EXACERBATION OF LUNG DISEASE
Chronic lower respiratory diseases such as COPD and asthma are the third leading cause of death in the United States, and there are an estimated 11.3 million US adults living with COPD.22
Flu is a major driver of mortality and morbidity in COPD.23 It is well established that COPD increases susceptibility to flu-related complications,24 and there is evidence that acute viral infections may alter the clinical course of the disease (eg, progressive loss of lung function) after acute exacerbation.25 In a US study, influenza virus was detected in 25% of individuals hospitalized for COPD exacerbations.26
In addition, the number of US adults with COPD is likely to be even greater than the official data indicate. More than 50% of US adults with impaired pulmonary function (likely due to COPD) have not been diagnosed27,28 and consequently are less likely to take necessary precautions against flu infection.
Furthermore, individuals with asthma are at increased risk of severe disease and complications resulting from influenza infection.29 Asthma, a lung condition caused by chronic airway inflammation, affects an estimated 18.7 million US adults, and in 2010, it was responsible for more than 14 million physician office visits, nearly 2 million emergency department visits, 439,000 hospitalizations, and more than 3400 deaths.22
EXACERBATION OF DIABETES
In the United States, diabetes is widespread—affecting nearly one-quarter of adults aged 65 to 74 years and one-fifth of adults 75 years or older.4 Diabetes is the seventh leading cause of death in the United States and a leading cause of blindness, end-stage kidney failure, lower limb amputation, and cardiovascular disease.30,31 Type 2 diabetes accounts for up to 95% of all diabetes cases.32,33
Emerging data have identified probable links between obesity, chronic inflammation, and insulin resistance. Prospective studies have documented an association between insulin resistance and accelerated cardiovascular disease in individuals with type 2 diabetes.34,35
Flu can cause significant and severe health complications for individuals with diabetes. The interaction of flu and diabetes is associated with significant morbidity and mortality attributed to metabolic complications.36 In addition, the emerging data regarding inflammatory reactions to the flu and increasing cardiovascular risk must be considered when addressing flu risk in the diabetes population.37
One study of individuals with diabetes found a 6-fold increased risk of hospitalization due to flu compared with people of similar age and sex distribution who did not have diabetes.38 In addition, the frequency of comorbid conditions, such as renal disease and heart disease, complicates the impact of flu on this population and can leave individuals with long-term disability beyond acute flu infection.39
BENEFITS OF INFLUENZA VACCINE FOR ADULTS WITH CHRONIC HEALTH CONDITIONS
Because of the serious complications of flu in individuals with chronic health conditions, it is critical to protect them from infection. Even during seasons when flu vaccines are not a good match with circulating virus strains, vaccination is still important in preventing serious outcomes.40 In one study of adults hospitalized with influenza, vaccination during the 2013–2014 season was associated with a 52% reduction in flu-related deaths in adults aged 50 to 64 years and a 61% reduction in those 65 years and older, along with reduced ICU and hospital length of stay among older adults, compared with similar-aged unvaccinated adults.14 Another recent study showed that flu vaccines reduce the risk of cardiovascular events in individuals with preexisting heart disease by 53% among patients who had had a myocardial infarction in the previous year and 36% overall; in addition, the vaccine reduced the risk of death by 19% among all study participants.41
Several studies have demonstrated the efficacy of flu vaccine in preventing disease exacerbations and complications in people with chronic health conditions. In those with chronic heart disease, the flu vaccine compares favorably with other preventive measures such as smoking cessation and the use of statins and antihypertensive drugs.42 Among individuals with COPD, flu vaccine produces a significant drop in COPD exacerbations compared with a placebo,43 is associated with lower risk of ischemic heart disease in older COPD patients,44 and can reduce serious illness as well as death.45
For individuals with diabetes, the American Diabetes Association has stated that annual flu vaccination is an important part of preventive care (see callout box, Statements on Flu Vaccine in Persons With Chronic Health Conditions).46 In this population, flu vaccine significantly reduces admission rates for stroke, heart failure, and all other causes of death in older patients with type 2 diabetes.47
It is also important to note that flu vaccination of household and community contacts greatly reduces transmission of flu virus to all in the community but most importantly to vulnerable individuals with chronic health conditions. High vaccination coverage across the population helps protect vulnerable individuals by greatly reducing the number of infected people overall, disrupting transmission, and providing indirect protection by preventing susceptible persons from being exposed to the virus (Fig. 6).13
CHALLENGES TO INCREASING INFLUENZA VACCINATION RATES IN ADULTS WITH CHRONIC HEALTH CONDITIONS
- Flu Vaccine Recommendations for 2018–2019 Season: Advisory Committee on Immunization Practices (ACIP) Recommendations48
- Routine annual influenza vaccination is recommended for all individuals 6 months or older who do not have contraindications.
- Influenza can cause serious illness and death, especially in older adults, very young children, pregnant women, and individuals with chronic health conditions.
- Vaccination is particularly important for persons at increased risk of severe complications and influenza-related outpatient/emergency department/hospital visits.
- When vaccine supply is limited, vaccination efforts need to focus on persons at high risk of flu-related complications:
- Children 6 to 59 months old
- Adults 50 years or older
- Chronic disease: pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic, metabolic (including diabetes)
- Immunocompromised individuals
- Women who are or will be pregnant during flu season
- Residing in nursing home/long-term care facility
- Native American/Alaska Native
- Extreme obesity (body mass index ≥40 kg/m2)
Health Care Professional Challenges
Who should be responsible for ensuring and providing flu vaccination? Many specialists believe that it is the job of primary care providers. Consequently, specialists such as cardiologists and endocrinologists may not routinely stock flu vaccines. In fact, according to a joint publication of the American Heart Association and the American College of Cardiology, 50% of cardiologists do not stock the flu vaccine, although flu prevention is paramount to avoiding exacerbations of heart disease.49 Pharmacists may stock and offer vaccines, but strong recommendations from other health care professionals (HCPs) help to increase patient interest in seeking vaccination at the pharmacy.
Limited Time and Resources
Time with patients is limited, constrained by practices and payers. Predetermined time limits are particularly challenging with patients who have multiple chronic conditions. Physicians—particularly specialists who do not typically administer flu vaccines—may be reluctant to add the service because of concerns that it may potentially increase the length of the visit. Patients may have questions about the effectiveness, necessity, and safety of a vaccine. Moreover, specialty medical office workflow often does not accommodate vaccination. A revised workflow would be required to determine who administers the vaccine, who provides the informed consent, who answers patient questions, and when in the workflow does this all happen. In addition, clinicians and office staff need to be trained on the various types of vaccines, indications and contraindications, and the importance of annual flu vaccination in mitigating severe illness.
Lack of Awareness
The relationship between acute flu infection, inflammation, and exacerbation of a patient's underlying disease, even if the disease is well controlled, is under appreciated by both primary care physicians and specialists. Beyond the acute infection, the potential effects of influenza illness in exacerbating chronic health conditions are not widely discussed or well known.
Myths and Misperceptions About Vaccination
In addition to misperceptions about and underappreciation of influenza infection, false notions about flu vaccine are also prevalent. It is not uncommon to hear individuals incorrectly state that flu vaccine “does not work,” that it “gives you the flu,” or even that it is “toxic.” Countering these false declarations with facts, even from credentialed HCPs and scientists, does not always overcome these ingrained beliefs.
Myths and misperceptions held by patients may stem from friends, family, or social cohorts such as parent groups or retirement communities. Social media posts against flu vaccine can exert influence over decision making, as can news reports with misleading information about low vaccine efficacy, despite various studies affirming the benefits of flu vaccination in mitigating disease.
Of particular concern, patients may assume that influenza vaccination is not necessary if HCPs are not strongly recommending it, which may, in part, be due to lack of awareness around the importance of annual flu vaccination for patients with chronic health conditions.
Misperceptions About the Burden of Flu
In addition to misunderstandings about the flu vaccine, false notions about influenza infection also present a challenge: “it's not so bad,” “having the flu builds your immune system,” and “I never get the flu” or “if I do get the flu, I'll recover.”
Eighty percent of unvaccinated adults believe that their likelihood of getting the flu is somewhat low or very low.12 Among adults aged 50 to 64 years, 47% think the flu would not be serious for them personally, and fewer than half of 50- to 64-year-olds admit that they are “less than very well informed” about the impact of flu and the elevated burden and risks for adults with chronic health conditions.12
Lack of Awareness of Risks of Flu for Adults With Chronic Health Conditions
Information on the interactions between influenza infection and chronic health conditions is not widely available or understood by patients. This may well be due to lack of clear accountability (between primary care and specialty providers) and underappreciation of the impact of flu on these vulnerable populations.
RECOMMENDATIONS FOR INCREASING FLU VACCINATION RATES IN ADULTS WITH CHRONIC HEALTH CONDITIONS
- Statements on Flu Vaccine in Persons With Chronic Health Conditions
- American Diabetes Association: Position Statement46
- Vaccination should be recommended for patients with diabetes aged at least 6 months beginning each September.
- Intervention strategies strongly suggested for specific diabetes patients (eg, >64 years of age, those with chronic cardiopulmonary disorders, residents of nursing homes/chronic care facilities).
- Dosage and type of flu vaccine vary based on patient age.
- American Heart Association/American College of Cardiology: Science Advisory49
- Vaccination is recommended as a component of secondary prevention for persons with coronary disease and other atherosclerotic vascular conditions
- Vaccination should be administered to all persons with cardiovascular disease, unless they have a contraindication.
- Providers can increase influenza vaccination coverage by stocking the vaccine, and by promoting annual immunization with strong recommendations and standing orders.
- American Lung Association: Influenza50
- People with asthma or other lung diseases are at higher risk of developing complications from flu.
- Health officials recommend that everyone 6 months and older receive an influenza vaccination every year.
- Individuals are encouraged to speak to their health care providers to learn more about influenza and annual vaccination.
All Health Care Professionals Have a Role in Protecting Adults With Chronic Health Conditions From Influenza
- Both primary care providers and appropriate specialists should stock and insist upon annual flu vaccination—particularly for patients with known chronic health conditions and for all patients 50 years and older, who may have an undiagnosed chronic health condition or are likely to spread flu to those with chronic health conditions.
- Specialists, such as cardiologists, endocrinologists, and pulmonologists, who treat patients with chronic health conditions must routinely incorporate flu vaccine into fall visits.
- Health care providers should reach out to patients with chronic health conditions who do not have a scheduled early-fall visit and ask them to come in for flu vaccination.
- Health care providers who are unable to provide flu vaccination onsite should write a “prescription” for flu vaccine for patients with chronic health conditions. Although a prescription is not required to get a flu vaccine at a pharmacy or other health provider, a written “flu vaccine prescription” can help signal the importance and urgency of the recommendation. A strong health care provider recommendation is known to improve vaccination rates.
Identify/Assign a Flu Vaccine Champion in Your Medical Practice or Health System
- Educate all clinicians and office staff on current Centers for Disease Control and Prevention influenza vaccine recommendations.
- Clearly communicate that flu vaccine is an integral and important part of health care for adults with chronic health conditions. Emphasize the potential for disease exacerbation and continuous frailty that can result from influenza infection.
- Create a point in the workflow during the flu season (typically September to March) for vaccine administration.
- Establish a targeted goal of at least 90% vaccination coverage among patients in the practice and assess progress on an ongoing basis.
Reset Messages About the Value of Flu Vaccination
- Emphasize the benefits of flu vaccination not only for individuals but also for the whole community. Benefits include the following:
- Risk reduction. No vaccine is 100% effective but flu vaccination helps to reduce risk in individuals and reduces the amount of virus circulating in the community. Partial protection is the norm and the goal for flu vaccines.
- Mitigation of disease. Vaccination lessens the effect of influenza illness and reduces the risk of long-term consequences if an individual becomes infected despite having been vaccinated.
- Disruption of transmission. The more people who are vaccinated, the less influenza virus will be transmitted in the population, leading to a healthier community overall. Vaccination also provides indirect protection by reducing exposure of susceptible individuals to the virus.
- Community immunity. Getting a flu vaccine is the socially responsible thing to do to protect both healthy individuals as well as those with chronic health conditions.
- Motivate patients.
- Insist on flu vaccination for all adult patients with a strong recommendation.
- Inform adults with heart conditions, lung conditions, and/or diabetes that influenza infection could exacerbate their condition, or even worse, trigger an adverse cardiovascular event.
- Emphasize the importance of remaining vital and active, going to work, enjoying life, and spending time with family/friends.
- Explain the potential for post–flu frailty. A frail person may lose the ability to take care of him/herself and maintain independence without burdening younger family members. Individuals may never return to their pre–flu state.
- Integrate flu vaccine messages into overall wellness messages and programs. Eating healthfully, not smoking, exercising, and getting the flu vaccine every year are all part of maintaining a healthy lifestyle.
- Create a practical vaccination reminder tied to an annual fall ritual—Labor Day, the first day of school, and so on.
Reinforce Medical/Scientific Consensus Linking Improved Patient Outcomes With Annual Flu Vaccination
- HCP audience:
- Educate doctors, nurses, pharmacists, and other medical professionals via professional meetings, publications, and continuing medical education.
- Consumer/patient audience:
- Enhance point of care education, including waiting room videos and brochures, targeted signage, and direct conversations between patients and HCPs.
- Initiate public awareness campaigns to ensure that people can self-identify as having a health condition that may be exacerbated by flu. One way to do this is to associate flu vaccination with behaviors versus diagnosis. For example, instead of saying that patients with chronic heart or lung conditions or with diabetes should get a flu vaccine, say that those who take statins, those who use an inhaler, or those who take insulin should get a flu shot.
SUMMARY AND CONCLUSIONS
Flu is a dangerous and potentially deadly virus with impacts that extend beyond the initial acute infection. Flu is of particular concern for the millions of adults in the United States who have chronic health conditions such as diabetes, lung disease, and cardiovascular disease, which may increase the risk of infection and influenza-related complications including hospitalization, catastrophic disability, and even death. In particular, influenza-related inflammation can exacerbate chronic lung diseases and has been shown to increase the risk of myocardial infarction and stroke long after resolution of the acute illness.
For these reasons, annual flu vaccination is critical in adults with chronic health conditions to mitigate disease severity, reduce hospitalization rates, and disrupt viral transmission. Unfortunately, vaccination rates remain suboptimal in adults, and the severity and true impact of influenza infection are underappreciated and often misunderstood by both patients and HCPs.
There is an urgent need to raise awareness of the burden of flu in adults with chronic health conditions. Health care professionals must communicate the importance of protecting patients with chronic health conditions against flu and subsequent exacerbations and complications. They play a key role in communicating the known benefits of flu vaccine in mitigating these risks, and they must be prepared to recognize and address key barriers to vaccination, including lack of consumer confidence in vaccine efficacy, lack of HCP ownership in administering flu vaccines, and misperceptions about the impact of flu.
All HCPs have the opportunity to help reframe the conversation about the value of annual flu vaccination, not only for adults with chronic health conditions but also for the community as a whole. By following the recommendations outlined in this report, HCPs and health systems can significantly increase vaccination rates and improve patient outcomes in adults with chronic health conditions. Encouraging routine immunization behaviors in middle-age adults may also ensure that they continue to seek annual vaccination as they age into the 65-plus-year cohort, another group at particularly high risk of flu-related complications.
- Several influenza vaccine options are available specifically for older adults. Health care professionals should review available clinical evidence when making selections for their patients. To learn more, visit the Centers for Disease Control and Prevention Web site.
The following organizations participated in the Roundtable discussions:
Alliance for Aging Research
American Academy of Family Physicians
American Association of Diabetes Educators
American College of Cardiology
American College of Physicians
American Lung Association
American Medical Group Association
American Nurses Association
American Pharmacists Association
Centers for Disease Control and Prevention
Immunization Action Coalition
National Adult and Influenza Immunization Summit
National Association of Chain Drug Stores
National Foundation for Infectious Diseases
The Gerontological Society of America
1. Centers for Disease Control and Prevention, AARP, American Medical Association. Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships
. Atlanta, GA: National Association of Chronic Disease Directors; 2009: Available at: http://www.cdc.gov/aging/pdf/promoting-preventive-services.pdf
. Accessed August 1, 2018.
5. Andrew MK, Macdonald S, Ye L, et al. Impact of frailty on influenza
vaccine effectiveness and clinical outcomes: experience from the Canadian Immunization Research Network (CIRN) Serious Outcomes Surveillance (SOS) Network 2011/12 Season. Open Forum Infect Dis
. 2016;3(suppl 1):710.
7. Zimmerman RK, Lauderdale DS, Tan SM, et al. Prevalence of high-risk indications for influenza
vaccine varies by age, race, and income. Vaccine
8. Garten R, Blanton L, Elal AIA, et al. Update: influenza
activity in the United States during the 2017–18 season and composition of the 2018–19 influenza
vaccine. MMWR Morb Mortal Wkly Rep
9. Centers for Disease Control and Prevention (CDC). Estimates of deaths associated with seasonal influenza
—United States, 1976–2007. MMWR Morb Mortal Wkly Rep
12. Nowak GJ, Cacciatore MA, Len-Riós ME. Understanding and increasing influenza vaccination
acceptance: insights from a 2016 national survey of U.S. adults. Int J Environ Res Public Health
. 2018;15(4): pii: E711.
14. Arriola C, Garg S, Anderson EJ, et al. Influenza vaccination
modifies disease severity among community-dwelling adults hospitalized with influenza
. Clin Infect Dis
15. Thompson MG, Pierse N, Sue Huang Q, et al. Influenza
vaccine effectiveness in preventing influenza
-associated intensive care admissions and attenuating severe disease among adults in New Zealand 2012–2015. Vaccine
16. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart Disease and Stroke Statistics—2015 update: a report from the American Heart Association. Circulation
17. Kochanek KD, Murphy SL, Xu J, et al. Mortality in the United States, 2013. NCHS Data Brief
19. Kwong JC, Schwartz KL, Campitelli MA, et al. Acute myocardial infarction after laboratory-confirmed influenza
infection. N Engl J Med
20. Madjid M, Aboshady I, Awan I, et al. Influenza
and cardiovascular disease
: is there a causal relationship?. Tex Heart Inst J
21. Loomba RS, Aggarwal S, Shah PH, et al. Influenza vaccination
and cardiovascular morbidity and mortality: analysis of 292,383 patients. J Cardiovasc Pharmacol Ther
23. Sanei F, Wilkinson T. Influenza vaccination
for patients with chronic obstructive pulmonary disease: understanding immunogenicity, efficacy and effectiveness. Ther Adv Respir Dis
24. Hsu AC, Starkey MR, Hanish I, et al. Targeting PI3K-p110α suppresses influenza
virus infection in chronic obstructive pulmonary disease. Am J Respir Crit Care Med
25. Sethi S. Infection as a comorbidity of COPD. Eur Respir J
26. Rohde G, Wiethege A, Borg I, et al. Respiratory viruses in exacerbations of chronic obstructive pulmonary disease requiring hospitalisation: a case-control study. Thorax
27. Tilert T, Dillon C, Paulose-Ram R, et al. Estimating the U.S. prevalence of chronic obstructive pulmonary disease using pre- and post-bronchodilator spirometry: the National Health and Nutrition Examination Survey (NHANES) 2007–2010. Respir Res
28. Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease
and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey 1988-1994. Arch Intern Med
30. Murphy SL, Xu JQ, Kochanek KD, et al. Deaths: final data for 2015. Natl Vital Stat Rep
31. Rao Kondapally Seshasai S, Kaptoge S, Thompson A, et al. Diabetes
mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med
34. Eckel RH, Kahn SE, Ferrannini E, et al. Obesity and type 2 diabetes
: what can be unified and what needs to be individualized?. J Clin Endocrinol Metab
35. DeFronzo RA. Insulin resistance, lipotoxicity, type 2 diabetes
and atherosclerosis: the missing links. The Claude Bernard Lecture 2009. Diabetologia
36. Peleg AY, Weerarathna T, McCarthy JS, et al. Common infections in diabetes
: pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev
38. Bouter KP, Diepersloot RJ, van Romunde LK, et al. Effect of epidemic influenza
on ketoacidosis, pneumonia and death in diabetes
mellitus: a hospital register survey of 1976–1979 in the Netherlands. Diabetes Res Clin Pract
39. Smith SA, Poland GA. Use of influenza
and pneumococcal vaccines in people with diabetes
. Diabetes Care
40. Sah P, Medlock J, Fitzpatrick MC, et al. Optimizing the impact of low-efficacy influenza
vaccines. Proc Natl Acad Sci U S A
41. Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination
and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA
42. MacIntyre CR, Mahimbo A, Moa AM, et al. Influenza
vaccine as a coronary intervention for prevention of myocardial infarction. Heart
43. Poole PJ, Chacko E, Wood-Baker RW, et al. Influenza
vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev
44. Huang CL, Nguyen PA, Kuo PL, et al. Influenza vaccination
and reduction in risk of ischemic heart disease among chronic obstructive pulmonary elderly. Comput Methods Programs Biomed
45. Wongsurakiat P, Maranetra KN, Wasi C, et al. Acute respiratory illness in patients with COPD and the effectiveness of influenza vaccination
: a randomized controlled study. Chest
46. Smith SA, Poland GA; American Diabetes
Association. Immunization and the prevention of influenza
and pneumococcal disease in people with diabetes
. Diabetes Care
. 2003;26(suppl 1):s126–s128.
47. Vamos EP, Pape UJ, Curcin V, et al. Effectiveness of the influenza
vaccine in preventing admission to hospital and death in people with type 2 diabetes
48. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza
with vaccines: recommendations of the Advisory Committee on Immunization Practices-United States, 2018–19 Influenza
Season. MMWR Recomm Rep
49. Davis MM, Taubert K, Benin AL, et al. Influenza vaccination
as secondary prevention for cardiovascular disease
: a science advisory from the American Heart Association/American College of Cardiology. J Am Coll Cardiol
. 2006;48(7):1498–1502. Epub 2006 Sep 15.
A minimum assessment score of 80% is required.
- Following adults 65 years and older, which age group had the highest cumulative flu-related hospitalization rate in the 2017–2018 influenza season?
- 0–4 years
- 5–17 years
- 18–49 years
- 50–64 years
- The benefits of influenza vaccination include which of the following?
- Mitigating disease severity
- Reducing hospitalization rates
- Disrupting viral transmission
- All of the above
- Which of the following is not an identified challenge to increasing influenza vaccination rates in adults with chronic health conditions?
- Lack of ownership in administering influenza vaccines
- There is no influenza vaccination recommendation for this population
- Limited time during the medical visit
- Lack of awareness of the potential effects of influenza illness in exacerbating chronic health conditions
- How long can the inflammatory reaction caused by influenza last?
- 2–3 days
- Several weeks
- 6 months
- 1 year
- Influenza vaccination has been associated with which of the following patient outcomes?
- Reduced risk of cardiovascular events in individuals with pre-existing heart disease
- Reduced risk of ischemic heart disease in older COPD patients
- Reduced admission rates for stroke, heart failure, and all other causes of death in older patients with type 2 diabetes
- All of the above
Your input is important in improving future publications and identifying areas of need for other educational activities. Please circle the choice that best answers the following:
1. The format was appropriate for the subject matter.
2. This activity supported achievement of the learning objectives.
3. The material was organized clearly for learning to occur.
4. I acquired a new strategy to use in my clinical practice.
Agree Disagree Not Currently in Practice
5. The activity was objective and free of commercial bias.
6. I would recommend this activity to my colleagues.
Additional comments and suggested continuing education topics that would be of value to you: __________________________________________________
You must print legibly and provide all of the information below to obtain credit. Incomplete requests will not be processed. Certificates will be sent to the e-mail address provided below:
Check the appropriate box:
□ I am a physician and wish to receive 1.0 AMA PRA Category 1 Credit™
□ I wish to receive a certificate of participation
Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
influenza; chronic health conditions; diabetes; lung disease; cardiovascular disease; vaccination