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Influenza Knowledge and
Preparedness for Massage Therapists
By
Doug Alexander, BSc, RMT
Overview
Influenza, or the
“flu”, is a common occurrence for massage therapy clients (and
therapists). Almost every winter the flu attacks 10 – 20 % of the
population over a 5 – 6 week period (Treanor). Most people will
have fever, myalgia (muscle ache) and cough, for a few days and
then recover. “It has been estimated that a typical case of
influenza, on average, is associated with 5 – 6 days of restricted
activity, 3 – 4 days of bed disability, and about 3 days lost from
work or school (Treanor).
However
some people (notably the old, very young and immunocompromised)
will progress to a viral or bacterial pneumonia, and some of
these people will die. The estimate of influenza-related deaths was
roughly 36,000 people per year in the 1990sin the United States
(Fiore).
As
massage therapists we need to be knowledgeable about the flu to
protect ourselves and our clients, especially those at risk for
developing dangerous complications.
This
article explores what is known about influenza, and how to prevent
its spread. We also move beyond the regular epidemic of influenza
that occurs in the winter of most years to the issue of “pandemics”
or severe epidemics of world-wide scope. Pandemics are much more
frequently fatal than the common flu; they happen when a novel
strain of influenza appears that humans have little or no
resistance to. Pandemics usually occur 2 or 3 times a century.
According to many experts the world is “overdue” for a pandemic
(Darr, Stewart) and as health care professionals we need to engage
in pandemic preparedness.
Influenza Types,
Antigenic Shift and Antigenic Drift
Influenza is caused by
a family of viruses that are composed of 3 different types,
Influenza A, B or C. Viruses are named according to the type, the
location they were initially isolated, the designation of the
strain and the year the virus was initially isolated. “For example,
the influenza A virus isolated from a patient in Puerto Rico in
1934 is designated: A/Peurto Rico/8/34. Sometimes it is referred to
as the “PR8” virus.” (Treanor)
Viruses
are further categorized by the activity of the glycoprotein
molecules on their surface. Some of these glycoproteins have
hemagglutinin activity (HA) and some have neuraminadase (NA)
activity. Correspondingly, strains of viruses are also
categorized by the pattern of glycoproteins they have on their
surface with the terms H and N incorporated into their names
(Treanor).
The
influenza virus is always undergoing mutation that results in minor
variations in the hemagglutinins or neuraminadases on its surface
from year to year. This minor changing of the antigenic coat of the
virus is termed antigenic drift. Antigenic drift causes the
virus to be somewhat more successful in infecting people as most
people have developed immunity to the previous virus and will be
somewhat more vulnerable to the new one.
However, 2 or 3 times
a century (on average) a more advanced influenza virus emerges with
unique HA and NA characteristics for which humans have not
developed any immunity. This is termed antigenic shift (as
opposed to the more innocuous antigenic drift). As a result, the
virus is more or less an entirely new species of influenza that is
more dangerous, and able to attack an even higher percentage of
people. This results in a pandemic (a world wide
epidemic).
Epidemic
Influenza
Seasonal, yearly
influenza epidemics occur within communities. The pattern is a
sharp onset in the first 2 to 3 weeks, with the whole epidemic
tending to last 5 to 6 weeks altogether (Treanor).
The
outbreak usually begins with children and moves into adults,
although it can commonly start in a nursing home with the elderly.
As the influenza works its way into the community there will be
hospital admissions for people whose influenza has caused pneumonia
or worsened an already present chronic obstructive pulmonary
disease (bronchitis and emphysema), as well as those with chronic
congestive heart failure. The people who die from influenza will be
the unlucky ones within these hospitalized populations.
Influenza Infection
and Infectiveness
A flu
infection begins when respiratory secretions containing the virus
from an infected person infect a susceptible person. This occurs
from unprotected coughing and transmission by contact.
The
virus is deposited on the lining of the respiratory tract of the
recipient. Defense to the virus at this point is a result of an
effective immune system and mucociliary elevator (which carries
foreign bodies out of the respiratory tract). If defense is not
adequate then the virus attaches to the lining of the respiratory
tract and penetrates the epithelial cells where it replicates
itself. This leads to cell death and further invasion and
replication of the virus. It takes 18 to 72 hours for the person to
become noticeably ill (Treanor).
As the
infection progresses the virus begins to be shed from the
respiratory tract of the infected person. In laboratory studies of
infected persons, the virus begins to be detected in their
respiratory secretions in the 24 hours prior to the infected person
begins to feel ill (within 24 hours).
The
virus continues shedding in the mucous secretions at a high
concentration for 1 – 2 days and then there is less and less virus.
Within 5 to 10 days of sickness onset most people are no longer
shedding any virus and can no longer infect anyone. However, young
children and those with diminished immune function may shed high
levels of the virus for much longer periods of time
(Treanor).
Symptoms
The
symptoms experienced in a bout of influenza include fever, chills
(the person may shake), headache, muscle pain, feeling sick
(malaise) and lack of interest in food. Muscle ache and headache
are usually the worse symptoms and they increase as the fever
does.
Cough,
pain in the throat, and nasal obstruction and discharge are
also present, but are not usually as significant to the person as
the systemic symptoms mentioned above.
The
fever tends to last 3 days, but can commonly last from 4 – 8
days.
The
most common complications of influenza are viral and secondary
bacterial pneumonia, croup and worsening of pre-existent conditions
such as bronchitis, cystic fibrosis, emphysema and heart
conditions. There are also possibilities of toxic shock, central
nervous system complications and Reye’s syndrome (a complication
seen with viral infections in children).
Management
Most
cases of the flu are self-limiting and the affected person simply
needs to rest. Folklore remedies of intake of fluid, a quiet
environment, etc. are key to optimizing recovery. Those who try to
carry on during an influenza infection may work through it,
although, some of these people will prolong the sickness and will
likely be shedding the virus through respiratory secretions which
may endanger vulnerable people in their environment.
Preventing the Spread
of Influenza: Cough Etiquette and Hand Washing
Protocols
Influenza spreads via
droplets from coughing, through hand contact with infected
secretions, and on the surfaces of objects.
Cough
etiquette needs to be practiced
in all environments in order to reduce the spread of influenza (or
any respiratory infection). Cough etiquette is as
follows:
1)
The mouth and the nose should be covered with facial tissue(s) (eg.
Kleenex) that captures the secretions during the
cough.
2)
The facial tissue(s) should be disposed of in a
receptacle.
3)
The hands should be washed thoroughly with soap and water as
outlined below.
 Hand
washing is vital to
preventing the spread of infection. It is used after we have
coughed or handled Kleenex that our clients have coughed in, as
well as before and after every clinical encounter with
clients.
The
following steps should be drilled regularly until they become
habits.
1.
Wet your hands with warm running water. Wash away any debris on
your hands before applying soap.
2.
Add soap and rub your hands together to make lather.
Don’t wash the
lather away, but work it into the front and back of your hands as
well as between fingers and under the nails. Take at least 10
seconds to do this (some sources suggest 20 seconds). A simple
suggestion is to rub the lather over and into your hands for the
length of time it takes to sing the “Happy Birthday”
song!
3.
Rinse your hands thoroughly with the warm running
water.
4.
Pat your hands dry with a paper towel. Don’t rub them dry as
frequent hand washing and rubbing can roughen and irritate the
skin.
5.
Use the same paper towel that you dried your hands with to turn off
the taps.
6.
Deposit the paper towel in a garbage receptacle (without touching
the receptacle).
Massage
therapists should wash their hands before and after each client
contact, as well as when using bathroom facilities.
Influenza
Pandemic
In
contrast to the nearly annual epidemics of influenza that occur in
various communities, 2 to 3 times per century there is a new
influenza strain to which our species has no immunity. As a result
of a lack of “herd immunity”, this influenza is much more severe
than the annual epidemic and spreads rapidly throughout the entire
world. This results in a “pandemic” with a much higher morbidity
and mortality (sickness and death rates). In a severe epidemic 30 –
50% of a population will become sick, whereas in a pandemic up to
70% of people can become sick. In this latter scenario 10% of those
infected may require hospitalization and up to 2 % of those sick
may die (CPIP).
There
is currently a lot of activity in the public health departments
around the world to build pandemic preparedness.
Pandemic Preparedness
for Massage Therapists
In 1983
Canada began planning for the next influenza pandemic. The Canadian
Pandemic Influenza plan for the Health Sector is a continuously
revised document available at: http://www.phac-aspc.gc.ca/cpip-pclcpi/index.html#toc
The
goal of pandemic preparedness is to “minimize serious illness and
overall deaths,” and to minimize societal disruption among
Canadians as a result of an influenza pandemic.” (CPIP). A key
component of minimizing illness, death and disruption will be rapid
communication to the public of developments. For example, the
College of Massage Therapists of Ontario is planning on
communicating to its members via e-mail and bulletins on the
website, www.cmto.com
Some of
the assumptions that planners are operating under
include:
There
will likely be a lead-time of roughly 8 weeks before the initial
reports of a new strain of influenza in the world and the first
wave of sicknesses in North America. After this initial wave, there
will be a second wave of influenza within 3 – 6 months
(Stuart).
There
will be no vaccine specific to the new virus available for the
first wave of influenza, although retroviral medications that
attack viruses in a general sense will be available, but will be in
high demand. This latter medication will be available to those
people who get seriously ill as well as for those people in
critical positions in society (Stewart).
There
will be societal disruption as a result of people getting sick
(roughly 30 – 70% of the population depending on the novelty of the
virus), as well as from people staying away from work and social
settings out of fear and the necessity to care for loved ones.
Daycares, nurseries and schools may be shut down, and parents may
need to stay home to take care of children, spouses or other
extended family members (Stewart).
Depending on the
attack rate of the virus, there is also likely to be a disruption
of key services from food and fuel shortages to power outages.
People will likely hoard some of these key supplies and it may be
difficult for people to obtain basic necessities of food and
shelter.
Limiting the Spread of
Influenza in a Pandemic
All of
the measures that limit the spread of influenza in an epidemic will
be helpful in a pandemic. Because the virus is spread through close
(less than 1 meter) contact, social distancing (increasing the
space between people in social settings may be helpful. Increasing
the use of electronic commuting (working at home) may help as
well.
Frequent, thorough
hand washing is the basic intervention in all settings. Hand
sanitizing facilities (from sinks to sanitizing gels) must be
available and used in all work places, social settings and the
home. Cough etiquette and the self-removal of those infected from
social and work environments will be vital.
In
environments where there are many people in contact with hard
surfaces (counters, etc), these will need to be frequently cleaned
and sanitized.
For
those who must be in contact with the public, masks will likely be
necessary. Microbial containment masks require special fitting in
order to function well. People will require very brief training on
how to fit masks effectively.
Anything that
contributes to immune system health is important and needs to be
followed including regular exercise, optimum diet and sufficient
rest. There is also some evidence that people who take the seasonal
flu vaccine every year may be at less risk of getting sick with a
new, novel strain.
Personal
Preparedness
Massage
therapists need to be prepared on a personal level for a pandemic.
You will be able to stay informed by following bulletins on the
Internet at government websites. Provincial governments are
committed to being transparent and rapid in their communication
with health care professionals and the public. You will be able to
track the latest information and developments in this
way.
Do your
best to stay healthy, yourself! This includes frequent hand
washing, cough/sneeze etiquette and avoiding crowds when possible.
Maintaining your own immune health is important, too!
It may
also be helpful to take a few minutes and ask yourself if you have
contingency plans in place for the distinct possibilities of
unavailable daycare, food shortages, limited fuel and time and
energy for caring for ill friends and family. The common financial
guideline of having a three-month financial reserve available if
you need to take time off work or if your business is adversely
affected by a pandemic is a minimum financial
preparation!
Biography
Doug
Alexander is a massage therapist educator teaching at Algonquin
College in Ottawa. This article has been a wake up call for him on
this issue and has strengthened his resolve to have a strong social
network and immune system.
Doug
can be reached at alexander2000@sympatico.ca
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Hand
Washing Handouts and Videos 
For
handouts that describe hand washing procedures and a video on hand
washing click on the image at right or go
to:
http://www.publichealthgreybruce.on.ca/Communicable/Handwashing/
References
Australian Government
on Cough Etiquette at: http://www.industry.gov.au/pandemicbusinesscontinuity/index.cfm?event=object.showContent&objectID=03E5E30B-BCD6-81AC-1581D9A6CA343CAE
Bootsma
MCJ, Ferguson NM: The effect of public health measures on the 1918
influenza pandemic in U.S. cities. PNAS;2007. Available at www.pnas.org/cgi/doi/10.1073/pnas.0611071104
CPIP:
The Canadian Pandemic Influenza Plan for the Health Sector
available at: http://www.phac-aspc.gc.ca/cpip-pclcpi/
Centre
for Disease Control on Cough Etiquette at: http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
Darr K:
Beyond Triage: Avian Flu and the Impending Services Demand Crisis.
Nexus: Ethics, Law and Management 2006:32-35.
Fiore
AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, Bresess JS,
Cox NJ: Prevention and Control of Influenza: Recommendations of the
Advisory Committee on Imunization Practices (ACIP), 2007. This
report and other information are available at CDC's influenza
website (http://www.cdc.gov/flu).
Fraser
C, Riley S, Anderson RM, Ferguson NM: Factors that make an
infectious disease outbreak controllable.
PNAS;2004;101(16):6146-6151. Available at:
www.pnas.org/cgi/doi/10.1073/pnas.030706101
Koch T:
Cartographies of Disease: Maps, Mapping and Medicine. Redlands,
California: ESRI Press; 2005.
Ontario
Government on Hand Washing at: http://www.health.gov.on.ca/english/public/program/pubhealth/handwashing/handwashing_mn.html
Stuart
AJ: Are You Ready? Pandemic Planning in Ontario. Amalgamated
Transit Union Canadian Council Conference on Violence and Security.
March 9, 2006.
Treanor
JJ: Chapter 153: Influenza Virus in: Mandell GL, Bennett JE, Dolin
R: Principles and Practice of Infectious Diseases 5th
ed. Philadelphia; Churchill Livingstone:2000,1823 –
1849.
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