Influenza season - Lippincott Williams & Wilkins

www.nursingmanagement.com20 January 2009 Nursing Management

nfluenza is a highly contagiousrespiratory infection that's caused by a variety of influenza viruses. Theillness produced by the virus can be mild to severe, and can even lead todeath. Seasonal flu refers to the anticipated outbreak that occurs each yearusually in late fall and winter. Typically, between 5% and 20% of the populationin the United States is infected each year.1

Influenza season:

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Jane Kapustin, CRNP, PhD

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Influenza isn't just a nuisanceillness that causes misery for theinfected; the tolls of the disease arefar-reaching. More than 200,000 ofthose infected with influenza eachyear will require hospitalization, and36,000 will die from complicationsrelated to influenza, such as pneu-monia, encephalitis, and respiratoryfailure.2

Historically, influenza is responsi-ble for a massive number of deathsworldwide. In the pandemic of1918-1919 during World War I,more than 675,000 Americans diedfrom influenza—10 times the num-ber who died in the actual war.Moreover, 20 to 40 million peoplein the world died from influenzaduring that time period.3

Influenza spreadInfluenza is a highly contagiousviral illness that spreads readilyvia droplet transmission, primarilyfrom coughing and sneezing. Theincubation period is 1 to 4 days,and the average is 2 days.1,4 Onefactor that facilitates the spread ofinfluenza is that people are able totransmit the disease even beforethey display noticeable symptoms,and remain contagious for up to5 days after the symptoms appear.Children are often contagious10 days after the onset of symp-toms. People who are immuno-compromised can shed the virusfor up to 3 weeks after the illnessbegins.5

Influenza spreads readily inclosed environments, particularlyschools and daycare centers. Notonly does it spread by person-to-person contact, influenza can alsosurvive for up to 2 hours on sur-faces such as doorknobs, desks,phones, and counters.5,6

The groups that are at risk fordeveloping complications follow-ing infection with influenza includethe following: over age 65, under

age 5, concurrent medical illnessfor any age, and immunocompro-mised state. The two highest riskgroups that are hospitalized mostfrequently are those over 65 andthose under 2 years of age.6,7 Chil-dren are two to three times morelikely to get the flu than adults, andthey frequently spread the virus toothers. Younger children are partic-ularly vulnerable to influenza, asthey don't have natural immunity.Children who suffer with chronicdisease such as diabetes or asthmaare more likely to be hospitalizedwith complications such as pneu-monia, dehydration, Reye’s syn-drome, croup, bronchiolitis, andear infections.6,7

The elderly account for up to 90%of the deaths related to influenza.7

The effects of influenza are moreprofound for the elderly for severalreasons. First, they're more likelyto suffer from comorbidities thatpredispose them to influenza com-plications6 and have diminishedimmunologic response to influenzaantigens. This is mostly due toreduced T-cell response, whichshould assist with recognition ofinfected cells’ outer layers. Afterage 50, T-cell response begins tolessen, and by age 70 or 80, theresponse is markedly reduced.8

There's recent evidence to suggestthat in elderly patients, intradermalinjection of influenza vaccine maybe more effective than an intramus-cular injection because a more rapidimmune response can be producedwhere a higher concentration ofimmune cells reside.9

Data from one retrospectivestudy suggest that morbidity asso-ciated with influenza may have aheritable component. In the study,family members of people whodied from influenza were morelikely to also suffer a poor outcomerelated to influenza, suggesting apredisposition to death.10

Types of influenzaThe three types of influenza virusare A, B, and C. Influenza A and Bare the culprits associated with sea-sonal epidemics, but influenza Cgenerally causes a mild respiratoryillness that doesn't instigate anepidemic.

The flu virus contains eight singlestrands of RNA to make new copiesof the virus. The outer layer of spike-like projections is characteristic offlu virus. There are two types ofspikes: protein hemagglutinin,which has a sticky surface thatallows it to adhere to a cell to infectit, and protein neuraminidase,which facilitates the exit of newlyformed virus cells from host cells.5,6

Type A is the most troublesome.It's responsible for the majorinfluenza epidemics of 1918, 1957,and 1968. Type A subtypes areclassified by naming the strain, alab identification number, yeardiscovered, and the type ofprotein (hemagglutinin [H] andneuraminidase [N]) it possesses.For example, consider A/HongKong/156/97 (H5N1).5,6

Influenza is divided into sub-types according to the two proteinson the viral surface: H and N.Although there are 16 differenthemagglutinin subtypes and 9 dif-ferent neuroaminidase subtypes,only subtype A (H1N1) and subtypeA (H3N2) are found in people. TypeB isn't divided into subtypes, but isfurther broken down into differentstrains. These three are includedin a vaccine each year but subtypeC isn't.11

Etiology of influenzaInfluenza virus is found in aquaticbirds (such as ducks and shorebirds) where it has persisted formillions of years, incapable of hurt-ing the host bird. However, if thevirus mutates, it can “jump” thespecies barrier from wild birds to

Nursing Management January 2009 21www.nursingmanagement.com


Influenza season: Are you ready?

domesticated ducks and chickens to(eventually) pigs. Pigs can becomeinfected by both avian and humaninfluenza virus. In this setting, thereassorted flu virus may reflect anexchange of genes between the twoviruses that can spread from pigs tohumans.5,6,12

In 1997, scientists discovered thatbird influenza skipped the pig anddirectly infected humans. As it didn'tappear to spread from human tohuman, the virus didn't cause anepidemic. H5N1 avian flu viruswould need to infect cells viahemagglutinin-binding proteinsby adapting to the glycans of theupper respiratory tract. Currently,H5N1 virus binds to a different gly-can than human influenza virus,preventing its efficient spread.13

Influenza virus is highly change-able. Small, continuous changesthat happen intype A and typeB influenza are

called antigenic drift. Because thisdrift produces a new strain of virusthat's unrecognized by the humanimmune system, a new flu vaccinemust be produced each year tomatch that year’s prevalent strain.5

Type A virus can also make sud-den, infrequent changes called anti-genic shift. This occurs when twodifferent flu strains infect the samecell and exchange genetic material.This can create a new influenzasubtype that's capable of producing

a severe flu epidemic or pandemicbecause there's little to no immu-nity associated with it. Theinfluenza epidemic of 1918 resultedfrom this pathophysiologic mecha-nism and was responsible for mil-lions of deaths worldwide.3,5

Symptoms of influenza anddiagnosisThe flu is different from a commoncold in several respects. Influenza isnotable for producing fever, usuallyquite high. Additional symptomsinclude headache, myalgia, fatigue,sore throat, cough, and stuffy orrunny nose, and gastrointestinalsymptoms such as nausea, vomit-ing, and diarrhea (more common inchildren than adults). The symp-toms of sudden onset, fever at onset,headache, and cough are most use-ful for making a clinical diagnosis

and carry a 75% positive predictivevalue.4

Because early treatment withantivirals can mitigate some ofthe severe symptoms, influenzashould be diagnosed quickly. Earlydiagnosis is also key to avoidingunnecessary antibiotics. Accuratelydiagnosing influenza is somewhatdifficult because several bacterialinfections can masquerade asinfluenza or coexist as a complica-tion of influenza. It's important to

identify bacterial infections andtreat them appropriately.4,6

The diagnosis based on symptomscan be assisted by surveillance infor-mation as well as diagnostic testing.State and local health departments, aswell as the CDC, can alert providersabout the incidence of influenza andthe influenza A subtypes and strainsoccurring in the community. Beingaware of the presence of influenzaand the particular strain assistshealthcare providers in accuratelydiagnosing influenza by finetuningtheir index of suspicion.6,14,15

Viral culture, serology and rapidantigen testing, polymerase chainreaction (PCR), and immunofluores-cence assays are available for thediagnosis of influenza. Nasopharyn-geal swabs or nasal washing are pre-ferred over throat swab specimens toenhance the sensitivity and speci-

ficity of the test.Some outpatientrapid commer-

cial diagnostic tests are available aswell; however, they differ in theirability to distinguish among viraltypes. Some can detect the presenceof type A viruses only or bothinfluenza A and B viruses, eitherwith or without the ability to distin-guish between the two types. Noneof them can detect A subtypes.6,14,15

PCR tests yield results in 30 minutesand are 85% to 95% sensitive.4

Rapid tests have lower specificityand sensitivity than viral culture;

eing aware of the presence of influenza and the particular strain assists healthcare providers in

accurately diagnosing influenza by finetuning their index of suspicion.

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therefore, all negative resultsshould be further tested by viralculture to reduce the chance of falsenegativity, especially during thepeak flu season.6,14 The positiveand negative predictive valuesshould be considered in contextwith the community’s influenzaactivity. The CDC recommendsobtaining viral cultures for the fol-lowing reasons: to detect circulatingstrains and subtypes of virus, tocompare strains with vaccinestrains, to specify proper treatment,to help predict vaccine content forthe coming year, to identify antivi-ral resistance patterns, and to sur-vey for new influenza A subtypesthat may bring a pandemic out-break.14,15

Treatment of influenzaAlthough not all patients requireantiviral medications, the high riskor severely ill should receive themwithin 48 hours of symptoms tolessen the likelihood of complica-tions.6 There are four availableantiviral medications used to treatinfluenza. (See Pharmacologic agentsto treat influenza.) The first two areneuroaminidase inhibitors thatblock the ability of the virus toinfect and spread to other cells.

Oseltamivir (Tamiflu) is indicatedfor preventing and treating uncom-plicated influenza A and B in adultsand children age 1 and older. It'savailable in pill form as well as apediatric liquid formulation.5,6

Zanamivir (Relenza) is indicatedfor treating uncomplicated influenzaA and B in children age 7 or older,or for adults who have had symp-toms for no more than 2 days. It'sapproved for preventing influenzaA and B virus in adults and chil-dren age 5 and older. It's deliveredas an inhaled powder via a dry-powder inhaler.5,6

The next two compounds inhibitviral replication in the host cell.Rimantadine (Flumadine) is indi-cated for adults with influenza Avirus; it has no effect on influenzaB. Amantadine (Symmetrel) is indi-cated for adults and children 1 yearor older; it's used to prevent andtreat type A influenza only. To max-imize effectiveness, these medica-tions need to be started within 48hours of onset of influenza. Theyreduce the length of time symptomspersist, particularly fever. Theyboth are available in pill form.5,6

The CDC no longer recommendsuse of rimantadine or amantadinedue to the high resistance of influenza

A virus. Resistance to both washigh among influenza A (H3N2)viruses globally and variableamong influenza A (H1N1).6,16

Oseltamivir resistance wasdetected in A (H1N1) viruses inseveral countries in varied places,and those viruses remained sensi-tive to amantadine and rimanta-dine. Recently, oseltamivir andzanamivir received safety warn-ings regarding the risk for neu-ropsychiatric adverse effects,including delirium, abnormalbehavior, fatal self-injury, andseizures, particularly in childrenand adolescents.17

Influenza vaccinesThe most effective way to manageinfluenza is to prevent the illnesswith a yearly administration ofinfluenza vaccination. The vaccineis estimated at 70% to 90% effectivefor healthy adults and children.6

While October and November arethe best times to receive a flu shot,it's never too late in the flu seasonto be vaccinated. The AdvisoryCommittee on Immunization Prac-tices (ACIP) of the CDC recentlyexpanded recommendations toinclude 5- to 18-year-olds. Becauseof the necessity for widespread

Pharmacologic agents to treat influenza

Medication Type Indications/ Formulation Side effects type of influenza

Zanamivir Neuraminidase Chemoprophylaxis, Dry powder Wheezing, headache, (Relenza) inhibitor treatment of A and B diarrhea, neuro-

psychiatric effects

Oseltamivir Neuraminidase Chemoprophylaxis, Capsules and liquid Nausea, vomiting, (Tamiflu) inhibitor treatment of A and B form neuropsychiatric effects

Rimantadine* Adamantane Treats type A Tablet or liquid form Insomnia, anxiety, (Flumadine) M2 blocker nausea, anorexia,

seizures

Amantadine* Adamantane Treats type A Tablet or liquid form Insomnia, anxiety, (Symmetrel) M2 blocker nausea, anorexia,

seizures

*Not recommended by CDC due to high resistance



Approved influenza vaccines for different age groups—United States 2008-2009 season

Vaccine Trade Manufacturer Presentation Mercury Age group No. of Routename content doses

(mcg Hg/0.5mL dose)

TIV* Fluzone Sanofi 0.25-mL 0 6-35 months 1 or 2† Intramuscular§Pasteur prefilled syringe

0.5-mL 0 36 months 1 or 2† Intramuscular§prefilled syringe and older

0.5-mL vial 0 36 months 1 or 2† Intramuscular§and older

5-mL 25 6 months 1 or 2† Intramuscular§multidose vial and older

TIV* Fluvirin Novartis 5-mL 24.5 4 years 1 or 2† Intramuscular§Vaccines multidose vial and older

0.5-mL ≤1 4 years 1 or 2† Intramuscular§prefilled syringe and older

TIV* Fluarix GlaxoSmith- 0.5-mL <1 18 years 1 Intramuscular§Kline prefilled syringe and older

TIV* FluLaval GlaxoSmith- 5-mL 25 18 years 1 Intramuscular§Kline multidose vial and older

TIV* Afluria CSL 0.5-mL 0 18 years 1 Intramuscular§Biotherapies prefilled syringe and older

5-mL 25 18 years 1 Intramuscular§multidose vial and older

LAIV¶ FluMist** Medlmmune 0.2-mL sprayer 0 2 to 49 years 1 or 2†† Intranasal

* Trivalent inactivated vaccine (TIV). A 0.5-mL dose contains 15 mcg each of A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007(H3N2)-like, and B/Florida/4/2006-like antigens.

† Two doses administered at least 1 month apart are recommended for children aged 6 months to 8 years who are receiving TIVfor the first time. Those who only received 1 dose in their first year of vaccination should receive two doses in the followingyear.

§ For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants andyoung children is the anterolateral aspect of the thigh.

¶ Live attenuated influenza vaccine (LAIV). A 0.2-mL dose contains 106.5-7.5 fluorescent focal units of live attenuated influenzavirus reassortants of each of the three strains for the 2008-09 influenza season: A/Brisbane/59/2007 (H1N1), A/Brisbane/10/2007(H3N2), and B/Florida/4/2006.

** FluMist is shipped refrigerated and stored in the refrigerator at 2°C–8°C after arrival in the vaccination clinic. The dosage is0.2 mL divided equally between each nostril. Healthcare providers should consult the medical record, when available, to identifychildren aged 2-4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children whomight be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV. Parents or caregivers ofchildren aged 2-4 years should be asked “In the past 12 months has a healthcare provider ever told you that your child haswheezing or asthma?” Children whose parents or caregivers answer “yes” to this question and children who have asthma orwho had a wheezing episode noted in the medical record during the preceding 12 months, should not receive FluMist.

†† Two doses administered at least 4 weeks apart are recommended for children aged 2 to 8 years who are receiving LAIV for thefirst time. Those who received only one dose in their first year of vaccination should receive two doses in the following year.

Source: Centers for Disease Control and Prevention. Prevention and Control of Influenza—Recommendations of the Advisory Commit-tee on Immunization Practices (AICP). MMWR. 2008. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm.

planning to ensure vaccination ofall appropriate children, the ACIPhas targeted the 2009-2010 seasonfor full implementation of the newrecommendation. It's anticipatedthat full-scale campaigns, such asschool-based vaccine clinics, may benecessary to implement the goal ofvaccinating children.6

The CDC specifically recommendsvaccination for:♦ children 6 months to 18 years ofage♦ children and adolescents at highrisk for influenza complicationsshould continue to be the focus ofvaccination efforts, including chil-dren 6 months to 4 years of age,those with chronic conditions, andthose receiving long-term aspirintherapy (may be at risk for Reyesyndrome after influenza infection)♦ anyone 50 years of age and older♦ women who will be pregnantduring the flu season♦ adults or children with chronicpulmonary, cardiovascular, renal,hepatic, hematological, or metabolicdisorders♦ adults and children withimmunosuppression or HIV♦ individuals with any conditionthat can compromise respiratoryfunction♦ residents of long-term-care facili-ties, such as nursing homes♦ healthcare workers♦ healthy household contacts.6

Because children are frequentcarriers of disease to others in closecontact with them (other children,family members, caregivers,babysitters, teachers), it's vital tovaccinate them to prevent thespread of influenza. The vaccineisn't approved for use in childrenunder the age of 6 months, so allwho come into contact with themshould be vaccinated to help pro-vide herd immunity. Childrenunder 9 years of age who are beingvaccinated for the first time or who

only received one dose the first yearneed to receive vaccination early inthe flu season, as they require twodoses (1 month apart) to be fullyeffective.6

The influenza vaccine can inducean immune reaction to the two sur-face glycoproteins—neuraminidaseand hemagglutinin—that offer pro-tection from influenza infection.There are two vaccines available:trivalent inactivated influenzavaccine (TIV) and live attenuatedinfluenza vaccine (LAIV). (SeeApproved influenza vaccines for differ-ent age groups—United States 2008-2009 season.)

TIV is injected intramuscularly.It has been the most extensivelystudied and has a well-establishedsafety profile. Soreness at theinjection site is the most com-monly reported adverse reactionversus placebo in adults. The vac-cine still suffers from perceptionsthat it can cause influenza orGuillain-Barré syndrome. Becauseof well-publicized vaccine short-ages, the public still erroneouslyperceives that it isn't widelyavailable. The vaccine is stillsomewhat less effective in pre-venting influenza in the very young(younger than 9 years) and in thefrail and elderly (65 and older).6

In a Cochrane review of vaccina-tion effectiveness for young adultsthat included a review of 48 reports,TIV was 80% (95% confidence inter-val [CI] 56% to 91%) efficaciousagainst influenza when the vaccinematched the circulating strain andcirculation was high; however, it

decreased to 50% (95% CI 27% to65%) when it didn't.18

Although widely available andconsidered highly effective, thevaccine is still underutilized amongcertain groups, such as minorityethnic groups, low socioeconomicstatus, young people with chronicdiseases, and healthcare profession-als.19 Healthcare professionals aremost often cited as avoiding theinfluenza vaccine due to the needfor an intramuscular injection, andconsequently, the rate of vaccina-tion is estimated at only 40%.20

LAIV was created to help addressthe perceived problems associatedwith TIV. Because it's givenintranasally, an intramuscular injec-tion is eliminated. As it needs to bein a cool environment to replicate,LAIV doesn't replicate at core bodytemperature; instead it only pro-duces immunity in the cooler upperairways. This favors its inability toproduce illness in the recipientwhen it's systemically absorbed.6

LAIV is slightly more expensivethan TIV and may be associatedwith mild upper respiratory infec-tion. There are five other miscon-ceptions regarding the vaccine thatneed to be addressed to improveits acceptance in the community.(See Five myths associated with liveattenuated influenza vaccine.) Of note,none of the common myths havebeen reproduced in trials or withuse in the community since 2003.19

The current recommendation forLAIV is for healthy people ages 2 to49 years. People with underlyingchronic conditions such as pul-


Five myths associated with live attenuated influenza vaccine19

1. Vaccine will revert to a wild type, causing disease2. Viral shedding will occur and result in viral transmission3. Live virus vaccination leads to serious adverse reactions4. LAIV is effective only with the vaccine that is identical to circulating virus5. LAIV isn't as effective as TIV

monary, cardiovascular, metabolic,renal, or hematologic diseases shouldreceive TIV instead. Healthcare pro-fessionals can receive either vaccine;however, it's recommended that ifthey're in contact with severelyimmunocompromised patients, theyshould receive the TIV.6,19

Strategies to increase vaccination ratesVaccinations are usually conductedin primary care or public healthsettings across the country. However,rates of vaccination against a poten-tially deadly disease remain low inspite of the presence of highly effec-tive, safe vaccines. New evidenceshows that in the National HealthInterview Survey study of 1,248subjects with asthma, only 36% werevaccinated against influenza betweenSeptember 2005 and February 2006.Because of the risk of severe compli-cations, people with asthma shouldreceive the influenza vaccine.21

Investigators noted several strate-gies to increase vaccination ratesthat are useful in practice. In gen-eral, reminder systems implementedto prompt people to seek vaccina-tion, such as postcards, letters,telephone, or auto dialer calls, arehighly effective but can be costlyand time consuming for primarycare and public health agencies.22

The CDC recommends severalother strategies to improve vacci-nation rates. Maintaining standingorders at primary care offices,implementing computerizedrecord reminders, chart reminders(colorful stickers or checklists),performance feedback for health-care providers (tracking percent-age of vaccinated patients in theagency), using home health work-ers to reach home-bound patients,and implementing drop-in clinicaccess for patients are highlyeffective ways to improve rates ofvaccination.6,21,22

Influenza vaccine The forecast for flu season 2008-2009is formulated on the data collectedover the previous year. The WorldHealth Organization recommendsobtaining and distributing flu vac-cine information twice a year, withpertinent data collected from 118influenza centers in 84 countries. Inthe United States, the FDA deter-mines the flu vaccine constituents.

Influenza vaccine for the 2008-2009 season consists of threeviral strains: influenza A (H3N2),influenza A (H1N1), and influenzaB virus. When the vaccine is well-matched with the anticipated strains,the vaccine can be expected toreduce the chances of gettinginfluenza by 70% to 90% amonghealthy adults. Even if not well-matched, receiving vaccinationwill lessen the patient’s impact ofillness.6 Based on surveillance dataand forecasts from the previousyears, the FDA’s Vaccines andRelated Biological Products Advi-sory Committee recommend the fol-lowing constituents for the trivalentvaccine for 2008-2009:

♦ A/Brisbane/59/2007 (H1N1)-likevirus♦ A/Brisbane/10/2007 (H3N2)-likevirus♦ B/Florida/4/2006-like virus.23,24

Rapid diagnosis importantBecause it's linked with high mor-bidity and mortality rates amongvulnerable populations, influenzashould be regarded as a potentiallydeadly condition. It's important todiagnose it rapidly so that antiviralmedications can be used. Still, thebest approach is prevention withinfluenza vaccine. NM

REFERENCES1. Centers for Disease Control and Pre-

vention. 2007-2008 Influenza preventionand control recommendations. Clinicalsigns and symptoms. http://www.cdc.gov/flu/professionals/acip/clinical.htm.

2. Thompson WW, Shay DK, WeintraubE, et al. Influenza activity-associatedhospitalizations in the United States.JAMA. 2004;292:1333-1340.

3. Billings M. The influenza pandemic of1918. RDS 2005. http://virus.stanford.edu/uda/.

4. Worrall G. Influenza. Canadian FamilyPhysician. 2008;54:415-416.

5. National Institute of Allergy and Infec-tious Disease (NIAID). Understandingthe flu virus. http://www3.niaid.nih.gov/topics/Flu/understandingFlu/.

6. Centers for Disease Control and Pre-vention. Prevention and control ofinfluenza-recommendations of theAdvisory Committee on ImmunizationPractices (ACIP). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1.htm.

7. Thompson WW, Shay DK, Weintraub E,et al. Influenza-associated hospitaliza-tions in the United States. JAMA.2004;292:1333-1340.

8. Simonsen L, Taylor RJ, Viboud C, et al.Mortality benefits of influenza vacci-nation in elderly people: an ongoingcontroversy. Lancet Infect Dis.2007;7:658-666.

9. Bennett S. Flu shot under skin mayimprove protection for aged. http://www.bloomberg.com/apps/news?pid=newsarchive&sid=auHDkkYbFF8Y.

10. Albright FS, Orlando P, Pavia AT, et al.Evidence for a heritable predisposition



he vaccine canbe expectedto reduce the

chances of gettinginfluenza by 70%to 90% amonghealthy adults

TT

to death due to influenza. J Infect Dis.2008;197:18-24.

11. Centers for Disease Control and Pre-vention. Types of flu viruses. http://www.cdc.gov/flu/about/viruses/types.htm.

12. Centers for Disease Control and Pre-vention. Infection control guidance forprevention and control of influenza inacute care facilities. http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm.

13. Carlson E. Study of sugars on cellsurface identifies key factor in fluinfection. US Department of Healthand Human Services. NIH News 2008.http://www.nih.gov/news/pr/jan2008/nigms-06.htm.

14. Centers for Disease Control and Pre-vention. Influenza-testing and antiviral-agent prescribing practices-Connec-ticut, Minnesota, New Mexico, andNew York, 2006-07 influenza season.MMWR. 2008; 57(3):61-65.

15. Centers for Disease Control andPrevention. Role of laboratory diagno-sis of influenza. http://www.cdc.gov/flu/professionals/diagnosis/labrole.htm.

16. Altman LK. Mutant flu virus is foundthat resists popular drug. http://www.nytimes.com/2008/01/31/health/31flu.html?_r=1&oref=slogin.

17. Waknine Y. Antiviral drug labels getwarnings for neuropsychiatric changes.http://www.medscape.com/viewarticle/570996_print.

18. Jefferson TO, Rivetti D, DiPietrantoniC, et al. Vaccines for preventinginfluenza in healthy adults. CochraneDatabase of Syst Rev. 2006;4.

19. Tosh PK, Boyce TG, Jacobson RM.Five myths associated with live attenu-ated influenza vaccine. Mayo ClinProc. 2008;83:77-84.

20. Poland GA, Tosh P, Jacobson RM.Requiring influenza vaccination forhealthcare workers: seven truths wemust accept. Vaccine. 2005; 23(17-18):2251-2255.

21. Centers for Disease Control and Pre-vention. Department of Health andHuman Services. Strategies forincreasing adult vaccination rates.http://www.cdc.gov/vaccines/recs/ratestrategies/adultstrat.htm.

22. Jacobson Vann JC, Szilagyi P. Patientreminder and patient recall systemsfor improving immunization rates.[Systematic review] Cochrane Effec-tive Practice and Organisation of CareGroup. Cochrane Database of SystRev. 2005;2.

23. Centers for Disease Control and Pre-vention. Department of Health and

Human Services. Interim within-seasonestimate of the effectiveness of triva-lent inactivated influenza vaccine-Marshfield, Wisconsin, 2007-2008influenza season. MMWR. 2008;57(15):393-397;404-409.

24. World Health Organization. Recom-mended composition of the influenzavirus vaccines for use in the 2008-2009influenza season. http://www.who.int/csr/disease/influenza/recommended_compositionFeb08FullReport.pdf.

The author has disclosed that she has nosignificant relationship or financial interestin any commercial companies that pertainto this educational activity.

Jane Kapustin is an assistant dean at theUniversity of Maryland School of Nursing,and a nurse practitioner at Joslin DiabetesCenter, University of Maryland MedicalCenter, Baltimore, Md.

Adapted from The 2008-09 influenza sea-son: Are you ready. Nurse Practitioner.2008;33(10):12-20.


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