The Enigma of the H1N1 Flu: Are You Ready?

Article Outline

• ABSTRACT
• What Is H1N1 Flu?
• Signs and Symptoms
• High-Risk Patients
• Diagnosis
• Vaccination
• Prevention and Treatment
• Disease Management
• Surgical Department Response to the H1N1 Virus
• Summary
• Examination
  • The Enigma of the H1N1 Flu: Are You Ready?
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • The Enigma of the H1N1 Flu: Are You Ready?
• Learner Evaluation
  • The Enigma of the H1N1 Flu: Are You Ready?
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

This flu season, health care providers must be prepared to treat patients who have the seasonal flu and also those who have contracted a novel strain of the H1N1 influenza virus. Although H1N1 flu is sometimes incorrectly called “swine flu,” the virus is transmitted from person to person; it cannot be contracted from pigs or from eating pork products.

Symptoms of the H1N1 flu include fever, chills, nausea, vomiting, body aches, lethargy, and fatigue, which usually appear in rapid succession. People at high risk include children, pregnant women, and those with certain medical conditions. The most common cause of death from the virus is respiratory failure, but other causes of mortality include sepsis, dehydration, and electrolyte imbalance. The first line of defense against H1N1 flu is vaccination. Treatment includes use of antiemetics, antipyretics, and respiratory support. AORN J 90 (December 2009) 852–862. © AORN, Inc, 2009.

Key words:  H1N1 virus , swine flu , influenza

On August 27, 2009, the physicians and nurses at a Columbus, Ohio, hospital delivered a healthy baby girl, and her mother named her Ava Renee. What was different about this delivery? It was not that an emergency cesarean delivery had to be performed or that the pregnancy was only 32 weeks along. It was that the 20-year-old mother, Kelsey, had been diagnosed with H1N1 flu.¹

Kelsey, who worked at Port Columbus Airport, was eagerly awaiting the birth of her first child during her uneventful pregnancy. After she contracted the H1N1 virus, she became very ill. The physicians decided to perform an emergency cesarean delivery because she was in respiratory distress. After the delivery, Kelsey rallied but then quickly deteriorated, suffering from pneumonia and high fever. On September 3, just five days later, Kelsey died and became the first mortality from H1N1 flu in Franklin County, Ohio. The baby continues to do well and is not infected with the H1N1 virus.¹

Forecasts for the normal 2009 seasonal flu include the potential for 36,000 deaths in the United States, with 5% to 20% of people becoming ill.² Plans for handling the normal flu season have now intensified because of the appearance of another form of flu, the novel H1N1 virus.² Predictions about the effects of H1N1 flu have concerned both the public and health care providers.³, ⁴

Back to Article Outline

What Is H1N1 Flu? 

Stories like this have been appearing in newspapers throughout the United States during the past months: “2,000-plus sick with swine flu at university,”⁵ “District school teacher contracts swine flu,”⁶ “Swine flu hits college campus.”⁷ This virus was originally referred to as the “swine flu” because

laboratory tests showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America. But further study has shown that this new causative virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia, a bird (ie, avian) gene, and a human gene. Scientists call this a “quadruple reassortant” virus.²

The roots of the H1N1 virus began in 1918, when humans and pigs both became sick from influenza at the same time. This was the first indication that H1N1 flu was related to human influenza.⁸ The current identified strain of H1N1 flu is considered to be a descendant of the cause of the 1918 flu pandemic, which killed an estimated 50 million to 100 million people worldwide.⁸ This strain of flu has persisted in pigs and humans throughout the 20th century, and it is believed that pigs may have caught the disease from humans.⁹ Even though some of the strains that were present in humans have disappeared over the years, the pig population has retained the virus. Therefore, pigs may be the reservoir in which this virus can exist and later emerge to once again infect humans. Nevertheless, it is safe to eat pork because the H1N1 virus is passed from person to person not from pigs to humans or from eating pork products.¹⁰

The first case of the 2009 H1N1 virus surfaced in Mexico in April. The virus spread quickly and became an international concern. In May, pigs in Alberta, Canada, were reported to have the same virus that was linked to the outbreak in Mexico. It was suspected that a farm worker who had just returned to Canada from Mexico may have exposed the pigs to the new H1N1 virus.⁸

On June 11, 2009, the World Health Organization (WHO) declared the H1N1 flu a pandemic “as a reflection of the spread of the new H1N1 virus, not as a result of the severity of the illness caused by the virus.”² It has been declared a pandemic because it is occurring in every country. This is the first WHO pandemic declaration since 1968 when the Hong Kong flu killed more than 1 million people.¹¹, ¹²

The Centers for Disease Control and Prevention (CDC) has determined that the 2009 H1N1 virus is very contagious and spreads from human to human much as the seasonal flu virus spreads. Transmission occurs when one person coughs or sneezes, and another person is exposed to that airborne contamination. Sometimes the infection can be spread when a person touches an object or surface that is contaminated with the virus and then touches his or her own mouth, nose, or eyes.

The number of reported cases of H1N1 flu continues to rise daily. In the United States, between mid-April and the end of August 2009, the number of hospitalized patients with H1N1 influenza totaled 9,079. There were 593 reported deaths related to the H1N1 flu during this time period.¹³ The rate of exposures, hospitalizations, and deaths will likely continue to rise, so health care workers should be prepared to encounter and treat patients with this illness.

Back to Article Outline

Signs and Symptoms 

The signs and symptoms of the 2009 H1N1 flu usually appear in rapid succession. They are similar to those of the seasonal flu, which can include fever greater than 100° F (37.8° C), chills, headache, cough, nausea, vomiting, diarrhea, lethargy, lack of appetite, body aches, and fatigue. Often people confuse symptoms of the common cold with symptoms of the flu. Figure 1 compares these symptoms. Children who exhibit the following signs should have immediate medical attention:

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  Comparison of the symptoms of the common cold with the symptoms of the H1N1 flu.

Medical care may be needed if adults exhibit the following symptoms:

The symptoms of H1N1 influenza range from mild to severe, with some people needing medical treatment or hospitalization. Death has occurred from the severe illnesses caused by this virus. The most common cause of death is respiratory failure (ie, pneumonia), but other causes of mortality include sepsis, dehydration, and electrolyte imbalance.

The person with H1N1 influenza can infect others from one day before the appearance of symptoms to five to seven days after. The infective period may be longer for some, depending on age, general health, other invasive conditions, and immune system response.²

Back to Article Outline

High-Risk Patients 

The people who are most at risk from the H1N1 virus have one thing in common—they are more vulnerable to serious complications if they contract H1N1 influenza. These high-risk patients include:

About 70% of the people who have been hospitalized with the H1N1 virus have had one or more medical conditions that place them in the high-risk category, including pregnancy, heart disease, diabetes, asthma, and kidney disease.²

Back to Article Outline

Diagnosis 

The diagnosis of H1N1 virus can be made by examining nasal and oral secretions in the first 24 to 72 hours after the symptoms of the disease have presented. The influenza virus also can be detected in blood samples.

An H1N1 influenza test kit has been developed to test for the virus so that immediate action can be taken to limit its spread. The test kit contains collection tools to gather specimens using nasopharyngeal swabs, nasal swabs, throat swabs, dual nasopharyngeal/throat swabs, and nasal aspirates. Information from this test along with other clinical evidence can lead to a clinical diagnosis so that immediate treatment can be initiated. According to the CDC,

these tests vary in the chance that they will miss an influenza infection and sometimes falsely detect an infection. During an influenza outbreak, a positive test is likely to indicate influenza infection.¹⁵

Health care providers must ensure that they are using a reputable test kit. The US Food and Drug Administration has issued a warning about web sites where unapproved, uncleared, or unauthorized products for H1N1 flu virus testing are being illegally marketed.¹⁶

Back to Article Outline

Vaccination 

The first line of defense against influenza is to build immunity by administering an influenza vaccination. The H1N1 vaccination tests showed that a single shot of 15 mcg of antigen is effective within eight to 10 days.¹⁷ Researchers examined the blood of 120 adults 21 days after they received the 15-mcg injection, and approximately 97% of the adults had enough antibodies to be considered protected against the virus.¹⁷ In comparison, a group that received two shots with 15 mcg of the HIN1 vaccine demonstrated no greater protection.¹⁷ No deaths or risky side effects were reported. Approximately half of the participants reported soreness at the injection site or headaches, which are normal side effects of flu shots.¹⁷ The CDC states that

seasonal and 2009 H1N1 flu shots can be given on the same day but should be given at different sites (eg, one shot in the left arm and the other shot in the right arm).¹⁸

By the end of 2009, the government hopes to have about 195 million doses of the H1N1 vaccination.¹⁷ The CDC estimates that more than 159 million people in the United States are in the high-risk category for H1N1 influenza.¹⁷ Only having to administer one shot for adequate protection from the H1N1 virus ensures that there will be an adequate supply of the vaccine for all those within the high-risk category. If there is a shortage of H1N1 vaccine, the Advisory Committee on Immunization Practices of the CDC recommends that the following groups be given priority:

After the initial supply of vaccine has been distributed, the remaining amount can be administered to those not listed in the high-risk category.

Making the seasonal flu vaccine mandatory for health care workers is being debated throughout the United States. In August, New York was the first state to require seasonal flu and H1N1 vaccinations for health care providers who have direct contact with patients.²⁰ The New York State Health Department recently announced that as a result of the vaccine shortage, it has reversed the mandate for seasonal and H1N1 influenza vaccination.²¹ One theory is that the reversal may be a result of claims that the state overstepped legal boundaries by implementing the mandate.²¹

In the United States, approximately 50% of health care workers opt not to receive the seasonal flu vaccination, with physicians and nurses being the highest offenders.²¹ This raises two major concerns:

For years, health care providers have been required to receive the measles and mumps vaccinations and no major resistance has transpired. But great concern has been voiced when health care providers are required to annually receive the seasonal flu vaccination. Proponents have said that health care providers are ethically obligated to get vaccinated, not only for the seasonal flu but for the H1N1 influenza when the vaccination is available.²¹ But fear remains, especially because the H1N1 vaccine has never been used before. Although testing of the H1N1 vaccine has not produced serious side effects, because it will be fast-tracked, some say that adequate safety tests have not yet been established.²¹ Some people fear that there could be a repeat of the serious side effects, like Guillain-Barré syndrome, that occurred in 1976 during a swine flu vaccination period. Later evidence showed that the vaccine was not related to the incidental increased incidence of that condition.²¹

One by one, hospitals are joining the crusade to mandate seasonal flu vaccinations. Loyola University Medical Center outside of Chicago and the Charleston Area Medical Center in West Virginia now require seasonal flu shots for all health care workers.²¹ Some facilities are planning to mandate H1N1 vaccination as well.²¹ The move toward mandated flu vaccinations may have taken root when a healthy, 51-year-old oncology nurse in California died on July 17, 2009, from a co-infection of H1N1 and methicillin-resistant Staphylococcus aureus (MRSA) that led to a severe respiratory infection and pneumonia.²² Administrators not only want to protect their patients but also their health care providers by making the influenza vaccine available and giving incentives for compliance with vaccination.

As health care administrators make plans to protect their workers and patients, challenges of these mandates are surfacing. Ensuring that all workers are vaccinated can be time consuming. If H1N1 vaccination also is mandated, keeping track of who has received which vaccination can be daunting. Some hospitals have other plans in place. For example, at Virginia Mason Medical Center in Seattle, Washington, which requires the flu vaccination for health care employees, those who object must wear a face mask throughout the flu season or risk the possibility of being fired.²¹

Some nurses have considered leaving the profession in response to vaccination mandates.²³ Some of the reasons that nurses do not want to receive the annual flu shot are

Many health care facility administrators are determined to increase compliance rates among health care providers, so they offer a variety of incentives from free meals to theater tickets. Educational programs also are offered to increase the knowledge that nurses and other health care professionals have regarding the effect of the influenza virus. Possible side effects of the flu shot and mandated vaccinations continue to be points of debate between health care facility administrators, nurses, and nurses' unions.

Back to Article Outline

Prevention and Treatment 

A well-planned treatment program begins with a prevention strategy to limit the spread of the H1N1 virus. Strict medical asepsis (ie, reducing the number of organisms and preventing their spread) must be followed so that transmission is controlled. Steps to prevent the spread of the H1N1 virus include

If a person becomes sick and has been exposed to the H1N1 virus, the CDC recommends that the person stay home for at least 24 hours after the fever is gone, except to get medical care or other necessities.² This 24-hour time period does not start until antipyretic medications are stopped.

Treatment of the H1N1 flu focuses on treating the symptoms. Antipyretic medicines should be used to help control a fever. Antiemetic medications can be used to decrease nausea. Respiratory support should be immediate if the patient appears to be in respiratory distress. An endotracheal tube can be inserted and the patient mechanically ventilated to ensure adequate perfusion is accomplished.

Antiviral medications, such as oseltamivir (ie, Tamiflu®) and zanamivir (ie, Relenza™), can be administered, but the person should be watched closely for any side effects (eg, anxiety, bronchitis, bronchospasm, cough, decreased respiratory function, diarrhea, difficulty concentrating, dizziness, headache, lightheadedness, loss of appetite, nausea, nervousness, nasal infections, sinusitis).²⁵ The patient, caregivers, and family members should be instructed regarding side effects associated with antiviral medications and told what to do if any appear. Usually, antiviral medications are not administered unless the infection is confirmed because there is always a risk that the virus will become resistant to these medications.

Special care for children and pregnant women must be considered when implementing an antiviral program. People who have a higher risk for complications should begin an antiviral program as soon as flu symptoms appear. These people include pregnant women; children younger than five years of age; people with chronic medical or immunosuppressive conditions (eg, undergoing chemotherapy); and people who are younger than 19 years and are on long-term aspirin therapy.²⁶

Back to Article Outline

Disease Management 

The WHO has developed a free, patient-care checklist for H1N1 influenza. This checklist was created by a team of experts in the WHO Patient Safety Program and the WHO Health Security and Environment along with specialists in infection control. The WHO Patient Care Checklist for the New Influenza A (H1N1) was created to guide practices and make certain that nothing is overlooked during the care of a patient with H1N1 influenza.²⁷ This versatile checklist can be used as a documentation tool that becomes part of the patient's clinical record, can be reproduced and displayed as an informative poster, or can be printed as reminder cards for health care professionals to carry in their pockets.

The checklist consists of important considerations and reminders that are categorized into different areas of care for managing a patient who may have the H1N1 virus. Considerations are highlighted under each area of care that are critical when caring for these patients. The areas of care include

Reviewing the critical reminders listed beneath each area of care ensures that the most comprehensive care will be delivered without any oversights. For example, during the patient's initial assessment, the health care provider is reminded to alert a physician immediately if the patient's respiratory rate is increased with less than 90% oxygen saturation. Also, the health care provider must report suspected cases of H1N1 flu to the local authority. A health care provider should post infection control signs restricting entry before moving a patient into an isolation room. All health care providers should wash their hands before entering or leaving a designated area.

After confirmation has been made that the patient has the H1N1 virus and before the patient is discharged, a health care provider should educate the patient and his or her home caregivers and provide them with written, take-home information on respiratory hygiene, cough etiquette, home isolation, and other infection control practices. These reminders should be organized for easy reference so that all essential actions are performed during critical moments of care.

Also highlighted in the middle of the patient care checklist are reminders of what to do before every patient contact, such as washing hands, using eye protection when needed, changing gloves, and disinfecting equipment. Protective practices to perform during aerosol-generating procedures, such as using a particulate respirator, are emphasized.

Management of the 2009 H1N1 flu is being influenced by lessons learned during the peak H1N1 season that has already occurred in the southern hemisphere. Many preventive measures are being employed today and changes are being made to prevent the spread of the H1N1 virus. Some of the changes recently made represent a departure from tradition. For example, some Catholic churches are changing their act of communion. Customarily, everyone drinks from the same chalice; now, small individual serving cups are provided. French schools are telling children not to greet each other with a kiss. Men are avoiding the traditional handshake and opting for a gentle punch on the arm. Senior communities are providing alcohol-based hand rubs throughout their facilities. Companies are installing alcohol hand rubs at elevator entrances and on employee desks. Offices are sending employees home earlier if they exhibit any flu-like symptoms.

Health care facility disaster plans are being revised to handle an H1N1 influenza pandemic. Emergency departments, which are already busy with patients involved in trauma and medical emergencies, are feeling the effects of adding patients with H1N1 flu to the mix. If careful planning has not been implemented, the anticipated large numbers of people who will contract H1N1 flu could easily impair the effectiveness of a health care system.

Health care facilities are stocking up on antiviral medications, masks, gowns, and other supplies. Advertisements, public service announcements, and multimedia campaigns are being shown to educate the public and convince people to stay home if they are suffering with only mild symptoms. Web sites and hotlines are providing up-to-date information on how to prevent the spread of the flu and handle those who are ill. Emergency departments and physicians' offices are setting up methods to quickly screen those who are exhibiting flu-like symptoms so those needing immediate attention can be separated from those who will be sent home to recover. Masks are given to patients as soon as they walk through the door if flu-like symptoms are present. These patients are moved immediately into another area to minimize transmission of the virus. Flu clinics are being opened to divert patients from emergency departments and physicians' offices. For the worst case scenarios, mobile hospitals, as planned in Iowa and California, can be quickly constructed to form a series of tents placed within an open area like a football field.²⁸

Health care facilities also are counting their available ventilators, not overlooking those assistive respiratory devices that are used in surgery. Backup plans are being made to call up reserve physicians and nurses to help if an influx of patients occurs.

Plans for pediatric patients continue to be a focal area because a disproportionate number of children could be affected. An increased number of pediatric breathing tubes, IV supplies, and other pediatric-appropriate devices are being stocked to handle the potential influx of younger patients.

Some hospitals are suspending the use of student volunteers to limit patients' possible exposure to the H1N1 virus since the influenza virus spreads quickly in academic and university settings. Policies about social distancing and restricted visiting hours also are being implemented to curb transmission.

Researchers have found that the H1N1 virus can survive on an environmental surface and can infect a person from two to eight hours after it is introduced to that surface.²⁹ A virus can spread when people touch a contaminated object (eg, telephone) and then touch their own mouth, nose, or eyes before washing their hands. Surfaces (eg, bedside tables) and objects can be kept clean by wiping them down with a household disinfectant according to the manufacturer's instructions on the product label.

The H1N1 virus can be destroyed by heat at a temperature of 167° F to 212° F (75° C to 100° C).² Chemicals also can be used to kill the virus, including chlorine, hydrogen peroxide, soap-based detergents, and iodine-based antiseptics.² Alcohols can be used to kill the virus too but must be used in the proper concentrations to be effective and must be applied for a sufficient length of time. For example, alcohol hand rubs are effective against the H1N1 virus but must be rubbed into the hands until they are dry.²

Back to Article Outline

Surgical Department Response to the H1N1 Virus 

Anticipating the effect of the H1N1 virus in surgical departments can be a challenging task for administrators, perioperative nurses, and other surgical team members. An education plan—including continual updates—on the signs and symptoms of the H1N1 flu, protective measures, and the negative effects of the virus should be implemented immediately. Staff e-mail blasts, daily postings on a web site, newsletter columns, bulletin board notices, meeting discussions, inservice programs, and verbal exchanges are ways to communicate information about H1N1.

Early identification of the H1N1 flu in both patients and surgical team members should be a high priority for the department. Surgical staff members should be sent home immediately to recover from the virus. If patients present in the surgical holding area or outpatient surgery department and exhibit signs of the flu, they should be given a mask to wear and then separated from the other patients. A negative pressure room should be available for patients needing more care, and those with mild symptoms should be sent home. Strict hand washing and the use of alcohol-based hand rubs should be mandated to minimize transmission. If a patient with the H1N1 virus must undergo emergency surgery, the patient should be transferred to the OR suite wearing a mask.

Surgical team members must use personal protective equipment, such as an N-95 respirator. A study conducted at two teaching hospitals showed that nearly 40% of the nurses, physicians, and respiratory therapists in the intensive care unit setting reported poor compliance with using personal protective equipment when caring for influenza patients.²⁹ Some of the reasons for the lack of compliance included inconvenience, interference with patient care, and just forgetting to use the proper respiratory protective equipment. Surgical department managers and educators must ensure that surgical staff members and surgeons understand the need for personal protective equipment and how to use it appropriately.

The N-95 respirators also must be available and the necessary fit checking must be performed. Health care providers have complained that wearing an N-95 respirator for long periods of time is uncomfortable. A report from New York stated that a limited number of N-95 respirators were available in some hospitals and that fit testing was not being conducted.²³ Recently, the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that the CDC downgrade the requirement to use the N-95 respirator to the use of a surgical mask. This recommendation had not been acted on as of October 2009. The HICPAC also suggests that an N-95 respirator always be used during aerosol-producing procedures (eg, bronchoscopy, open airway suctioning, sputum induction, cardiopulmonary resuscitation) performed on patients with H1N1 influenza.³⁰

Surgical department administrators should ensure that all surgical staff members are offered the seasonal flu and H1N1 flu vaccinations. Whether this is mandated will depend on the policies of the health care facility and state regulations.

Other activities to protect surgical team members and patients can be conducted according to the facility plans for the flu season. Postoperative patients should be protected from contracting the H1N1 virus during their recovery time. Immune system resistance often is lowered when patients have undergone surgery, thus allowing the negative effect of the virus to quickly surface.

Back to Article Outline

Summary 

Because the behavior of the new H1N1 virus is unpredictable, plans should be made and implemented to minimize the transmission of the virus. Perioperative nurses must remain current with the most recent information and advice on how to treat patients and health care professionals who are infected with the virus. The potential effects of the H1N1 virus can only be prevented with a prepared and knowledgeable health care workforce. It is important to avoid a repeat of the 1918 pandemic, when the influenza virus hit communities quickly then disappeared within a few weeks of its arrival. One historian described the course of the virus powerfully when he wrote, “The disease moved too fast, arrived, flourished and was gone before … many people had time to fully realize just how great was the danger.”³¹ To avoid repeating history, health care workers should be prepared, start learning about the H1N1 virus, and be sure to get vaccinated.

Back to Article Outline

Examination 

The Enigma of the H1N1 Flu: Are You Ready? 

Purpose/Goal 

To educate perioperative nurses about resurgence of the H1N1 influenza.

Behavioral Objectives 

After reading and studying the article on the H1N1 flu, nurses will be able to

Questions 

Back to Article Outline

Answer Sheet 

The Enigma of the H1N1 Flu: Are You Ready? 

Event #09292

Session #1224

• 
  • View Large Image
  • Download to PowerPoint

Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

AORN Customer Service

c/o AORN Journal Continuing Education

2170 S Parker Rd, Suite 400

Denver, CO 80231-5711

or fax with credit card information to (303) 750-3212.

Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ______________________________________

AORN (ID) # ____________________________________________

Name __________________________________________________

Address ________________________________________________

City ___________________________________________________ State __________ Zip __________

Phone number __________________________________________

RN license # ____________________________________________ State __________

Fee enclosed ___________________________________________

or bill the credit card indicated MC Visa American Express Discover

Card # ___________________________________ Expiration date _____________________

Signature _______________________________________________________________ (for credit card authorization)

Fee: Members $16.50 (includes $5 processing fee);

Nonmembers $28 (includes $5 processing fee)

Save time and money by completing this CE activity online.

No processing fees at aorn.org/CE.

Program offered December 2009; The deadline for this program is December 31, 2012.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion.

Back to Article Outline

Learner Evaluation 

The Enigma of the H1N1 Flu: Are You Ready? 

• 
  • View Large Image
  • Download to PowerPoint

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about resurgence of the H1N1 influenza.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ____________________________________________________________________________________________________________________

Author names and addresses: ________________________________________________________________________________________________________

Back to Article Outline

References 

1. Crane M . Franklin County's first swine-flu death is woman who delivered baby week earlier. Columbus Dispatch. September 3, 2009:A1 . http://www.dispatch.com/live/content/local_news/stories/2009/09/03/flu_death.html?sid=101 Accessed October 4, 2009.
   • View In Article
2. Questions and answers: 2009 H1N1 flu (swine flu) and you. September 24, 2009. Centers for Disease Control and Prevention . http://www.cdc.gov/H1N1flu/qa.htm Accessed October 4, 2009.
   • View In Article
3. 90k dead from swine flu? [videotape]. CNN.com. Atlanta, GA; September 25, 2009 . http://www.cnn.com/video/#/video/health/2009/08/25/nr.swine.flu.predictions.cnn Accessed October 4, 2009.
   • View In Article
4. Dire predictions for swine flu's future. CBS News World . http://www.cbsnews.com/stories/2009/07/24/world/main5185843.shtml July 24, 2009; Accessed October 4, 2009.
   • View In Article
5. Stucke J . 2,000-plus sick with swine flu at WSU. The Spokesman-Review. September 4, 2009:A1 . http://www.spokesman.com/stories/2009/sep/04/2000-plus-sick-at-wsu Accessed October 4, 2009.
   • View In Article
6. Segal C . Bay District school teacher contracts swine flu. Panama City News Herald. August 21, 2009:A1 . http://www.newsherald.com/news/swine-76817-city-teacher.html Accessed October 4, 2009.
   • View In Article
7. Swine flu hits Maryland campus [videotape] . Newsday.com Melville, NY http://www.newsday.com/news/swine-flu-hits-maryland-campus-1.1431701 September 8, 2009; Accessed October 4, 2009.
   • View In Article
8. Taubenberger JK , Morens DM . 1918 influenza: the mother of all pandemics . Emerg Infect Dis . 2006;12(1):15–22
   • View In Article
   • MEDLINE
9. The story of influenza . In:  Knobler S ,  Mack A ,  Mahmoud A ,  Lemon S editor. The Threat of Pandemic Influenza: Are We Ready? Workshop Summary . Washington, DC: The National Academies Press; 2005;p. 75
   • View In Article
10. Martin A , Krauss C . Pork industry fights concerns over swine flu. April 28, 2009. The New York Times . http://www.nytimes.com/2009/04/29/business/economy/29trade.html?_r=1 Accessed October 15, 2009.
    • View In Article
11. Pandemic paralysis: H1N1 influenza underscores barriers to timely research . IRB Advisor . 2009;9(8):85–87
    • View In Article
12. Wilde JA . 2009 H1N1/swine flu—anatomy of an outbreak. Special supplement . Aids Alert . 2009;24(6):1–2 suppl
    • View In Article
13. FluView: 2008-2009 Influenza Season Week 34 ending August 29, 2009. Centers for Disease Control and Prevention . http://www.cdc.gov/flu/weekly/weeklyarchives2008-2009/weekly34.htm Accessed October 4, 2009.
    • View In Article
14. Swine flu: who's most at risk? WebMD. April 30, 2009 . http://blogs.webmd.com/breaking-news/2009/04/swine-flu-whos-most-at-risk.html Accessed October 4, 2009.
    • View In Article
15. Interim recommendations for clinical use of influenza diagnostic testing during the 2009–2010 influenza season. Centers for Disease Control and Prevention . http://www.cdc.gov/h1n1flu/diagnostic_testing_clinicians_qa.htm Accessed October 31, 2009.
    • View In Article
16. Fraudulent 2009 H1N1 influenza product list. US Food and Drug Adminstration . http://www.accessdata.fda.gov/scripts/h1n1flu Accessed October 4, 2009.
    • View In Article
17. Update on influenza A (H1N1) 2009 monovalent vaccines . MMWR Weekly . 2009;58(39):1100–1101 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5839a3.htm Accessed October 29, 2009.
    • View In Article
18. 2009 H1N1 influenza shots and pregnant women: questions and answers for patients. Centers for Disease Control and Prevention . http://www.cdc.gov/H1N1flu/vaccination/pregnant_qa.htm Accessed October 15, 2009.
    • View In Article
19. CDC advisors make recommendations for use of vaccine against novel H1N1 [news release] . Atlanta, GA: Centers for Disease Control and Prevention; July 29, 2009; http://www.cdc.gov/media/pressrel/2009/r090729b.htm Accessed October 4, 2009.
    • View In Article
20. New York mandates seasonal flu vaccinations for health care workers: is H1N1 shot next? . Hosp Infect Contr Prevent . 2009;36(9):97–101
    • View In Article
21. Tanner L , Bauman V . Health workers under pressure to get flu shots. Associated Press. September 8, 2009 . http://nl.newsbank.com/nl-search/we/Archives?p_product=APAB&p_theme=apab&p_action=search&p_maxdocs=200&s_dispstring=Health%20workers%20under%20pressure%20to%20get%20flu%20shots&p_field_advanced-0=&p_text_advanced-0=(“Health%20workers%20under%20pressure%20to%20get%20flu%20shots”)&xcal_numdocs=20&p_perpage=10&p_sort=YMD_date:D&xcal_useweights=no Accessed October 4, 2009.
    • View In Article
22. Death of nurse sets ominous pandemic tone . Hosp Infect Contr Prevent . 2009;36(9):97; 104.
    • View In Article
23. Will NY flu shot mandate drive nurses from field? . Hosp Infect Contr Prevent . 2009;36(9):101; 103.
    • View In Article
24. Fraleigh JM . Vaccination: compliance controversy . RN . 2009;72(5):36–40
    • View In Article
25. 2009 H1N1 and seasonal flu: what you should know about flu antiviral drugs. Centers for Disease Control and Prevention . http://www.cdc.gov/H1N1flu/antivirals/geninfo.htm Accessed October 5, 2009.
    • View In Article
26. Reinberg S . Antiviral drugs should be used cautiously to fight flu, US says. US News and World Report . http://health.usnews.com/articles/health/healthday/2009/09/08/antiviral-drugs-should-be-used-cautiously-to.html September 8, 2009; Accessed October 4, 2009.
    • View In Article
27. World Health Organization  . Pandemic (H1N1) 2009 Patient Care Checklist . http://www.who.int/patientsafety/activities/ah1n1_checklist/en Accessed October 4, 2009.
    • View In Article
28. Stein R . Disaster plans being revised for swine flu. The Washington Post . http://www.washingtonpost.com/wp-dyn/content/article/2009/09/12/AR2009091200936_pf.html September 13, 2009; Accessed October 4, 2009.
    • View In Article
29. Daugherty EL , Perl TM , Needham DM , et al.   The use of personal protective equipment for control of influenza among critical care clinicians: a survey study . Crit Care Med . 2009;37(4):1210–1216
    • View In Article
    • CrossRef
30. Respirators or masks? A “Solomonic” decision . Hosp Infect Contr Prevent . 2009;36(9):103–105
    • View In Article
31. The great pandemic: the United States in 1918–1919. US Department of Health & Human Services . http://1918.pandemicflu.gov/the_pandemic/04.htm Accessed September 14, 2009.
    • View In Article