Here is the PICO analysis for the article:
Full Article Title:
Treatment of an Influenza A Outbreak in a Teaching Nursing Home: Effectiveness of a Protocol for Prevention and Control
Authors: Nancy L. Peters, MD, Steven Oboler, MD, Carole Hair, RN, MS, GNP, et al.
Journal: Journal of the American Geriatrics Society (JAGS) (1989); 37(3):210–218
DOI: 10.1111/j.1532-5415.1989.tb06809.x
✅ PICO Analysis
Type of Study:
Retrospective descriptive study of a protocol-guided intervention during an influenza A outbreak in a Veterans Affairs teaching nursing home
P – Population
- Setting:60-bed VA Nursing Home Care Unit (NHCU) in Denver, Colorado
- Participants:
- 60 male-dominated residents with chronic, hospice, or rehabilitation needs
- 81 full-time and part-time staff (nurses, clerks, support staff)
- Residents had a median age in the 60s; employees spanned a broader age range
I – Intervention
Institution-wide influenza outbreak response protocol, comprising:
- Annual influenza vaccination of residents and staff (target: 90% for residents, 80% for staff)
- Amantadine chemoprophylaxis during suspected or confirmed influenza A outbreaks
- 100 mg daily standard dose
- Renal-adjusted doses for elderly or impaired
- Outbreak management steps:
- Immediate serological testing and throat cultures
- Amantadine started on day 2 of outbreak
- Employee in-service education and medication review
- Daily monitoring of side effects and symptom onset
- Post-outbreak follow-up with serological data, employee compliance survey, and adverse effect reporting
C – Comparison
- No formal control group
- Implicit comparison: outbreak spread and symptoms before vs after amantadine initiation
- Between-group contrasts:
- North wing (outbreak site) vs East wing (no cases)
- Vaccinated vs unvaccinated residents
- Residents vs employees (side effects, compliance)
O – Outcomes
Person-Centred Outcomes:
- Resident illness: 12 of 60 developed influenza-like symptoms (8 serologically confirmed)
- Mortality: No influenza-attributable deaths during outbreak; one death (pneumonia) occurred six weeks later
- Symptom severity: Residents who started amantadine had milder symptoms than index cases
- Falls: Reduced significantly during prophylaxis (2 falls during month of use vs ≥12/month before/after)
Process Outcomes:
- Vaccination: 94% of residents; 41% of staff prior to outbreak (rising to 73% with catch-up)
- Amantadine use: Initiated in 59 of 60 residents and 71 employees
- Resident side effects (Table 2, page 214):
- Mostly mild (GI distress, sleep disturbance); 11 dose reductions/discontinuations
- One late skin reaction (rash, fatigue) led to pneumonia and brief hospitalisation
- Employee side effects (Table 3, page 215):
- 61% reported ≥1 moderate to severe adverse event (nausea, dizziness, weakness)
- Only 44% completed ≥70% of 2-week course
- North wing staff had lowest compliance and highest dissatisfaction (P < .01)
Health System Outcomes:
- Containment success: Outbreak confined to one wing of the facility
- Serological evidence: Only 6 of 60 residents showed seroconversion; East wing showed no spread
- Amantadine effectiveness: Despite some breakthrough cases, drug appeared to reduce illness severity
Summary Conclusion
This study demonstrates the feasibility and partial success of a protocol-driven outbreak management strategy for influenza A in a high-risk nursing home setting. High resident vaccination rates and early amantadine use likely curtailed spread and illness severity, with infection restricted to a single wing. Amantadine was better tolerated by residents than staff, where side effects reduced compliance. The findings support CDC recommendations for annual vaccination and rapid chemoprophylaxis in nursing homes but highlight the need for better staff engagement and possibly alternative antivirals with fewer side effects .
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