Influenza: The Unwanted Visitor Vaccination is the most important method of prevention and control of the influenza virus in the nursing home resident.

B Y C A R O L W A R D

Thelma, an 86-year-old retired teacher, sat quietly eating in her room at the nursing home. Her favorite niece, Cathy, had come to Visit with her newborn baby. As they sat visiting, a nurse came in and was surprised that Cathy was there. An in- fluenza outbreak had struck the nursing home, and a quarantine was in place. Cathy had not seen the small sign on the door, but on learning of the outbreak she quickly said her good-bye and left.

E ach year in the nursing home as the Christmas sea- son approaches, family members, staff, and resi- dents anticipate holiday cheer. Visitors arrive and

gifts are exchanged. Some visitors, however, such as in- fluenza, are unwanted. Influenza is a major concern each year for families, staff, and residents of nursing homes. The results of an influenza infection can be devastating for institutionalized elderly, who are more prone to ill- ness.

Currently the influenza vaccine is the most effective way of protecting nursing home residents and staff from the deleterious effects of the influenza virus. Unfortu- nately, residents and family, as well as health care pro- fessionals, have concerns about the side effects of the vac- cine or about its inconvenience in administration. This ar- ticle will address these issues.

B a r r i e r s to In f luenza Vacc ine A c c e p t a n c e

The residents and their families often have concerns about the influenza vaccine. They may believe they will contract the virus or unwanted side effects if they receive the vaccine. These negative attitudes and fear of side ef-

CAROL A. WARD, RN,C, BSN, is a graduate student at the School of Nursing, University of Wisconsin-Madison. She has received certi- fication as a gerontological nurse through the American Nurses Asso- ciation. 34]1/36627

fects have been major deterrents to influenza vaccination in the elderly. Many studies have shown no significant side effects of the vaccine, and a more recent study has again shown no significant difference between influenza vaccine and placebo in respect to the proportion of sub- jects reporting disability or systemic symptoms, l' 13, 14

Residents and family are not the only ones concerned; health care professionals also have concerns regarding side effects of the influenza vaccine. Two of the reasons health ca reworkers gave for not receiving the vaccine were that they tried to avoid medications whenever pos- sible and that vaccine administration was inconvenient. 2 These negative attitudes and fears must be overcome if nursing home residents and staff are to be protected from the influenza virus.

C h a n g e s in t h e R e s p i r a t o r y Sy s t e m o f t h e E l d e r l y

A progressive decline in respiratory function in the eld- erly puts the elderly person at risk for problems that can arise from influenza. The weakened pectoral muscles and

Geriatric Nursing November/December 1992 329

increased stiffness of the chest wall are exacerbated by a loss of recoil of the lungs. 3' 4 This process leads to reduced cough efficiency, decreased ciliary activity, and increased dead space--all of which will reduce the resident's ability to adapt to infections. 4 Also, confinement to bed for short to moderate periods promotes stasis in the lungs. Cere- bral oxygenation is decreased, which can bring about confusion or aggravate an already demented state. Be- cause of these aging changes, many residents are unable to adapt to the influenza virus when it strikes, leading to high rates of morbidity and mortality, s'7

Morbidi ty and Morta l i ty

The elderly residents of nursing homes are at particu- lar risk for the development of influenza. There seems to be no escaping the transmission from family to resident, staff to resident, resident to staff, and resident to resi- dent. There are two subtypes of influenza A (HsN2 and HINI) and one type B that circulate throughout the United States each year. s' 8d0 Of these, H3N2 is most often responsible for the 10,000 to 40,000 deaths associated with influenza, s, 9 Elderly persons account for 80% to 90% of all influenza-related deaths: There is a way, how- ever, to combat influenza before it strikes, and that is through vaccination.

The influenza virus causes 10,000

to 40 ,000 deaths per year, with

80 % to 90 % occurring in the

elderly.

Prevent ion and Control

Before influenza cases can be prevented or controlled, education has to take place in nursing homes and in the population at large. 6 Clinical trials have shown the effi- cacy of the influenza vaccine in healthy adults. Uncon- trolled studies among elderly persons have shown that in- fluenza vaccination can be at least 60% protective against serious illness, hospitalization, and death: The Centers for Disease Control (CDC) recommends certain high- risk groups be vaccinated against influenza each year. Among these groups are residents of nursing homes, those 65 years and older, any patient who has a chronic illness, and anyone who has close contact with any of these groups. 6, 8 These recommendations significantly af- fect nursing home administrators in their attempt to lessen influenza outbreaks each year. There is a respon- sibility to vaccinate not only residents but also staff. If the staff is not vaccinated, stringent policies need to be im- plemented and enforced regarding when staff members should not report to work because of symptoms of influ- enza. Staff members often report to work when they do not feel well, possibly passing the influenza virus to other staff members and residents?' 6

Every year the Advisory Committee on Immunization Practices publishes recommendations in the Morbidity and Mortality Weekly Report on the vaccine available for this influenza season. For the 1991-92 season, triva- lent vaccine included the A/Taiwan/I/86-1ike (HIN1),

A/Beijing/353/89-1ike (H3N2), and B/Panama/45/90- like hemagglutinin antigens? The recommended dose for adults and nursing home residents is 0.5 ml of either the whole or the split-virus vaccine injected intramuscularly: An adult of any age needs only one injection annually and, according to the Advisory Committee on Immuni- zation Practices, it should be given in November. The reasoning behind this timing is that the flu season does not usually begin until December, and antibody levels tend to decline within a few months after vaccination? It is important to note that anyone with a hypersensitivity to eggs, who has a febrile illness, or who has had an ana- phylactic reaction to the influenza vaccine in the past should not receive the vaccine) The type of reaction should be elicited from the person, however, as it may have been unrelated to the vaccine.

Although being vaccinated against influenza should be the first priority for the pre- vention and control of influ- enza, the use of amantadine, an antiviral agent, is some- times war ran ted . When given prophylactically to young adults, it is 70% to 90% protective against type A influenza virus infec- tions.5, 9 Amantadine works by interfering with the un- coating of type A influenza

viruses during their replication cycle. It reduces shedding from the infected person, s, io The CDC recommends amantadine be given at the onset of outbreaks in institu- tions and given each day for the duration of influenza activity. When amantadine is given for outbreak con- trol, it should be administered to all residents regard- less of whether or not they received the influenza vaccine the previous fall. It should also be given to un- vaccinated staff members who provide direct care or who may have been missed in the vaccination process. Amantadine can also be given prophylactically until the influenza vaccine has had time to take effect, a period of approximately 2 weeks. The dosage recommendations and side effects of amantadine need to be considered when an elderly person is being treated because of its effect on the nervous and gastrointestinal systems? When given to anyone with renal impairment (resulting in re- duced drug clearance), a smaller dose should be admin- istered.

Nursing Implications

On the basis of a survey in 1988 by the CDC, it was ev- ident that education of physicians and patients could sub- stantially improve immunization rates. Having the vac- cine recommended by health care professionals increased acceptance of vaccine elevenfold to twelvefold. II

The need for studies in nursing homes to help substan- tiate efficacy of influenza vaccine is paramount. It would give information that has been lacking in the literature thus far. Until more information is available, however, nursing home residents and personnel need to be vacci- nated as recommended by CDC's Advisory Committee

330 Geriatric Nursing November/December 1992

on Immunization Practices for the prevention and control of influenza. More information can be obtained about in- fluenza and its control by writing to Technical Informa- tion Services, Center for Prevention Services, Mailstop EO6, CDC, Atlanta, GA 30333. 9

It is important to diagnose influenza by its signs and symptoms, because it can take up to a week to isolate the virus for identification. If it is routine for nursing homes to try to isolate the influenza virus, a protocol is a must. Typical influenza illness is characterized by abrupt onset of fever, myalgia, sore throat, and nonproductive cough.9, 12 Recognizing these entities as symptoms of in- fluenza is a challenge in the nursing home population be- cause of residents' atypical symptoms of physical illness and the large number of residents with dementia and aphasia. Again, studies in this population are needed for improvement in identifying the influenza virus and the treatment needed once influenza has occurred.

In 1988 several recommendations were made as a re- sult of a Wisconsin nursing home survey. These include the following: (1) when feasible, nursing home adminis- trators should delay giving the vaccine until November, (2) all nursing homes should try to achieve an immuni- zation rate of 80%, (3) education programs should be conducted for staff to emphasize the importance of staff immunization, (4) all nursing homes should develop an influenza outbreak control plan, (5) all nursing homes should institute a daily surveillance program of counts of influenza-like illness, (6) when an influenza outbreak is suspected, it should be reported to the public health agency, and (7) all nursing homes should be aware of the importance of virus testing and be able to obtain isolation kits within 24 hours. 13 The Advisory Committee on Im-

munization Practices also recommends that 80% of resi- dents be immunized against influenza. 6, 13

These goals can be reached only by establishing ad- ministrative guidelines and procedures for influenza vac- cination programs and then ensuring that they are im- plemented. A program that includes residents, family (visitors), and staff is a must for the prevention and con- trol of influenza in the nursing home population.,~

REFERENCES

1. Margolis K, Nichol K, Poland G, Pluhar R. Frequency of adverse reactions to influenza vaccine in the elderly. JAMA 1990;264:1139-4 I.

2. Weingarten S, Riedinger M, Bolton L, Miles P, Ault M. Barriers to influenza vaccine acceptance. A survey of physicians and nurses. Infect Control 1989;17:202-7.

3. Tockman MS. The effects of age on the lung. In: Abrams WB, Berkow R, eds. The Merck manual of geriatrics. Rahway, New Jersey: Merck, 1989.

4. Gioiella EC, Bevil CW. The aging process: physical adaptions. In: Gioiella EC, Bevil CW, eds. Nursing care of the aging client: promoting healthy adap- tion. East Norwalk, Connecticut: Appleton-Century-Crofts, 1985.

5. Fedson DS. Prevention and control of influenza in institutional settings. Hosp Pract 1989;24:87-96.

6. Weingarten S, Riedinger M, Bolton L, Miles P, Ault M. Barriers to influenza vaccine acceptance. Am J Infect Control 1989;17:202-7.

7. Sprenger M, VanNaelten M, Mudler P, Masurel N. Influenza mortality and excess deaths in the elderly, 1967-82. Epidemiol Infect 1989;103:633-41.

8. Now is the time to vaccinate. Emerg Med 1989;Oct:84-6. 9. US Department of Health and Human Services. Prevention and control of in-

fluenza. MMWR 1991;40:1-15. 10. Influenza: the deadly potential. Emerg Med 1989;Oct:61-72. 11. Siegel B, Mahan C, Witte J, Janowski H. Influenza and pneumococcal pneu-

monia immunization. J Fla Med Assoo 1990;77:593-5. 12. Collier VU, Reinbardt J, Halloway W. Grand rounds: influenza. Del Med J

1990;62:867-7 I. 13. Parkman PD, Galasso G J, Tap FH, Noble GR. Summary of clinical trials of

influenza vaccines. J Infect Dis 1976;134:100-7. 14. La Mantagna JR, Noble GR, Tuinnan GV, et al. Summary of clinical trials

of inactivated influenza vaccine--197g. Rev Infect Dis 1983;5:723-36. 15. US Department of Health and Human Services. Influenza prevention and

control update. Wis Epidemiol Bull 1990;12:1-8.

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