Catherine Conlon: When it comes to flu, prevention is better than cure
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I have just risen from my sick bed after four days of temperatures, burning throat, rasping cough, and the general feeling of being hit by a truck.
While I had the flu vaccine 10 days ago, it was too late to offer full protection.
Rattling with antibiotics, painkillers, and anti-inflammatory drugs, I long to feel well again.
Reports of flu surging in hospitals to over 1,000 cases, patients on trolleys, staff overwhelmed, and all but the most urgent warned to stay away — why are the basics of health protection not being comprehensively addressed?
Hospitals and residential care facilities are yet again overwhelmed by another vaccine-preventable illness.
A new Centre for Disease Control and Prevention (CDC) study reveals that flu vaccines reduced hospital admissions by 60% for children and 40% for adults.
They also reduced flu-related emergency department and urgent care visits by nearly 60% for children and 40% for adults.
Yet flu vaccination rates in Ireland remain stubbornly low across all age groups, as well as among healthcare workers.
The uptake of the free nasal vaccine for children, aged 2-17 years, is just under 16%, while uptake for adults over 60 is 58.8%.
Vaccination rates of healthcare workers in long-term care facilities in the 2022/2023 winter season was 42.8%, a significant fall from the previous winter where almost half (48.9%) of workers were vaccinated.
These figures are a long way off from the HSE target for 75% for influenza vaccination among healthcare workers.
Added to that, the adoption of masks, so prevalent during the covid-19 pandemic to reduce the risk of transmission of respiratory infection, is not being enforced during the “twindemic” of flu and RSV surging in hospitals and residential care facilities across the country.
It is left to individuals to decide whether they should wear masks.
As a result, some people are adopting ‘strategic masking’ — doing it where and when it might matter the most — often by people vulnerable to infection or a complicated illness.
An article in last July described how universal masking in healthcare facilities ended with the covid-19 pandemic, with many healthcare workers wearing masks in only limited circumstances.
The paper highlights that nosocomial infections caused by respiratory viruses other than covid-19 are common and underappreciated, as are the possible adverse health effects associated with these viruses in vulnerable patients.
“Nosocomial transmissions and clusters of cases of influenza, respiratory syncytial virus [RSV], human metapneumovirus, parainfluenza virus, and other respiratory viruses occur surprisingly frequently,” the paper stated. “Moreover, the morbidity associated with respiratory viruses extends beyond pneumonia. Viruses can also cause substantial harm by exacerbating patients’ underlying conditions.
“Acute respiratory viruses are well-established triggers for obstructive lung disease flares, heart failure exacerbations, arrhythmia, ischaemic events, neurologic events, and death.”
The paper suggests that viewed through the lens of these concerns, masking in healthcare facilities continues to make sense.
Masks reduce respiratory viral spread from people with both recognised and unrecognised infections.
Covid-19, influenza, RSV and other respiratory viruses can cause mild and asymptomatic infections, so staff or visitors may not realise they are infected, yet asymptomatic and presymptomatic people can still be contagious and spread infections to patients.
Added to that, despite repeated requests from healthcare system leaders for symptomatic staff to stay home, ‘presenteeism’ (coming to work despite feeling sick) remains common.
Even during the height of the pandemic, some healthcare systems reported that half of staff worked while symptomatic.
Studies from both before and during the covid pandemic suggest that masking among healthcare workers can reduce hospital-acquired infection by approximately 60%.
The incidence of hospital-acquired respiratory infection correlates closely with respiratory viral transmission in the community.
The higher the incidence of viral infections in the community, the greater the chance a healthcare worker, visitor, or patient will be infected and transmit infection to a patient.
The paper advises that healthcare facilities can therefore consider calibrating masking policies to community transmission levels.
The CDC has proposed surveillance metrics that hospitals can use to trigger masking requirements, such as the rates of influenza-like illness or emergency department visits for influenza, RSV, and covid-19.
Alternatively, facilities might find it more straightforward to plan on requiring masking during the specific months of the year when respiratory viral activity has historically been elevated. This approach might serve as a reasonable compromise by increasing protection for patients when risks are highest and minimising the imposition on healthcare workers when risks are lower.
The strategy of requiring masking during set months each year would also involve simpler communication and planning for facilities than an approach that entails triggering masking at different times each year, depending on when community transmission rates cross specific thresholds.
Similarly, the authors suggest healthcare centres need not require everyone in the institution to mask in all settings.
It’s most important for workers and visitors to mask when seeing patients, given the ethical imperative to protect patients from acquiring an additional infection in the hospital.
There is less basis for compelling staff members to mask outside of patient care.
Allowing workers to elect to forego masking outside of patient interactions would again strike a balance between protecting patients and minimising the imposition on workers.
Medical and public health communities have learned a huge amount over the past three years about the morbidity associated with respiratory viruses, nosocomial (hospital-acquired) transmission, and measures to protect patients.
Society has reached a transition point with covid-19, allowing a move away from universal masking in places other than healthcare facilities, and even in these facilities during periods of low community transmission.
The paper concludes that rather than abandoning universal masking for protection against covid-19, “healthcare facilities could reimagine masking policies to protect patients from the full array of nosocomial respiratory viral infections, using masking to protect all patients when viral activity is elevated and the most vulnerable patients year round.”
The lack of masking policies in hospitals and long-term residential facilities at a time of peak transmission of respiratory viruses is placing vulnerable and elderly patients at additional risk.
A reintroduction of masking policies for healthcare workers in these settings has the potential to reduce transmission of infection and the risk of complicated illness, as well as taking vital pressure off hospital emergency departments, limited bed supply, and overwhelmed staff.
Catherine Conlon is a public health
doctor and former director of human health and nutrition at Safefood