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Topics About 'Influenza'.

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  1. Covid-19 should not be compared to seasonal Influenza It’s normal to look at the CFR (case fatality rate) of seasonal influenza when considering Covid-19. After all, 20-45 million get “the flu” every year. The numbers vary depending on the year. The “low” was the 2011-2012 season with 9.3 million cases and 12,000 deaths and the high was the 2017-2018 season with 45 million cases and 61,000 deaths.1 Let us look at the worst of eight recent flu seasons. The CFR for that was 0.0014 meaning, 1.4 persons died per 1000 cases. Interestingly, if we look at the “best” of the past eight seasons (the “good” one) the CFR is 0.0013, almost the same number of deaths per thousand cases. So, hold on to this thought... Seasonal influenza’s average risk of dying is about one death per 750 cases. I see and hear CFR for the Covid-19 repeatedly being quoted at around 2-3%. CFR currently (as of 2/27 12:23AM EST) is 3.4%. That is 2,810 deaths divided by 82,550 cases. But to say that the CFR for Covid-19 is 3.4% is not wise. Why? Simply put, the CFR is not applicable are even a number that one can calculate since it's a "look-back" number. For data current as of 2/27, click here. CFR is a “look-back” rate It is very useful when we look back to an epidemic/pandemic that has ended. For instance, when comparing the “good” 2011-2012 flu season to this season’s numbers. CFR is death rate / # of confirmed cases. To divide the known number of cases today by the number of deaths, we get 3.4%. But this is not wise to use because it assumes that ALL of the remaining cases (total cases today of 82,550, minus cases where the person has recovered or died) will be cured. This is “magical thinking.” Many of those remaining 46,488 will recover, but some will die. In short, we won’t know the true CFR for another year or more. CFR is useless at this time, it will be helpful sometime next year. Known outcomes So, let us look at the cases with known outcomes, meaning the sum of the cases of those who have recovered plus those who have died. This population is composed of those 33,252 who have, to today, recovered plus the 2,810 who have died; thus, our population is 36,062. If we divide 2,810 (deaths) into our population of 33,252, we find an overall death rate of 8.45% or about 85 per one thousand cases with known outcome. Please let that sink in for a bit. Today, looking at Covid-19 cases with known outcomes, 85 out of 1000 cases have died. Should this hold, and it may, then 1 out of 12 cases will die. Compare this to seasonal influenza where 1 out of 750 cases will die. The death rate currently for Covid-19 is 62x the death rate of the average seasonal influenza. These two illnesses do not compare, although we’ll really not know for a year or so, at which time we can look back to see what the true CFR rate was. Let us look now at areas/countries to see the current death rate is, of those cases with known outcomes. I’ll call the current fatality rate of known outcome cases: CFR-KO. I shall call the population with known outcomes: PWKO Total deaths / PWKO = CFR-KO or current death rate. World: 2801 / 36,062 = 8.45% or ~85 deaths per 1000 cases. Hubei Province: 2641 / 26,024 = 10% or ~100 deaths per 1000 cases. South Korea: 13/35 = ~37.2% or 372 deaths per 1000 cases. Italy: 14/54 = ~26% or 260 deaths per 1000 cases. We see that regional epidemic outbreaks tend to drop in CFR-KO as time goes by. Whether the true “look-back” CFR will drop to 2 or 3% or some other number (lesser or higher) depends on many factors which are simply unknown. For instance, children appear to be much less at risk for Covid-19, and cases within Africa (other than the one in Egypt) seem oddly absent. Perhaps the virus does not do well in warmer climates. Perhaps the fatality rate will drop as we approach Summer in the Northern hemisphere—we do not know. Perhaps the tendency of the media to quote the 2-3% theoretical CFR comes from the fairly recent 2009 H1N1 flu pandemic. The 2009 “swine” flu was very feared. It infected 10-200 million world-wide with estimates of death ranging from 105,700 to 395,600 and a CFR of 0.03% or 3%. (30 per 1,000 cases). (Wikipedia). It was expected to return far, far worse numbers. The “swine” flu, which was the first pandemic of this century, turned out to be far less lethal than many expected. Triggle wrote in an article from December 10, 2009 titled, Swine flu less lethal than feared, "The swine flu pandemic is ‘considerably less lethal’ than feared, chief medical officer Sir Liam Donaldson says,” adding, “A study led by Sir Liam found a death rate of just 0.026% in those infected, the British Medical Journal reported.”2 Will we be lucky? Perhaps we’ll be lucky this time, too, although I suspect we won’t be as lucky as we were for the “swine flu.”
  2. Nursesusu

    Influenza

    Just curious how many are seeing Flu A or B? Seems we are getting hit with a lot of Flu A, especially in K.
  3. Ah….fall! That time of year where we start to prepare for winter. Autumn brings leaves, pumpkins, and warm sweaters. Everyone heads outside for bonfires, football games, and trick-or-treating. Yet, lingering right around the corner is flu season. This isn’t a season that brings joy and happiness. The flu is a dangerous and even deadly virus that is preventable. Here are the essentials you need to know about the Influenza vaccination recommendations from the CDC for 2019-2020. What is the Flu? Influenza, commonly called the flu, is a respiratory infection. The flu can cause serious complications in those who are compromised for any reason, such as older adults, young children, or individuals living with conditions that decrease their ability to fight off infection. Vaccines are not 100% effective. However, they are the best way to prevent the flu and possible complications. How are flu vaccines created? Flu viruses are constantly changing. Each year, researchers across the country, study the current strains, and review the composition of vaccines. Updates to the vaccines are needed to match the viruses that are seen the most. There was a delay in selecting the viruses for the 2019-2020 season due to frequent changes in some of the common viruses. Flu shots protect individuals against three or four viruses that are expected to be most common during the season. Four vaccines will be available to the public this year. Medication Rights: Right Patient, Right Time Annual flu vaccination is recommended for everyone over the age of six months unless contraindications exist. Getting vaccinated is of utmost importance for a few specific populations, including women who are pregnant, young children, and older adults. Young children may need up to two doses of the vaccine to be fully protected. Other populations that are at high risk of complications from the flu include individuals living with obesity, liver or kidney disease, diabetes, HIV/AIDS, asthma, cancer, COPD, or cystic fibrosis. Will there be Enough Vaccine this Year? The amount of vaccine available each year depends on manufacturers. The projection for the 2019-2020 season is between 162 million and 169 million doses for the U.S. alone. These numbers may change depending on how the season progresses. Arguing for Mandatory Flu Shots If you work around people with the flu, your chances of contracting the virus are increased. Getting the vaccine not only protects you, but can also help to protect your family, friends, and patients. Individual’s with the flu are contagious one day before symptoms show up and up to seven days after becoming sick, which means that many people can pass the flu on to others without even knowing it. The CDC recommends that all U.S Healthcare workers get vaccinated against the viral infection. More than 78% of all healthcare workers received the vaccine during the 2017-2018 season. Doctors and pharmacists were the most vaccinated at 96.1% and 92.2% respectively. Nurses came in at 90.5% and nurse practitioners at 87.8%. Healthcare workers in long-term care settings were the least likely to get the vaccine, and those in hospitals were the highest. Some healthcare settings mandate flu vaccines for all clinical and non-clinical staff. These clinical setting had the highest rate of coverage at 94.8%. Arguing Against Mandatory Flu Shots While the CDC recommends getting vaccinated, not everyone wants to get a flu shot. Hospitals report that making flu vaccines mandatory is to protect patients. However, what about the rights of the healthcare worker? Researchers report that vaccinating healthcare providers will help with patient safety, increase the effectiveness of the vaccine, and protect those staff who are at an increased risk of complications from the virus. Those who oppose the vaccine report factors like side effects of the drug, setting a precedent to require healthcare professionals to comply with other medical treatments, or just feeling like a shot isn’t needed as their reasoning for opposing the requirement. Many nurses feel that following standard and transmission-based precautions such as hand washing, wearing masks, and even keeping people in isolation should be enough to minimize the spread of the infection. How Do You Feel? Vaccines can elicit much debate these days. And, requiring professionals to take a medication that they don’t want could cause some tempers to flare. So, where do you stand on the issue? Take our poll so that we get an idea of how many of you only take the vaccine because it’s required at work. And, comment below to let us know how you really feel about the topic.
  4. The flu epidemic has been causing overcrowding all over across the United States. In northern California the outbreak is no stranger and flu season is only half way done. Like every hospital we test for the flu and are required to ask every admitted patient if they want the flu shot to decrease transmission. It seems as though, every patient being admitted is wearing a mask and being ruled out for the flu. I received my flu shot this season but was I bound to catch the flu from the start because of my increased exposure? Sure enough, I caught the flu this winter season. I experienced the fever, the chills, and the night sweats that are all common symptoms. I would have been more surprised if I did not catch the flu this season with all the sick calls from my fellow nurses. I only had to call into work for one day based on my three day schedule when I started getting sick. I believe the flu only lasted a couple of days because I received the flu shot and I was taking my immune boosters. I returned to work later in the week with no further signs or symptoms. However, a few days later I started getting this chest pain feeling that I believed was heartburn. It was at the center of my chest, a burning sensation, and I had that acid reflux feeling in my throat. This was a rare occasion for me to experience heartburn but I keep tums in my household for guest. After a couple tums the pain still took an hour to be resolved and I could resume my daily activities. Later on, I had another episode of heartburn that was not correlated with my meal times that day. I started to think to myself "am I starting to get older?" I purchased some Pepcid and took some at the start of the day to help prevent heartburn symptoms but again another case of heartburn presented itself. On day three, I decided to head into the Emergency room to try a GI cocktail to knock this heartburn out. I informed the ER clerk that I was experiencing chest pain that I originally attributed to heartburn but not was unsure. Unfortunately, all that was heard in the admission process was "heartburn" and I was told to wait. Two and half hours later I was finally triaged and seen by the MD to help resolve my heartburn. The MD told me the plan which I agreed with: Chest x-ray, EKG, Labs, and a GI cocktail for the pain. The MD did not have a good poker face when the EKG was handed to him by the nursing assistant. I asked to see the EKG because my background is in cardiology nursing. I presented with ST elevation is majority of my leads, which caused me some alarm. The ER MD told me he was going to consult cardiology while wait for my test results and have my chest x-ray. The x-ray results normal which was a good sign. The ER MD came to my bedside and informed me that I have Pericarditis. It finally all came together when I heard Pericarditis from my PCCN training. I had a viral infection first, then had chest pain that was affected by position, and can show ST elevation in an EKG. I was told I could be discharged from the ER and need to take Motrin 600mg every 8 hours for the inflammation. The last thing I needed before discharge was the results from my lab test. Everything looked normal besides a slight elevation in my WBC, which caused no concern because I was recovering from the flu. Then my cardiac enzymes test results were run and I had a troponin of 11.0. No longer was I able to be discharged from the ER, I was being admitted for observation and a bedside ECHO. In our line of work people are told worse news every day. However, I am told I need to be admitted for observation and I was actually scared. I started thinking of all the worse possible scenarios that could happen i.e. heart transplant from cardiomyopathy. I tried to be a good patient by putting on the grip socks and wearing the continuous pulse oximetry. I did refuse the SCD and tried my best not to silence my alarm monitor. I failed in the latter attempt and found myself silencing my bedside alarm because it was disturbing my sleep. I didn't want the nurses to experience alarm fatigue which is a new focus for Joint Commission. Finally, morning arrived and I was seen by cardiology. My troponin peaked at 12.6, but finally down trended to 7.6 later on. My ECHO results were normal, and I was diagnosed with Myo/Pericarditis. The medication regime stayed the same with Motrin 600mg every eight hours. This experience was an eye opener to see things from the patient's perspective and how disruptive those alarm monitors can be. I am happy to report everything is back to normal and I am able to resume normal activity. Thanks again for reading. To read more about alarm fatigue and participate in an academic research survey which I am doing for a MHA degree, please go to Alarm Fatigue Survey here on allnurses.
  5. Lynda Lampert, RN

    Five Ways to Convince Patients they Need Flu Shots

    Patients, especially chronically ill patients, need flu shots, but many in the general public have an open distrust for this vital vaccine. In fact, some people reject all vaccines, and that's a different issue entirely. Flu shots are still important, and some members of the public take a little convincing to get them to accept the shot. There are a great deal of myths and misconceptions about this shot, and some patients believe the hype. As nurses, we have to try to do what's best for the patient, and sometimes that means educating about those myths. Of course, we could never force someone to take a shot that they are dead set against, but the persuasion of education may be enough to allow them to see that the need for the shot. If you come up against a patient who is chronically ill that refuses a shot, here are a few strategies to combat the myths they may believe. Explain How Flu Shots are Created Some patients do not understand exactly what the flu shot is, and this can lead to distrust and refusal. It helps to explain to them that it is an amalgamation of the various flu strains thought to be active for the coming season. You can also use this information to help explain why the shot needs to be performed every year. The flu strains change, and the new vaccine differs every year. It helps to explain the flu and get patients to understand that it can knock them out for weeks. Emphasizing that the people in charge of creating the vaccine make it as safe as possible, but it isn't a guarantee against getting the flu. Some strains pop up every year that can infect even patients who have gotten the shot. Once this is explained, some patients are more open to the idea of getting a flu shot. Emphasize Safety of Flu Shots Flu shots are generally considered safe. You can use this information to educate the patient that they are better off with it than without it. Of course, there is often local irritation where the shot is administered, but most people don't tend to have reactions to the shot itself. The vaccine is rigorously tested for safety, and the possibility of a reaction is minimal. You may also find patients who are afraid of getting a shot. It helps to explain that the shot only hurts for a minute, though they may have soreness later. The shot goes into the deltoid, an IM shot, and these are usually more painful than others. Explain that they will feel some discomfort at first, but it quickly goes away. Usually, the benefits of the flu shot are far more important than the momentary pain that some patients experience. Assure Them They Won't Get the Flu from the Shot One of the most prevalent myths about the flu shot is that it gives you the flu. This keeps more patients away from the shot than any other excuse. It is your job to explain to them that the preparation is a dead one. This means that the virus isn't active and helps the immune system recognize and destroy the virus when it comes around to infect. Some patients do get the flu after a flu shot, but this is usually because they were already infected when they got the shot. In this case, it is difficult to convince the patient that the shot didn't lead to their symptoms. If you were the patient, you would have a hard time believing it, too. Tell the patient that getting the shot as early in the season as possible will prevent this phenomenon, but it is still possible. Educate about Symptoms of Flu Those who refuse the flu shot should be told the symptoms for several reasons. First, it is more likely that they can get the flu without the shot, and they should know what to look for in case they do become infected. Second, they may decide to have the shot once they realize how miserable it is to actually have the flu. The public is not usually educated about the signs and symptoms of the flu, and they may change their mind once they know. You should tell them to watch for high fever, over 101 degrees F. The symptoms of the flu often are confused with that of the common cold. Stuffy head, congested chest, and muscle aches are all common symptoms. The difference is that the flu is generally more severe and lasts for a longer time. While the cold can last for a few days, the flu can linger for weeks, and this can cause inconvenience and health problems for the patient. Explain the Complications of Flu Healthy people do not usually suffer complications of the flu. Yes, they are miserable, can't go to work, and generally inconvenienced, but it doesn't descend into a medical crisis. This isn't true for those who are very young, very old or have a chronic disease. The immune system in these patients is not generally as robust, and this means that the flu can take hold and lead to further problems. The most common problem that arises from the flu is the manifestation of pneumonia. In those with a compromised respiratory system, pneumonia can lead to a stay in the hospital and possibly a trip to the ICU. Even those with diabetes are at risk for the condition developing into pneumonia because of the general decrease in immune function due to high blood sugars. For the very young and the very old, pneumonia can be devastating and particularly hard to treat. Explaining these complications can help to convince even the most recalcitrant patient to accept the vaccination.
  6. mooreea8

    The flu, how it could be worse...

    According to the CDC, the influenza activity continues to increase from week to week this 2017-2018 season. The number of influenza cases is extremely widespread and seen across all the states in America. As a matter of fact, the number of states experiencing widespread influenza activity increased this past week to 47 states. Each year there are different strains of influenza dispersing in the population. The current strains this season include H3N2, H1N1 and B viruses. It has been noted that H3N2 is the most prevailing strain and is linked to more hospitalizations according to the CDC. Due to the high involvement of H3N2 in this year's flu season, health officials are seeing more health complications and higher flu-related deaths. The H3N2 is noted to hit people harder than other strains of the flu. The flu vaccine is modified or revised every year in hopes of targeting the most common strain. However, this is not a guarantee and the CDC estimates that this year the vaccine is approximately 30 percent effective against the H3 strains. Research shows that the current H3N2 component of the vaccine is a poor match for the circulating strain and has a low effectiveness rate. This week it was noted that the hospitalization rate for influenza is higher than the previous years. Recent data collected by the CDC shows that the flu-related hospitalizations increased to about 60 people out of every 100,000. It was also noted that people seeking medical attention for influenza-like symptoms is 7.7 percent. This is the highest reported percentage since the flu pandemic in 2009. However, there is something even more dangerous to our health than influenza and that is pneumonia. Pneumonia is a serious infection of the lungs that leads to inflammation. Pneumonia can be caused by bacteria, a virus or even a fungus. Influenza can absolutely turn into pneumonia without people even realizing it. In the United States, approximately one-third of all pneumonia cases were caused by respiratory viruses, and the most common contributor was influenza. The flu and pneumonia were actually the eighth leading cause of death in 2014 in the United States. The percentage of deaths contributed to influenza and pneumonia has drastically increased this season to 9.7 percent. Everyone is at risk for getting pneumonia since it is airborne and highly contagious. However certain populations are more at risk including the elderly (especially with multiple comorbidities), pediatrics, people who are immunocompromised, people in intensive care units, people who recently had a cold, people with respiratory illnesses such COPD, smokers, and people who recently had surgery. What's important to remember is if you have influenza and begin developing new symptoms such as a new fever, shortness of breath, tightness in the chest, congestion leading to chest pain, rapid heart rate, coughing up green/yellow or bloody mucus and rapid breathing, seek medical attention. Do not wait! The flu creates the perfect breeding ground for pneumonia. As soon as the pneumonia-causing organism enters the lung tissues, the air sacs known as alveoli, fill up with fluid and mucus. The organism then causes the lungs to swell blocking the flow of oxygen. This combination is what makes it difficult to breathe. The fluid and mucus buildup in the lungs along with the sedentary recovery period associated with being sick allows for the growth of the organism. The key is not to stay at home with the development of these symptoms. Untreated pneumonia can develop into sepsis. Sepsis is a serious complication of an infection caused by the body's reaction to that infection. It can be life-threatening. Sepsis is when the body's defense mechanisms work overtime to fight an infection. When sepsis occurs the body releases a large number of chemicals in the bloodstream to the fight the infection resulting in an inflammatory response. The inflammation can then lead to a cascade of changes causing damage to organ systems and clotting disorders, ultimately resulting in organ failure. Severe sepsis restricts the blood flow to vital organs such as the brain, heart, and kidneys. Sepsis is treatable but early detection and aggressive treatment are vital. Antibiotics and fluids play a huge role in treating sepsis depending on the infectious organism. If the organism is bacterial then antibiotics are required. If the organism is fungal then antifungal medications are used. If the organism is viral then rest and fluids are required. It's important to stop the infection to keep the vital organs functioning. Fluids and vasopressors are often used to help improve low blood pressures associated with sepsis. There is a vaccine available to help prevent pneumonia and hand washing is also important to help reduce the occurrence of pneumonia. Covering your mouth when you cough or sneeze can go a long way in decreasing the exposure of gems. It's important to wipe down surfaces that come in contact with infectious organisms because the flu contagion can live up to 24 hours on them. Prevention is key but if you or someone you know starts to develop symptoms of pneumonia seek medical attention. Are you guys seeing any complications from influenza in your work setting? If so, what are they and how have they affected the overall health of your patients? Also, are you finding that many of your staff members are contracting the flu?
  7. With Ebola in the news and the flu season upon us, I wanted to share some information about the immune system. It is and always will be your best defense against disease. The immune system is your defense against anything that seeks to attack the body. It is your defense against bacteria, viruses, fungus and even cancer. It will respond to environmental allergies as well as allergies from food. This brings us to the first reason your immune system may not protect you this flu season and that is because of diet. 1. S.A.D.: Standard American Diet The typical diet is 75% processed with an overdose of sugar in food and drinks. The intake of sugar is actually at pharmaceutical doses contributing to major disease. Did you know the United States is number 1 in the world for Chronic Degenerative Disease? The US spends more money than any other on Diets and Diet products. In fact, the amount spent nationally on diets has more than doubled from $30 billion in 1992 to over $70 billion today. And Americans eat more sugar than anywhere else in the world with most people consuming over 200 pounds of sugar per year. Food is the major "go to" for stress relief and portions have tripled in the last 10 years. As food and drink have supersized, it is a set up for weight gain and Diabesity. A Happy Meal, about 590 calories, used to be an adult size portion. Today you can supersize your way to fast food heaven and take in over 1500 calories in one meal. With 70% of the population overweight, and eating a processed food diet, it isn't really surprising that Diabetes and Heart Disease are showing up in younger and younger people. It doesn't take 20 years for adult-onset diabetes anymore. Fast food sets up its own cravings and vicious cycle. The most rushed you are and the more you give in to this diet, the more sugar and fat you crave. Your immune system needs minerals and water. Your gut needs fiber. The ideal diet should actually be 60% vegetables. A simple solution to start cleaning up your diet is to add in an apple a day. Next, add in salads. One day a week eat only fruits and vegetables and drink water. This will begin to re-mineralize your body and provide the needed hydration. A fast food diet high in sugars has dramatically decreased the amount of water people take in leading to dehydration. Without water, your body cannot eliminate toxins, lubricate joints and support healthy mucus membranes. Food today has become entertainment, comfort and even love and really doesn't provide the nutrients or fuel for the body to do what it needs to do to support optimal health. The S.A.D., Standard American Diet is pretty sad lacking the very nutrients to support the primary function of the gut; the ability to digest and absorb nutrients out of food. This brings us to the number 2 reason your immune system may not protect you. 2. 80% of your immune function comes from your gut With all that sugar consumed, most of which is in the form of high fructose corn syrup, you are at risk for leaky gut. Leaky gut results when the lining of the intestine becomes damaged, inflamed and permeable (porous) releasing undigested foods, bacteria, fungus, and other foreign invaders into the sterile environment of the bloodstream. As these toxins move through the bloodstream the immune system is triggered causing generalized inflammation that contributes to many chronic conditions. Depression, joint pain, Crohn's disease, food allergies, eczema, psoriasis, asthma, autoimmune diseases, and more can result from leaky gut. The heavily processed diet also includes trans fats, additives, excitotoxins, flavor enhancers along with modified gluten, all known to cause inflammation and damage to the gut lining. Add to this a lack of fiber and water and your gut builds up mucus in the digestive tract (which includes the sinuses) leading also to an imbalance in the ratio of healthy to unhealthy bacteria causing candida and yeast overgrowth. As your gut becomes compromised so does your immune system putting you at risk for increased allergic reactions and ultimately autoimmune conditions. The reason so many people are eating fast food is because stress has become chronic. This brings us to the 3rd reason your immune system may not protect you from the flu. 3. Chronic stress suppresses immune function Making changes to your diet may first have to start with managing your stress. They both go hand in hand and a poor diet adds to the stress response as much as increased stress sets up the cravings for a fast food diet. When your body goes into sympathetic overdrive, all blood is shunted away from your digestive system and your immune system and sent to your muscles so you can fight or flee. This primitive, survival instinct is triggered with real and imagined threats. The more you ruminate and worry, the greater you set up this chronic stress reaction. There are other reasons the immune system is compromised today like overuse of antibiotics and germicidal hand gels, but these 3 reasons are the biggest. Start with a simple fix and drink more water, next add in an apple and then begin to eat more vegetables. Every meal is a choice and a chance to support overall health which includes an immune system that is designed to protect you from colds and flu.
  8. Sarah Matacale

    ER Nurse's "Funky Flu" Video Goes Viral

    We've all had these moments after working a particularly insane shift. We have to vent. Your brain is still reeling, you are exhausted yet still in overdrive. Sometimes it's related to coworkers or employer issues, but many times it relates to our patients. Let's face it, healthcare is a combination of the science of medicine, the art of nurturing, the business of hospitality and service and the skills of retail and education. We deal with people at their worst. They are sick, scared, frustrated, angry for either themselves or a family member or friend. We get the brunt of it all. Somedays frustrated doesn't even come close to explain how we feel, especially when the illness or injury that brought them to be under our care is preventable. We just want to say, "what on earth are you thinking?" and "Let me tell you something right now....!" Katherine Lockler, an Emergency room nurse from Milton Florida did just that via social media. Dubbed the The "funky flu" video, Katherine went to Facebook with a bit of advice for people on how to avoid the flu and how to protect yourself and others. Her video titled "After Work Thoughts", quickly went "viral" with over 4 million views at the time this article was written. In her post, Katherine is direct, matter of fact, sarcastic and very honest about what she is seeing as an ER nurse during this flu season. The video provides helpful tips on how to avoid the flu this season, as well as how to properly protect yourself and others in a funny and dramatic way, such as how to properly sneeze and cover. She also provides some insight into what an ER nurses shift looks like during this flu season by discussing Emergency Room wait times, asking people to understand and trust that the person seen before you is more sick than you are. She goes on the talk candidly about the anger, cursing and frustration given by patients to the nurse, explaining that wait times are due to several factors that one can not see beyond the lobby. Most of the reactions from viewers has been positive especially from fellow nurses and medical personnel, but as with anything posted on social media, Katherine's video has had some negative feedback. Several have expressed their offense to her "sarcastic tone" and demeanor and according to several media sites, Katherine has allegedly been turned in to the Board of Nursing. While we can't know for sure of the facts surrounding the alleged report, an online petition, showing support for Katherine, has been formed to be submitted to the Board of Nursing. The petition reads: "Katherine Smith Locklear is an ER Nurse. She posted an AMAZING video on Facebook regarding the flu and how it is spread along with great tips on home treatment. For her time and effort, she is being reported to the Board of Registered Nursing and her hospital." Nurse calls hospital ER ‘cesspool of funky flu’ This presents several hot-topics for thought and discussion. What did Katherine do or say that presents a valid complaint to the Board of Nursing? Does a nurse have the right to vent about her job, shift, or patient experience on social media if the names and exact details are left out? What about after your shift ends and you meet coworkers for dinner and vent out loud without disclosing names? Does this border on HIPAA violations? Does the hospital or Board of Nursing have the right to penalize this or any nurse who sends a strong message via social media? Is what you do on your time your business or does Katherine's video reflect upon her employer? Does her "tone" work to educate the public here, or did it hurt? Katherine responded in an interview with TCPalm stating: "I think there's a little bit of sarcasm in my voice because the instructions were given so many times and they were not received well," Lockler told TCPalm. "I tend to be sarcastic in all my speaking, but if it's taken wrong, I would definitely apologize to that group that misheard my message because of my tone. The message is still right on the money, but if the tone was offensive, that was not the intention." I, like many others, caught this video on my facebook feed and watched from beginning to end. Of note, I rarely watch any video on social media in its entirety. Her manner of speaking, the tone, the subject matter and the stone cold truth about life as a nurse during one of the worst flu seasons in the past decade, had my attention. I found myself waiting to hear what else she would say. She did provide a public service regarding flu prevention and care, but I will say that the whole time I watched, I asked myself several of the above listed questions. I wondered how this would be received. No matter your thoughts, Katherine Lochler has sparked media attention including such national sites as FoxNews and hit instant stardom with her video rant regarding "the cesspool of funky flu in the ER". I would love to hear thoughts on this healthcare/ social media topic. How many of us know if our hospital or State Board of Nursing has policies on such matters? Did she go too far or is Katherine the "Hero nurse" that several followers have dubbed her as she speaks up and supports nurses and healthcare workers?
  9. Bridgid Joseph

    The Influence of the Influenza Vaccine:

    According to the CDC, in the US, deaths from influenza (flu) can hit up to 49,000 annually. As nurses, we all work really hard at preventing transmission of infections within the hospitals through diligence with hand washing, aseptic technique with IV access, and contact precautions for patients with C. Diff, MRSA, and VRE because we care about our patients and we are also helping them heal from their current illnesses. Why does it feel different to protect our patients by getting a vaccine that is required by the hospital as opposed to following all of the other policies and protocols that are imposed upon us? Yes, we are taking a medication, an injection, created to prevent an illness that is easily spread and can have devastating effects to our patients...either through infecting them or infecting other staff members and leaving us without adequate staffing to take care of said patients. It does seem to take away our ability to make an informed decision: How do you know what YOU think is best when the information from the CDC recommends that basically, everyone should get the flu vaccine, of which there are a few different kinds of vaccinations that you can get, and then there are always hospital policies about flu vaccinations that can also have an impact on when and what type of flu vaccine you obtain? How the Vaccinations Work This year all of the vaccinations are either trivalent or quadrivalent to protect against the two strains of influenza A and either 1 or 2 strains of Influenza B that research indicates will be most virulent this season. You can be vaccinated two different ways, either by nasal spray or through an actual injection; two weeks after vaccination, your body starts to create antibodies against the flu that will help prevent you from getting infected, and if you do, it will be a very mild form, like a cold, but you will not have the true flu. The injection is an inactivated form of the virus, and, being injected with the inactivated strains of the flu, means that you aren't actually infected with the live virus so you won't get the flu from the vaccine. After the injection, there may be some redness at the site, soreness, and low fever that can last 1-2 days. The nasal-spray vaccine is made with living, but weakened, flu virus that does cause an immune response, but you don't get as sick as you would with the actual flu after use. It is not suggested for pregnant women or asthmatics (there can be an acute respiratory reaction from the live virus directly reacting with the lungs.) After the nasal-spray vaccine, the side effects are a little more than the injection: runny nose, headache, sore throat, and cough that last just a few days. This gives your immune system a real challenge because you are actually getting the virus, so you do feel unwell for a few days. What are the Types of Vaccines? Trivalent: Standard- dose injection: can be given to anyone 6 months old to 64 years of age. Intradermal injection: a dose given with a smaller needle into the skin instead of intramuscularly and can be given to patients aged 18 years to 64 years. High dose injection: is recommended for adults over the age of 65 years because of a diminished immune system, the injection has more antigens prevalent to help prevent the flu. Recombinant egg-free injection: for those with an egg allergy and it is approved for adults over 18 years. Quadrivalent: Standard-dose injection: can be given to anyone 6 months to 64 years of age. Nasal Spray: can be given to anyone 2 years through 64 years, however, it is emphasized for children 2 years to 8 years that have no other medical conditions that could be complicated by the flu. Who should get vaccinated? According to the CDC, basically everyone 6 months and older should get vaccinated (which I tend to agree with!) The "high risk" list for definite vaccination: Pregnant women (injection only) Children younger than 5 years old (especially those in pre-school activities, daycare, etc.) Anyone > 50-years-old Anyone with chronic medical conditions People who live in nursing homes or long-term care facilities People who live with or care for those at high risk (healthcare workers, family members of those at high risk, and family and caregivers for those less than 6 months old.) Who might need to discuss their risk further with their healthcare provider? Anyone with an allergy to chicken eggs (if the non-egg injection is not available) Anyone who has had a severe reaction in the past (i.e. anaphylactic reaction) Anyone who has had Guillain-Barre syndrome within 6 weeks of a flu vaccine Children under 6 months of age (their immune systems are too immature to respond appropriately) Anyone who actively has a fever or is unwell. How does hospital policy work? Patients: Where I work, and in most of the surrounding hospitals (I don't want to say all because there are a lot of hospitals and I haven't discussed with each one), every patient is screened within 24 hours of admission and offered the flu shot. Every single one. And this screening allows everyone on the healthcare team to be a part of the conversation (whether patients rule in or out) and we educate and discuss with patients their own risks. Staff: When it comes to the staff, our policy is that all staff that work in direct patient care, are required to have a flu vaccine (which is offered free of charge to all staff), and it needs to be documented by mid-November each year, as a contingency of employment. If you are medically unable to have a flu shot, it needs to be documented annually. It is part of a safety initiative to prevent the spread of disease and protect patients. If you get the vaccine from the hospital, you get the injection that is offered. I appreciate that they offer kiosks to get my flu shot, and they collect the paperwork to file away for me; it couldn't be easier. But once I started doing some research for my family members who had questions about which vaccines they should get, I realized that I put zero thought into receiving a vaccine. I would never take a medication without knowing the side effects, dose, type, etc. but because it is policy, and easy, without a medical consult, I got the injection. I honestly didn't even know all of the options that I had for flu vaccines! I would have gotten it anyway, I am a believer in the flu vaccine, and I always have been, but I am not sure how I feel that I let hospital policy blind me from going to my own healthcare practitioner and making a truly informed decision that might be best for me. What do others think about getting the flu vaccine mandated at work? Does it make you feel like you made a medical decision with little to no actual thought about it? I know the flu shot is best practice to protect our patients and ourselves...I just wish there was a way to make me feel like I was making an informed medical decision about getting a vaccine, as we encourage all of our patients to do, even though it is mandated.
  10. Nurse Beth

    Flu Shot or Mask?

    Recently at the nurse's station at work, I was talking with Lisa. Lisa was wearing a surgical mask. To keep her job, she has to wear a mask until flu season is over because she declined to get a flu vaccination this year. I asked how it felt to wear a mask for 12 hours. She said, "Well...it's kinda claustrophobic, but I'm getting used to it. What's really weird is people keep asking me to repeat myself.. It's like they can't hear me if they can't see my lips moving. And when I smile at patients, I have to try really hard to smile with my eyes." Position Statements The American Nurses Association (ANA), the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), a CDC panel of medical and public health experts that advises on vaccine use, all align in recommending flu vaccines for healthcare workers with allowable exceptions for religious and/or medical reasons. National Nurses United (NNU) opposes mandatory flu shots as fostering an atmosphere of distrust. Likewise, they oppose masking on the basis of stigmatizing the individual. Masking: the Science The influenza virus is transmitted by direct contact, large droplet spray (like a sneeze or cough, distance of about 3 feet), and by aerosolization (smaller particle aerosols). The rationale for masking is that unvaccinated asymptomatic persons can shed the influenza virus for 24 hours before symptoms appear and up to 5 days after the onset of illness. However, minimal data regarding aerosol shedding and infectiousness of aerosol particulates exist. The effectiveness of N95 respirator masks in preventing transmission of airborne viruses has been shown but the results of studies on the efficacy of surgical masks are mixed. Many surgical masks are not certified as protective against respiratory infections and are loose fitting. There are no clear guidelines on how frequently surgical masks should be changed. According to the CDC, there are no definitive studies to show that surgical masks worn by health-care workers reduce influenza transmission. Legislation State law, state Departments of Health, and county health officers have the authority to mandate flu shots and/or masks. For example, California state law (Health & Safety Code §1288.7 / Cal OSHA §5199) requires either flu vaccination or the signing of a declination statement for all acute care hospital workers and most health-care personnel, including clinic and office-based staff. Additionally, many county health officers in California mandate that health care workers either receive an annual flu vaccine or wear a mask during the flu season. Employee Rights Many acute care facilities have adopted coercive "flu shot or mask" policies. In some cases, healthcare workers have been fired for refusing to be vaccinated. Legally, most employers can require flu shots as a condition of employment as most employees work under an "at-will" work agreement. However, the research used by employers to justify mandating flu vaccines for healthcare workers may be flawed and insufficient. Four such studies cited by employers were conducted in long-term care facilities and have not been proven to be generalizable to acute care settings. Ethics The ANA maintains vaccination is a public health concern and nurses should role model illness prevention through immunization. Nurses have a responsibility to not place their patients at risk. Vaccination is for the greater good, but individual rights must also be considered. Sometimes the ethical principle of preventing harm is in direct conflict with the ethical principle of autonomy. Protective or Punitive? When I see a co-worker wearing a surgical mask I cringe a little. My core values of justice and fairness are triggered. Is this really about protecting patients based on robust evidence or is this about shaming the nurse? I believe in doing what is best for the greatest good but I also believe in autonomy. It comes down to personal rights versus social responsibility. I am pro-vaccination but stop short of supporting "flu shot or mask" policies. For me, it would take irrefutable evidence of patient benefit to justify overriding personal rights and I don't believe we have that. The rush to disregard individual freedom over scanty evidence concerns me more than the thought of Lisa not wearing a surgical mask. Do you believe nurses should be required to get mandatory flu shots or mask? Why or why not? I'd love to hear your view. More thought-provoking articles by Nurse Beth: Ageism in Nursing is Real Why Do Nurses Quit? References Booth, C. M., Clayton, M., Crook, B., & Gawn, J. M. (2013). Effectiveness of surgical masks against influenza bioaerosols. Journal of Hospital Infection, 84(1), 22-26. CDC. Interim Guidance for the Use of Masks to Control Influenza Transmission.2009. Accessed January 2017 Interim Guidance for the Use of Masks to Control Influenza Transmission | Health Professionals | Seasonal Influenza (Flu) Serres, G., Skowronski, D., Gardam, M., Lemieux, C., Yassi, A., Patrick, D., Krajden, M., Loeb, M., Colignon, P., Carrat, F. 2017. Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement. PLOS.org. accessed January 2017 Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement
  11. twinmommy+2

    Caregivers Taking Care Of Ourselves

    Let's get it together folks. As health care professionals, we sound like the silly group of birds on the ice age. Remember the ones that are going "prepare for the ice age" and trying in vain to hide the last melon? How are we going to help our patients over their fears and answer their questions if we are panicking? Let us start by realizing that the vast majority of us will only suffer from the flu and that is only if we are the unlucky ones to get sick. The people most affected will be those who don't have access to health care, and those that are healthy. That's right, it's hitting the 20 something's to the 40 something's the hardest. Yeah, it sucks, we will deal with it, ladies and gentlemen. What is one way to deal with a tough situation at work...come on you remember...it was in nursing school...a thorough self-examination of the way you feel about something. Talk to your peers, talk to your family, really examine how you feel. Don't just go through scenarios in your mind, actually talk it over with other staff members. What are your facilities policies regarding a flu pandemic? Is there one in place? Could you be instrumental in helping put policies in place that help in patient flow and reducing infection rates? Actually doing something about the problem can help in reducing your fears. That way you know what is coming down the line should there be a problem, and not only for pandemic flu but also for internal/external disaster scenarios at your facility. Are you prepared at home for an emergency in the community if you had to leave in a hurry? Despite what I said above it does help to ease your mind if things are taken care of at home. There should be water stored, canned and dried foods available, important papers in a fireproof container, and emergency routes made out from homework and schools along with an emergency contact number that everyone knows by heart. Now, are you all like me, go to work...go home...sleep...go to work...go home...kiss the kids...go to bed...you all know what its like. We all need to start taking better care of ourselves. We have all heard it before but now we really need to take inventory of our stress level and reduce it, because it's going to be the main thing that gets us sick (besides the nasty little old man in room 512 that just harked up a lung on your scrubs). Get some exercise, play with your children/grandkids, garden, run, read something besides a drug guide, make passionate love (what a great stress reducer eh?). Do something not nursing related. In the end, please take care of yourselves guys so we can take care of those frightened patients out there. You are important and we need you!!!
  12. Varghese John

    "I'm sick and I'm off" - "me too!" Flu!!!

    Every year, cold and flu outbreaks result in hundreds of missed office days for workers especially health care workers in the hospital. The problem often stems from - when a worker comes to the workplace sick and spread germs via touch points. Influenza is a serious disease that can lead to hospitalization and sometimes even death. Every flu season is different, and influenza infection can affect people differently, but millions of people get the flu every year, hundreds of thousands of people are hospitalized and thousands or tens of thousands of people die from flu-related causes every year. Even healthy people can get very sick from the flu and spread it to others. Often times germs, bacteria, and viruses are found on doorknobs, keyboards, desks, and railings. The threat of infections lurks on every surface workers touch, and on every door handle they open. That is why it is important to know how to prevent their spread. It means knowing what tools - soap or sanitizer - to offer and where. Hand sanitizers are best at killing microorganisms where hand washing helps to take out the microorganisms from our hand. Even though among these two, hand sanitizers are best in case of easy accessibility. But you can kill them, but science shows that those germs can repopulate pretty quickly. You never kill 100 percent of the germs when you're using hand sanitizer. So repeated hand hygiene is needed whenever possible. "Hand sanitizers are never a suitable replacement for washing your hands if your hand is visibly soiled. Along with, early recognition of your sickness and early medical advice always helps you and your workplace to prevent further spread. If you recognized that you are sick - be away from others - seek medical advice. Say no for shake hands - even your friend can offer you FLU. Cleaner hands reduce the risk of cross-contamination and goes a long way in creating healthier facilities. In fact, a strong hand hygiene program can reduce absenteeism by a fairly significant number. The best way is always following WHO's 5 moments of hand hygiene. i.e, Before contact with the patient Before an aseptic/clean procedure After contact with the patient After exposure to patient body fluids After contact with patients surroundings and 6 steps of hand hygiene... Palm to palm (5 times) Left palm over right dorsum (5 times) Right palm over left dorsum (5 times) Palm to palm with fingers interlaced (5 times) The back of fingers to opposite palm - fingers interlocked (both hand) Rotational rubbing of right thumb by the left palms (5 times) Rotational rubbing of left thumb by the right palm (5 times) Rotational rubbing of the tips of right fingers by the left palm (5 times) Rotational rubbing of the left fingers by the right palm (5 times) Most importantly take your flu shot before you get sick with flu.... Flu vaccines cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide protection against infection with the viruses that are in the vaccine. The seasonal flu vaccine protects against the influenza viruses that research indicates will be most common during the upcoming season. Traditional flu vaccines (called "trivalent" vaccines) are made to protect against three flu viruses; an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus. There are also flu vaccines made to protect against four flu viruses (called "quadrivalent" vaccines). These vaccines protect against the same viruses as the trivalent vaccine and an additional B virus. Remember - the vaccine should be new and if it's not - you may not be covered. Seek medical advice for the prophylaxis if it is necessary..
  13. Julie Reyes

    The Controversy: Mandatory Flu Vaccines

    First, let me just go over some of the symptoms of the flu, and then we will get down to business on the controversy surrounding the push to create mandatory flu vaccines for healthcare workers: Sudden onset fever Headache Chills Myalgia Dry cough Sore throat Stuffy nose Loss of appetite Limb or joint pain Difficulty sleeping Diarrhea or upset stomach I can't think of anyone who wants any of these symptoms, or to come down with the flu, can you? Influenza vaccination research has clearly documented the benefits of receiving the flu vaccine (google it - you will find a plethora of information...however, I will list some links at the end of this article for your information). However, even though there is sufficient evidence to prove the benefits of receiving the flu vaccine, vaccination rates among healthcare workers are pitifully low. In 2013, only 55% of nurses in the frontlines were vaccinated. Organizations such as The Joint Commission, the American Nurses Association, the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the Centers for Medicare & Medicaid Services, the Centers for Disease Control, Healthy People 2020, etc., etc., have stated their position on recommending the flu vaccine for healthcare workers in order to decrease the risk of exposure and reduce deaths. Due to this recommendation, many healthcare facilities are now creating mandatory flu vaccine policies as a condition of employment. Employers who create mandatory policies will have exemptions, of course. Exemptions are made for medical and religious exceptions. For places that do not have a mandatory flu vaccine, they may "strongly recommend" the vaccination and may have a declination form for employees to submit if they refuse the vaccine. Additionally, some employers will enforce refusers to wear a mask during flu season while they are at work in order to protect the patients and the employee. What is the purpose behind the push toward flu vaccines? Evidence has shown that there are more than 36,000 deaths in the US each year related to influenza, and more than 200,000 hospitalizations. Influenza is the 6th leading cause of death. Healthcare workers are the leading cause of influenza outbreaks in the healthcare system. up to 50% of people who are infected by the flu virus do not fill ill for several days and can spread the virus to people at risk of complications and death from the flu. Additionally, evidence shows vaccination decreases mortality by 40%, decreases the spread of nosocomial infections by 43%, and decreases absenteeism by 20-30%. Additionally, there is the ethics to consider. As healthcare workers, we have all taken an oath to "do no harm". As a nurse caring for patients who are not in their most physically healthy state, do we take the vaccination in order to prevent spreading the flu to our vulnerable patients, in order to "do no harm"? We must consider this when we make our decision to take or refuse the vaccination. What hospitals have created a mandatory flu vaccine policy? I have the names of a few hospitals, and this is by no means a comprehensive list. This is based on a ListServe survey of hospitals and these are the responses received: Children's Hospital of Philadelphia (Philadelphia, PA) - since 2009 Children's Mercy Hospitals and Clinics (Kansas City, MO) Children's Colorado (Aurora, CO) Children's Hospital of the King's Daughters (Norfolk, VA) Children's Medical Center Dallas (Dallas, TX) - since 2012 Riley Children's (Indianapolis, IN) - since 2012 East Tennessee Children's (Knoxville, TX) - since 2013 Boston Children's (Boston, MA) Sharp Mary Birch Hospital for Women and Newborns (San Diego, CA) - since 2013 Roger Williams Medical Center (Providence, RI) Brookwood Medical Center (Birmingham, AL) Johns Hopkins (all hospitals/clinics) (Baltimore, MD) Driscoll Children's Hospital (Corpus Christi, TX) Spohn Health System (Corpus Christi / San Antonio, TX) All Connecticut Hospitals What are some reasons that people refuse the flu vaccine? Refusal may be largely due to misconceptions related to the vaccine. Fears that the immune system will cause them to get the flu, beliefs that hygiene and better nutrition are more helpful than the vaccine, fear of needles, beliefs that the vaccine does not work, and fear of side effects. Others believe that they have a constitutional right to refuse the vaccine and that mandatory policies are violating these rights. Common concerns and myths about the flu vaccination (taken from the Los Angeles County Department of Public Health outline of flu vaccine talking points for managers) The flu shot will give me the flu The flu shot does not give people the flu. It uses inactivated ("dead") virus. People may still catch a cold or other virus that the vaccine is not designed match. I don't believe the flu vaccine actually works Studies have shown that flu vaccination prevents flu in 70% to 90% of healthy adults younger than 65 years old. I had the vaccination last year You need a new vaccine every year - the virus changes over time. What about possible adverse reactions Serious adverse reactions are very rare. They are explained on the CDC's Vaccine Information Statement, which is distributed when the vaccine is administered. Local short-term reactions - such soreness at the vaccination site, slight fever, achy feeling - may occur but usually do not last long. Over the counter medicines are helpful. Even short-term reactions are much less bothersome than catching the flu and feeling very sick for days. I'm not in a high-risk group Your patients are at-risk, and possibly some friends and family members. You can be infected with the flu virus but not feel ill - and can still transmit flu to at-risk patients. The flu vaccine made every year does not match the circulating flu strain Inactivated influenza vaccine is effective in preventing transmission and reducing complications of the flu. In years when there is a close match between the vaccine and circulating virus strains, the vaccine prevents illness among approximately 70%--90% of healthy adults under 65 years of age. Vaccinating healthy adults also has been proven to lead to decreased work absenteeism and use of health-care resources, including use of antibiotics. Strong protection is also expected when the vaccine is not a close match with circulating strains, with 50%--77% effectiveness in these instances. In addition, effectiveness against influenza-related hospitalization for healthy adults from inactivated vaccine is estimated at 90%. Knowledge is Power All healthcare facilities will be facing the choice of creating a mandatory influenza vaccination in the near future, if they have not already. In order to make an informed decision on the topic, we must have information. Knowledge is power. Before you make a blanket statement on pros or cons, have the information you need, know the research, and make an educated decision. Please respond to this article by answering the following questions: Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)? Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work? What concerns do you have about the flu vaccine? Do you know if anyone who has been released from their job because they did not get the flu vaccine? References American Association of Family Practitioners. (2011). AAFP supports mandatory flu vaccinations for healthcare personnel. Retrieved from: AAFP Supports Mandatory Flu Vaccinations for Health Care Personnel ATrain. (2014). To accept or refuse the flu vaccine. Retrieved from: ZZZ_133_Influenza: Module 7 CDC. (2014). Vaccination: Who should do it, who should not and who should take precautions. Retrieved from: Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions | Seasonal Influenza (Flu) | CDC Influenza Action Coalition. (2015). Influenza vaccination honor roll. Retrieved from: Honor Roll: Mandatory Influenza Vaccination Policies for Healthcare Personnel Los Angeles County Department of Public Health. (2014). Talking points for managers. Retrieved from: http://tinyurl.com/p6nbg2u National adult and influenza immunization summit. (2015). Vaccinating healthcare personnel. Retrieved from: Vaccinating Healthcare Personnel - National Adult and Influenza Immunization Summit NursingTimes. (2014). Why do health workers decline flu vaccination? Retrieved from: http://www.nursingtimes.net/Journals/2014/11/28/y/k/x/031214-Why-do-health-workers-decline-flu-vaccination.pdf TJC. (2012). R3 Report: Requirement, rationale, reference. Retrieved from: http://www.jointcommission.org/assets/1/18/R3_Report_Issue_3_5_18_12_final.pdf
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