From left, Infection control nurse Pat Rutherford, Lucy Tompkins, professor of medicine and chief of infectious diseases and geographic medicine; and Alexandra (Sasha) Madison, MPh, manager of infection prevention at SHC have a full workload this flu season - added to the day-to-day control of infection at SHC. (See related story)

Infection team braces for vaccine-deficient flu season - and for year-round prevention

The arrival of flu season amidst a shortage of seasonal vaccine has produced special challenges for the American public. At SHC, the recent award-winning infection control staff members have been preparing - as they do every year - for the flu season. But this year with only limited supplies of vaccine, there are special considerations for hospital patients, physicians, and the local public. We talked with SHC infectious disease medical director Lucy Tompkins, MD, PhD, professor of medicine and chief of infectious diseases and geographic medicine; Alexandra (Sasha) Madison, MPH, CIC, the hospital's manager of infection control and epidemiology; and infection control nurse Pat Rutherford, RN, BSN, CIC, about what steps the hospital is taking this year - as well as what physicians can do this season to protect themselves, their patients and their families:

Q: What are you doing this flu season?
A: We were tight on vaccine this year and had to triage our supplies carefully according to Santa Clara County and CDC guidelines. But there is some good news. The vaccine this year appears to be more effective than in past years for those who were fortunate enough to receive it. And we were able to secure enough vaccine to provide the vaccine to those who needed it most - health workers and outpatients at highest risk. Unlike past years we weren't able to give the vaccine to everyone who wanted it, so now we are extra vigilant. We should emphasize that the respiratory etiquette we employ to protect our health care workers, our patients and our other staff gets a lot of attention during flu season, but what we do is really a year-round effort. We have simple but effective protocols we always employ in the hospital for surveillance, prevention and protection of a variety of infections, including tuberculosis and SARS to protect our complex and varied patient population. The flu season does give us an opportunity to get the word out on some practical preventive and treatment measures that busy physicians might not always have on their front burners.

Q: With vaccine in short supply, will people who have had the vaccine in past years retain any protection?
A: It's likely that past vaccines will produce a beneficial effect, probably shortening the duration of flu or reducing its severity. Keep in mind, however, that in older patients, immunization, even if given every year, may not be as effective.

Q: This season, with increased vulnerability, what should physicians be looking for?

1. When sending a patient to the hospital:

a. Let the hospital know if you are ruling out influenza on a patient you are admitting. Patients with suspected influenza are placed in private rooms and promptly tested for influenza A and B. The hospital will take special precautions, such as sending a flu-suspected person directly to a private room rather than having the patient stop in a waiting room.

b. Take a brief travel history. If your patient has traveled recently to Asia or another area, especially rural communities, where flu is prevalent, that information is vital for patient monitoring. The hospital would step up precautions.

c. Tell patients to discourage family members with flu or flu-like symptoms from visiting the hospital.

2. Practice Respiratory Etiquette in your clinic, office or anywhere you have contact with patients. The hospital has signage, masks, tissues and alcohol gel available in waiting areas. (Signs are available for physician offices from SHC; call 650-725-1106). If patients are coughing, give them a mask and have them sit away from other patients in the waiting room. Incidentally, inexpensive surgical masks are adequate, since the flu is a relatively large virus that does not remain airborne. It is spread by direct physical contact or extremely close respiratory exposure.

3. If supplies of the flu vaccine are available but restricted, triage prudently. For example, while medical associations and public health officials now often recommend flu vaccines for everyone over age 50, the nation will probably have to retreat to previous standards that called for reserving prophylactic immunization for healthy people over age 65. Give special consideration to patients residing in, going to or about to leave a nursing home. This is a particularly high-risk environment.

4. If the patient contacts you during the first 48 hours of symptoms, consider ordering an M-2 inhibitor such as oseltamivir (Tamiflu), rimantadine (Flumadine) or zanamivir (Relenza). These drugs ameliorate early flu symptoms. Choices? Oseltamivir appears to produce fewer side effects. Rimantadine is less expensive but appears to be effective only against influenza A. Early symptoms may involve muscle aches without cough or other respiratory symptoms. Consider offering the prescription over the phone before asking the patient to come to the office and exposing others, unless in your judgment the patient should be examined for other risk factors.

5. If you have contact with patients, get vaccinated even now if possible regardless of your own risk profile. (Vaccine for community physicians is available through the SHC/LPCH Occupational Health Dept. 723-5922). It's not selfish to vaccinate yourself ahead of others, because patients need to be protected from you. For example, at Stanford, all house officers, who are generally young and healthy, were encouraged to be vaccinated. Besides protecting patients, the hospital wanted to make sure that its house officers were available for rotations - not out sick with the flu. A nasal vaccine is a possible immunization alternative for healthy people ages 5 to 49.

6. Limit needless exposure to the flu and advise your patients and friends to do the same. On the simplest level, stay away from crowds whenever possible. Practice good personal hygiene: wash your hands for 10 seconds after using the restroom, change gloves and wash or use alcohol gel on your hands before, between and after each patient. Be a role model.

Q: Do you vaccinate patients in the hospital?
A: No. It probably wouldn't be helpful for persons who are already exposed. Also, vaccination causes risks not only of exacerbating symptoms of patients but also of complicating diagnoses; typical flu symptoms such as high fever might be confused, for example, with signs of transplant rejection.

Q: What if a patient gets the flu in the hospital, what would you do to protect other patients?
A: We would consider prophylactic use of an antiviral among patients who might have been exposed.

Q: What does the future look like?
A: This year's epidemic, at least as we talk in mid-November, appears no worse than normal. However, we are likely on the verge of a major pandemic of influenza that might be as virulent as the 1918 pandemic that killed between 20 million and 100 million people worldwide. Global studies indicate that sooner rather than later we are likely to see a mixing of avian flu genes in new combinations that will make these mutated viruses particularly virulent and adaptable to human transmission.

Q: What can be done to mitigate a pandemic?
A: Ordinarily flu affects children most frequently but produces the highest death rates in the elderly. Since children serve as the reservoir of influenza, pediatricians are making a push to immunize all children to prevent more generalized transmission. We also are working on new, faster methods of producing a live vaccine. It now takes about nine months to culture a new vaccine, but newer techniques of genetic engineering may in the not too distant future replace live cell culturing. However, if a pandemic broke out, we'd still need to prevent the first wave of cases. That's why respiratory etiquette will remain our first line of defense.

Q: Has the CDC identified a culprit for the predicted outbreak?
A: The H5N1 infection has been transmitted from poultry to humans in Asia but there appear to be limited cases of human-to-human transmission. A slight genetic modification could make this strain easily transmittable among humans. However, if it's not this strain, it will be another. Influenza is a highly dynamic virus.

Q: The long-term outlook sounds pretty bleak. Is there any silver lining?
A: Sure. The flu vaccine shortage has raised the awareness of the public and of the health care community. People understand they have to take precautions and be more careful in their daily lives. We also have been smarter here and throughout the country at triaging vaccine use to those who need it most. The breakdown in the flu vaccine supply, including the dependence on market forces, has even started to raise the attention of public officials. We need more funding for research, which will help us find a way to engineer specific flu strain vaccines and get them out to the public in as close to real time as possible.