Already the 2019 flu season is shaping up to be one of the worst years on record, due to the large number of influenza cases already confirmed
As early as April this year, an unusual increase in influenza activity was identified. The National Notifiable Diseases Surveillance Scheme (NNDSS) reported that in the quarter (13 January–12 April 2019) there were 27,537 cases of laboratory confirmed influenza. This is four times the quarterly rolling five-year mean.
Influenza typically affects between 5–10% of the community but in some instances it can be as high as 20%. This places a huge burden on the community in terms of economic losses through increased healthcare utilisation and lost productivity.
While the severity of flu season is unpredictable, vaccination is the most essential measure to prevent individuals from contracting the flu virus.
The influenza virus strains included in the 2019 seasonal influenza vaccines in Australia are:
- A/Michigan/45/2015, (H1N1)pdm09-like virus;
- A/Switzerland/8060/2017, (H3N2)-like virus;
- B/Phuket/3073/2013-like virus, Yamagata lineage; and
- B/Colorado/06/2017-like virus, Victoria lineage.
According to the Department of Health, so far in 2019 the notification rates have been highest in adults aged 80 years or older (305.2 notifications per 100,000), followed by children aged less than 10 years (253.6 notifications per 100,000).
Influenza A has accounted for the greatest number of notifications across all age groups. Where further sub-typing information was available, notifications of influenza A(H1N1)pdm09 is highest in children aged less than 10 years (13.1 per 100,000) and notifications of influenza A(H3N2) were highest in adults aged 80 years and older (31.1 per 100,000). Notification rates for influenza B were highest in children aged 5 to 9 years (38.1 per 100,000).
Who’s most at risk?
There are a number of individuals at higher risk of developing complication from the flu. This includes:
- older adults (65 years and older);
- Indigenous Australians (6 months to <5 years and 15 years and older);
- pregnant women;
- people aged 6 months and older with medical conditions that can lead to complications from influenza, such as:
– COPD and other lung conditions;
– diabetes (type 1 and type 2)
– impaired immunity such as HIV infection;
– malignant cancers;
– chronic neurological disorders;
– residents of nursing homes and other long-term care facilities are also at increased risk of severe complications from influenza.
Angela Newbound, immunisation education consultant based in South Australia, tells the AJP: “With the increased knowledge pharmacists have about influenza and the influenza program, they are in a prime position to have discussions with consumers about the importance of influenza vaccination, to not only protect the individual but to contribute to herd immunity.
“Individuals with medical risk factors are frequent visitors to pharmacies to purchase medications, so once again pharmacists are key to having this discussion with this cohort.”
Pharmacists can advise those people that fall into the high-risk group that the influenza vaccine is available free under the National Immunisation Program (NIP).
Symptoms of influenza
According to the Immunisation Coalition, in adults the symptoms of influenza can include:
- dry cough;
- muscle and joint pain;
- tiredness/extreme exhaustion;
- headache; and
- sore throat.
In children, influenza may present as:
- high fever;
- listlessness or lack of energy; and
It is noted that children can also get diarrhoea and vomiting with influenza infection.
It’s also important to recognise the features that usually distinguish influenza from the common cold.
Duration of symptoms. With influenza symptoms typically last 1–2 weeks compared to a few days for a cold.
Fever. This is often high with influenza but infrequent and mild with a cold.
Muscular aches and shivering. These are common with influenza but rare with a cold.
Unlike the common cold, it may take several weeks to fully recover from influenza, even for healthy younger people, and for some people the infection may lead to serious consequences including hospitalisation and death.
Complications of influenza include:
- acute bronchitis;
- acute otitis media;
- cardiovascular complications (e.g. myocardial infarction, myocarditis, pericarditis, stroke);
- Reye syndrome;
- Guillain-Barre syndrome; and
- death from pneumonia or cardiac failure.
Additionally, many people are at increased risk of severe influenza or influenza-related complications due to underlying medical conditions, such as diabetes, heart disease, or lung disease. This may be the case even where these conditions are controlled by medication.
Because of the many complications, morbidity rates due to influenza may be under-played. Angela Newbound explains, “While there are approximately 1500–3000 deaths a year from influenza in Australia, not all influenza-associated deaths are reported as such. They may be reported as a stroke, myocardial infarction or pneumonia.
The flu vaccine is the single best way for individuals to prevent themselves from contracting the flu virus.
Alongside the 2019 quadrivalent influenza vaccine, an enhanced trivalent vaccine, Fluad, is being supplied for those aged 65 years and older.
However, the Immunisation Coalition reveals that 61% of Australians do not intend to get the flu vaccine this year. It seems there are a number of barriers preventing people from protecting themselves against influenza.
Newbound advises, “Often people think the flu will just lay them up in bed for a couple of days and they will enjoy not having to go to work. The word ‘flu’ is over-used so every time someone has a sniffle, they will say they have the flu. Unless people are swabbed, no one knows if they have flu or not—given some people can experience little or no symptoms, while others will be very unwell.
“There has not been a robust advertising campaign encouraging people to get the flu vaccine. Messages are often about the ‘risk groups’ getting vaccinated. This often sends the wrong message. Sometimes it is as simple as people not knowing where to go for vaccination. They are often surprised to hear that some pharmacists and some councils can administer flu vaccine to adults.”
Typically the identified barriers include:
- ‘I never get the flu so don’t need the vaccine.’
- ‘The vaccine gives me the flu.’
- ‘I’m healthy; flu is only a serious disease for old people and people with health problems.’
- ‘Just never thought about it.’
“Pharmacists who are trained to administer vaccines have an exceptionally good understanding of the influenza vaccines, their efficacy and related adverse events. They understand that while flu vaccine is not 100% effective in preventing influenza, it is effective in reducing hospital admissions, the severity of disease and serious complications. This is key information they can pass on to the public,” says Newbound.
She adds, “Pharmacists are also well poised to discuss the common myths about flu vaccine such as ‘The vaccine gave me the flu’ or ‘I don’t have the flu vaccine because I never get the flu’. Pharmacists have a good understanding of the vaccine; they know that inactivated flu vaccines cannot cause influenza and that only inactivated flu vaccines are currently recommended for use in Australia.
“Pharmacists are also key in advising consumers that influenza can be sub-clinical; in other words, the consumer may not be aware they are infected with flu and that they can be silently spreading disease to vulnerable people.”
Influenza and pregnancy
Newbound advises, “Pregnancy and influenza are not a good mix. Back in 2009 with the flu pandemic, pregnant women were over-represented in intensive care units with a number of pregnant women dying around the world, including in Australia.”
She tells the AJP, “It would be ideal for pharmacists to have pamphlets on hand, which can be downloaded from the Commonwealth Government website, to give to pregnant women who present to the pharmacy.
“Pharmacists are in a prime position to provide information about the dangers of contracting the flu virus when pregnant, and the benefits of vaccine antibodies crossing the placenta to help protect the infant in the early weeks of life.
“As the funded vaccine is mostly not available in pharmacies (there may be some state and territory exceptions), pharmacists should advise these women they are eligible for free vaccine from their GP, under the National Immunisation Program.
“Of course, if women would prefer to pay the associated costs at the pharmacy, the pharmacist can administer the vaccine. Flu vaccine can be given at any stage of pregnancy.”
Treating flu and stopping the spread
The influenza virus is highly contagious. Furthermore, it can survive on hard surfaces for more than eight hours, so if someone touches a doorknob or keyboard they can pass on the infection to the next person who touches the infected surface.
Pharmacists and their staff can promote flu-smart practices such as good cough and sneeze etiquette, using disposable tissues, avoiding physical contact with others and washing hands with soap and water or an alcohol-based product.
Newbound says, “Posters promoting ‘Wash, Wipe, Cover’ displayed in the pharmacy, along with having alcohol-based hand gels and boxes of tissues on sale (or packaged together), will help push this message.”
To aid recovery, the Influenza Specialist Group recommends the following:
- resting and keeping warm;
- drinking plenty of liquids;
- cutting down consumption of alcohol and stopping smoking; and
- staying away from the workplace to avoid contaminating others.
Pharmacists may wish to discuss antiviral medication, as this can reduce the effect of influenza if taken in a timely manner.
The NSW Ministry of Health states, “Anti-influenza treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of symptoms.
“Evidence for benefits from treatment in studies of seasonal influenza is strongest when treatment is started within 48 hours of illness onset. However, some studies of treatment of seasonal influenza have indicated benefit, including reduction in mortality or duration of hospitalization, even for patients whose treatment was started more than 48 hours after illness onset.”
While these antivirals are prescription-only, the 2009 flu pandemic in the US highlighted the fact that timely administration of antiviral drugs is a critical factor in mitigating the effects of future outbreaks.
As such, pharmacists can play an important role in referring individuals to their GP. Newbound says, “If a person presents to the pharmacy with high fever and other influenza-like symptoms, influenza should be considered, and the person should be referred to their GP so they can be swabbed and have discussion about antivirals.”