FLU SEASON has ethical implications for nurses, who have a duty to keep patients safe from avoidable complications. No matter where they work, nurses are in direct contact with vulnerable patients every day. Some patients may be at high risk for influenza infection because they have an autoimmune disorder, or are receiving chemotherapy or have received an organ transplant requiring immunosuppressant therapy. Infants, children, pregnant women, people with specific chronic illnesses, and adults age 65 and older are also especially vulnerable.1

What can nurses do to keep their patients safe from influenza infection and influenza-related complications? This article will explain nurses' important role in herd immunity and their ethical duty during flu season.

Herd immunity, defined

Herd immunity, also known as community immunity, is a term used to describe protection from a contagious disease via community-wide vaccination.2 Although the underlying goal of vaccination is the prevention and containment of diseases, this important concept is often overlooked when discussing its benefits. Besides offering a person active immunity against a disease, vaccination interrupts the chain of infection by helping to prevent a pathogen from encountering a susceptible host.3 This, in turn, lowers the incidence of that disease in a given population.4

If an infected nurse passes an influenza virus strain to any immunocompromised patient, that patient is at increased risk for serious complications, such as pneumonia, sepsis, or death.1 Nurses have a duty to protect the people around them, especially patients who can't receive one of the recommended seasonal influenza vaccines.

Last season, only 66.7% of healthcare workers opted to receive the annual seasonal influenza vaccine, and of that group only 9% reported receiving it to protect patients, friends, or family from getting the influenza virus.5,6

However, influenza vaccination is no longer a matter of personal choice. The importance of herd immunity is so strongly accepted by the medical community that laws requiring compliance now exist.6 As of this year, 18 states have established mandates for healthcare personnel to receive the annual influenza vaccine. These laws are based on the hospital or facility type; for example, acute care, outpatient, and surgical settings. Of these 18 states, 11 permit medical exemptions, 4 permit religious exemptions, and 10 permit philosophical exemptions for receiving the vaccine.6 For information about requirements and exemptions pertaining to your state, please visit http://www.cdc.gov, and search "Public Health Law."

LAIV warning

Since February 24, 2010, the CDC has maintained its recommendation that everyone age 6 months and older receive an annual influenza vaccination.7 While the CDC's Advisory Committee on Immunization Practices (ACIP) continues to recommend annual flu vaccination for the same population, it clarifies that only the inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) should be administered during the 2016-2017 flu season. In June of 2016, the ACIP issued a statement warning that the live attenuated influenza vaccine (LAIV), also known as the nasal spray flu vaccine, had lower effectiveness when compared to previous years.7 For that reason, nurses and healthcare professionals should be offered and receive only the IIV or RIV flu vaccine this year.

Contraindications

Newborns aren't the only exception to the CDC's recommendation. IIV shouldn't be administered to infants younger than 6 months, people with specific chronic illnesses, some immunocompromised patients, people who've experienced a severe allergy to a prior dose of a IIV or LAIV, or anyone with a severe allergy to a component of the IIV vaccine.8

FLUCELVAX (ccIIV3), the first U.S.-licensed (trivalent inactivated) influenza vaccine made with cell culture technology, shouldn't be administered to people who've had a severe allergic reaction to any component of the vaccine or any other influenza vaccine.8 (See FLUCELVAX facts.) And RIV shouldn't be administered to anyone who's had a severe allergic reaction after a previous dose of RIV or any vaccine component.8

For a list of vaccine components and contraindications, healthcare providers should refer to the package inserts and understand who among their patients can't receive the vaccines and are at highest risk for contracting influenza.

Vaccination effectiveness

Many strains of the influenza virus mutate rapidly, so completely eradicating the influenza virus isn't feasible, as it was the case with polio in the United States.9 Nonetheless, influenza vaccination has decreased hospitalizations and deaths among those who are vaccinated each season.10

Recent studies show that the seasonal influenza vaccine reduces the risk of influenza virus infection by 50% to 60% among the overall population during seasons when most circulating influenza viruses match the vaccine viruses.10 When fewer people in the community are reservoirs for the virus, it's less likely that a susceptible person will become infected with the influenza virus. The chance of an outbreak is also greatly reduced.11 Nurses should follow these CDC-recommended actions to prevent the spread of seasonal influenza:12

* Avoid close contact.

* Stay home when you're sick.

* Cover your mouth and nose when coughing or sneezing.

* Perform frequent hand hygiene.

* Avoid touching your eyes, nose, or mouth.

* Practice other good health habits.

The cold, hard facts

The influenza virus, which occurs in epidemics nearly every winter season, is an acute respiratory illness caused by influenza A or B viruses.13 Most people with seasonal influenza are contagious from 1 day before signs and symptoms develop to 7 days afterward.14 As such, asymptomatic nurses who carry the virus can potentially infect many patients and coworkers, causing a facility-wide outbreak.

Influenza is primarily spread through respiratory droplets.15 Coughing, sneezing, or speaking in close proximity can easily spread influenza from nurse to patient or vice versa. The influenza virus can also survive on contaminated surfaces for 2 to 8 hours.16 It can be found on bed rails, doorknobs, computer keyboards, countertops, faucets, clipboards, and many other objects used often by hospital personnel.

H1N1 risk

One strain of the influenza virus especially important to note this year is the deadly influenza A H1N1 virus, which caused a pandemic in 2009 and claimed approximately 203,000 lives worldwide.17 This strain affects mainly young adults rather than infants and older adults who are typically more susceptible to flu.18 Since 2009, every seasonal influenza vaccine has provided protection against this particular strain.19 However, only about one-third of adults ages 18 to 49 in the United States are vaccinated each season.20

Since 2015, many countries including the United States have seen a sharp increase in the number of reported H1N1 cases. Related death tolls now climb into the hundreds.21 As influenza season begins again in 2016, nurses must help protect patients and themselves by getting vaccinated. If enough people receive the seasonal influenza vaccine each season, herd immunity can be established and then eventually, single virulent strains of influenza, including H1N1, can be eradicated.19,22

Give it a shot

Remember that vaccination is a community effort. Encourage colleagues to receive all vaccines recommended by the CDC.23 Nurses' commitment to vaccination best practices is critical to saving patient lives this influenza season.

FLUCELVAX facts

Clinical testing has demonstrated FLUCELVAX safe and effective for use in people 4 years of age and older. Cell culture technology used to manufacture FLUCELVAX has previously been used in the production of other U.S.-licensed vaccines for diseases including rotavirus, polio, smallpox, hepatitis, rubella, and chicken pox.

Due to its potentially increased flexibility over the traditional egg-based manufacturing process, cell culture technology is being used to develop cell-based influenza vaccines. The process involves growing viruses in animal cells, rather than hen's eggs, eliminating the need for an ample supply of eggs. Cell culture technology is also advantageous over traditional methods in the case of a potential pandemic, because the cell-based vaccine manufacturing process has a much faster potential start-up time.

Source: Centers for Disease Control and Prevention. Cell-based flu vaccines. 2016. http://www.cdc.gov/flu/protect/vaccine/cell-based.htm.

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