Elaine Higson, RGN, is practice nursing sister, Goodwood Court Medical Centre and the Eaton Centre, Hove
The one thing you can guarantee about flu is that it comes every winter. Although elderly people have been encouraged to receive vaccination, only 58% of those vaccinated become immune to the flu strains in the vaccine. With an uptake of 60%-70% in the over-65s this winter, this means that only some 30%-40% of this high-risk group will be immune. This is insufficient to prevent the virus spreading rapidly - particularly where a number of susceptible people live together, as in nursing or residential homes (Box 1).
Children spread flu by coughing and sneezing over each other. But they suffer few complications themselves. Visiting elderly relatives - particularly at Christmas and New Year, as happened in 1999-2000 - accounts for outbreaks.
The virus can also be spread to communities by health care professionals bringing it to work from home. Historically, outbreaks have been shown to be transmitted between closed communities by a single individual. According to public health laboratory statistics, most years, influenza A is the dominant virus causing an increased workload for nurses - most outbreaks last for six-weeks, usually between November and February. Influenza B has been responsible for recent lesser outbreaks.
Flu is characterised by the speed and intensity with which it strikes the patient (Fig 1). He or she is rapidly so exhausted and unwell that the only thing they can do is stay in bed. Fever is prominent, but elderly people run an average temperature lower than that of younger adults. Hence a ‘normal’ temperature may actually be a pyrexia for an elderly person.
There is a dry cough and loss of appetite. This is distinct from other viral respiratory tract illnesses which cause less fever and certainly less malaise.
A few simple triage questions to the patient’s representative - it will rarely be the patient as he/she will be too weak to phone - can elicit a likely diagnosis of flu, particularly when it is known that influenza is circulating locally.
Managing the virus
Amantadine has been licensed to treat influenza A for many years, while zanamivir is the first of the neuraminidase inhibitors to be licensed in the UK. These drugs are safe and are eminently suitable for patient group directives (Fig 2).
However, both drugs are most effective if administered very early in the disease process. Nurses who manage residential or nursing homes, community nurses and primary care triage nurses therefore play an important role in the control of any local outbreak or epidemic of flu.
Amantadine or zanamivir can be administered under local patient group directives or on prescription by the medical practitioner. Amantadine is a single daily oral medication while zanamivir needs to be inhaled twice a day - both are for five days. Care must be taken with amantadine in those who have poor renal capacity although, in reality, this is probably not a significant problem as the drug is only administered in relatively a low dose and for a limited period. Zanamivir exacerbates asthma in those with pre-existing chronic airways disease, so a bronchodilator may be needed more often.
Nursing and residential homes
Prophylaxis is useful in close communities when it is known that either a member of staff or one of the residents has flu. Amantadine is licensed both as a treatment for influenza A, but also as a prophylactic medication for high-risk groups. Administering this drug to staff members and to all residents for 14 days is effective in decreasing the number of subsequent cases of the flu virus.
Amantadine prophylaxis can also protect an individual after late administration of flu vaccine. The vaccine is only effective after about 10 days and does little good if flu strikes soon after vaccination. Nursing home or rest home nurse managers should consider vaccination and antivirals for staff to prevent flu being passed to residents and to ensure staff are not absent due to sickness.
Managing flu does not stop at vaccinating patients or using antiviral agents - it requires good nursing care and observation for complications. The most common cause of morbidity from influenza is secondary bacterial infection and invasion, resulting in organ damage and collapse.
Observation of patients for deterioration can indicate the development of secondary bacterial infection and the need for hospital admission. Pneumococcal vaccination is recommended in all those with chronic morbidity - a group which overlaps closely with those at risk from flu.
Using protocols enables nurses caring for high-risk patients to diagnose flu and recommend antiviral medications to prevent secondary morbidity and reduce the time the patient suffers the distress of the virus. It may also be necessary to use antiviral agents prophylactically to prevent flu being spread to other high-risk patients.