Biting Back
Faced with a particularly virulent flu bug this year, nurses emphasize prevention and protective measures to curb the spread

By Heather World
January 29, 2004

June Stanley, MSN, FNP, RN, knew this year's flu season would be bad when her first laboratory confirmation of influenza came Nov. 21.

"We usually don't see it until February," said Stanley, a nurse at the student health center at California Polytechnic State University, San Luis Obispo. "I felt so bad for the students, because this hit around midterms, and then they'd be going into finals."

Epidemiologists cannot draw broad conclusions about this year's flu until the season ends in the spring. Certainly, the situation seems worse: During the last week in December 2002, no states reported widespread flu activity. During the last week of December, 42 states reported widespread activity.

But nurses agree on at least one thing: This season, the flu came early. Around Thanksgiving, the CDC reported seeing more severe influenza, as well as cases stemming from a strain of the virus not included in the vaccine.

The CDC and media coverage kept the number of cases and severity of the flu in the public eye, said Pam Axelson, MSN, NP, RN, nurse manager of the Adult Immunization and Travel Clinic at the San Francisco Department of Public Health.

Soon, there was a run on the vaccine.

"We had lines around the building for about a week," Axelson said. "We had to have people from other offices in the health department come monitor the door. People waited in line three hours to get a flu shot."

By the end of the week, Dec. 12, her office had administered 5,000 doses and was officially out of vaccine.

"This will be the first year we've ever run out," she said. "Most years, we're getting rid of 2,000 doses at the end of the year."

Anecdotal evidence suggests this year's flu also may be more virulent.

For example, during December, Stanley and the health center staff administered IVs for dehydration from nausea and vomiting; treated gastroenteritis, high fever and cough; and remedied secondary acute infections like new colds and pneumonias.

"We had a lot of myalgias-where every little hair follicle hurts," she said. One patient came to the health center after an anatomy class. Between sessions of vomiting, he described pain at his "bifurcation of the main stem of the bronchia."

"He was right!" Stanley said.

Stanley also contracted the flu, despite a late vaccination. She suffers from asthma, and did not recover for two weeks.

Risk groups

As someone with a chronic medical condition, Stanley is at high risk for complications from the flu, according to the CDC. Adults older than 65-the population in which 90 percent of flu-related fatalities occur-pregnant women and children aged 6 months to 23 months make up the other three high-risk categories. The CDC recommends these people get the vaccine as a priority.

According to the CDC, an estimated 10 percent to 20 percent of Americans contract the flu each year. Of those, about 114,000 are admitted to the hospital and about 36,000 die.

But these numbers may not reflect the true magnitude of the flu, said Neil Pascoe, RN, a nurse epidemiologist for the Texas Department of Health.

"Most cases of influenza are not medically attended," he said. "Generally, I would say 30 percent of the population gets flu, but how many recognize it is unknown."

Influenza has three strains, although the third, C, is mild. The B strain has remained stable over the years, but the A strain mutates and adapts, making it more difficult to predict which type must be included in the vaccine. Seasons in which A strain predominate have been more severe in the past, with higher numbers of influenza-related deaths and hospitalizations.

This year, scientists realized too late that A/Fujian would be one of this year's dominant strains. A/Fujian was not included in the vaccine, although it does contain Fujian's close cousin, A/Panama, which will provide limited protection against Fujian.

Limited protection can mean the difference between life and death for people in the high-risk categories. Pascoe estimates 185 million Americans are at high risk. According to the CDC, manufacturers produced 87.1 million doses of the vaccine this year.

Early reports of healthy children dying from complications from the flu helped spur a run on vaccine that left doctors' shelves empty this year. In most years, health care workers throw away thousands of leftover doses. As Axelson and other nurses who order the vaccine know, predicting demand can be tricky.

"Every year we try and we fail," she said. This year, she guessed that more people would opt for the vaccine based on the SARS scare, even though the two diseases are unrelated.

Since the shortage in 2000, people have begun placing orders for vaccine earlier, which means manufacturers may not have any left for those who order late, said Nisha Gandhi, the adult immunization coordinator for the California Department of Health Services, Immunization Branch.

"It's a matter of people thinking about it earlier," she said.

Furthermore, manufacturers no longer allow returns of unused vaccine, she said.

Ounce of prevention

Clearly, not everyone who needs an inoculation gets it, and some people think nurses can do more to stop the swirl of misinformation that surrounds influenza and its vaccine. In fact, the biggest lesson from this year's heavy season may be that people in health care can do more to encourage prevention and reduce rates of transmission.

Many nurses who do not administer the shots don't know the recommendations about risk groups, said Cindy Noa, MS, RN, director of community health nursing and clinical services for the Champaign-Urbana Public Health District in Illinois.

"The best thing they can do is to educate themselves because patients listen to nurses," she said.

Contrary to common myth, the flu shot does not give its recipient the flu, although it can cause soreness around the area of injection, low-grade fever and aches. The vaccine contains dead virus, which cannot replicate.

This year, manufacturers were able to offer a new vaccine, a nasal spray that contains live but weakened virus. The spray is recommended only for healthy people aged 5 to 49 who are not in close contact with people at high risk for complications from flu.

Side effects of the nasal spray include everything from runny nose to vomiting, but not the flu.

Health care workers surrounded by sick patients are in the second wave of priority vaccinations, according to the CDC. Noa encourages nurses to start by getting the vaccine themselves.

"Many do not," she said.

Encouraging patients to wash their hands and get the vaccine is the next step, she said.

Judy Rotthoff, RN, studies influenza at the University of Michigan School of Public Health. She said some health care providers do not understand even basic facts about the flu. For example, influenza can be only a respiratory virus-stomach flu does not exist-that affects the upper chest, including the lungs, trachea and bronchi.

Furthermore, nurses should know that patients who call in complaining of fever and aches during flu season may need to be prescribed antiviral medications immediately, rather than the old "take two aspirin and call me in the morning."

"You need to take it within the first 48 hours," she said. Antivirals work by stopping the virus from reproducing.

"If you wait four or five days, then you have a bunch of virus circulating," she said.

Nurses in emergency rooms also can help prevent the spread of the virus. Trisha Flanagan, MSN, RN, works as a clinical nurse specialist in the emergency department at Massachusetts General Hospital in Boston.

On any given day, her triage room can have neonatal babies, geriatric patients and everyone in between-all of whom must be protected.

She watched admissions to the emergency department surge 10 percent to 6,600 in December.

"You feel every one of those over 6,000," she said. "It was like an assembly line of nasal swabs."

Flanagan's ED instituted guidelines to those waiting for care: Coughers must wear a mask (or use a tissue) to prevent the spread of droplets containing flu that are released in a 3-foot radius when people talk, laugh or cough. This is the most common way the flu is spread.

Less frequently, a person is infected by touching an object containing a virus droplet, then touching his mouth or nose.

"The mask initiative has been very successful," Flanagan said.

The hospital also warms up for flu season by educating its staff with posters, e-mails and one-on-one classes.

In the second week of January, the CDC reported this year's flu season may have peaked, but the season is far from over, Pascoe said.

"Will we get a second wave?" he asked. Last year, Texas had a second wave of B strain that closed more than 70 school districts for more than one day.

Any bad flu season meets the criteria for epidemic, but the far more serious pandemic occurs when a strain "shifts" or differs significantly from the contents of the vaccine.

"We're overdue for a pandemic," Noa said. In such a crisis, she said, death rates are high, even in young, healthy adults.

Rotthoff referred to the Spanish flu of 1918, a pandemic in which an estimated 20 million people died, although scientists think the number may be closer to 40 million.

"Spanish flu killed young, healthy people, sometimes within hours," Rotthoff said. "They still don't know why it was so lethal."

A pandemic could mean a shutdown of everything because police, health care workers, teachers and parents fall ill.

"Who is going to take care of you?" asked Rotthoff, rhetorically.

Respect the flu before the bad season hits, she said.

"As long as you have birds, mammals and people living together, flu is going to be around," she said. "Because it's a smart virus and is able to change, it's unpredictable what will happen in the future."

Contact Heather World at h_world@yahoo.com