Description

Acute, typically self-limited, febrile infection caused by orthomyxovirus influenza types A and B marked by inflammation of nasal mucosa, pharynx, conjunctiva, and respiratory tract

Epidemiology

• Outbreaks of influenza occur annually during the fall–winter months in the Northern and Southern Hemispheres.
• Influenza virus can undergo antigenic shift (abrupt change) leading to viral strains with little immunologic resistance in a population, resulting in pandemic outbreaks. Minor seasonal variations are called antigenic drift.
• Persons of all ages are susceptible to infection. Higher concern for:
  • Those <2 and >65 years of age
  • Immunocompromised states, including pregnancy and up to 2 weeks postpartum
  • Individuals with cardiovascular or pulmonary disease, Addison disease, or diabetes
  • Residents of nursing homes or other long-term care facilities

Etiology and Pathophysiology

Orthomyxovirus (influenza types A [majority] and B); influenza A virus subtypes HxNx based on hemagglutinin and neuraminidase

• Incubation is 1 to 4 days; infected persons are most contagious during peak symptoms. Spread by aerosolized droplets or contact with respiratory secretions, hemagglutinin binds to columnar respiratory epithelium where replication occurs, and neuraminidase protein facilitates spread along respiratory epithelium (1).

Risk Factors

• For contracting disease:
  • Crowded environments such as nursing homes, barracks, schools, and correctional facilities
• For complications:
  • Neonates, infants, elderly; pregnancy (including 2 weeks postpartum) especially in 3rd trimester
  • Chronic pulmonary diseases; cardiovascular diseases, including valvular pathology and congestive heart failure
  • Metabolic disease, morbid obesity; hemoglobinopathies; malignancy
  • Immunosuppression; neuromuscular diseases that limit respiratory function and ability to handle secretions

General Prevention

• All persons ≥6 months should be vaccinated annually unless contraindicated.
• Live attenuated influenza vaccine (LAIV) is a quadrivalent intranasal vaccine approved for healthy, nonpregnant individuals between 2 and 49 years of age.
• Inactivated influenza vaccine (IIV) is available either as trivalent (IIV3) or quadrivalent (IIV4) with either three or four strains of influenza. IIV also is available as high-dose, intradermal, cell culture–based (ccIV3), MF59-adjuvanted (aIIV3), and recombinant hemagglutinin vaccine (RIV3).
• IIV is recommended annually for all persons aged ≥6 months. Protection occurs 1 to 2 weeks after immunization. Mild side effects include low-grade fever and local reaction at the vaccination site. Inactivated IM dose: ≥3 years of age: 0.5 mL; children 6 to 35 months of age: 0.25 mL Intradermal formulation for 18- to 64-year-olds uses a short 30-gauge needle in a single-use prefilled syringe with 0.1 mL vaccine; somewhat higher local reactions when given intradermal; single annual dose except for children <9 years of age, who should receive 2 doses (4 weeks apart) the 1st year they receive influenza vaccine
• Vaccine contraindication: Severe allergy such as anaphylaxis to IIV components, allergies from eggs are not considered a contraindication; observe all patients for 15 minutes after vaccination; no skin testing with influenza vaccine is needed in egg-allergic patients. RIV is safe in patients with an egg allergy.
• IIV-HD: High-dose quadrivalent IIV contains 4 times the antigen concentration of IIV. Licensed for persons ≥65 years of age. Results in higher antibody levels but somewhat higher rates of local reactions. Advisory Committee on Immunization Practices does not express a preference for/against IIV-HD.
• Antiviral prophylaxis depends on current resistance patterns each year; see https://www.cdc.gov/flu/ for patterns or check with local health department.
• Prophylaxis is not a substitute for vaccination but consider in high-risk groups that have not been vaccinated or need additional control measures during epidemics. Consider in staff and residents in nursing home outbreaks, immune-deficient persons who are expected not to respond to immunization after viral exposure.

Pediatric Considerations
Vaccinate children aged ≥6 months annually. Recommend all household members with children aged <6 months be vaccinated. For children who need 2 doses, administer first dose as soon as available, second dose to be given before the end of October. For prophylaxis, oseltamivir dosage varies by weight and is recommended by the CDC for prophylaxis for children aged ≥3 months; zanamivir is approved for prophylaxis for children ≥5 years of age at a dosage of 2 inhalations per day. Prophylaxis treatment duration is 7 days.Pregnancy Considerations

• The CDC recommends vaccinating all women who will be pregnant during influenza season. If unvaccinated at the time of flu season, pregnant women should receive IIV or RIV.
• Oseltamivir, zanamivir, peramivir, rimantadine, and amantadine are pregnancy Category C. Baloxavir not recommended in pregnant patients due to lack of data.

Commonly Associated Conditions

Pneumonia, cardiac complications, central nervous system involvement, myositis, rhabdomyolysis, multisystem organ failure