Fighting Flu, Flu Shots, and For Flu Masks

Figure: Hannah Lee, 3, and her mother waited in line to receive a free H1N1 vaccine at the Performing Arts Center in Cerritos, California, on October 28, 2009. More than 2,000 people lined up at the center for the flu shot. Photo by Ana P. Gutierrez / Associated Press.In April of last year, New York City school nurse Mary Pappas alerted health officials when an unusual number of children showed up in her office with flu-like symptoms (see In the News, June 2009). This new flu, identified as a novel H1N1 influenza virus, spread rapidly throughout North America and Europe in the ensuing summer months—an unusual time for flu to occur. Infectious disease officials worldwide monitored the rapid spread of the virus, and on June 11, Margaret Chan, director-general of the World Health Organization (WHO) declared, "The world is now at the start of the 2009 influenza pandemic." The clinical picture. By now we know that the 2009 H1N1 pandemic influenza differs from the seasonal flu in that it primarily strikes young children and healthy young adults (including pregnant women) as opposed to the elderly. Underlying conditions that place people at high risk for serious complications include asthma, heart and kidney disease, a suppressed immune system, and obesity and diabetes. According to the Centers for Disease Control and Prevention (CDC), 19% of adults hospitalized from flu complications have diabetes. In the WHO's weekly telephone briefing on November 5, Keiji Fukuda, special adviser to the director-general on pandemic influenza, said "the WHO remains quite concerned" that serious complications are occurring in healthy people younger than 65. He noted that although most people will recover without incident, those with serious complications are putting a strain on hospital resources in many countries. Reports in the November 4 issue of JAMA detailed the experiences of California, Mexico, and Canada in responding to patients hospitalized and critically ill from the H1N1 flu. Those requiring hospitalization were often young people who had a short prodromal illness followed by a rapid decline with respiratory distress and multisystem failure. Many required significant lengths of stay in ICUs and complex mechanical ventilation therapies, leading to concerns about whether resources will be sufficient should the pandemic have a long season. In a December 1 press briefing, the CDC reported a decline in flu activity but stressed that "the flu virus is unpredictable." The CDC also pointed out that during the 1957–1958 flu pandemic, after an initial waning of activity in the fall, there was a resurgence from December through January. The flu season is typically December to May. The vaccine. The H1N1 vaccine was developed in less than six months, leading many to question if there was sufficient testing. Government agencies went to great lengths to reassure both the public and health care workers that the vaccine was developed and tested under the same rigorous conditions as the seasonal flu vaccine and should be considered safe. By November, just as public fears about receiving the H1N1 vaccine seemed to be abating, the vaccine was unavailable. Even groups deemed high priority (pregnant women, health care workers, caregivers of and those living with infants younger than six months, those ages six months to 24 years, and adults 25 to 64 years with chronic illnesses) had difficulty finding providers with a supply. And as we went to press, health care providers were still scrambling for supplies. For health care workers, the issue was one of choice. Many hospitals—and New York State—issued directives that all direct caregivers receive the vaccine, setting off protests by nursing and other unions that the mandate infringed on personal rights. New York rescinded its order, claiming the vaccine shortage made it unfeasible. In a North Carolina health care facility, some employees quit to preserve their choice. Nursing organizations urged their members to get vaccinated, but in general didn't support mandatory vaccination. (For more on this topic, see Point Counterpoint in this issue.) The mask. Based on animal studies and a study conducted in China by Australian researchers, the CDC and the Institute of Medicine (IOM) endorsed the use of N95 respirator masks in health care workers, ignoring findings of a study in the November 4 issue of JAMA showing that regular surgical face masks were just as effective. On October 31, at a meeting of the Infectious Diseases Society of America, the Australian researchers recanted the findings of their study, saying a subsequent review of data showed that their results were not significant and the N95 masks were not superior to surgical masks. As of December 1, the CDC and IOM had not used the findings presented at recent meetings to develop recommendations. Maureen Shawn Kennedy, MA, RN, editorial director and interim editor-in-chief.

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