SEASONAL SPOTLIGHT

Flu Care

Why was the flu a no-show last year, and how can we keep it from coming back?

The COVID-19 pandemic has revolutionized our understanding and experience of viral infections of the respiratory system, including infection by the influenza virus, says Neil Schachter, MD, a pulmonologist and medical director of pulmonary rehabilitation at the Mount Sinai — National Jewish Health Respiratory Institute in New York City and the author of The Good Doctor’s Guide to Colds and Flu.

Last year, for example, there was virtually no flu season. Typically, flu season lasts from October to April, with the official charts that track flu rates showing a huge statistical bump in the middle of winter and then a subsequent decline. But from October 2020, to April 2021, there was no bump whatsoever, domestically or internationally, says Dr. Schachter. Why was the flu a no-show last year, and how can we keep it from coming back?

Masks and Social Distancing

“There is no definitive scientific proof that social distancing, masks and other pandemic-based preventive measures contributed to or were the major players in preventing the flu, but … this is probably what happened,” says Dr. Schachter. He explains that since the influenza virus, like COVID-19, can be spread via airborne transmission, it’s unsurprising that the flu “can be mitigated by the same protective barriers, such as masks, and by social distancing.” So, the most important advice to give patients for preventing the flu is the same advice as for preventing COVID-19: Wear a mask, practice social distancing, wash your hands frequently, and don’t touch your face.

At-a-Glance

• To prevent the flu, patients (and clinicians) should mask up, practice social distancing, wash their hands frequently, and avoid touching the face.

• With rare exceptions, everyone ages 6 months and older should get a flu vaccine early in the season every year.

• There are four antiviral drugs that are FDA-approved for the treatment of influenza.

• A variety of over-the-counter products can ease symptoms and make patients more comfortable.

Vaccination: Yearly and Early

Equally important for prevention is getting the yearly influenza vaccine. The Centers for Disease Control and Prevention (CDC) advise that, with rare exceptions, everyone ages 6 months and older be vaccinated.1

“The flu virus changes yearly, and vaccines are carefully formulated every year to provide protection against the most common and current strains,” says Jay Woody, MD, chief medical officer of Intuitive Health and co-founder of Legacy ER & Urgent Care, the first retail-based joint emergency room and urgent care center. “This means the vaccine [a patient] got last year isn’t necessarily going to be effective this year — which is why it’s important to get a flu shot every year.” Moreover, patients should get their annual influenza vaccinations as early in the flu season as possible. The flu vaccine takes up to three weeks to reach maximum efficiency, says Dr. Woody.

There are nine different influenza vaccines this year, and all are “quadrivalent,” containing four types of influenza viruses that have been earmarked by the CDC as the most likely sources of flu infection this year. A table with all nine vaccines and their indications is available at the official CDC website.

Some influenza vaccines might be more appropriate for a particular patient than others. • For instance, most vaccines are manufactured using eggbased technology, but there are two egg-free vaccines for patients with egg allergies: Flucelvax Quadrivalent (Influenza Vaccine; Seqirus) and Flublock Quadrivalent (Influenza Vaccine; Sanofi Pasteur). • For patients who are afraid of needles, there’s a vaccine called FluMist (Influenza Vaccine, live, intranasal; AstraZeneca) that’s administered by nasal absorption. • Patients over age 65 should consider a high-dose vaccine, such as Fluzone High-Dose Quadrivalent (Influenza Vaccine; Sanofi Pasteur).

Still Some Risk

Be sure to let your patients know that getting vaccinated against the flu does not provide them with total immunity: The vaccines are only 40% to 60% effective, so patients should still follow other preventive measures once vaccinated. The flu virus is a much older virus than COVIID -19 and has had many more generations to evolve to evade the human immune system, explains Dr. Schachter. “The flu vaccine, along with social distancing and masks, are the best ways of protecting against the flu.”

Antiviral Medications

If a patient does get the flu, there are four antiviral drugs that are FDA-approved for the treatment of influenza: peramivir (Rapivab; BioCryst Pharmaceuticals), zanamivir (Relenza;

Relieving Flu Symptoms

Symptoms of the flu include fever, chills, coughing, chest discomfort, sore throat, a stuffy or runny nose, muscle aches (particularly in the back and legs), fatigue, and headaches. If an infected patient wants to feel a little better while the flu runs its course, there are many over-the-counter medications that can help reduce their symptoms:

• For fever, aches, and general fatigue:

Patients can take acetaminophen or ibuprofen (whatever works best for the patient at the onset of flu symptoms.

Patients can continue taking the chosen medication every four to six hours (follow the dosage instructions on the label) for the next four to five days. Aspirin should not be used for children and young adults under age 20 because of the possible complication of Reye’s syndrome, a rare but often fatal complication of the use of aspirin and related compounds in this age group.

• For coughing and sore throat: Lozenges with benzocaine can quiet the cough reflex and soothe throat pain.

• For sneezing and congestion: Patients can take a traditional antihistamine twice a day. The sedation that often accompanies antihistamines shouldn’t prove problematic if the patient feels too sick to work or play.

Congestion can also be alleviated with a decongestant spray, but the spray should be used no longer than three days to avoid rebound congestion. Older individuals and people with hypertension or cardiovascular disease should avoid decongestants altogether.

Patients who are interested in home remedies can consider supplementing their diet with vitamin C, zinc lozenges, or the herbal remedy echinacea. Some studies suggest these remedies lessen flu symptoms and decrease the duration of the infection; however, other studies don’t, so results may be mixed.

GlaxoSmithKline), oseltamivir phosphate (Tamiflu; Hoffmann-La Roche Inc.), and baloxavir marboxil (Xofluza; Genentech).

Dr. Schachter says all four are best used in the first two or three days after the onset of flu symptoms, and also offers some drug-specific notes: • Rapivab is administered intravenously in a one-time dose. • Relenza is a nasal spray that’s taken for five days. It shouldn’t be given to people with chronic lung disease because it irritates the airway and can cause exacerbation. • Tamiflu is a pill that’s taken for five days. • Xofluza is a pill that’s taken only for one to two days, but as the most recently approved of the four drugs, it doesn’t yet have extensive clinical documentation.

If a patient is at high risk for developing complications from the flu (e.g., if they live in a nursing home, are immunocompromised, or have a cardiorespiratory ailment), the antiviral drugs can be given preventively.

Complications: Bronchitis and Pneumonia

Three out of five people who get the flu develop acute bronchitis, says Dr. Schachter. People who have asthma or another chronic lung disease, or who are routinely exposed to air pollution or cigarette smoke, are at particular risk.

In a typical case of the flu, the fever, sore throat, and body aches start to go away after three days. If, after three days or so, the patient develops a burning chest pain and their coughing becomes more severe, they may have acute viral bronchitis. If the patient produces green mucus or their fever is 101oF or higher, they might also have a bacterial infection and may need to take antibiotics.

If a patient experiences serious shortness of breath, they may have developed viral pneumonia and should go to the emergency room. This is particularly important for young children and the elderly, who are most vulnerable to pneumonia. C

How to Talk to the Vaccine-Hesitant

Now, more than ever, you’re likely to meet patients who don’t want to be vaccinated for the flu. Stacia Hays, DNP, a pediatric nurse practitioner in Gainesville, Fla., and an associate professor at Baylor University’s Louise Herrington School of Nursing in Waco, Texas, shares her strategy:

“My job as a provider is to support the patient, to arm them with the facts, and let them make their decision. If they don’t want to get the flu shot, they don’t have to, but I’ll continue to have conversations with them.

“An experience I often share with vaccine-hesitant patients and families is that of a 15-year-old who wasn’t vaccinated for the flu. She contracted influenza and her symptoms were so severe she required a lung bypass machine. She barely survived. She now suffers from chronic lung damage. I don’t tell that story to scare the patient or make them change their mind about vaccination. But I want them to have a real picture of the dangers and the downsides — for themselves and for their children — so they can make an informed choice.”

REFERENCE

1. Centers for Disease Control and Prevention. Influenza Vaccination: A Summary for Clinicians. Accessed Jan. 12, 2022. https://www.cdc.gov/flu/professionals/vaccination/vaxsummary.htm