The Flu Blues
Vaccine shortage presents health care workers with some tough
choices about who should receive the precious shots

By Cathryn Domrose
November 1, 2004

As California health care providers scramble to find flu vaccines this year, many nurses are wondering whether they should get a flu shot or skip it this year so more vaccines will be available to their patients. It’s a question without an easy answer, nurse epidemiologists, administrators, and government health officials say.

Some nurses will have no choice, at least until their facilities receive more doses of the vaccine. The Centers for Disease Control and Prevention recommends that all health care workers with “direct patient care” get a flu shot.

But because vaccines are in such short supply, some hospitals and county health departments are prioritizing even among health care workers, recommending that those who do not work with severely at-risk patients put off getting a flu shot until more vaccine becomes available.

Other health facilities — even those with enough vaccines for all qualified workers — report that some nurses were forgoing or postponing the vaccines voluntarily to make sure their elderly or at-risk patients receive the shots.

Whether nurses should get the shot, postpone it, or forgo it altogether is a personal decision and depends on their individual situation, nurses and health officials say.

“It’s noble for nurses to say I would just as soon forfeit my vaccine and give it to a patient,” says Barbara DeBaun, RN, MSN, CIC, director of infection control at the California Pacific Medical Center in San Francisco. But although young, healthy health care workers have a better chance at weathering the flu than sick or elderly people, they also may be more likely to transmit the illness to patients and colleagues.

The state health department recommends that all health care workers involved in direct patient care receive the vaccine so they can stay healthy, says Norma Arceo, spokeswoman for the California Department of Health Services. But some county officials say they have only so much vaccine to go around.

Short supply

After learning that only 58 million of an anticipated 100 million doses of the flu vaccine would be available nationwide this year, the CDC asked health care providers to limit the shots to certain high-risk groups: people older than 65; those with certain types of chronic illness; children aged 6 months to 2 years; women who will be pregnant during the flu season; caregivers of children younger than 6 months; and health care workers involved in direct patient care. State guidelines mirror those of the CDC.

California was particularly hard-hit because the state ordered all of its flu vaccines from Chiron Corp., which had to cancel its deliveries after its flu stock was quarantined by British and U.S. health authorities Oct. 5. Through a CDC redistribution program of vaccines from the only other U.S. supplier, Aventis Pasteur, the state will have about half of what it had planned to distribute to county health departments. The counties provide shots to nursing homes and low-income residents.

As a result of the shortage, Sacramento County is asking health care providers with limited amounts of vaccine to give flu shots first to the “frail elderly,” people with chronic illnesses such as diabetes or lung disease, and health care workers who work directly with severely immunocompromised patients.

As more vaccine becomes available, the county will expand its guidelines, says Glennah Trochet, MD, public health officer for Sacramento County. “We would like to see it reserved for the patients now,” she says, adding that the guidelines were not set in stone, and every provider should use clinical judgment in deciding who would most benefit from getting the shot.

Los Angeles County has no plans yet to further restrict the state recommendations for patients or health care workers, says Alvin Nelson El Amin, MD, MPH, medical director of the Los Angeles County immunization program. But county health officials are advising healthy health care workers younger than 50 to consider getting a nasal mist flu vaccine developed last year or using antiviral medications if they cannot get a flu shot.

UCSF Medical Center, which ordered from Chiron and came up short, plans to offer flu shots to physicians, nurses, and other health care workers who provide direct patient care in the emergency department, acute care clinics, intensive care units, and hematology and oncology services, says hospital spokeswoman Carol Hyman.

Workers in areas such as med/surg and outpatient services will not be able to get vaccinations through the hospital, at least initially, she says. “We’re hoping to get more vaccine and as we do, more workers and more patients will be getting vaccinated,”Hyman says.

Other facilities say they have enough vaccine to give flu shots to most health care workers involved in direct patient care who want one. The Palo Alto Medical Foundation in Palo Alto received its shipment of flu vaccine from Aventis early and has enough for its high-risk patients and workers involved in direct patient care, says Theresa Manley, RN, BSN, MBA, director of clinical operations at the Palo Alto division of the Palo Alto Medical Foundation.

But because the foundation gave some of its supply to a sister clinic and to the Santa Clara County Health Department, it has still come up a little short, Manley says. So managers and administrators, including those who sometimes care directly for patients, decided as a group to forgo getting the shot, she says.

Protecting the protectors

Kaiser Permanente also reported it would have enough vaccine to give flu shots to workers in direct patient care who wanted them. “We want to make sure there is somebody to take care of anyone who gets sick,” says Paula Lowery, RN, MPA, service manager of adult medicine at Kaiser Permanente WalnutCreek Medical Center.

The medical center is making the vaccine available to nurse administrators and advice nurses who work with large groups of people even if they are not caring directly for patients because they could potentially pass the virus to coworkers and patients. Kaiser is actively encouraging workers in direct patient care to get the shots, and Lowery says compliance has been “pretty good” so far this year.

Studies have shown that in a typical year, between 30% and 40% of health care workers get the shot. Health officials said that while they are not discouraging workers involved in direct patient care from getting the shots if they can, they are not promoting them, either. A plan by the Northern California Partnership for Influenza Protection to target health care workers this year was scrapped because of the shortage, Trochet says.

In past years, nurses’ reasons for skipping the shots are similar to those of the general public, DeBaun says. The main reason is they erroneously believe they can get the flu from a flu vaccine, which uses a dead virus.

meet CDC guidelines attempting to sneak in for a shot. But they did report disappointment and frustration among patients who were turned away, either because they did not meet guidelines or because the clinic did not have enough vaccine.

“It’s a hard call for everybody this year,” says Nancy Knott, RN, a wellness clinic nurse for the Sutter Visiting Nurses Association & Hospice in Emeryville. She was supposed to hold 40 flu clinics this year. So far, she has done two and has no idea whether she will be able to do more.

“We’ve had to say no to a lot of people who normally would be getting a shot,” she says. “It puts us in a very awkward position. It’s kind of like being the police and being God and being a psychic.”

How these decisions — by health officials, hospital administrators, and individuals — will play out depends on the whim of an unpredictable virus. So far, only sporadic cases of the flu have been reported in California. More vaccine has been promised by January, which won’t do much good if the flu season already is under way, nurses and health officials say, but will help if the season starts late.

A bad flu season could be disastrous for already embattled emergency departments, but a mild flu season — which everyone is hoping for — could mean difficulty persuading people to get a flu shot next year. Or, if people remember this year’s shortage, there could be a mad rush to get the shots early.

If there’s a silver lining to this year’s flu vaccine fiasco, DeBaun says, it may be that people will pay more attention to the old ways of flu prevention, such as washing their hands, staying home when they are sick, and using alcohol gel.

“We’re kind of back to the basics,” she says. “This could be a very good thing.”

Flu shot alernatives

If you cannot get a flu shot this year, the Centers for Disease Control and Prevention suggests the following alternatives:

• Nasal-mist vaccine. The nasal-spray flu vaccine, sold as FluMist, was licensed last year and contains weakened live influenza viruses instead of the killed viruses in the shots. It is sprayed into the nose and stimulates the body’s immune system to develop protective antibodies, just as the shot does. The nasal-spray flu vaccine is approved for use only in healthy people aged 5 to 49 years who are not pregnant. It should not be used by those in contact with people with severely weakened immune systems, but is a good alternative for most other health care workers and people caring for infants younger than 6 months.
• Antiviral drugs. Three antiviral drugs — amantadine, rimantadine, and oseltamivir — can be used to prevent the flu. All require a prescription. They are about 70% to 90% effective for preventing illness in healthy adults. These drugs and one more — zanamavir — are also approved to reduce symptoms and the duration of the flu in people who have contracted it.
• Good health habits. These include avoiding close contact with people who are sick, staying home when sick, covering the mouth and nose with a tissue when coughing or sneezing, washing hands frequently, and avoiding touching the nose and mouth.
  For more information on the availability of flu shots and who should get them, visit the CDC website at www.cdc.gov/flu/ or the California Department of Health Services website at www.dhs.ca.gov/ps/dcdc/izgroup/flu.htm.