health & science

Five died from flu caught in hospital

This year more than 132 patients caught influenza in hospital - at least five of whom died. That tally is from just three hospitals. The national toll of hospital-caught flu is unknown, but experts say we must do more to reduce the danger, including widening free access to the flu jab.

When you’re already seriously sick or injured, a dose of flu is the last thing you need.

Every year, an estimated 500 New Zealanders die from complications of influenza – more than the annual road toll.

Most at risk are people over 65 and those with underlying illnesses, who can develop potentially fatal heart and lung complications. 

Yet, every year, well-meaning visitors take influenza into hospital wards.

Although it’s been drummed into us that influenza is much more serious than a cold, many healthy adults who catch it will have mild symptoms or no symptoms at all, meaning they can spread it without realising.

This year alone, across just three New Zealand hospitals, more than 132 patients caught influenza from visitors, other patients or hospital staff. Often, the precise source of the infection isn’t known – only that the patient developed influenza several days after being admitted. A hundred and two of the cases were at two hospitals in Auckland: North Shore (58 cases) and Waitakere (44). The rest were at Tauranga hospital (30). Those are only the cases we know about. The national total will be higher, but most DHBs told Newsroom they don’t track their cases of hospital-acquired flu. Others supplied vague figures, such as “a small number” each year. 

Flu can tip an already-sick person over the edge. This winter alone, five patients died after catching flu at Waitakere or North Shore hospitals, both of which are run by Waitemata DHB. The DHB says all five patients were elderly and had underlying health conditions that made them highly vulnerable.

While 102 hospital-acquired cases may sound high, Waitemata says its rates may not be worse than any other large DHB. It tracks its cases rigorously, it says, counting any patient who is admitted to hospital without flu symptoms, but who develops symptoms on or after their third day in hospital.

The DHB wouldn’t supply anyone for an interview about the issue, saying its expert was overseas. But in an email, a spokesman cautioned against “painting it as an outlier”. “The incidence of hospital-acquired influenza is linked to the prevalence of flu in the wider community and should not be seen as a measure of the care provided in our hospitals,” Waitemata says.

Infection and health experts agree it’s hard to make comparisons. “It is difficult to make cross-DHB inferences,” says Carolyn Clissold, the chair of infection prevention and control at the New Zealand Nurses Organisation. “DHBs use different systems for tracking … and use different definitions of hospital-acquired influenza.”

“It’s likely a mixture of awareness and recording - and good on them - as well as large numbers of people going through [the hospital]," says Nikki Turner, the director of the Immunisation Advisory Centre. "People didn’t used to measure and notice."

“Concerning trend”

Waitemata began noticing the issue in 2017, which, like 2019, was a bad year for flu in its part of Auckland.

In 2017, 104 people caught flu inside the DHB's two hospitals – more than a tenth of the total number of people who were hospitalised with flu in its area that winter.

This year, at least 1211 patients were hospitalised with influenza across the two hospitals. A hundred and two of them caught the virus on DHB premises.

Meeting notes from Waitemata’s health advisory committee show concerns were raised when the tally reached 80.

In June, two outbreaks of Influenza A struck the Muriwai ward at Waitakere Hospital, sickening 10 people. In July, another outbreak infected eight people in North Shore Hospital’s Ward 14. Both wards cater to elderly patients. Staff also reportedly got sick during these outbreaks.

Patients were also catching flu in other Waitemata wards. In July, the health advisory committee was warned of a “concerning trend”. It was told the 2017 tally of 104 had been “unacceptable”.

By September's end, the 2019 count was 58 from North Shore hospital and 44 from Waitakere.

The health advisory committee was told that five of these patients had died, all of them within 10 days of being diagnosed with Influenza A. “While influenza may not be the only contributor to their demise, it likely contributed significantly to the deterioration of their health,” the meeting notes say.

When hospital makes you sicker

It’s frustrating to think that you might go to hospital, only to end up sicker than you were on admission. Every year, people who are already sick catch viruses and bacterial infections in hospitals, whether it’s an antibiotic-resistant superbug that invades via a catheter, influenza from a visitor, or measles.

Waitemata’s meeting notes reveal, for example, that at least three people caught measles in the waiting room at Waitakere’s emergency department this year. Christchurch Hospital had its own outbreak of measles in February and March. Nationwide, at least 20 hospital workers were diagnosed with measles by October.

While it’s tempting to blame hospitals when viruses spread, it is frequently visitors who are the source of infection, says Turner. “It is way more common than people realise. Every year, probably 20, maybe 25, percent of the community catches flu and the majority of them are asymptomatic," she says. "Therefore people walking into hospitals carry flu, lots and lots of them. They go and kiss people and touch people and they put their hands on things. So we’ve got a real problem,” she says.

DHBs typically try hard to contain flu. They have started putting up notices warning sick people to stay away. Hand gels are now placed at hospital entrances. Many hospitals – including Christchurch, North Shore and Waitakere – test patients with suspected flu as soon as they are identified, so they can see what strain they have and keep people separated. Staff wear masks in known flu wards. Hospitals also administer the antiviral Tamiflu.

But people still visit when they probably shouldn’t – and often there's no way to know they're infectious, says Canterbury clinical virologist Lance Jennings. “They want to see their grandparents,” he says. “And, of course, influenza doesn’t put everyone to bed. Some people may just have asymptomatic infection or a mild cold, but they are still shedding virus and can pass it on.”

Many of this winter’s infections were the H3N2 strain of Influenza A, which Jennings says spreads easily in hospitals. “They are associated with more severe influenza outbreaks and more severe infections, particularly when they get into elderly populations,” says Jennings. “These viruses spread very easily from person to person, with more severe outcomes and, potentially, fatality, sadly.”

“What you’re seeing in the North Island is the conditions where this virus has got into a hospital setting, and of course it has spread,” says Jennings. “The mere fact that people are hospitalised means they are at risk.” Are they sitting ducks? “Yes, they are sitting ducks,” he says.

Making matters harder is that flu can be harder to detect in elderly patients, says Jennings. “They don’t always develop a high temperature, they just slow down and go off their food so you don’t really know they have influenza until they start coughing. It’s not so obvious until it starts spreading from person to person on the ward.”

Vaccinate the healthy?

Influenza spreads through virus-laden droplets, mainly from people coughing or sneezing, but also from particles landing on surfaces. Unlike measles, which floats through the air over a wide area, the droplets usually fall within a 1-2 metre radius from the infected person, says Clissold. “The influenza virus can also get into your nose if you touch a surface where a flu virus has landed, then touch your nose. However, the flu virus will die on the surface within two days,” she says.

Wearing a face mask will stop flu spreading. Coughing and sneezing into a tissue or your elbow helps, as does thorough cleaning around you. “Patients with flu should be isolated in their own room or area, so as not to transmit to others. The staff who look after patients with flu will wear a mask to protect themselves when close to the patient,” says Clissold.

Jennings says hand sanitisers and thorough hand washing help, but wearing face masks is most important whenever a case of flu is suspected. Even droplets shared when people talk to each other can spread the virus, for example, if someone leans in close over a bed. 

People's immune systems change as they age, which makes elderly people more susceptible to flu.

That's why the government has made the seasonal flu vaccine free for over-65s as well as other vulnerable groups. In Waitemata, for example, 63 percent of people over 65 have received the free flu vaccine. 

But rates of influenza vaccination among healthy adults and children are lower - less than 15 percent among Auckland children.

This winter, uptake was restrained because Pharmac didn’t order enough vaccines to meet the demand. Nor did private providers. Turner would like to see Pharmac over-order to create a buffer, even if it risks ending up with expired stock. “It is not an expensive vaccine,” she says.

There's a more fundamental question too, which both Turner and Jennings raised. 

While healthy kids and adults have to pay if they want the flu vaccine, it is often them who pass the virus to a more vulnerable person.

And, healthy adults have a much better chance of gaining immunity from the flu jab than elderly or sick people. 

The weakened immunity that makes elderly people susceptible to flu also hinders their chance of gaining immunity.

Even in the best scenario, the influenza vaccine is much less effective than a measles jab. Every year, the vaccine-makers have to guess what flu strains will be dominant that winter and try to keep ahead of how the virus is changing. And it works worse than average for H3N2, says Jennings.

A flu jab is still well worth getting, says Turner. “We tend to say the [flu vaccine] is around 50 percent effective, which is not great, but there’s so much flu around that that actually reduces the amount of flu a lot,” she says.

“The problem ... is that for the very elderly and the very young it is less effective. So even though we recommend flu vaccines for the very elderly or people with chronic medical conditions, like those in hospital, the vaccine’s effectiveness for them as individuals is even lower,” says Turner. “So we are relying on healthy people not spreading it, and the vaccine’s effectiveness for healthy people is higher, more like 60 percent, sometimes 70 percent.”

The elderly would be more protected if healthy relatives and friends had the vaccine - but right now these healthy people typically have to pay. 

“We really probably have the wrong flu vaccine strategy,” says Turner. “We should be saying that the community needs to be vaccinated to protect the vulnerable as much as possible. We know that if you have enough flu vaccine in a community you do reduce spread, so I think our strategy needs to move towards herd immunity.”

Staff immunity

Jennings says you’d need something like 80 percent vaccination rates to gain herd immunity from influenza. But while that would be challenging to achieve across the whole community, it should be possible to reach those levels inside of hospitals.

Yet hospital staff - who get flu vaccines free at their workplace - averaged 68 percent uptake last winter, compared to the Ministry of Health’s target of 80 percent.

“Staff vaccination rates are too low,” says Turner.

Just two DHBs - Tairawhiti and Northland - achieved 80 percent flu vaccine coverage last year. Waitemata’s rate was 62 percent.

This year a meeting of the Waitemata DHB noted a “pleasing” increase in its staff rates, to 66 percent.

Aside from reducing sick days, one of the main reasons for offering free flu vaccines to healthcare workers is to stop them spreading flu. “It’s not as highly contagious as measles,” says Jennings. “But when you’ve got institutional settings where you have got close proximity between people and you have got staff going from one person to another [it can be passed on],” he says.

Turner says many of us are only just realising how easily we can pass viruses on. She says the message still needs to get out there. “All of us need to be aware of flu and respiratory viruses in general and how we spread them to each other,” she says. 

“Particularly for the very vulnerable and the elderly, we have got a long way to go in learning that if you’re coming to see a sick frail elderly person, think very hard about exposing them. If you’re worried, use those hand gels a lot and keep at least a metre distance. I think hospitals need to be way more aggressive in helping the community get its heads around it,” Turner says.

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