiflu prophylaxis at $10 per person per day, or about $1000 a day for the 
facility.  Prophylaxis typically runs for 1 week after the last new case, so may last for 2 
weeks to a month or more at a cost simply for the Tamiflu of $15,000 - $30,000.  Add in the 
additional cost of increased care for sick patients, replacement staff and additional costs 
of treating the secondary morbidities of increased heart failure, heart disease, pneumonia 
and other comorbidities that increase during an outbreak and the costs quickly skyrocket.  
Since Part A patients are typically sicker at the time, many of them end up exposed and 
going back to the hospital as you watch your readmit rates skyrocket while new admissions 
are placed on hold. Vaccination efforts put into perspective.  If every resident, staff member, 
vendor, visitor and volunteer – everyone entering the facility – were vaccinated, chances are 
minimal you would have an outbreak.  Vaccinating residents over 65 with the high-dose vaccine
likely doubles or triples their level of protection, further decreasing the chances for an outbreak.

The good news is that this year’s strains are essentially the same as last year’s.  Since 
last year was relatively mild and this year’s vaccine will be more like a booster shot, 
chances are excellent that we could have another mild year.
In Colorado, this is year #2 for the Influenza Vaccination Rules for LTC 
(Chapter II: General Licensure Standards).  These require vaccination of most persons 
regularly in the facility or will require that those who are not vaccinated wear masks 
throughout the defined influenza season while at work if specific facility targets are 
not met.  For the coming season, 75% of “employees” must be vaccinated by December 31, 
2013 to avoid the consequences.  Employees are defined in the regulation, but in simple 
terms it applies to anyone that the facility has a remunerative relationship with who 
will be in patient areas during the flu season, e.g., facility staff, providers, vendors, 
lab, pharmacists…  Although masks are not required for others, many facilities / chains 
have chosen to require them for non-vaccinated persons anyway.

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