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According to the CDC, an estimated 10 percent to 20 percent of Americans contract the flu each year. Of those, about 114,000 are admitted to the hospital and about 36,000 die.

But these numbers may not reflect the true magnitude of the flu, said Neil Pascoe, RN, a nurse epidemiologist for the Texas Department of Health.

"Most cases of influenza are not medically attended," he said. "Generally, I would say 30 percent of the population gets flu, but how many recognize it is unknown."

Influenza has three strains, although the third, C, is mild. The B strain has remained stable over the years, but the A strain mutates and adapts, making it more difficult to predict which type must be included in the vaccine. Seasons in which A strain predominate have been more severe in the past, with higher numbers of influenza-related deaths and hospitalizations.

This year, scientists realized too late that A/Fujian would be one of this year's dominant strains. A/Fujian was not included in the vaccine, although it does contain Fujian's close cousin, A/Panama, which will provide limited protection against Fujian.

Limited protection can mean the difference between life and death for people in the high-risk categories. Pascoe estimates 185 million Americans are at high risk. According to the CDC, manufacturers produced 87.1 million doses of the vaccine this year.

Early reports of healthy children dying from complications from the flu helped spur a run on vaccine that left doctors' shelves empty this year. In most years, health care workers throw away thousands of leftover doses. As Axelson and other nurses who order the vaccine know, predicting demand can be tricky.

"Every year we try and we fail," she said. This year, she guessed that more people would opt for the vaccine based on the SARS scare, even though the two diseases are unrelated.

Since the shortage in 2000, people have begun placing orders for vaccine earlier, which means manufacturers may not have any left for those who order late, said Nisha Gandhi, the adult immunization coordinator for the California Department of Health Services, Immunization Branch.

"It's a matter of people thinking about it earlier," she said.

Furthermore, manufacturers no longer allow returns of unused vaccine, she said.

Ounce of prevention

Clearly, not everyone who needs an inoculation gets it, and some people think nurses can do more to stop the swirl of misinformation that surrounds influenza and its vaccine. In fact, the biggest lesson from this year's heavy season may be that people in health care can do more to encourage prevention and reduce rates of transmission.

Many nurses who do not administer the shots don't know the recommendations about risk groups, said Cindy Noa, MS, RN, director of community health nursing and clinical services for the Champaign-Urbana Public Health District in Illinois.

"The best thing they can do is to educate themselves because patients listen to nurses," she said.

Contrary to common myth, the flu shot does not give its recipient the flu, although it can cause soreness around the area of injection, low-grade fever and aches. The vaccine contains dead virus, which cannot replicate.

This year, manufacturers were able to offer a new vaccine, a nasal spray that contains live but weakened virus. The spray is recommended only for healthy people aged 5 to 49 who are not in close contact with people at high risk for complications from flu.

Side effects of the nasal spray include everything from runny nose to vomiting, but not the flu.

Health care workers surrounded by sick patients are in the second wave of priority vaccinations, according to the CDC. Noa encourages nurses to start by getting the vaccine themselves.

"Many do not," she said.

Encouraging patients to wash their hands and get the vaccine is the next step, she said.