INFLUENZA

Scott Lippacher
Helen McDonald
State University of New York Polytechnic
Institute

Influenza
Acute Respiratory illness
Acutely debilitating but self-limiting
Outbreaks and epidemics mainly in winter
Increased mortality in high-risk populations
Pay close attention to local epidemiology and outbreaks

(Zachary, 2015) (Domino et al., 2013)

Pathophysiology
Influenza viruses are single stranded RNA virus
There are 3 types of the virus, A,B and C
Influenza A infects birds, pigs, horses, and humans and is

the most common of the 3 types

The B virus infects humans and seals, and the C virus
infects humans and pigs
Influenza A and B have 8 gene segments while influenza C
has 7
The virus has a protein coat that has 10 proteins in flu A
and 11 in flu B
(Derlet, Nguyen, & Sandrock, 2015) (Public Health Agency of Canada, 2011) (Public Health
Agency of Canada, 2012)

Pathophysiology- cont.
Hemagglutinin and Neuraminidase are 2 proteins needed

for the virus to be infective, both being on the surface of

the virus
Hemagglutinin causes the virus to stick to sugars on the
human cells and then injects the virus into the cells
Neuraminidase keeps the replicated virus, when it leaves
the cells, from sticking to the sugars on the surface of the
cells
The designations of H and N after the flu name comes
from the the subtypes of these proteins (i.e. H1H1)
(Goodsell, 2006) (Goodsell, 2009)

Pathophysiology, cont.
Mutates easily, with influenza A mutating 300 times

greater than other microbes

Transfers between species, specifically between pigs,
chickens to humans
Transmission to humans occurs during slaughter and
touching water contaminated with feces
Human to human is by aerosolization
1-4 day incubation, may start shedding the virus 1 day
prior to symptoms appearing
(Derlet, Nguyen, & Sandrock, 2015)

Etiology
Respiratory secretions from infected persons
Aerosolized small particle respiratory droplets
Sneezing, coughing
Large particle droplets (up to 6 feet)
Droplets land in mouth/nose of recipient
Less frequently contaminated surfaces

(Center for Disease Control and Prevention [CDC], 2015a)

Incidence
Seasonally episodic
More than 20,000 cases every year in the U.S

(Derlet, Nguyen, & Sandrock, 2015)

Screening
History and physical
Awareness of community and institutional outbreaks
Rapid influenza diagnostic tests
Reverse transcription polymerase chain reaction (RT-

PCR)

High Risk Populations

Increased mortality with high-risk populations
Nursing home residents
Younger than age 2, older than age 65
Pregnancy through 2 weeks postpartum
Chronic medical conditions
Pulmonary disease
Cardiovascular
disease
Active malignancy
Chronic renal
insufficiency

Diabetes mellitus
Sickle cell
Immunosuppression
Neurological
conditions
(Zachary, 2015)

Clinical Findings
Cough, chest pain, dyspnea
Fever- low or high grade
Myalgias- mild to severe
Headache- Severe frontal and retro-orbital
Rhinorrhea- mild if any
Fatigue- can be severe
Sore throat- may be severe, commonly the symptom

causing the patient to present to health care

Burning, red, watering eyes
(Derlet, Nguyen, & Sandrock, 2015)

Differential Diagnosis
Infectious mononucleosis
Coxsakievirus infection
Viral/streptococcal tonsillitis
Atypical Mycoplasma pneumonia
Respiratory viral infection
Syncytial virus
Parainfluenza
Adenovirus
Enterovirus
(Domino et al., 2013)

Social/Environmental
Usually can be handled by the available health care

institutions
People with chronic illness are at the highest risk for
increased morbidity and mortality
Between 3,000 and 49,000 deaths per year over the last
30 years in the U.S.

(U.S. Department of Health & Human Services, n.d.)

Laboratory/Diagnostics
Gold standard polymerase chain reaction from

nasoparyngeal swab or aspirate (result in 24hrs)

Negative results do not exclude influenza; treatment
should not be withheld from symptomatic patients
Testing is not required for diagnosis during active
community outbreaks
CXR- usually negative unless there is a secondary
infection such as pneumonia
CBC- leukopenia; leukocytosis (indicates complication)
BMP- dehydration
Oxygen saturation
(Domino et al., 2013)

Rapid Influenza diagnostic Tests (RIDTs)

Some identify influenza A

and B viral nucleoprotein

antigens
Some cleared for office
and bedside use
Results in 30 min or less
Poor sensitivity (50-70%)
Poor specificity (90-95%)
compared to viral Cx or
RT-PCR

(CDC, 2015a) (CDC, 2015d)

False-positives

more likely
when community disease
prevalence is low, beginning
and end of season
False-negative more likely
when community disease
prevalence is high during flu
season
Reduce false results
Collection of specimen within 34 days of illness onset
Consider sending RT-PCR to
confirm result of rapid test

Management/Treatment
Non-pharmacological
Handwashing- soap and

water or alcohol based

cleanser
Cough etiquette
Usage of masks
Staying home from work
for 24 hours after fever is
gone
Resist touching eyes,
mouth or nose to reduce
transmission

Limit contact
Rest and fluids
Avoid smoking
Humidifier
Symptomatic treatment
Saline nasal spray
Analgesic gargle
May need hospitalization for IV

fluids and possible intubation

(Derlet et al., 2015; U.S. Department of Health &
Human Services, n.d.)
(Domino et al., 2013)

Management/Treatment
Pharmacological
Vaccination-prevention
Inactivated, live attenuated and recombinant
Quadravalent
Trivalent

Antiretrovirals

Given within 2-5 days of onset of symptoms have shown a

decrease in morbidity and mortality

Oseltamivir
Zanamivir
Peramivir
(CDC, 2014)

Primary prevention
Intramuscular

Nasal Spray
Ages 2-49 years

6 months and older

Approved and recommended

during pregnancy
Contraindications to vaccine
Children younger than 6 months
Severe, life-threatening allergy
to vaccine or any of its
ingredients
History of Guillain-Barre
Syndrome
Fever
(CDC, 2015c)

Contraindications to nasal spray

Pregnancy
Immunosuppression
Asthma or wheezing within 1yr
Influenza antiviral drugs within
48 hours
Severe, life-threatening allergy to
vaccine or any of its ingredients
History of Guillain-Barre
Syndrome
Fever

Complications
Pneumonia
Most common
Frequently in high risk populations
Primary viral (influenza) PNA
Most severe, least common
Influenza directly involves lungs producing severe PNA
High fever, dyspnea, cyanosis

Secondary bacterial PNA

Contributes to morbidity and mortality, especially 65 years or older
Relapsing fevers, cough, purulent sputum, pulmonary infiltrates
Both Primary and Secondary

Muscle
Myositis and rhabdomyolysis- most frequently in children
(Dolin, 2015a)

Complications
Central nervous system
Encephalopathy, encephalitis, transverse myelitis, aseptic
meningitis, Guillain-Barre syndrome
Toxic shock syndrome
Cardiac
ECG changes
MI
Ischemic heart disease
Myocarditis and pericarditis (rare)
(Dolin, 2015a)

Follow up
Follow up depends on the patient symptoms and

comorbidities. The patients with a decreased ability to

tolerate respiratory symptoms or have illnesses such as
heart problems, DM, or are immunocompromised require
closer monitoring

Counseling/Education
Primary prevention
Influenza vaccine every year, especially in high risk populations
Pneumonia vaccine to minimize secondary infection

Hand Hygiene
Course of illness
Avoid school/work for 24 hours after fever subsides
Cough etiquette
Usage of masks
Resist touching eyes, mouth or nose to reduce transmission
Limit contact
Rest and fluids
Avoid smoking
Humidifier

Consultations
Infectious Disease specialist may be considered
Intensivist may be required depending on the severity
If the H1N1 variety, Pulmonologist, Intensivist, ID, and the

local health department

(Derlet, Nguyen, & Sandrock, 2015)

Questions
1. How many cases of seasonal flu are there in a year?
a. 3,000
b. 20,000
c. 49,000
2. Sore throat is the common reason that patients present
to healthcare with the flu.
a. true
b. false

3. What is the optimum time frame for administration of

antiretrovirals?
a. 1-6 days
b. 3-5 days
c. 2-7 days
d. there is no optimum time frame
4. Influenza vaccine is?
a. a RNA virus
b. a DNA virus
c. double stranded
d. needs 4 proteins for it to be infective

5. Viral shedding can start occurring ?

a. when symptoms start
b. 1 day after symptoms start
c. 1 day before symptoms start
d. 1 week before symptoms start
6. Rapid influenza testing has high sensitivity.
a. True
b. False

7. When is it okay to return to work after diagnosis?

a. Immediately, work needs me.
b. 24 hours after onset of symptoms.
c. 24 hours after 1st dose of antiretrovirals.
d. 24 hours after fever subsides.
8. Who should not receive the Nasal Spray Vaccine?
a. A two year old
b. A 32 year old with active asthma
c. A 44 year old who has taken antiviral medication
for the flu 2 weeks ago
d. A 39 year old in colon cancer remission for 3 yrs

9. What is the GOLD standard diagnostic for influenza?

a. CXR
b. Rapid influenza diagnostic test (RIDTs)
c. Reverse transcription polymerase chain reaction (RT- PCR)
d. None of the above
10. All are considered high risk populations for influenza except:
a. Nursing home resident
b. Immunocompromised
c. 75 year old living home with his son
d. 32 year old agoraphobic living home alone with limited
community contact

Answers
1. B
2. A
3. B
4. A
5. C
6. B
7. D
8. B
9. C
10.D

References

Centers for Disease Control and Prevention. (2014). How the Flu Virus Can Change:
Drift and Shift. Retrieved October 12, 2015, from
http://www.cdc.gov/flu/about/viruses/change.htm
Center for Disease and Prevention. (2015a). Guidance for clinicians on the use of
rapid influenza diagnostic tests. Retrieved
fromhttp://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm#figure1
Center for Disease and Prevention. (2015b). How flu spreads. Retrieved from
http://www.cdc.gov/flu/about/disease/spread.htm
Center for Disease and Prevention. (2015c). Key facts about seasonal flu vaccine.
Retrieved from http://www.cdc.gov/flu/protect/key facts.htm
Center for Disease and Prevention. (2015d). Rapid diagnostic testing for influenza:
information for health care professionals retrieved from
http://www.cdc.gov/flu/professionals/diagnosis/rapidclin.htm
Derlet, R., Nguyen, H., & Sandrock, C. (2015, September 29). Influenza. Retrieved
October 12, 2015, from http://emedicine.medscape.com/article/219557-overview#a5
Dolin, R. (2015a). Clinical manifestations of seasonal influenza in adults. Retrieved
from
http://www.uptodate.com/contents/treatment-of-seasonal-influenza-in-adults?source
=search_result&search=influenza&selectedTitle=1%7E150

References Cont.
Dolin, R. (2015b). Diagnosis of seasonal influenza in adults. Retrieved

fromhttp://www.uptodate.com/contents/diagnosis-of-seasonal-influenza-in-adults?topicKey=ID
%2F15871&elapsedTimeMs=1&source=search_result&searchTerm=influenza+screen&selecte
dTitle=1%7E150&view=print&displayedView=full#
Domino, F. J., Baldor, R. A., Golding, J., Grimes, J. A., & Taylor, J. S. (2013). The 5-minute
clinical consult 2013. Philladelphia, PA: Lipplincott
Goodsell, D. S. (2006). Hemagglutinin. RCSB Protein Data Bank.
http://doi.org/10.2210/rcsb_pdb/mom_2006_4
Goodsell, D. S. (2009). Influenza Neuraminidase. RCSB Protein Data Bank.
http://doi.org/10.2210/rcsb_pdb/mom_2009_5
Public Health Agency of Canada. (2011, February 18). Influenza Virus Type A. Retrieved from
ww.phac-aspc.gc.ca/lab-bio/res/psds-ftss/influenza-a-eng.php
Public Health Agency of Canada. (2012, April 30). Influenza Virus (B and C). Retrieved from
http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/influenza-grippe-b-c-eng.php
U.S. Department of Health & Human Services. (n.d.). About Pandemics. Retrieved November
1, 2015, from http://www.flu.gov/pandemic/about/
Zachary, K. (2015). Treatment of seasonal influenza in adults. Retrieved from http://
www.uptodate.com/contents/treatment-of-seasonal-influenza-in-adults?source=search_result
&search=influenza&selectedTitle=1%7E150