Flu Vaccine and Hand Washing

In much of the United States, influenza season is again underway. The Centers for Disease Control and Prevention (CDC) estimates that every year 5-20 percent of the U.S. population gets this very contagious and potentially life-threatening illness. Influenza can worsen chronic heart disease, lung disease, and diabetes, and can lead to bacterial or viral pneumonia. CDC estimates that as many as 200,000 persons will be hospitalized because of flu-related complications, and up to 36,000 people will die from flu.

Influenza Vaccine as Primary Tactic to Reduce Influenza Incidence

Yearly influenza vaccination is the best way to help protect against this disease. Influenza vaccine is recommended to all persons who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others. Up to 146 million doses of vaccine will be available from currently licensed manufacturers in the United States, so plenty of vaccine will be available this influenza season.

The groups for which vaccination with inactivated influenza vaccine (TIV) is recommended are listed below:

• all persons aged >50 years;
• all children aged >6 months to 18 years of age (new recommendation this year); (Children aged 6 months-8 years who have not been vaccinated with influenza vaccine or only received one dose previously have special recommendations. Please see MMWR Recommendations and Reports, Aug. 8, 2008: Prevention and Control of Influenza, Vol. 57, RR-7, pp. 26-27 for the current recommendations.)
• women who will be pregnant during the influenza season (NOTE: California law prohibits flu vaccine with >1mcg mercury per 0.5mL for pregnant women or children under 3 years old);
• children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for Reye syndrome after influenza infection;
• adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus);
• adults and children who have immunosuppression (including immunosuppression caused by medications or HIV);
• adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions, or that can increase the risk for aspiration; and,
• residents of nursing homes and other chronic-care facilities.

To prevent transmission to persons identified above, vaccination with TIV or LAIV (Live, Attenuated Influenza Vaccine) also is recommended for the following persons:

• healthy household contacts (including children) and caregivers of children aged <5 years and adults aged >50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and
• healthy household contacts (including children) and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza.

All healthcare professionals (HCPs), as well as those in training for healthcare professions, should be vaccinated annually against influenza. This includes:

• physicians, nurses, and other workers in both hospital and outpatient-care settings;
• medical emergency response workers (e.g., paramedics and emergency medical technicians); and
• employees of nursing home and chronic care facilities who have contact with patients or residents.

HCPs are asked to remind their patients that the flu season often lasts until spring, and therefore getting immunized against the flu in December, January, or later is not too late. And, as indicated above, vaccine supply is not an issue this year.

Both inactivated influenza vaccine (TIV) and live attenuated influenza vaccine (LAIV) are contraindicated in persons with life-threatening allergies to eggs, severe allergy to any vaccine component or who have had a severe reaction to a previous dose, including Guillain-Barre Syndrome of influenza vaccine. Additionally, the LAIV (nasal spray) should only be given to healthy persons 2-49 years of age who are not pregnant.

There are a number of myths about the flu vaccine that providers are encouraged to dispel. Three of the most common are:

1. The vaccine causes illness;
2. The patient feels he or she is not at risk for influenza; and
3. The vaccine doesn't work.

Each of these myths can be debunked with facts.

1. Influenza vaccine, made either with killed (TIV) or weakened live (LAIV) influenza virus, is unable to cause significant illness. Any illness that follows influenza immunization is either not influenza (many other respiratory diseases are circulating among the population at any given time) or a different strain of influenza not contained in the vaccine.
2. Influenza is highly contagious, and the CDC estimates that every year, between five percent and 20 percent of the U.S. population becomes ill with it. Many of those who get influenza are otherwise healthy people, not frail or chronically ill. Tens of millions of people get sick each year from influenza.
3. The vaccine has been intensively studied and is effective in preventing influenza in most people, or at least greatly reducing its severity. Even some protection against influenza is better than no protection at all.

Proper Hand Hygiene Is a Complementary Tactic

The practice of hand washing (hand hygiene) is another simple but powerful tactic to help control the spread of flu and other contagious diseases, not just during flu season, but all year long.

December 7-13, 2008, is National Hand Washing Awareness Week (an observance to encourage hand washing in promoting health and preventing disease) and a good time to emphasize the importance of hand washing as a tool in flu prevention campaigns. Thorough hand washing, done regularly with plenty of soap and warm water, can help reduce the spread of contagious diseases like influenza, as well as colds, hepatitis A, meningitis, and norovirus. Hand washing can also play an important role in maintaining overall good health, especially when combined with other behaviors such as getting enough sleep; exercising regularly; and eating a healthy, balanced diet with plenty of fresh fruits and vegetables.

Unfortunately, observation indicates that hand washing may not be as widely practiced as it should be. In a 2005 survey (sponsored by the American Society for Microbiology and the Soap and Detergent Association), 91 percent of adults said they always wash their hands after using public restrooms; however, just 83 percent were observed doing so. The survey reported that Americans who said they "always wash their hands" after using the bathroom in their home (83 percent) and before handling or eating foods (77 percent) was reported. However, smaller percentages of Americans always wash after petting a dog or cat (42 percent), after coughing or sneezing (32 percent), or after handling money (21 percent).

It is estimated that that some bacteria and viruses can live from up to 20 minutes to two hours or more on surfaces like doorknobs, desks, and cafeteria tables. The logical conclusion is that poor hand washing (or a lack of hand washing) plays a factor in the spread of contagious diseases like influenza and others.

Hand washing is most effective at reducing the chances of getting and spreading disease if it is done properly and often - especially after using the restroom, before preparing food and eating, and anytime the hands get dirty. The following are tips physicians and other health professionals can use to inform their patients about proper and thorough hand washing and related prevention steps:

1. Wet hands with warm running water.
2. Apply liquid or clean bar soap.
3. Away from the running water, rub hands together vigorously and make a soapy lather. Scrub all surfaces - the front, the back, between the fingers, under your fingernails, and around the wrists. Take about 15-20 seconds; a fast splashing does not remove germs.
4. The soap and scrubbing action dislodges the germs.
5. Rinse well under warm running water to remove the germs and dry hands with a clean towel. Turn off the water with a paper towel.
6. The paper towel should be thrown in a wastebasket when finished.
7. Keep your hands away from your eyes, nose, and mouth.
8. Avoid touching surfaces that are constantly being touched by others.

If soap and running water are not available, hand wash gels containing at least 60 percent alcohol significantly reduce the numbers of germs on skin and are fast acting. Some hand wash gels also contain ingredients to moisturize the skin.

Adults and children should be advised not to sneeze or cough into their bare hands, but to use a tissue (and dispose of it immediately) or their sleeve, whenever possible, and to avoid putting their fingers into their eyes, nose, or mouth.

Healthcare professionals as well as the general public benefit from proper and frequent hand washing. Studies have shown that proper hand washing (hand hygiene) is the leading measure to prevent cross-transmission of microorganisms and to reduce the incidence of healthcare-associated infections. However, research also has shown that hand hygiene practices in healthcare personnel may be less than optimal. A 2004 Annals of Internal Medicine article indicated that physicians' adherence to hand hygiene was low in most hospitals. Developing a positive attitude about hand hygiene by healthcare staff is important to promote these behaviors in patients.

Increased acceptance and use of influenza immunization, in combination with proper hand washing technique, gives communities the potential to prevent transmission of influenza and reduce morbidity and mortality for those at highest risk of complications from the disease.

San Diego County Statistics

• Rates of serious illness and death from influenza and its complications are highest among persons aged >65 years, children aged <2 years, and persons of any age who have medical conditions that place them at increased risk for complications of influenza (1).
• Influenza A (H3N2) viruses, which have been associated with higher mortality, predominated in 90 percent of influenza seasons during 1990-1999, compared with 57 percent of seasons during 1976-1990 (2).

To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends and comparisons to national targets, please call the County's Community Health Statistics Unit at (619) 285-6479. To access the latest data and data links, including the Community Regional Profiles, go to www.sdhealthstatistics.com.

References:

1. CDC, MMWR Recommendations and Reports, Vol. 56, RR-6, Prevention and Control of Influenza, Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007, pp. 1-2.
2. Ibid., p. 5.