PRACTICE

Research evidence finds:

•Influenza is caused by viruses.

•Complications of influenza include pneumonia and

exacerbations of underlying chronic heart and lung

conditions often resulting in hospitalization or death.

•An effective vaccination exists.

•Flu vaccination is an indispensable part of the care of

persons 65 years of age and older.

•All people, not just elderly or at risk groups, should

consider annual vaccination if they wish to avoid

illness due to flu.

•Vaccination is cost effective.

•All VA patients and employees should be considered for

vaccination.

•Vaccination of healthy working adults decreases

absenteeism from work due to flu.

•Influenza vaccination is not associated with adverse

systemic side effects.

•Concern about side effects is a barrier to vaccination in

healthy adults, but studies show that mild soreness of the

arm at injection site is the most common side effect.

INFLUENZA

IMMUNIZATION

A Publication of the Management Decision and Research Center,

A program within the Department of Veteran’s Affairs Health Services Research and Development Service.

Matter s

SEPTEMBER, 1996 VOL. 1 ISSUE 1
BACKGROUND

I

nfluenza together with pneumonia remains the

sixth leading cause of death in the United States despite

the availability of a highly effective vaccine. 1

The Advisory Committee on Immunization Practices

recommends annual vaccination for persons over 65 years

of age and all at-risk groups. Although most deaths from

influenza occur among the elderly, VA researchers have

recently found that younger healthy working adults would

also benefit from annual vaccination. 2 VA studies have

found that influenza vaccination protects VA patients

from influenza related complications, protects workers and

reduces their number of sick days due to flu resulting in

substantial economic and productivity benefit.

VA POPULATION

O

ver 2.8 million veterans were treated in VA

hospitals and outpatient clinics in FY 1995 and

almost 38% of them were over 65.

VA employs 258,275 people of which 240,588 work in

the Veterans Health Administration. VHA employees

care for the large VA at-risk patient population and can

transmit the influenza virus to them. Care givers can

substantially reduce the risk of patient exposure by being

vaccinated. VHA care givers include:

– Physicians, nurses, and other personnel in both hospital

and outpatient-care settings;

– Employees of nursing homes and chronic-care facilities

who have contact with patients or residents;

– Providers of home care to persons at high risk (e.g.,

visiting nurses and volunteer workers); and

– Household members (including children) of persons in

high-risk groups should also consider vaccination.

SYMPTOMS

T

ypical influenza symptoms include the abrupt

onset of fever, myalgia, sore throat, non productive

cough, headache and debilitating weakness. Influenza can

cause debility lasting for several days or even weeks and in

some severe cases may lead to pneumonia or exacerbations

of other underlying heart and lung conditions. Influenza

accounts for millions of days lost from work each year. 3

During influenza epidemics, there is a rapid increase in the

number of visits to physicians’ offices, walk in clinics and

emergency rooms as well as increased hospitalizations for

management of lower respiratory tract complications.

CONTROL THROUGH

VACCINATION

V

accination each year, before the influenza

season, is currently the most effective means of

reducing the impact of influenza. Studies show that

vaccination of the elderly results in a 50% reduction of the

incidence of serological and clinical influenza, and is even

more effective in preventing the complications of influenza

(60% to 70%). 4,5 In healthy younger persons receiving the

vaccination, cases of flu can be prevented by over 80%,

resulting in significant economic benefits due to fewer sick

days from work and visits to physicians for flu. 2

The 1996-97 influenza vaccine contains antigens of

three virus strains (two type A’s and one type B)

representing influenza viruses presently circulating in the

world and believed likely to occur in the United States next

winter. The vaccine contains 15 mg each of A/Texas/36/

91-like (H1N1), A/Wuhan/359/95-like (H3H2), and B/

Beijing/184/93-like hemagglutinin antigens in each 0.5

ml. For both A/Wuhan/355/5-like and Beijing/184/93-

like antigens, U.S. manufacturers will use antigenically

equivalent strains A/Nanchang/933/95 (H3N2) and B/

Harbin/07/94 because of their growth properties. The

vaccine is made from highly purified, egg-grown viruses

that have been made noninfectious (inactivated). It should

not be administered to persons known to have anaphylactic

hypersensitivity to eggs or to other components of the

influenza vaccine without consulting a physician. 6,7

2

Practice Matters is a new series which covers topics in a short and

focused style summarizing the results of important research

within VA and promoting the application of research for

improved health care delivery and decision making. For more

information or to provide us with your suggestions, please

contact:

Information Dissemination Program

Management Decision and Research Center (152-M)

Veterans Affairs Medical Center

150 South Huntington Avenue

Boston, MA 02130

Phone: COM (617) 278-4433 or FTS 839-4433

FAX: (617) 278-4438

Email: mcglynn.gerry@forum.va.gov
EXPERT OPINION

T

oo few people receive influenza vaccine each

year. Among the barriers to vaccination are

uncertainty about the benefits and risks of vaccination and

failure to implement organized programs for vaccine

delivery.

Influenza vaccination is among the most cost effective

interventions available for our patients and their care

providers. Among seniors in an HMO, 8 vaccination was

associated with a reduction in hospitalizations for

pneumonia and influenza of 48% to 57% and for all

respiratory conditions by 27% to 39%. Vaccination was

also associated with 39% to 54% fewer deaths. Direct cost

savings averaged over $100 per person vaccinated. Among

healthy working adults, vaccination is also associated with

substantial benefits. 2 In a placebo controlled trial,

vaccination reduced upper respiratory illness episodes by

25%, sick leave by 43%, and physician’s office visits by

44%. Cost savings averaged over $45 per person

vaccinated.

Influenza vaccination is not associated with higher rates

of systemic symptoms than is placebo as shown in recent

studies in elderly 9,10 and healthy, younger adults. 11 Local

side effects may occur more frequently, but are usually

mild. The safety of influenza vaccine should be stressed to

providers and patients alike.

Knowing “the facts” about a bad disease and good

vaccine is not enough. To achieve higher immunization

rates, providers must also implement organized programs

which automate offering and administering vaccine.

Components of one such program include standing orders,

walk-in clinics, pre-printed information/documentation

forms, and an annual educational/publicity mailing to

patients. 12

Kristin L. Nichol, MD, MPH

Acting Chief of Medicine Service,

VAMC, Minneapolis

RECOMMENDATIONS

Based on research evidence:

•A formal influenza vaccination program should be

developed at the local level that strives toward 100%

compliance as the goal.

•A successful influenza vaccination program requires

efficiency and multi-disciplinary collaboration and should

address methods for identifying and informing target

patients and providing chart reminders to practitioners.

•The vaccination program should be made as convenient

as possible allowing for ease of access to both patients and

staff and include activities such as: patient reminder letters,

walk-in clinics, standardized documentation and

information forms, including overprinted progress notes. 13

•All providers should administer the vaccine to their

patients during the course of regularly scheduled visits and

a standing order should be established for clinic nurses to

give the vaccine to eligible patients without individually

signed physician’s orders, provided patients report no

contraindications to the vaccine.

•Large announcements should be posted in clinic lobbies

and waiting areas designating locations and dates of

immunization to capture patients who may not use the

system during the immunization period.

•Instructions for administration and documentation of

the vaccine should be posted in exam rooms.

•Clinic clerks should ask patients on check-out if they

received their vaccination.

•Education should be provided to patients, providers and

staff that emphasizes the seriousness of influenza, the

effectiveness of the vaccine and the safety of the vaccine.

•Place patient education handouts with post-flu shot

information in all exam rooms as cue for patient and

provider.

•Measure and evaluate the program’s success.

3

This Influenza Immunization issue of Practice Matters was prepared by the Information Dissemination Program at the Management

Decision and Research Center with information and assistance from the following:

John R. Feussner, Chief Research and Development Officer; Ronald J. Gebhart, MD, Chief Consultant, Primary and Ambulatory

Care; Kristin L. Nichol, MD, MPH, Acting Chief of Medicine Service, VAMC Minneapolis; Gary A. Roselle, MD, Program Director,

Infectious Diseases Program; Office of Policy, Planning and Performance; National Center for Health Promotion; and Office of

Patient Care Services.
REFERENCES:

1. National Center for Health Statistics. Vital Statistics of the United States, 1986,

Vol. II, Mortality, Part B, DHHS pub no. (PHS) 88-114. Washington, DC:

Public Health Services, US Government Printing Office: 1988.

2. Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against

influenza in healthy, working adults. New England Journal of Medicine 1995;

333:889-93.

3. Riddiough MA, Sisk JE, Bell JC. Influenza vaccination: cost-effectiveness and

public policy. JAMA 1983; 249:3189-95.

4. Govaert TM, Thijs CT, Masurel N, et al. The efficacy of influenza vaccination in

elderly individuals. A randomized double-blind placebo controlled trial.

JAMA 1994; 272(21):1661-5.

5. Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA.

The efficacy of influenza vaccine in elderly persons. A meta-analysis and review

of the literature. Annals of Internal Medicine 1995; 123(7):518-27.

6. Prevention and Control of Influenza: recommendations of the Advisory

Committee on Immunization Practices (ACIP), Morbidity and Mortality

Weekly Report 1996; 45(RR-5)1-11.

7. Veterans Health Administration Influenza Vaccine Directive for 1996-1997.

8. Nichol KL, Margolis KL, Wuornema J, Von Sternberg T. The efficacy and cost

effectiveness of vaccination against influenza among elderly persons living in the

community. New England Journal Medicine 1994; 331: 778-84.

9. Margolis KL, Nichol KL, Poland GA, et al. Frequency of adverse reactions to

influenza vaccine in the elderly: a randomized, placebo-controlled trial.

JAMA 1990; 246:1139-1141.

10. Govaert TME, Aretz K, Masurel N, et al. Adverse reactions to influenza vaccine

in elderly people. A randomized double blind placebo-controlled trial.

BMJ 1993; 307:988-90.

11. Nichol KL, Margolis KL, Lind A, et al. Side effects associated with influenza

vaccination in healthy working adults. Archives of Internal Medicine

1996;156:1546-50.

12. Nichol KL. Preventing influenza in the VA. VA Practitioner 1994; (September):

34-41.

13. Nichol KL. Long-term success with the national health objective for influenza

vaccination: an institution-wide model. Journal of General Internal Medicine

1992; 7(6):595-600.

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Vereran’s Affairs Medical Center,

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Your comments and suggestions are welcomed!

Feedback on this issue as well as suggestions for future topics would be

greatly appreciated. Feel free to contact us using the address, phone

and email given on page 2 or simply write your suggestions here and fax

it to us today, attention Information Dissemination Program at

(617)278-4438.

What do you think about the amount of information on the topic of

influenza immunization provided in Practice Matters? Please check one.

___Not enough information

___Just enough

___Too much

 Will it make a difference in what you do about influenza

immunization in your facility?

___Yes

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Please explain.

Do you have suggestions for future topics for Practice Matters?

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PRACTIC Matter Es