1. Hale, Deborah MSN, RN, ACNS-BC


Each year, 5% to 20% of the U.S. population is infected with the influenza virus. The influenza season occurs annually between the months of October and May, with 3,000 to 49,000 influenza-related deaths each year. Since complications delay recuperation, those in high-risk groups need to be monitored carefully. High-risk groups are more vulnerable to severe illness and complications of the disease and include: people older than 65 years of age, children under 2 years of age, pregnant women, obese patients, and patients with other serious comorbid conditions. This article provides home healthcare clinicians with important information on influenza, how it is transmitted, influenza virus types and changes in the virus, signs and symptoms of complications, and measures to prevent the occurrence and transmission of influenza.


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Influenza season is upon us. How much do you know about influenza? What can home healthcare and hospice providers do to stem this yearly epidemic? Influenza, sometimes known as "the flu," is caused by a virus that affects the airway and lungs (Centers for Disease Control and Prevention [CDC], 2013a). It is a serious illness that should not be taken lightly. It is sometimes confused with "stomach flu" or gastroenteritis, but influenza is a respiratory illness, not gastrointestinal illness. It is important for home healthcare and hospice providers to have a basic understanding of influenza, including: how many people are affected, how it is transmitted, what to expect when someone has influenza, and complications to monitor after an influenza illness.

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Each year, about 5% to 20% of the U.S. population get influenza, and more than 200,000 people are hospitalized because of influenza-related complications (Health and Human Services, 2014). Anywhere from 3,000 to 49,000 people have died during each influenza season from 1976 to 2006 (CDC, 2013a). Older adults are a highly vunerable population, as they represent more than 90% of the estimated deaths due to influenza each year (Gozalo et al., 2012).


Because of its high prevalence, healthcare providers need to be prepared for the influenza season. Thus, it is helpful to have a timeframe for when to expect it to occur. In North America, the influenza season usually occurs sometime between October and May, and the peak (the time when the most cases arise) of the influenza season changes each year (CDC, 2014). For example, the 2013-2014 season peaked at the end of December, whereas other seasons have peaked in mid-March (2011-2012 season), February (2010-2011 season), and October (2009-2010 season) (CDC, 2014).


Knowing how influenza spreads will help healthcare providers prevent transmission. Influenza is spread via droplets made when people talk, sneeze, or cough (CDC, 2013b). People who have the influenza virus can spread it a day before symptoms begin, to up to 5 to 7 days after they are sick. Those with weakened immune systems (e.g., children who do not have well-developed immune systems) may be able to infect others for a longer period of time (CDC, 2013a) because they will not be able to destroy the virus as quickly as those with well-functioning immune systems. It generally takes about 2 days for a person to see symptoms after becoming infected with the virus (World Health Organization [WHO], 2014a).


It is important to understand the signs and symptoms of influenza to help care for someone with the virus. Common symptoms of influenza illness include:


* cough (although clear chest sounds will be heard on auscultation),


* fever (presence of a fever does not determine if a person has influenza or not),


* myalgia (muscle aches),


* headache, and


* sore throat (Lewis et al., 2011).



Manifestations may range from a mild illness that does not need medical intervention to a severe sickness that requires hospitalization and may even cause death. Although most patients without complications will run through the course of the illness in about a week, full recovery to normal functioning often takes longer, as much as 2 or 3 weeks (Schutten et al., 2013). If a person suffers any complications associated with influenza, recovery can take much longer.


Because complications delay recuperation, those in a high-risk group need to be monitored carefully. High-risk groups are more vulnerable to severe illness and complications of the disease and include people over 65 years of age, children under 2 years of age, pregnant women, obese patients, and patients with other serious co-morbid conditions (CDC, 2013b). A home healthcare and hospice provider may be the first one to notice potential issues with a patient's recovery from influenza. Some of the more common complications to monitor include:


* ear and sinus infections,


* dehydration (watch for dizziness, decreased urine output, and lethargy),


* pneumonia (watch for improvement of influenza symptoms followed by worsening cough, difficulty breathing, purulent sputum, and diffuse crackles on auscultation), and


* worsening chronic conditions (such as diabetes, heart failure, and asthma) (CDC, 2013b; Lewis et al., 2011).



A home healthcare and hospice provider who notes any of these complications should notify the patients' primary care provider.


Influenza Virus Types and Changes

There are various types of the influenza virus, and some cause more severe illness than others. Additionally, some of the viruses have the potential to change. These changes are a cause for concern, as new forms of influenza may be developed. The influenza virus has three types: C, B, and A. Each influenza virus type has some distinct characteristics, such as how common it is and the severity of illness caused by the particular type. These factors will play a role in the virus types that are included in the season's influenza vaccine.


Type C viruses are not as common as Types A and B. When a person is infected with a Type C virus, the illness is generally milder than with the other types of influenza. This type is usually not included in the yearly influenza vaccine (Glezen et al., 2013). As such, no further discussion about Type C viruses will occur.


Type B viruses are more common and severe than Type C. There are two lineages of the Type B virus: the Victoria lineage and the Yamagata lineage. Both lineages have been in circulation worldwide since 1983, and one of these lineages is typically included in the influenza vaccine (Paul Glezen et al., 2013). Type A viruses typically receive the most attention due to their ability to cause severe illness (Paul Glezen et al., 2013). There are various subtypes of Type A viruses, which are named for the proteins (hemagglutinin [H], which allows the virus to enter a cell, and neuraminidase [N], which helps spread the virus to other cells) on the surface of the virus (WHO, 2014a). Different combinations of the H and N proteins will give each Type A virus a unique name. Currently, the circulating Type A viruses are H1N1 and H3N2, and have been included in recent influenza vaccines (WHO, 2014b).


Both Type A and B viruses have the ability to change. The viruses' ability to adapt and survive is because of modifications to the individual parts of the surface proteins (known as amino acids). The effect of these changes on humans will be determined by how quickly they occur and how many take place. Small changes are known as "antigenic drift," whereas large, abrupt ones are termed "antigenic shift" (Thomas & Noppenberger, 2007). These changes in the influenza virus are constantly being monitored for, and are the reason for changes in influenza vaccines each year. Antigenic drifts occur continually over time, and affect both Type A and B viruses (CDC, 2011). These minor variations typically occur every 1 or 2 years, and cause the influenza virus to change slightly (Thomas & Noppenberger, 2007). If the changes remain small, humans may still have partial immunity to the modified virus, thus causing fewer or milder cases of influenza than with major changes (Lewis et al., 2011).


With antigenic shift, there is a major and abrupt change to a Type A influenza virus. Antigenic shift can occur in one of three ways: (a) the virus originally found in waterfowl infecting an intermediate host (e.g., a pig or chicken) and being transmitted to humans by the intermediate host, (b) a strain of influenza directly "jumping" from an aquatic bird to humans, or (c) two viruses from separate hosts mixing (generally in an intermediate host) to form a new virus, which can be transmitted back to humans (Thomas & Noppenberger, 2007).


The threat of antigenic shift is real, and needs to be monitored for. Although there are currently 2 types of Type A viruses circulating in humans (H1N1 and H3N2), there are 16 subtypes of influenza found in animal species (especially birds and pigs). If any of these viruses undergo antigenic shift, there is a potential for an influenza pandemic, as humans will have no immunity to the new virus (Paul Glezen et al., 2013). Thus, it is important for home healthcare and hospice providers to watch current influenza trends to help prevent and contain influenza outbreaks, especially if a new type of virus emerges.


What Healthcare Providers Can Do

There are a number of actions home healthcare and hospice providers can take to help prevent influenza. Although getting vaccinated is the best method, there are other recommendations that can be followed for those who wish to prevent influenza or recover from the illness. A number of resources are available for home healthcare and hospice providers who wish to learn more. According to the CDC (2013c), there are a few everyday actions people can take regarding influenza prevention and care:


* Avoid contact with sick people.


* Cover your nose and mouth with a tissue when you cough or sneeze, and then throw it in the trash when done.


* Wash your hands with soap and water often throughout the day. If soap and water are not available, use an alcohol-based hand rub.


* Do not touch your eyes, nose, and mouth.


* Clean and disinfect surfaces and objects that might be contaminated with germs.


* Stay home for at least 24 hours after your fever is gone (without fever-reducing medicine) unless necessary (i.e., to get medical care).


* Antiviral medications may be prescribed, but work the best if started within 2 days of getting sick. Not everyone with influenza will need antiviral medications. Antibiotic use is not appropriate, as influenza is a viral infection, not bacterial.



The single best method of influenza prevention is vaccination (Schutten et al., 2013). Because of antigenic drift, the influenza vaccine is changed every year to help provide proper immunity to those who receive the vaccine (Thomas & Noppenberger, 2007). For the 2014-2015 influenza season, healthcare providers will see the H1N1 and H3N2 and a Yamagata lineage Type B virus included in the influenza vaccine (WHO, 2014b).


Vaccination Myths

Some people are hesitant to receive the influenza vaccine due to several known misconceptions. Healthcare providers play an important role in correcting the myths that surround the influenza vaccine and teaching patients about the benefits of vaccinations. One of the myths is that the influenza vaccine causes illness. This may be because of vaccine adverse effects that are similar to symptoms of the disease (e.g., mild fever, aches, pains), or it may be because of infection with another respiratory illness (e.g., another strain of the influenza not included in the vaccine). Because the intramuscular influenza vaccine does not contain a live virus, it cannot cause influenza ("Vaccinations: Myth vs. Reality," 2013).


Another influenza vaccine myth involves the mercury content (i.e., thimerosal) in the vaccine. Some people believe thimerosal will make them sick, so they do not want to be exposed to it. Although there is no evidence regarding harm due to thimerosal, patients are able to request a thimerosal-free vaccine if they have concerns regarding the vaccine component ("Vaccinations: Myth vs. Reality," 2013). Other myths relate to older adults and the vaccine. Some believe the influenza vaccine is not effective in older adults or that older adults no longer need to be vaccinated. Neither of these are true, as older adults tend to have more chronic health conditions (putting them at greater risk for getting influenza and complications from the illness), and they also typically have the highest rates of influenza and pneumonia of any age group. Older adults may benefit from a high-dose influenza vaccine to help boost the immune response to the influenza virus. The disadvantage of a higher-dose vaccine is that the side effects are also greater ("Vaccinations: Myth vs. Reality," 2013).


All persons over the age of 6 months old are recommended to receive an influenza vaccine, barring contraindications (CDC, 2013b). This means it is important not just for patients to receive the vaccine, but for healthcare providers to be vaccinated as well. Healthcare organizations are recognizing the importance of healthcare providers receiving an influenza vaccine and many facilities are requiring staff to receive it as a condition of employment. This protects not just the employee, but the patients being cared for as well. Some facilities allow staff to wear facemasks while coming in contact with patients if the staff member did not receive an influenza vaccine, whereas other facilities have mandated the vaccine as part of employment. A study conducted via a self-selected opt-in Internet survey of 1,944 healthcare professionals revealed overall vaccine coverage of healthcare professionals was 96.5% if there was a requirement for employees to receive the vaccine, whereas only 72% of healthcare providers received the vaccine if it was not mandated. The 72% is an increase from past influenza seasons, which were 66.9% in the 2011-2012 season and 63.5% for the 2010-2011 influenza season. It should also be noted that higher vaccine coverage was found when vaccines were offered free of charge to employees (CDC, 2013c).


Healthcare providers should begin receiving and offering patients the influenza vaccine as soon as possible, preferably by October. Vaccine efforts should contine throughout the influenza season, as the duration of the season varies and some communities may not be affected until February or March. It is also important to note that immunity from the influenza vaccine does not immediately take effect; it takes approximately 2 weeks for immunity in most adults (CDC, 2013d).


Some healthcare providers worry about how effective the vaccine will be if received early in the influenza season, as a person's antibody levels decline over the months following vaccination. Even though delaying vaccination may allow more immunity later in the influenza season, waiting to vaccinate may result in someone who does not get vaccinated at all. It is better to offer the influenza vaccine early (and have some immunity throughout the influenza season) rather than wait (and possibly never get vaccinated) (CDC, 2013d).


The next step is to get vaccines to patients. There are various methods to accomplish this goal. Organized campaigns (e.g., an influenza vaccine fair), offering the vaccine during routine health visits and hospitalizations, or home healthcare and hospice providers calling the patients's physician to receive an order and administer the vaccine on a home visit are a few ways to help get the vaccine to the most people possible. Whenever administering an influenza vaccine, make sure to give the vaccine information statement (VIS) to the patient before vaccination. Copies of the VIS can be located on the CDC's Web site:


Healthcare providers can also participate in National Influenza Vaccination Week, which runs December 7-13, 2014. Every year, the CDC runs this campaign to encourage vaccination of all people older than 6 months. Activities, flyers, posters, print and audio material, and more can be found at the CDC's Web site.


Home Healthcare and Hospice Provider Tips

Home healthcare and hospice providers need to stay up to date on influenza information. To do this, healthcare professionals can download an application on their mobile device to receive up-to-date information on influenza activity, best practices, influenza diagnoses and treatments, laboratory tests, recommendations on infection control, videos from topic experts, and more ( There are also free materials to print and hand to patients to help them understand and open the dialog about influenza vaccines.


Additionally, here are a few influenza tips for home healthcare and hospice providers to follow:


* teach patients everyday actions to prevent the influenza,


* educate patients and caregivers how to care for themselves and loved ones with the influenza,


* monitor those who are sick with influenza for complications and refer them for medical care as necessary,


* provide patients written information regarding influenza prevention and vaccines to post on their refrigerator,


* ask patients to demonstrate their hand-washing technique and correct any errors,


* provide them with cards on "How to wash your hands" to post in their bathrooms,


* call in an order and bring an influenza vaccination to the client (remember the VIS!),


* receive an influenza vaccine yourselves, and


* stay up to date on influenza information via the CDC's Web site.



Berries and Cognition: Did You Know?

Recent research in the Nurses Health Study found that higher intakes of blueberries and strawberries were associated with slower rates of memory decline in older women. Women who ate .5 cups of blueberries at least once per week or .5 cups strawberries at least twice per week appeared to have the best memory. Specifically, women who ate a lot of berries had similar memory skills to those who were 1 to 2 years younger. These findings could be because of a specific type of flavonoid called an anthocyanidin, which has antioxidants properties and gives berries their rich color. Anthocyanidin can cross the blood-brain barrier, which may explain how it affects a person's memory.

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