Influenza is usually considered a routine illness that, like the late comedian Rodney Dangerfield, often doesn’t get much respect. The 2017-18 flu season changed that.
Statistics on flu are sketchy because neither Texas nor the U.S. Centers for Disease Control and Prevention (CDC) require clinicians to report flu cases. Still, the CDC branded 2017-18 a “high severity season” based on anecdotal evidence and the data that are available. For instance, the number of flu-related deaths among children younger than 18 hit a record 172, surpassing the old record of 171 in 2012-13. In Texas, there were 16 pediatric flu deaths in 2017-18, up from eight in 2016-17 and seven in 2015-16, according to the Texas Department of State Health Services (DSHS).
For Texas physicians, this meant waiting rooms crowded with sniffling, coughing, miserable patients from October to March. In January, DSHS reported that many hospitals around the state had rerouted non-emergency ambulances because their emergency departments were full of flu patients.
Jennifer A. Shuford, MD, DSHS’ infectious disease medical officer and a consultant to the Texas Medical Association’s Committee on Infectious Diseases, cites several reasons for the season’s severity. Perhaps the most important: Last year’s vaccine was not effective against all the strains that appeared. In a typical flu season, flu vaccine can be up to 40- to 60-percent effective. The 2017-18 vaccine was 36-percent effective, one CDC study found.
More importantly, Dr. Shuford says, the most prevalent strain from last year was H3N2, and vaccines typically don’t protect well against it.
“Just having an H3N2-predominant year was going to make it a more severe year,” she said. “Usually, when it’s an H3N2-predominant season, we see more hospitalizations, more severe influenza, and more deaths. And it certainly happened that way last year.”
Predicting an epidemic
So will the upcoming flu season be better?
As usual, a lot will depend on the vaccine, Dr. Shuford says. The U.S. Food and Drug Administration (FDA) decides flu vaccines in February of each year based on consultation with disease-prevention authorities worldwide. Because the virus doesn’t normally show up in the United States until October, the FDA’s educated guess about which strains will be prevalent is just that — an educated guess.
“They’re working with imperfect, very early data in trying to predict what’s going to happen,” Dr. Shuford said. “And if there are genetic mutations that happen in the circulating virus, there’s no way to predict that ahead of time. It’s one way that the virus always stays ahead of us.”
Nevertheless, there are reasons to believe that the 2018-19 season could be better, says Trish Perl, MD, chief of the division of infectious diseases at UT Southwestern School Medical School in Dallas and a member of TMA’s Committee on Infectious Diseases. The most important preventative step is getting vaccinated, and publicity from last year is likely to put getting a flu vaccine on people’s radar, she says.
“The publicity always puts it back in people’s mind,” she said.
The nasal spray vaccine FluMist, which was removed from the list of recommended vaccines in 2016 because it was not as effective as injected vaccines, is now back on the list, Dr. Shuford says. That should make it easier to vaccinate young children. Also, this year’s U.S. vaccine is designed to improve protection against two of the strains that were not well matched in last year’s vaccine, which should minimize the disease’s impact.
Still, the No. 1 way physicians can reduce the severity of a flu season is by consistently reminding their patients to get flu shots, especially those who are most at risk: children 5 and under, pregnant women, people with weakened immune systems, and those 65 and older, says Catherine Eppes, MD, an obstetrician-gynecologist from Houston. She is assistant professor at Baylor College of Medicine in Houston and a member of TMA’s Committee on Infectious Diseases.
“In fellowship, I did a fair amount of research on influenza in pregnancy, and one of the things we found is that pregnant women were highly likely to get a vaccine if their physician recommended it,” Dr. Eppes said. “But a surprising number of women said their physicians were not recommending or offering flu vaccine. I think that’s a big gap that we can work on as clinicians.”
Studies indicate the more physicians know about influenza vaccine, the more likely their patients are to get it, Dr. Eppes says. But in her experience, a doctor’s knowledge seemed less important than simply finding the time during patient visits to recommend the vaccine.
“There are so many things we’re trying to do within clinical visits that sometimes preventative health falls lower on the list and gets forgotten,” she said.
Testing is also important, Dr. Shuford says. Rapid flu tests, designed to give results within 15 minutes, are notoriously inaccurate compared with other flu tests. As the number of flu patients rises during flu season, many physicians skip testing and simply assume patients who have flu-like symptoms have the flu.
Many physicians start high-risk patients on anti-viral medicines even before flu test results are in to prevent complications, and that is the right thing to do, Dr. Shuford says. Anti-viral medicines like Tamiflu are effective against all but about 1 percent of the strains that have circulated recently. Even so, doctors should not skip flu testing, she says.
“The testing is useful to actually make a diagnosis on the physician’s end but also for surveillance purposes, because [DSHS does] collect some of the data from across the state on influenza testing to know what types of virus are circulating and if there have been mutations in those viruses,” she said.
Dr. Shuford says physicians also should:
- Have vaccine available in their offices as early as possible in the flu season, preferably by the end of October, to help patients build up antibodies before flu hits;
- Help educate patients about when they should seek medical care if they contract flu. In many cases, getting anti-viral medications quickly is the difference between a mild and a severe case — or even death;
- Educate patients to take simple preventive steps like washing their hands and covering coughs and sneezes;
- Remind reluctant patients that even if the vaccine does not prevent flu infection, it can make their case of flu much milder and keep them from spreading the disease; and
- Remind patients who do get sick to stay home from work or school to prevent it from spreading.
Perhaps most important, Dr. Perl says, physicians need to do whatever possible to erase the ho-hum attitude many patients have about flu’s potential as a killer.
“There’s a sense that it’s not a big deal, but it is a big deal,” she said. “It may not be a big deal to you because you’re young and healthy. But it’s a big deal to the people around you. It’s a big deal for the health system.”
Can Practices Require Employees to Get a Flu Shot?
It may seem like the right thing do to, the sensible thing to do, even the obvious thing to do. But no, you can’t make everyone in your practice get a flu shot.
TMA supports “100-percent influenza vaccination among health care personnel, i.e., all employees of health care facilities with direct patient care contact.”
But, federal law says no employer with 15 or more employees can require those workers to get a flu shot. Title VII of the federal Civil Rights Act of 1964 protects them if they refuse the vaccine for sincerely held religious reasons or medical reasons such as pregnancy, severe adverse effects, or a life-threatening allergy.
Many health care employers “believe that a special exception exists for having a blanket policy on flu shots because of the heightened responsibility of maintaining the health and well-being of their clients,” says the Texas Workforce Commission (TWC), in Texas Business Today. “However, there is no such exception.”
What about practices and other businesses with fewer than 15 employees that are not subject to Title VII?
“[T]here is an argument that employers in this category might be able to impose a blanket requirement. However, this is not a best practice,” TWC said.
The agency warns that, depending on circumstances, problems could arise regarding workers’ compensation insurance, unemployment claims, or discrimination claims.
Any business can have a policy requiring flu shots that clearly informs employees of their right to request an exemption for legitimate reasons and how to opt out, such as by signing a declination waiver. These employers should reasonably accommodate exempted employees, for example by providing surgical masks or temporary reassignment, unless doing so would pose an undue hardship on the employer.
TWC says the flu policy should apply only to employees who regularly interact with patients. Or, practices might choose to adopt a less formal policy that only encourages employees to get a flu shot.
Note that Texas law does require some health care facilities, such as hospitals, ambulatory surgical centers, and freestanding emergency centers, to have a formal policy and procedures requiring vaccines, including procedures for opting out.
Read more on health care worker vaccination policies at www.texmed.org/HCWvaccination. And use the flu infographic on page 46 to share facts about flu and the flu vaccine.
Tex Med. 2018;114(10):42-43
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