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Diagnosis and Prevention of Common Respiratory Illnesses

      The 2019 novel coronavirus (COVID-19) pandemic is the defining global health crisis of our time and the greatest public health challenge we have faced since World War II. Since its emergence in Asia late last year, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to every continent except Antarctica. Cases are rising daily in Africa, the Americas, and Europe (United Nations Development Programme, “COVID-19 Pandemic,” 2020, https://bit.ly/31fHqvf).
      Influenza (commonly referred to as the flu) and COVID-19 are both infectious respiratory illnesses. Although the symptoms of COVID-19 and the flu can look similar, the two illnesses are caused by different viruses (Lisa Maragakis, “Coronavirus Disease 2019 vs. the Flu,” Johns Hopkins Medicine, June 23, 2020, https://bit.ly/3dypFd6).
      When a person becomes infected with COVID-19 or with seasonal influenza, the initial presentations are similar. The symptoms may include fever, cough, body aches, and sometimes vomiting and diarrhea. Because COVID-19 is a novel virus, the list of symptoms (such as loss of taste or smell) continues to evolve as more is learned about the disease. Both infections can be mild or severe in nature, and both are more deadly to people aged ≥65 years than younger patients [Centers for Disease Control and Prevention [CDC], “Coronavirus Disease 2019 (COVID-19): Frequently Asked Questions,” June 33, 2020, https://bit.ly/3hQrN3f].
      Pneumonia has a similar presentation to influenza and COVID-19, and the symptoms may range from mild to severe. These include productive cough (which may produce greenish, yellow, or bloody mucus), fever, sweating, shaking chills, shortness of breath, rapid shallow breathing, sharp chest pain that worsens with deep breath or cough, loss of appetite, low energy, and fatigue. Confusion is commonly seen in older adults (American Lung Association, “Pneumonia Symptoms and Diagnosis,” May 27, 2020, https://bit.ly/2CADOJR).

      COVID-19

      The CDC published COVID-19 testing guidelines for nursing homes in 2020, and revisions and updates are being issued as new information becomes available (“Testing Guidelines for Nursing Homes,” June 13, 2020, https://bit.ly/3doXeOt). The June 13 guidance includes reorganizing the recommendations to address responses to an outbreak and viral testing of health care personnel and residents.
      Viral testing in nursing homes, an important addition to other infection prevention control recommendations, is aimed at preventing COVID-19 from entering nursing homes as well as detecting cases quickly and halting transmission. Testing practices should aim for rapid turnaround times (<48 hours) to allow for effective interventions.
      Historically, vaccine development usually takes about 10 years, but vaccine makers are racing to develop an effective COVID-19 vaccine — as of June 2020 there were 10 candidates in clinical trials. The Trump administration chose five companies for Operation Warp Speed, the national program to accelerate the development, manufacture, and distribution of COVID-19 vaccines, treatments, and diagnostics. They are Moderna, Johnson & Johnson, Merck, Pfizer/BioNTech, and AstraZeneca/Oxford University (United Nations Development Programme, “COVID-19 Pandemic,” 2020, https://bit.ly/31fHqvf). Researchers at the University of Oxford and AstraZeneca hope to have the first phase-3 data completed this summer for their candidate (Kathleen Doheny, “COVID-19 Vaccine: Latest Updates,” June 10, 2020, https://www.medscape.com/viewarticle/932127).

      Influenza

      A number of tests are available to diagnose influenza viruses, and all require a sample obtained by rubbing the inside of the nose or back of the throat with a swab. The most commonly used are rapid influenza diagnostic tests (RIDTs), which can provide results within approximately 10 to 15 minutes; however, they are not as accurate as other flu tests and may produce false-negative results.
      Rapid molecular assays, which produce results in 15 to 20 minutes, are more accurate than RIDTs. Additionally, several other more accurate and sensitive flu tests are available, which must be performed in specialized laboratories such as those of hospitals or state public health services. The results may take one hour or several hours (CDC, “Diagnosing Flu: Questions & Answers,” Feb. 23, 2018, https://www.cdc.gov/flu/symptoms/testing.htm).
      Because there are many different flu viruses, and they are constantly changing, the composition of U.S. flu vaccines is reviewed annually and updated [CDC, “Frequently Asked Influenza (Flu) Questions: 2020–2021 Season,” June 26, 2020, https://bit.ly/38uxAqE]. These flu vaccines protect against the three or four viruses that research suggests will be most commonly circulating each year. For the 2020–2021 flu season, the trivalent (three-component) egg-based vaccines are recommended to contain:
      • A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus (updated).
      • A/Hong Kong/2671/2019 (H3N2)-like virus (updated).
      • B/Washington/02/2019 (B/Victoria lineage)-like virus (updated).
      Quadrivalent (four-component) egg-based vaccines, which protect against a second lineage of B viruses, are recommended to contain the three recommended viruses above, plus:
      • B/Phuket/3073/2013-like (Yamagata lineage) virus.
      For 2020–2021, cell- or recombinant-based vaccines are recommended to contain:
      • A/Hawaii/70/2019 (H1N1)pdm09-like virus (updated).
      • A/Hong Kong/45/2019 (H3N2)-like virus (updated).
      • B/Washington/02/2019 (B/Victoria lineage)-like virus (updated).
      • B/Phuket/3073/2013-like (Yamagata lineage) virus.
      For the 2020–2021 U.S. flu season, two new vaccines were licensed for use in adults aged ≥65 years:
      • Fluzone High Dose Quadrivalent, a quadrivalent high-dose vaccine (Sanofi Pasteur)
        • Contains four times the amount of antigen than the standard dose vaccine to create a stronger immune response.
        • Replaces the previously licensed trivalent Fluzone high-dose vaccine.
      • FLUAD Quadrivalent, a quadrivalent adjuvanted vaccine (Seqirus)
        • Is similar to the previously licensed trivalent vaccine containing MF59 adjuvant to illicit a stronger immune response but has one additional influenza B component.
        • Uses an egg-based process so is not recommended for use in people with a documented allergy to egg proteins.
      To date there have been no head-to-head trials comparing the efficacy of these two high-dose influenza vaccines. The CDC recommends the use of either in adults aged ≥65 years.
      The CDC recommends that the influenza vaccination be provided routinely to all residents and health care personnel of long-term care facilities by the end of October. Flu vaccines may continue to be administered in December or later, even if influenza activity has already begun.
      The duration of flu season varies year to year and might even continue until February or March, so continued vaccination may be beneficial. As of June 2020, influenza cases in the United States were low, and most respiratory illnesses were linked to COVID-19 (CDC, “Weekly U.S. Influenza Surveillance Report,” https://www.cdc.gov/flu/weekly/index.htm).

      Pneumonia

      Streptococcus pneumoniae (pneumococcus) can cause serious illness, including sepsis, meningitis, and pneumonia with bacteremia (invasive) or without bacteremia (noninvasive) (MMWR Morb Mortal Wkly Rep 2014;63:822–825). To confirm a diagnosis of pneumonia, several tests may be used, which include a blood culture to confirm infection and identify the pathogen, a chest X-ray to identify the location and extent of inflammation in the lungs, pulse oximetry to measure blood oxygen, and a sputum test.
      Older patients are considered high-risk for pneumonia, so additional tests such as a chest computed tomography (CT) scan, arterial blood gases, pleural fluid culture, and/or a bronchoscopy may also be performed (American Lung Association, “Pneumonia Symptoms and Diagnosis,” May 27, 2020, https://bit.ly/2CADOJR).
      Two pneumococcal vaccines are currently licensed in the United States for use in adults:
      • Prevnar 13 (PCV13), a 13-valent pneumococcal conjugate vaccine (Wyeth)
      • Pneumovax 23 (PPSV23), 23-valent pneumococcal polysaccharide vaccine (Merck)
      In November of 2019, the Advisory Committee on Immunization Practices (ACIP) published new updated pneumococcal vaccine recommendations for adults aged ≥65 years(MMWR Morb Mortal Wkly Rep 2019;68:1069–1075).
      PCV13. PCV13 vaccination is no longer routinely recommended for all adults aged ≥65 years. Instead, shared clinical decision-making for PCV13 use is recommended for persons aged ≥65 years who do not have an immunocompromising condition, cerebrospinal fluid (CSF) leak, or cochlear implant, and have not previously received a PCV13 vaccination.
      According to the CDC guidance, when patients and vaccine providers engage in shared clinical decision-making for PCV13 use in a specific individual aged ≥65 years, the considerations may include the individual’s risk for exposure to PCV13 serotypes and risk for pneumococcal disease as a result of underlying medical conditions.
      If a decision to administer PCV13 is made, it should be administered before PPSV23. PCV13 and PPSV23 should not be coadministered. The recommended intervals between pneumococcal vaccines remain unchanged for adults without an immunocompromising condition, CSF leak, or cochlear implant: ≥1 year between pneumococcal vaccines, regardless of the order in which they were received.
      ACIP continues to recommend PCV13 in series with PPSV23 for adults aged ≥19 years (including those aged ≥65 years) with immunocompromising conditions, CSF leaks, or cochlear implants.
      PPSV23 for adults aged ≥65 years. ACIP continues to recommend that all adults aged ≥65 years receive one dose of PPSV23. A single dose of PPSV23 is recommended for routine use among all adults aged ≥65 years. PPSV23 contains 12 serotypes in common with PCV13 plus an additional 11 serotypes that account for 32%–37% of invasive pneumococcal disease among adults aged ≥65 years. Adults who received one or more doses of PPSV23 before age 65 should receive an additional dose of PPSV23 at age ≥65 years, at least five years after the previous PPSV23 dose.

      Summary

      The CDC estimates there were approximately 50 million cases of influenza in the United States from October 1, 2019, through April 4, 2020, with 43,000 deaths. This is less than half of the >100,000 deaths from COVID-19 from March to June of 2020 (CDC, “2019–2020 U.S. Flu Season: Preliminary Burden Estimates,” Apr. 17, 2020, https://bit.ly/3iGENJd).
      For the 2020–2021 flu season, the CDC has recommended that all Americans receive a flu vaccine, and adults aged ≥65 receive an appropriate pneumococcal vaccine per recent schedules (CDC, “Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2020,” Feb. 3, 2020, http://bit.ly/33fEb47).
      For COVID-19, the guidance for health care facilities on the CDC website is updated regularly as knowledge increases (CDC, “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,” May 22, 2020, https://bit.ly/2ZFSPSy). The key concepts address:
      • Reducing facility risk
      • Isolating symptomatic patients as soon as possible
      • Protecting health care personnel
      Specific, regularly updated guidance for long-term care, assisted living, and other health care facilities is available on the CDC site.
      The 2020–2021 flu season will no doubt be challenging for health care professionals who must distinguish between influenza, pneumonia, and COVID-19 in patients who present with respiratory illness. Infectious disease protocols should be routine in all facilities, and they must include but are not limited to hand washing, wearing of personal protective equipment by all health care workers, using rapid diagnostic tools to determine pathogen(s) promptly, and administering medication protocols where suitable.
      Vaccinating patients and staff with the appropriate vaccines minimizes the spread of infectious disease. Timely identification of pathogens, isolation of infected individuals, and swift initiation of the proper treatment(s) are key to limiting disease transmission and maintaining good health for all patients and health care workers. The lessons we have learned from the disastrous impact of COVID-19 on long-term care, assisted living, and senior communities in the United States will hopefully prepare us for the 2020–2021 flu season and what lies ahead.
      Dr. Manzi has been a licensed pharmacist since 1990 and a Board Certified Geriatric Pharmacist since 1998. She is currently a clinical advisor for CVS/Caremark, coordinating with account teams and health plans on the details of their pharmacy benefit offerings, formulary implementation, medication utilization management, and MTM as well as providing clinical information and geriatric expertise. Any opinions in this article are that of the author and not of CVS/ Caremark.