Ready for the Flu

Dec 1, 2000

By Anton Zuiker

The flu, that nasty bug, visits North America every winter, and chances are good you’re familiar with the muscle aches, exhaustion, congestion, cough and fever that typify an influenza infection. Perhaps you?ve already steeled yourself for the coming winter?s return of the virus and stocked up on tissues while checking to see how much sick leave you have left until your next work anniversary.

If you?re a healthy adult, that might be enough.

And yet the region?s hospitals and health departments are preparing for the worst ? the possibilty of an influenza epidemic that could swamp hospitals, kill elderly and chronically sick patients, and panic the public. For the first time ever, though, there?s a coordinated plan to treat the sickest flu sufferers and stem the spread of flu.

?This is the first time health departments and hospitals are in the same room talking about the same health issue,? says Lisa Anderson, vice president for community health services at the Center for Health Affairs. Anderson brought together representatives from 32 hospitals and 13 health departments in nine counties to form the Regional Flu Preparedness Task Force.

The task force had to tackle two major issues: what to do about a shortage of the flu vaccine, and how to anticipate the need for emergency room beds for the most serious cases of patients suffering from flu.

The influenza virus is changing all the time, and new mutations generally pop up first in Asia. Every year, the Centers for Disease Control and Prevention decides on the strains that will be used to make a flu vaccine. The CDC picks out the three strains most likely to attack the U.S. and combines them into one vaccine.

?It?s like different colors of pepper,? says A. Gus Kious, M.D. senior vice president of medical management for the Eastern Region of the Cleveland Clinic Health System. ?They pick three and throw them into a grinder and spit them out.?

?We have a unique situation this year with the delay in the vaccine,? says Terry Allan, director of community health services at the Cuyahoga County Board of Health. Two of the five national flu vaccine manufacturers weren?t allowed to grow the vaccine because of prohibitions by the Centers for Disease Control and Prevention, and the three remaining manufacturers produced less vaccine than expected. ?Usually we order 15,000 doses for the county health department, but by mid-October we had received only a fourth of those doses,? says Allan.

This delay and shortage means the county, and other hospitals and health services, must prioritize the patients who receive the vaccine. CDC guidelines say persons over 65, those with chronic medical conditions, adults and children with asthma, women in the second or third trimester of pregnancy, and health care workers who care for flu patients should be the first to receive the vaccine.

?I can?t afford to have half of my work force sick in the midst of an epidemic,? says Kious. He?s pushing to have most of his flu care givers ? emergency room doctors and nurses ? vaccinated for the flu. But a shortage of nurses, a national trend, adds extra weight to maintaining a healthy medical team in an epidemic.

Kious, for one, is angry that area drug stores, many of which received doses of vaccine before the hospitals and health departments, have sold the vaccine ?willy nilly?—to anyone willing to pay for it, including those least at risk of dying from flu complications. And Kious is livid that his head of pharmacy received a ?black market? phone call from a Florida drug company peddling the vaccine at $150 a vial, when he normally pays only $24 a vial. (Each vial provides 10 doses of vaccine.) Hospitals and health departments benefit from a collective purchasing effort that holds down the cost of the vaccine. The Cleveland Clinic orders 55,000 doses each year, while the Eastern Region (the former Meridia hospital system) orders an additional 8,500.

The City of Cleveland Health Department, which usually orders almost 6,000 doses of the vaccine, this year had received only 1800 by mid October, and was down to only 200 doses by early November. ?This shortage concerns us greatly,? says Michele Whitlow, director of public health. Her department, like the rest, is priortizing those who receive the flu vaccine, but she?s also encouraging the elderly to receive the more-abundant pneumonia vaccine. ?Pneumonia is the fifth leading cause of death in Cleveland,? says Whitlow. Flu often leads to pneumonia infection and complications, especially in the elderly and chronically sick.

Last year?s flu season, if you remember, brought us regular local and national news reports of emergency rooms flooded with flu patients. Often, those patients were bedded down in the hallways, kind of like an episode of the television show ER. Dr. Kious wanted to make sure his hospitals had a protocol for a repeat of that situation, so he asked the Center for Health Affairs to see if the federal Health Care Financing Administration, which administers Medicare, would allow hospitals to admit elderly flu patients to hospital beds usually designated for other kinds of care. His request led to the formation of the Flu Preparedness Task Force, which did receive agreement from HCFA on the bed transfers.

The recent closure of Mt. Sinai Medical Center and the reduction of services at St. Luke?s Medical Center, says Anderson, added another reason for hospitals to plan together. While hospitals already collaborate on where an emergency patient goes when any given hospital is swamped, the new flexibility for flu admissions should keep patients out of the hallways this year. That doesn?t mean anyone arriving at a hospital with flu symptoms will get a cozy bed to hunker down in for a few days.

At St. Luke?s Medical Center Solon Emergency Department, for example, patients in their first two days of flu symptoms will receive a nose swab test to determine which major type of flu, A or B, is attacking the person. New antibiotics can lessen the seriousness and length of flu, so most patients will go home the same day with a prescription. The Cleveland Clinic?s Eastern Region hospitals operate a similar treat-and-release protocol.

?Our focus has been how to handle the sickest patients and care for those who most need the care,? says Kious. The last two winters, cases of flu and other respiratory infections have risen at the Cleveland Clinic?s Eastern Region says Kious, first 13 percent and last year 15 percent. ?People are in the hospital longer, and there?s a whole lot of them. We may have say to some patients, ?Look, we?re sending you home with intraveneous antibiotics. Don?t panic. You?ll recover fine.??

In a full-blown epidemic, even schools and community centers may be used as flu wards. ?People shouldn?t be afraid that ?Hawkeye? Kious will be treating them at Roxbury Middle School,? says Kious. M.A.S.H-like field hospitals are a worse-case scenario in the task force?s planning.

That planning, say Kious and Anderson, encompasses a comprehensive surveillance, vaccination and treatment program for Northern Ohio. The vaccination and treatment efforts build on past programs. The surveillance part is new.

Influenza is a Class B reportable illness, and reported to state and federal health officials only in total numbers. Still, Northern Ohio numbers for last year?s flu cases are hard to come by. Marguerite Erme, D.O., M.P.H., disease control medical officer for the Akron health department, wanted a better current picture of flu in Summit County, so she started a surveillance program in 1998. ?We didn?t have a good way of knowing when and where the flu was hitting,? says Erme. By monitoring school and business absentee rates, nursing home cases, and clinical diagnoses from emergency rooms, universities and correctional institutions, Erme knew that the flu in Summit County peaked in the middle of February in the 1998-?99 season, but in January last year. Her reports this season, which extends from mid October to late April, will be available at www.ci.akron.oh.us/health/epidemiology/control.htm. Likewise, Terry Allan of Cuyahoga County will post his ?What?s New With the Flu? reports at www.ccdh.net.

This monitoring, to be shared among the members of the task force, will tell hospitals and public health officials which strains of the virus are present in Northern Ohio and where the virus is spreading. This surveillance is extra important this year, says Erme, ?since we don?t have the population fully protected with the vaccine, and no one has a crystal ball to know when the flu is coming.?

But it is coming. It comes every year.

[Sidebar]
Foil the Flu
With a shortage of flu vaccines this year, an ounce of prevention from each one of us could be invaluable. The elderly, the chronically sick, children on aspirin therapy, and pregnant women should still get vaccinated. Call your doctor, local health department or nearby hospital to schedule a vaccination.
The rest of us should follow these prevention guidelines:

? Wash your hands before eating and preparing food, and before you put your hand to your nose, eyes or mouth.

? Follow good health practices: drink plenty of fluids, eat a balanced diet, get adequate sleep, exercise regularly, and avoid smoking and alcohol.

? If you do get sick, stay home from work so you don?t pass the virus to your colleagues. Stay inside in a well-ventilated area, and dispose of wet tissues in the trash. Drink extra fluids, rest, and take non-aspirin medicines to reduce the fever.

? New medicines help can minimize the severity of flu. At the first sign of flu-like symptoms, contact your doctor to see if you would benefit from the newer anti-viral medicines.

For more information about influenza, visit the Web site of the Centers for Disease Control at www.cdc.gov/ncidod/diseases/flu/fluvirus.htm.

Cleveland Magazine, December 2000

Anton Zuiker ☄