Flu Prevention and Tamiflu Use in Long-Term Care

Flu season is upon us and since the flu is a serious concern for older, high risk patient populations, awareness and prevention of the flu is important for the safety and health of residents in long-term care. According to the CDC, 50% of the reported 310,000 flu-related hospitalizations and 64% of the 12,000 flu-related deaths occurred in people 65 years and older in the US for the 2015-2016 influenza season. For the 2016-2017 flu season in King County, there was 83 flu-related deaths with 93% of them over 65 years old. There was also a high amount of flu outbreaks in long-term care facilities (LTCFs) with 91 outbreaks reported from 81 LTCFs, and 19 of those outbreaks resulting in the death of one or more residents. This is a serious health threat that can cause many health complications, hospitalizations, and deaths in long-term care residents.

Prevention is the first line of defense to prevent negative outcomes from the flu in residents. It is recommended that all residents and staff receive the flu vaccine as soon as possible once the yearly vaccine is released since it takes about two weeks for antibodies to develop after vaccination. Other preventative measure such as frequent hand washing, hygiene measures, cough etiquette, and infection control precautions (facemasks, isolation of infected residents, etc.) can also decrease the risk of infection.

Flu infections and outbreaks can still happen despite prevention efforts so it is also important to be able to recognize the symptoms that may be caused by the flu. Although residents may present with the common symptoms of flu such as fever, cough, sore throat, runny or stuffy nose, muscle aches, headaches, and fatigue, they may instead present with more subtle, atypical symptoms such as loss of appetite, mental status changes, pneumonia, low-grade to no fever, and worsening chronic respiratory conditions or congestive heart failure. Symptoms usually take 1 to 4 days to appear after infection, and infected people remain infectious to others from 1 day before symptoms occur to 7 days after symptoms start.

If any resident is suspected to have the flu, it is recommended to start treatment with Tamiflu as soon as possible while running influenza lab tests. Treatment should be started without waiting for the results of the lab test and can be given for an extended period of time longer than the usual 5 day course depending on the severity of their illness. Prophylaxis against flu should only be started if two or more residents have become ill and are suspected to have the flu within 72 hours of each other and one lab test has confirmed the cause to be due to a flu infection. At this time prophylaxis with Tamiflu should immediately be given to all at risk residents and staff to prevent the spread of the outbreak. In LTCFs, prophylaxis should be given for at least two weeks and continued until one week after the last case of the flu was identified. The prompt administration of Tamiflu for treatment or prophylaxis without delay can improve patient outcomes and decrease new infections.

Overall, Tamiflu is a well-tolerated medication. However, there are a few side effects that may need to be managed. The common side effects of Tamiflu are headache, nausea, and vomiting, with the additional side effect of diarrhea if the resident has a fructose intolerance and is taking the oral solution formulation. Manage these side effects by administering with food for the nausea and vomiting, giving OTC pain medications for the headache, and not using the premade oral solution for diarrhea from fructose intolerance. Rare but serious side effects are anaphylaxis, dermatologic reactions like Stevens-Johnson syndrome, and neuropsychiatric events. Monitor for signs of these serious side effects like allergic-like reactions, rash, and abnormal behavior or behavior changes. If doses are missed they can be taken as soon as it is remembered and the missed dose is skipped only when it is within 2 hours of the next dose.

There are two forms of Tamiflu: capsules and oral solution. The capsules can be taken regardless of meals, but can be taken with food to improve tolerance and side effects. If the patient has difficulty swallowing, the capsules can be opened and the contents mixed with sweetened liquids (chocolate syrup, caramel topping, brown sugar melted in water, etc.). The capsules can also be administered through feeding tubes by opening the capsules and dissolving the powder in 20mL of sterile water, injecting the mixture into the tubes, and then flushing with another 10mL of sterile water. The capsules can be stored at room temperature but the oral solution would need to be stored in the fridge for up to 17 days or at room temperature for up to 10 days after reconstitution.

Through careful surveillance and prevention, as well as rapid recognition and initiation of medications for flu infection, we will be able to better protect the residents under our care and improve health outcomes.

References:

CDC Influenza Resources: https://www.cdc.gov/flu/about/disease/index.htm

King County - Communicable disease data and information for Influenza: http://www.kingcounty.gov/depts/health/communicable-diseases/disease-control/influenza.aspx

CDC Long Term Care Toolkit: https://www.cdc.gov/flu/toolkit/long-term-care/index.htm