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INFLUENZA The Flu What Nurses Should Know


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Title: INFLUENZA The Flu What Nurses Should Know

INFLUENZA (The Flu)What Nurses Should Know
  • Felissa R. Lashley, RN, PhD, FAAN, FACMG
  • Professor, College of Nursing, and
  • Interim Director, Nursing Center for Bioterrorism
    and Infectious Disease Preparedness, College of
  • Rutgers, The State University of New Jersey
  • This module is designed to highlight important
    information about influenza. The influenza virus,
    in addition to being the cause of influenza, an
    important infectious disease, is also considered
    to be a potential agent for bioterrorism and is
    considered as a possible Category C bioterrorism
    agent by the Centers for Disease Control and
    Prevention (CDC). This module was supported in
    part by USDHHS, HRSA Grant No. T01HP01407.

Some General Points
  • The influenza virus is considered to have the
    potential for use as an agent for bioterrorism,
    most probably by altering it to a mutated form
    with greater virulence, infectivity, more
    efficient human-to-human transmission, and
    antiviral resistance.
  • CDC considers it to be a Category C agent under

Some General Points cont.
  • This module is arranged as follows etiology,
    epidemiology, transmission, incubation period,
    overall clinical illness picture, clinical
    manifestations, clinical differentiation between
    the common cold and flu, complications,
    diagnosis, treatment, management including
    infection control measures and patient/staff
    education, and prophylaxis and vaccination.
  • Avian influenza is considered at the end of the
    content before the case studies.
  • Case studies, test questions and information
    sources appear at the end of the module.

  • At the conclusion of this module, the
  • participant should be able to
  • Identify the viruses that can cause influenza
  • Describe signs and symptoms commonly associated
    with influenza
  • Identify the major complications of influenza
  • Describe symptoms that can help differentiate
    between upper respiratory infection and influenza

Objectives cont.
  • Identify antiviral agents in current use for
    prevention of influenza
  • Identify antiviral agents in current use for
    treatment of influenza
  • Name the groups for whom flu vaccination is
  • Describe what is meant by avian influenza

  • Influenza viruses types A, B, C infect humans
  • Influenza types A B can cause widespread
  • Influenza type A tends to be the most severe
  • Influenza A virus types have most potential for
    use as bioterrorism weapon
  • Influenza viruses are RNA viruses classified in
    Orthomyxoviridae family
  • Can mutate and cross species barrier such as fowl
    to humans

Etiology cont.
  • Influenza subtypes are referred to by their
    hemagglutinin (H) and neuraminidase subtypes (N)
    which are surface glycoproteins of the virus
  • Examples Avian influenza virus subtypes A H5N1
    and H9N2 which appeared recently in Hong Kong and
    other areas
  • Influenza viruses have the ability to develop
    antigenic variants through viral mutation.
    Persons develop antibodies to specific variants
    which may not confer protection against another.
    This helps explain why there are seasonal
    epidemics and provides the basis for
    understanding the rationale for what strains of
    the virus will be used each year in vaccine

  • Worldwide distribution
  • Outbreaks usually occur suddenly
  • Flu spreads through communities resulting in an
    epidemic. Cases tend to peak after about 3 weeks
    and begin to subside after another 3-4 weeks

Epidemiology cont.-2
  • Have been several great influenza pandemics
  • 1918-19 Spanish flu
  • Caused 20-40 million deaths worldwide
  • A large proportion of these deaths was in healthy
    adults 15 to 35 years of age
  • 1957 Asian flu
  • 1968 Hong Kong flu
  • 1977 H1N1 influenza A virus subtype, Russian flu

Epidemiology cont.-3
  • Peak season is November through March
  • Each year about 10 to 20 of Americans develop
  • In the US, approximately 100,000 people are
    hospitalized with influenza each year, and about
    36,000 die

  • Major transmission route is through airborne
    large respiratory droplets with particles larger
    than 5 microns (µ) in diameter that are expelled
    from the respiratory tract of an infected person
    when they cough or sneeze
  • Direct contact with fomites (inanimate objects)
    contaminated with infected droplets or secretions
    and then touching ones nose or mouth
  • Transmission from infected birds, poultry or pigs
    (less common)

Incubation Period
  • 1 to 4 days with average of 2 days
  • Adults are infectious from day before symptoms
    begin through about 5 days after onset children
    can be infectious for 10 or more days after onset
    and those who are immunosuppressed can shed virus
    for weeks or even months.

Overall Clinical Illness Picture
  • Influenza infection can run a spectrum from
    asymptomatic or mild illness through fulminant
    primary viral pneumonia
  • For most uncomplicated cases, influenza resolves
    spontaneously in a few days but cough and malaise
    often last 2 weeks or more
  • Major clinical pictures
  • Rhinotracheobronchitis
  • Primary viral pneumonia
  • Respiratory viral infection followed by secondary
    bacterial pneumonia
  • There is no stomach flu - these manifestations
    are from other disorders

Major influences on clinical illness development
and complications of influenza
  • Age - elderly (over 65 years of age) and young
    children particularly younger than 5 years of age
    and especially those 6 to 23 months are
    particularly vulnerable
  • Presence of other chronic underlying illnesses
    such as chronic cardiac or pulmonary disease
  • Compromised immune status such as from
    immunosuppressive drugs, or conditions such as
    malnutrition or pregnancy
  • Lack of access to health care
  • Crowded living conditions that facilitate
    transfer of respiratory pathogens that can
    include congregate and institutional settings
    especially if precautions such as respiratory
    hygiene dn cough ettiquette are not observed
  • Health care workers may be at higher risk for

Clinical Manifestations
  • Abrupt onset of constitutional and respiratory
  • Fever, duration typically 1 to 5 days, with an
    average of 3 days and peak within 12 hours after
    symptoms. Typical temperatures are 38 to 40 deg.
  • Myalgia
  • Headache
  • Chills
  • Cough, usually unproductive
  • Sore throat
  • Malaise
  • Rhinitis
  • May have eye tearing, burning, photophobia or eye
  • Children may have otitis media and nausea and
    vomiting as well as febrile convulsions in
    addition to other symptoms
  • Elderly persons may present with minimal
    respiratory symptoms but show lassitude, high
    fever and confusion
  • Respiratory symptoms may increase as fever

Clinical Differentiation Between the Common Cold
and the Flu (see Table 1 at end of module)
  • The following symptoms are more commonly seen in
    influenza rather than the common cold
  • High fever lasting 3 to 4 days
  • Headache
  • Myalgia
  • Fatigue and weakness
  • Extreme exhaustion
  • Severe chest discomfort and cough
  • The following symptoms are more commonly seen in
    the common cold rather than influenza
  • Stuffy nose is common
  • Sneezing is common
  • Cough is generally mild to moderate
  • Symptoms such as fever, headache, aches and pains
    and exhaustion are rare in those with colds.

Complications may be respiratory or
non-respiratory or both
  • Major respiratory complications include
  • Primary viral pneumonia
  • Occurs most frequently in elderly or persons with
    cardiopulmonary disease
  • Can occur in healthy immunocompetent persons or
    pregnant women
  • Usually develops rapidly, within 1 day or onset
    of illness
  • Symptoms include rapidly progressing fever,
    tachypnea, tachycardia, cyanosis and hypotension
  • Signs include bilateral crepitant rales on chest
    examination, chest x-rays showing
    nonconsolidating pulmonary infiltrates, but
    sometimes areas of consolidation, blood gas
    studies show hypoxemia, blood counts may show
    leukocytosis with a left shift
  • Mortality is high, and extensive fibrosis and
    interstitial inflammation may develop

Complications cont.-2
  • Secondary bacterial pneumonia
  • Occurs most frequently in elderly or persons with
    pulmonary disease
  • Typical course of influenza illness seems to be
    improving but fever with shaking chills returns,
    pleuritic-type chest pain, productive cough with
    bloody or purulent sputum
  • Signs include local areas of lung consolidation
    on chest X-ray, sputum culture and Gram stain may
    reveal predominance of bacterial pathogen, most
    commonly Streptococcus pneumoniae, Staphylococcus
    aureus, Haemophilus influenzae, or Moraxella
  • Mortality can approach 7

Complications cont.-3
  • Combined bacterial-viral pneumonia
  • Coinfection can yield varying symptoms which may
    be like primary viral pneumonia at first
  • Coinfection with S. aureus may carry a
    particularly high mortality rate
  • Exacerbation of chronic pulmonary disease such as
    asthma or in persons with cystic fibrosis

Complications cont.-4
  • Major non-respiratory complications include
  • Cardiac complications particularly
    electrocardiographic abnormalities and
  • Central nervous system complications such as
    seizures, especially in children, and acute
  • Reyes syndrome, a neurologic and metabolic
    disorder occuring mainly in children and
    adolescents from 2 to 16 years of age. It appears
    more closely associated with influenza B than
    influenza A and has a mortality rate of 10 to
    40. Not prescribing aspirin for patients,
    especially children and adolescents with viral
    infections has decreased the incidence of Reyes
  • Myositis may occur primarily in children and
    particularly after influenza B along with
    myoglobinuria and rhabdomyolysis leading to acute
    renal failure.

  • Important to make diagnosis as quickly as
  • Facilitated by community surveillance knowledge
    about influenza outbreak patterns in the
  • May be made on basis of clinical signs and
    symptoms along with knowledge about influenza
    patterns in the community. Thus in the setting of
    a confirmed influenza outbreak in a given
    community, persons who are not residents of
    institutions and who have muscle aches, fever and
    two respiratory symptoms probably have influenza
    according to Shorman Moorman, (2003).

Diagnosis cont.
  • Laboratory diagnostic methods include
  • Viral culture (need expert technicians and time
    but excellent specificity and sensitivity),
    reverse transcriptase polymerase chain reaction
    (labor-intensive, costly but quick with excellent
    specificity and sensitivity), serology, rapid
    antigen testing, and immunofluroescence assays.

Treatment (this is not comprehensive and is not
meant as recommendations)
  • Certain antiviral agents may be used
  • Newer antiviral agents include zanamivir and
    oseltamivir (Tamiflu). Both are effective against
    influenza A and influenza B. These also need to
    be administered within the first 48 hours of
    symptoms. Both are category C agents in pregnancy
    and there is a risk for adverse effects in those
    with underlying respiratory disease. It is
    administered via oral inhalation. Oseltamivir may
    result in nausea and vomiting side effects so
    needs to be taken with food. It is administered
    orally. Transient neuropsychiatric events have
    been described in adolescents and some adults
    taking oseltamivir. These two agents were the
    only ones licensed for flu prevention and
    treatment in 2008.

Management including Infection Control Measures
  • Management includes
  • Symptomatic treatment such as encouraging fluids
    and rest the treatment of symptoms with
    over-the-counter medications but not aspirin in
    children or adolescents
  • Comfort measures
  • Specific management approaches depend upon
    symptoms, complications and characteristics and
    condition of the individual patient

Management including Infection Control Measures
  • Infection Control Measures
  • Appropriate prophylaxis and immunization is an
    important part and is discussed below
  • Respiratory hygiene and cough etiquette programs
    are now a part of standard precautions
  • Initiate at first point of contact with even a
    potentially infected person
  • Includes education which may be visual and\or
    verbal at an appropriate educational level with
    cultural considerations of patients and the
    people who accompany them
  • Should include informing personnel if they have
    any symptoms of respiratory infection, having
    tissues provided to patients and visitors, throw
    tissues away after use in proper container,
    instructing them to cover their mouth and nose
    when coughing or sneezing, providing alcohol
    based hand rubbing dispensers and supplies for
    handwashing and educating patients and staff in
    their use, encourage handwashing after coughing
    or sneezing, offering masks to persons who are
    coughing, encouraging coughing persons to sit at
    least 3 feet away from others, instruct patients
    and providers not to touch eyes, nose or mouth
    and have health care personnel observe Droplet
    Precautions in addition to Standard Precautions.
    Health care workers should use standard
    precautions with all patients.

Management including Infection Control Measures
  • Infection Control Measures cont.
  • Standard Precautions are detailed in a separate
  • Droplet Precautions are detailed in a separate

Management including Infection Control Measures
  • Persons with respiratory infection symptoms
    should not visit patients
  • Health care workers with respiratory infection
    symptoms should be excluded from work for the
    duration of the illness
  • In health care settings, influenza testing should
    be done early in the outbreak to obtain the type
    and subtype of virus responsible
  • Droplet Precautions with suspected or confirmed
    influenza should be implemented and authority to
    do so should be decided with nursing staff
  • As detailed further under Droplet Precautions,
    suspected or confirmed influenza patients should
    be separated from asymptomatic patients

Management including Infection Control Measures
  • Health care staff movement between units and
    buildings should be restricted
  • In a setting or unit with influenza, patients
    without influenza should receive influenza
    antiviral prophylaxis unless contraindicated
  • Influenza antiviral therapy should be
    administered to those who are acutely ill with
    influenza within 48 hours of onset of illness
    unless contraindicated
  • Current inactivated influenza vaccine should be
    administered to unvaccinated patients and health
    care personnel if not contraindicated
  • Influenza antirviral prophylaxis should be
    offered to unvaccinated personnel for who it is
    not contraindicated and who work in the affected
    unit or who are caring for high-risk patients

Management including Infection Control Measures
  • Limit or eliminate elective medical and surgical
    admissions and restrict cardiovascular and
    pulmonary surgery to emergency cases only when
    influenza outbreaks especially those
    characterized by high attack rates and severe
    illness, occur in the community or acute care
  • Recommendations for peri-and post-partum settings
    may be found at http//

Prophylaxis and Vaccination
  • Antiviral agents may be used for prophylaxis,
  • often in combination with the flu vaccine in an
  • outbreak situation
  • Drugs used most often in the U.S. for prevention
    of flu are zanamivir and oseltamivir and are used
    particularly for those at high risk for
    complications from the flu or to prevent a person
    in close proximity from passing the flu to a high
    risk person

Prophylaxis and Vaccination cont.-2
  • Influenza vaccine
  • Current vaccines are inactivated influenza vacine
    administered by injection (Fluzone) and live
    attenuated, intranasal vaccine (FluMist)
  • In late July, 2008, the Advisory Committee in
    Immunization Practices (ACIP) issued their
    updated recommendations on prevention and control
    of influenza. The entire document is in
    Morbidity and Mortality Weekly Reports,
    Recommendations and Reports, 57 (early release) ,
    1-60, July 17, 2008

Prophylaxis and Vaccination cont.-3
  • Recommendations for 2008-2009 Influenza season
    are given below
  • It is recommended that all children aged 5-18
    years old receive vaccination .
  • Children younger that 6 months should not be
  • Children and adolescents at higher risk for
    influenza complication are those
  • aged 6 months 4 years
  • who have chronic pulmonary (including asthma),
    cardiovascular (except hypertension), renal,
    hepatic, hematological or metabolic disorders
    (including diabetes mellitus)
  • who are immunosuppressed (including
    immuno-suppresion caused my dedications or by
    human immunodeficiency virus)
  • who have any condition (e.g., cognitive
    dysfuction, spinal cord injuries, seizure
    disorders, or other neuromuscular disorders) that
    can compromise respiratory function or the
    handling of respiratory secretions or that can
    increase the risk for aspiration
  • who are receiving long-term aspirin therapy who
    therefore might be at risk for experiencing Reye
    syndrome after influenza virus infection
  • who are residents of chronic-care facilities
  • who will be pregnant during the influenza season.
  • Source CDC, MMWR 57, 2008 pg 2

Prophylaxis and Vaccination cont.-4
  • For adults for the 2008-2009 flu season
    recommendations are for any adult and for and for
    all adults in the following groups because of
    higher risk
  • Persons aged 50 years
  • Women who will be pregnant during the influenza
  • Persons who have chronic pulmonary (including
    asthma), cardiovascular (except hypertension),
    renal, hepatic, hematological or metabolic
    disorders (including diabetes mellitus)
  • Persons who have immunosuppressions (including
    immunosuppression caused by medications or by
    human immunodeficiency virus)
  • Persons who have any condition (e.g., cognitive
    dysfunction, spinal cord injuries, seizure
    disorders, or other neuromuscular disorders) that
    can compromise respiratory function or the
    handlig of respiratory secretions or that can
    increase the risk for aspiration
  • Residents of nursing homes and other chronic-care
  • Health-care personnel
  • Household contracts and caregivers of children
    aged 50 years, with
    particular emphasis on vaccinating contracts of
    children aged
  • Households contracts and caregivers of persons
    with medical conditions that put them athigh risk
    for severe complication from influenza.
  • Source CDC, MMWR 57, 2008 pg 2

Nasal Spray Vaccine
  • Live, attenuated vaccine administered by nasal
  • Option for those healthy people ages 2 to 49
    years old
  • Option for health care workers who take care of
    sick persons or care for babies under 6 months of
    age and who are healthy between 2 and 49 years of
  • Not to be used in pregnancy
  • Not to be used by those who care for or live with
    someone with a compromised immune system or
    children less than 2 years of age

Table 1. Is It a Cold or the Flu?Source
National Institute of Allergy and Infectious
Special Notes on Avian Influenza
  • Avian influenza viruses refers to those that are
    carried by birds, usually wild birds that when
    infected, shed virus in saliva, nasal secretions
    and feces. Birds or fowl become infected when
    they come into contact with secretions or
    excretions from infected birds most often through
    fecal-oral transmission. Transmission also occurs
    through contact with surfaces or materials such
    as feed, water, cages or dirt that are
    contaminated with the virus. Contaminated cages,
    for example, can carry the virus from one place
    to another.
  • Avian influenza viruses vary in their degree of

"Hong Kong" Flu
  • First documented direct transmission of an avian
    influenza (influenza A) virus (H5N1) to humans
    occurred in 1997 in Hong Kong
  • Severe respiratory disease occurred in 18 healthy
    young adults and children and 6 died
  • The outbreak was controlled by slaughter of the
    poultry population. More than 1.2 million
    chickens and 0.3 million other poultry were
    killed and imports of chickens from Hong Kong and
    China were banned by other countries. Quarantine
    and depopulation or culling of birds are common
    ways of control for the outbreak

"Hong Kong" Flu-2
  • Live poultry markets were source of the avian
    influenza virus strain H5N1 in this outbreak. In
    both influenza and SARS, the so-called
    wet-markets have been implicated as sources.
    This illustrates a cultural influence on
    emergence of infectious diseases since the
    preference of many Asian people for buying fresh
    foods at these markets have resulted in an
    increase in these types of markets. In New York
    City, these increased in number from 44 in 1994
    to 80 in 2002.

Additional Recent Avian Flu Outbreaks
  • In 1999, avian influenza viruses, H9N2, were
    isolated in Hong Kong from children with mild
  • In 2003, the avian influenza virus strain, H5N1,
    again emerged in 2 family members in Hong Kong
    after traveling in China. One died.

Additional Recent Avian Flu Outbreaks-2
  • In 2003, the avian influenza virus strain H7N7
    occurred in poultry farms in the Netherlands,
    spreading to Germany and Belgium. Infection,
    mainly conjunctivitis occurred in 83 humans with
    1 death. The outbreak was controlled by
    destroying over 30 million domestic poultry
  • In 2003, the avian influenza virus, H9N2 was
    identified in a child in Hong Kong with influenza
    who recovered

Additional Recent Avian Flu Outbreaks-3
  • In 2003, an outbreak of avian influenza virus,
    H5N1, occurred in South Korea, and in 2004
    emerged in Vietnam and Thailand. Human cases
    presented with severe respiratory infection and
    out of 23 known and confirmed cases, 18 died.
    Many countries banned the import of poultry
    products from the Asian countries affected. Other
    countries in which poultry were infected included
    Japan, Laos, China, Cambodia, and Indonesia.

Additional Recent Avian Flu Outbreaks-4
  • In 2004, an outbreak of avian influenza, H7N7
    occurred in British Columbia, Canada. Infection
    has been reported in 5 humans whose major illness
    was conjunctivitis.
  • In 2004-2005, east Asia again saw an outbreak of
    H5N1, particularly in Thailand, Cambodia, and
  • By June 19, 2008, there were 385 reported human
    cases of avian flu and 243 reported deaths.
  • Concern about pandemic flu has resulted in global
    efforts at prevention.

Documented human-to-human transmission of H5N1
has been noted but is limited. Of concern is that
the virus could mutate to allow sustained
person-to-person transmission.
  • Transmission includes
  • Direct exposure to infected birds/poultry
  • Exposure to surfaces contaminated with infected
    bird/poultry excretions, mostly through
    fecal-oral transmission
  • Rare human-to-human transmission
  • Symptoms
  • Fever, over 38 deg. C or 100.4 deg. F
  • Shortness of breath
  • Cough
  • Diarrhea

Suspecting Avian Influenza (H5N1)
  • Laboratory testing should be prompted for a
    hospitalized or ambulatory patient with
  • temperature over 38 deg. C AND
  • with any one or more of the above symptoms AND
  • a history of contact with domestic poultry such
    as a visit to a poultry farm or bird market
  • Laboratory testing should be prompted for
    hospitalized patients
  • with radiologically confirmed acute respiratory
    distress syndrome, pneumonia or other severe
    respiratory illness for which an alternate
    diagnosis has not been established AND
  • history of travel to an area with documented H5N1
    avian influenza within 10 days of the beginnings
    of symptoms.

Isolation Precautions
  • For hospitalized patients who have or are
    suspected of having avian influenza A (H5N1),
    isolation precautions are same as for severe
    acute respiratory syndrome (SARS). These include
  • Careful hand hygiene before and after all patient
  • Use gloves and gown for all patient contact
  • Wear eye protection when within 3 feet (and
    perhaps 6 feet) of the patient

Isolation Precautions-2
  • Place patient in an airborne infection isolation
    room (AIIR).
  • When entering the patient's room, use a fit
    tested respirator at least as protective as an
    N95 filtering-facepiece respirator approved by
    the National Institute for Occupational Health
    and Safety (NIOSH)
  • Outpatients or hospitalized patients discharged
    in less than 14 days should be isolated in the
    home setting on the basis of principles for home
    isolation of SARS patients
  • These precautions should be continued for 14 days
    after onset of symptoms until an alternative
    diagnosis is established or diagnostic test
    results indicate that the patient is not infected
    with inflenza A virus (CDC, 2004). Also see
    http//, and