News & Events

Seasonal flu and swine flu updates for 10.13.09-10.14.09

I thought you might find this article from Contingency Planning useful.
H1n1 is newest threat and this article seeks to point you in the right direction to taking on this daunting role.
To read the complete article, please go to


Kumar et al JAMA 2009.pdf

Dominguez-Cherit et al JAMA2009.pdf

ANC ECMO JAMA 2009.pdf

White Angus JAMA 2009.pdf


Fyi. Mandatory vaccination is currently not a threat in Massachusetts – at least at this time. MNA is working with the Massachusetts Department of Public Health, which has stated strongly, via a letter from Commissioner of Public Health John Auerbach, that it is opposed to the concept of mandatory vaccination and has no intention to mandate immunization in the Commonwealth. However, private entities and health care systems including HCA, have indicated plans to do so. We are monitoring developments across the U.S.

For an update on H1n1 and seasonal flu, if you would like to attend MNA’s Emergency Preparedness Task Force meeting on Tuesday October 27 2009 at 5:30 p.m., please contact Mary Crotty at
Or 781 830-5743.

Nurses Seek Protection From H1N1 Flu But Oppose Mandatory Vaccination Policies

BNA Occupational Safety & Health Daily

As flu season officially started Oct. 4 and the federal government Oct. 5 began to release the first doses of vaccine for the H1N1 flu virus, some health care employers around the country and at least one state government are implementing mandatory vaccination policies for health care employees. While unions representing registered nurses are strongly recommending that nurses get flu shots, they oppose policies mandating them.

“[E]very RN should be vaccinated against the H1N1 influenza virus, but nurses should maintain their right to decline for personal reasons,” according to the California Nurses Association, the nation’s largest union of registered nurses, representing 86,000 nurses. The CNA policy issued Sept. 30 stated that the “H1N1 flu vaccine should be offered as one part of a comprehensive program.”

Meanwhile, the New York State Department of Health approved regulations in August mandating that health care workers in hospitals, outpatient clinics, and home care services in direct contact with patients receive vaccinations both for seasonal flu and the H1N1 flu also known as “swine flu.” The regulations exempt employees for whom the vaccination is medically contraindicated.

Many hospitals throughout the country also have instituted their own policies mandating that their employees be immunized against the seasonal flu, the H1N1 flu, or both. Hospitals have been dealing with seasonal flu for years, but this year many are accelerating action against the spread of flu viruses.

H1N1 Vaccine Safety

On June 11, 2009, the World Health Organization declared a worldwide pandemic, indicating uncontained community-level transmission of the novel influenza A (H1N1) virus in multiple areas of the world. Since then, a vaccine approved by the Food and Drug Administration has been developed and started to become available in October.

There has been no change in the pattern or severity of illness with H1N1 and, although widespread, it has not been more deadly than the seasonal flu, Thomas Frieden, director of the Centers for Disease Control and Prevention, told the House Oversight and Government Reform Committee Sept. 29. As such, the vaccines being produced should be an “excellent match with the virus circulating at this time” and should be effective if the virus does not change, he said.

Because the H1N1 virus has not changed since spring, Jesse Goodman, FDA deputy commissioner, said at the hearing that the vaccine is being developed in the same manner as the millions of doses made and used every year for seasonal flu that have an “outstanding safety record.”

CDC Recommends Two Flu Vaccines

Flu shots are the most effective method for preventing influenza and influenza-related complications, according to the CDC. However, the seasonal flu vaccine is unlikely to provide protection against 2009 H1N1 influenza.

CDC has published its concerns that the new H1N1 flu virus could result in a particularly severe 2009-2010 flu season.
Although the federal government is not mandating the vaccine, Frieden said, “the evidence is there” that every year unvaccinated health care workers infect patients with the seasonal flu. He said only about 50 percent of health care workers are vaccinated for the flu annually.

CDC’s Advisory Committee on Immunization Practices (ACIP) has developed recommendations to provide vaccination programs and providers with information to assist in planning and to alert providers and the public about target groups who are recommended to receive the first vaccine for H1N1 flu.

Beside the union’s strong recommendation that all registered nurses be vaccinated against the virus, CNA guidelines call for improvements to hospital infection control procedures including a guarantee of an adequate supply of appropriate N-95 respirator masks and “thoughtful” isolation procedures.

Health care and emergency medical services personnel are among the five initial groups CDC has targeted as having first priority for vaccination. The other groups are pregnant women, caregivers to infants, children, and the chronically ill.

Half Get Vaccinations Voluntarily

Historically, the immunization rate among health care workers under “even the most vigorous of voluntary programs” is 40 percent to 50 percent, New York State Health Commissioner Richard F. Daines said Sept. 24 in an open letter to health care workers in the state. He called on health care workers to “put our patients’ interest ahead of our own” because patient safety “lies in being treated in institutions and by health care personnel with the nearly 100 percent effective immunity rates seen with other long-mandated vaccinations for health care workers, such as measles and rubella.”

Many labor unions representing nurses and other health care workers have issued information and guidance to members about the H1N1 flu virus and how to protect against it. They urge members to be immunized as well as inform them of other approaches to protect themselves, co-workers, and patients.

Less than one week after New York’s requirement was issued, the union 1199 SEIU United Healthcare Workers East Aug. 18 raised concerns, saying it is “extremely concerned about the ramifications of this requirement as a condition of employment, a pre-condition to hiring, and whether refusal or delay of any form could result in possible disciplinary action or termination.”
George Gresham, president of 1199 SEIU, said in a statement that mandatory vaccination as a condition of employment is “an invasive step.”

1199 SEIU, representing 350,000 health care workers in New York, New Jersey, Massachusetts, Maryland, and Washington, D.C., encourages its members to obtain a yearly flu vaccination, but the union said the mandatory program is unprecedented and restricts workers’ personal freedom and autonomy by not allowing employees to refuse vaccination for religious, cultural, or philosophical reasons. The union is an affiliate of the Service Employees International Union.

1199 SEIU also pointed to the example of the CDC and all other federal agencies, none of which have supported mandatory flu vaccination. The union noted that, except for New York, no state or local government has implemented mandatory policies.
Despite 1199 SEIU’s opposition to New York’s mandatory vaccination policy, the union said it is hoping to continue a dialogue with the state’s health department on its concerns about the regulation.

Broad Union Opposition in New York

SEIU Oct. 2 joined the Communications Workers of America; New York State Nurses Association; the American Federation of State, County and Municipal Employees; the International Brotherhood of Teamsters; and other organizations representing thousands of New York health care workers, in a letter to Daines declaring the mandatory vaccination regulation is “seriously flawed and should be withdrawn.”

The coalition said it strongly recommends education and encouragement of health care workers and other at-risk employees to avail themselves of the influenza vaccine as one part of a comprehensive infection prevention program. Such a program also would address the spread of influenza infection in emergency room waiting areas, would make appropriate personal protective equipment such as N-95 respirators available to health care workers, would abolish sick-leave policies that encourage employees to work when sick, and would educate workers about good hygiene practices, the groups said in the letter.

Instead of a mandatory program, the coalition advocated for voluntary programs with a three-pronged approach that increases the immunization rate among health care personnel to 80 percent or higher. Such programs, they said, would target workers’ objections to vaccination, would provide the vaccine cost-free at a convenient time and place, and would integrate facility support from management to front-line employees.

David LaGrande, CWA’s director of occupational safety and health, expressed his belief that the New York mandatory vaccination policy is driven more by concerns about hospitals’ potential liability than by public safety. If negligence is identified, community-based or individual lawsuits could put hospitals in a precarious position, he told BNA Oct. 9. LaGrande added that New York had an exceptionally high number of H1N1 flu cases last spring, which likely spawned a number of cases now “simmering” in the courts.

CNA Policy for H1N1 Safety

The California Nurses Association similarly has presented a broad policy to hospital management in bargaining about policies to address health and safety related to the H1N1 flu virus. The union has made the same recommendations as guidance to state regulators and legislators.

Beside the union’s strong recommendation that all registered nurses be vaccinated against the virus, CNA guidelines call for improvements to hospital infection control procedures including a guarantee of an adequate supply of appropriate N-95 respirator masks and “thoughtful” isolation procedures. In addition, every nurse who contracts H1N1 must be cared for properly by the employing facility and local government with a guarantee of appropriate sick leave and eligibility for workers’ compensation, CNA said.

The 45,000-member United American Nurses, which plans to merge with CNA and the Massachusetts Nurses Association in December, issued a resolution on seasonal flu vaccination in March. The union has not taken a separate position regarding the H1N1 flu however, UAN spokeswoman Suzanne Martin told BNA Oct. 6.

The UAN resolution calls for employers to apply basic infection control measures to prevent seasonal flu and encourages health care workers to be vaccinated to protect against the flu, but says it should be their decision. In addition, nurses should be allowed to decline vaccination for religious or personal health care reasons. Nurses with seasonal flu who use sick leave or other time- off benefit should not be disciplined, according to UAN.

A policy to require vaccination of represented registered nurses is a mandatory subject of bargaining, the UAN resolution said.
Hospital Policies With Threats of Discipline

For the first time, the Hospital Corporation of America, one of the largest hospital management corporations in the country, is requiring employees with direct patient contact in its 163 hospitals, 112 outpatient clinics, and other facilities in 20 states get vaccinated for seasonal flu. The policy makes exceptions for medical and religious reasons. Otherwise, failure to comply with the mandate is a voluntary resignation, HCA spokesman Ed Fishbough told BNA Oct. 7.

Fishbough said employees have responded to the mandate with “overwhelming support” because they understand the need and appreciate the policy. HCA instituted the policy in response to studies that show when all staff members are vaccinated, hospitals have a 40 percent reduction in patient flu mortality and a 41 percent drop in lost work days, he said.

University of Iowa Hospitals and Clinics in Iowa City, Iowa, Sept. 2 instituted a new mandatory seasonal flu immunization program for all faculty, staff, medical residents, fellows, volunteers, student employees, and health sciences students working or learning in the UI health settings. This year’s policy allows exemptions for medical and religious reasons. Those exempted who have direct patient contact will be required to wear a mask when in the presence of patients or other staff members during a community outbreak of influenza.

The employer “will work with employees” who do not comply with either alternative, Tom Moore, UI Health Care media relations coordinator, said. Termination would be the last resort, he said.

The hospital system for the past several years has had an education program to encourage voluntary flu vaccinations. When the program began, 60 percent were vaccinated. By last year, 84 percent of hospital staff got flu shots. This year’s mandatory immunization policy aims to raise the participation rate further because research shows immunization and hand hygiene are the top ways to protect patient health, according to Moore.

Union Objections Taken to Arbitration

Two unions that represent employees in the system separately filed injunctions against the program and requested restraining orders against it. Service Employees International Union Local 199 and American Federation of State, County and Municipal Employees Council 61 dropped the request after negotiating with the employer and reaching agreement to take the issue to arbitration, employer and union representatives told BNA Oct. 7. The arbitrator’s ruling is expected in early November.
Cathy Glasson, president of SEIU Local 199, said the union believes the hospital violated SEIU’s labor contract by not negotiating the new conditions of employment and imposing the new mandatory immunization policy. Local 199 represents about 2,800 registered nurses and members of 31 other professional job classifications at the hospital.

Local 199 encourages its members to be vaccinated, Glasson said, and also stresses the importance of balancing vaccination with attention to other means of preventing the spread of infection, such as use of face masks and frequent hand washing. She also spoke of methods such as the use of reverse-air hospital rooms and limits on hospital room sharing with non-flu patients. “We are afraid they will ignore other methods” by placing all of the attention on vaccination, she said

The union also questions the necessity of a mandate, which has created distrust, fear, and hostility, Glasson said.
The UI hospital might extend its mandate to require vaccination for the H1N1 flu as well, depending on its availability, Moore said. He noted that the first batches of the vaccine are in the inhaled form, which is not ideal for health care workers. The hospital also is reviewing mask efficacy with its epidemiologist to determine what type of mask—surgical masks or N-95 respirator masks—it will require as an alternative.

Washington State Nurses Take Issue to Court

In Washington state, a union representing nurses has taken the issue of mandatory flu vaccinations to federal court. The Washington State Nurses Association Oct. 1 filed a complaint in the U.S. District Court for the Western District of Washington charging MultiCare Health System with violations of the Labor-Management Relations Act in unilaterally imposing a seasonal and H1N1 flu vaccination policy for union-represented nurses, bypassing the collective bargaining process.
The complaint said MultiCare issued a directive that staff, including registered nurses covered by WSNA contracts, either obtain both flu vaccinations or wear paper masks when around patients.

The Washington State Nurses Association hopes the court will rule in the case before Nov. 1, when the vaccination policy is scheduled to take effect, Anne Tan Piazza, spokeswoman for the WSNA, told BNA Oct. 2. The union represents about 750 registered nurses at Tacoma General and some 500 at Good Samaritan, she said.

MultiCare said in a statement e-mailed Oct. 2 to BNA that it is “committed to keeping our patients safe.”
While WSNA believes flu vaccinations are important and strongly urges all health care providers to receive them, the union does not support a patchwork, hospital-by-hospital approach to vaccinations, Piazza said. Any mandate on flu vaccinations for health care workers should come from the state or federal government, Piazza said.

She noted that the U.S. Court of Appeals for the Ninth Circuit upheld an arbitration decision that Virginia Mason Medical Center could not unilaterally impose a flu vaccination program without bargaining with WSNA.

Massachusetts Allows Workers to Decline Flu Shots

In Massachusetts, the Department of Public Health (DPH) Aug. 27 announced licensed hospitals in the state must ensure all employees are vaccinated against both seasonal flu and H1N1 flu, but the policy allows workers to decline without providing a reason. The emergency regulation went into effect for 90 days beginning Sept. 14.

The Massachusetts Nurses Association Sept. 3 told members the state is likely to promulgate subsequent regulations and said it will be monitoring the issue.

The nurses’ union has raised concerns with the state about the declination form. DPH initially indicated that the form would be included in employees’ personnel records. The union said it is working to ensure the form is in employees’ confidential medical records to assure privacy, a policy consistent with other vaccinations such as Hepatitis B.

Divided About Flu Shots

The U.S. population in general is split about whether to get any flu shot, whether for the seasonal flu or the swine flu, according to a new survey. A public health national survey of more than 1,000 adults released Oct. 2 by the Harvard School of Public Health found that 53 percent think they will get the vaccine for the H1N1 virus, with 40 percent certain they will get it. Among all survey participants, however, 87 percent said they believe the vaccine for H1N1 virus is safe.

About 55 percent said they plan to get the seasonal flu shot this year. Ninety-four percent of survey participants said they think it is safe.

Among those who said they will not get the swine flu vaccine, 55 percent are concerned about getting side effects from it, 51 percent said if they get the flu they can get a medication to treat it, and 61 percent do not believe they are at risk of getting a serious case of swine flu.

By Susan R. Hobbs


LaGrange nurse sues to stop vaccine mandate
Larry Hertz • Poughkeepsie Journal • October 11, 2009

A registered nurse from LaGrange who has asked a judge to overturn a state directive requiring health-care workers to get flu vaccinations told the Poughkeepsie Journal on Saturday the crisis of her lawsuit is "the issue of choice."

An attorney for nurse Suzanne Field filed the lawsuit requesting a restraining order, which is now before a judge in Manhattan. A hearing is planned for Wednesday.

This fall, New York became the first state to require most doctors, nurses and health-care aides to get a vaccine for the seasonal flu and the new swine flu. The rule would cover about 60,000 medical workers.

Field said she feared a precedent might be set if the government is permitted to make such inoculations mandatory.

"The biggest problem health-care workers have with this," Field said, "is that from this point forward, it will give Big Brother the right to vaccinate or inject us not only with seasonal flu vaccines but it will give the government free rein for whatever the virus of the month is and inject us for that also."

Similar rules cited
State Health Commissioner Richard Daines said the rule is legal and necessary to protect the public.

Courts, he noted, have upheld similar rules that require health-care workers to get vaccinated for the measles and rubella.

Field said that since her court fight became public, she has heard from "hundreds" of health-care workers across the state and a vast majority of them have supported her.

Field has worked in the health industry for 25 years, the past 13 as a registered nurse.

She plans to attend a hearing in Manhattan hosted by the Assembly on Tuesday.


Dear All,

After getting feedback from many across the state, we have completed the SAMPLE H1N1 vaccine consent forms and the permission to share forms.  

Please note:  these forms are just EXAMPLES, do not have MDPH’s name on them and CAN be modified by schools, clinics or providers at

The attached forms can also be found on the DPH website:

1.   Directions for H1N1 Vaccine Screening Forms, Consent Forms and Permission to Share Information.  This page provides general guidance about when screening forms, consent form and permission to share forms should be used. The second page is   Additional Directions for H1N1 Vaccine Screening, Consent Forms and Permission to Share Information in Settings where a Child Is Being Vaccinated and the Parent or Legal Representative Is Not PresentThis page provides more detailed information about consent when a child is getting vaccinated in a setting (like a school) where the parent is NOT present.
â—¦     Please note that CDC is not requiring a reminder with the VIS and a Withdrawal of Permission form to be sent before young children get a 2nd dose if the parent has signed consent for the series.  
â—¦     However, CDC still requires a 2nd VIS and Withdrawal of Permission form to be sent home for seasonal influenza vaccine before young children get a 2nd dose if the parent has signed consent for the series.  

2.  Consent Form for H1N1 Vaccine Combination form for Injectable and Nasal Spray.  Use the “Combination” consent form if both injectable and H1N1 nasal spray (live) vaccine are available OR if only nasal spray (live) vaccine will be used.  The combination form applies to both types of vaccines and contains additional screening questions pertaining to the nasal spray (live) vaccine.

3.   Consent Form for H1N1 Vaccine Injectable Only.  This form is simpler, asks fewer questions and can be used in setting where no nasal spray given.

4.  Permission to Share H1N1 Information (For Adult Immunization).  Written consent is NOT needed for adults.  However, facilities may want to collects permission to share information, particularly if they will be billing for the administration fee.  The attached permission to share information is compliant with the Health Insurance Portability and Accountability Act (HIPAA).  If the individual refuses to sign the Permission to Share form, you may still vaccinate.

5.    Permission to Share H1N1 Information (For a Child Immunized with a Parent Present).  Written consent is NOT needed for children being vaccinated when a parent is present.  Facilities may want to collects permission to share information, particularly if they will be billing for the administration fee.  The attached permission to share information is compliant with the Health Insurance Portability and Accountability Act (HIPAA).  If the individual refuses to sign the Permission to Share form, you may still vaccinate.

The entire CDC School-Located H1N1 Manual and other materials, including sample letters in other languages can be found at: and

Vaccine Information Statements (VIS) for both inactivated and live, attenuated 2009 H1N1 Influenza Vaccine is available at   

Screening forms for injectable and live attenuated influenza vaccine (LAIV), for use in non-school settings, — and that can that be used for both seasonal AND H1N1 vaccine can be found at and


Nothing to Fear but the Flu Itself

Published: October 11, 2009

David Sandlin
PUBLIC health officials are now battling not only a fast-spreading influenza virus but also unfounded fears about the vaccine that can prevent it.

Since April, more than a million Americans have caught H1N1 flu, more than 10,000 have been hospitalized, and about 1,000 have died, including 76 children. And it’s only the beginning of October. Yet, in a new survey, 41 percent of adults said they will not get vaccinated.

The good news is that for the first time in more than 50 years we’ve made a vaccine against a pandemic strain of influenza before the onset of winter, when lower temperatures and humidity allow the virus to spread more easily. Distributing this vaccine to those who need it most — pregnant women, health care workers, children older than six months and people with compromised immunity — will be difficult enough. But the task is made harder by the various myths, spread on TV talk shows and Web sites, suggesting that Americans have more to fear from the vaccine than from the deadly disease it prevents. Here are some of those myths, and why they’re wrong:

SWINE FLU VACCINE IS UNSAFE The H1N1 virus revealed itself too late for it to be included in this year’s seasonal flu vaccine. But the H1N1-specific vaccine was manufactured in the same way as the regular vaccine: The shot form is made by growing the virus in hen’s eggs, purifying it and then treating it with a chemical that inactivates it. This technology has been used to make influenza vaccines for 60 years, and it has an excellent safety record. The nasal spray form is made by adapting the virus to temperatures below those typically found in the body. This allows it to reproduce in the relatively cool lining of the nose, but not in the lungs where it could cause harm. This technology has been used safely for more than 30 years. FluMist, a seasonal flu vaccine used since 2003, is made the same way.
THE VACCINE IS UNTESTED The H1N1 vaccine has already been given to thousands of volunteers to determine whether it could protect them from the virus and to make sure that it caused no adverse reactions. Only then did the Food and Drug Administration license it.

THE VACCINE CONTAINS A DANGEROUS ADJUVANT Some vaccines, like the hepatitis B and human papillomavirus vaccines, have substances called adjuvants, which are added to enhance the immune response, so that smaller quantities of vaccine can be given. Some people fear that the H1N1 vaccine contains, in particular, squalene, an adjuvant that, while included in other vaccines in Europe and Canada, has never been used in routine vaccines in the United States. But the H1N1 vaccine available in the United States has no adjuvant of any kind.

THE VACCINE HAS A DANGEROUS PRESERVATIVE Thimerosal, a preservative containing ethyl mercury that has been in vaccines since the 1930s, is used to prevent inadvertent bacterial and fungal contamination of multi-dose vials. H1N1 vaccine distributed in multi-dose vials will contain about 25 micrograms of ethyl mercury per dose. The issue of thimerosal received public attention in 1999 when the American Academy of Pediatrics and the United States Public Health Service took the precautionary step of asking that thimerosal be removed from single-dose vials of all vaccines. This was done in such a precipitous and frightening manner that it gave rise to the notion that thimerosal had led to autism or mercury poisoning. It hadn’t.

In fact, subsequent studies found that infants could safely receive eight times as much mercury as is contained in the H1N1 vaccine. But the public’s perception of thimerosal was damaged. This year, enough thimerosal-free vaccine is available to inoculate children under age 6, but that does not mean doses with thimerosal are unsafe.

New myths will inevitably arise as some of the millions of people who are inoculated against H1N1 flu suffer unrelated illnesses. Health officials will keep a close eye out for any real problems. One can only hope that the American public will understand that subsequence isn’t necessarily consequence, and not be scared away from a vaccine that can save lives.

Paul A. Offit, the chief of the infectious diseases division of the Children’s Hospital of Philadelphia, is the author of “Autism’s False Prophets: Bad Science, Risky Medicine and the Search for a Cure.”


The Legacy of 1918: Some Side Effects of Flu May Show Up Decades Later

By Adi Narayan Monday, Oct. 12, 2009

Parker / Fox Photos / Getty

Runny nose, persistent chill, fever, fatigue — these symptoms are all familiar evidence of influenza. But what about a heart attack, suffered 60 years later?

Researchers suggest that such distant health problems may be linked to early exposure to the flu — as early as in the womb — according to a new study that analyzed federal survey data collected from 1982 to 1996. Researchers found, for instance, that people who were born in the U.S. just after the 1918 flu pandemic (that is, people who were still in utero when the disease was at its peak) had a higher risk of a heart attack in their adulthood than those born before or long after the pandemic. (See pictures of thermal scanners hunting for swine flu.)

The new findings, published in the Journal of Developmental Origins of Health and Disease, are based largely on survey data available on some 100,000 Americans who were born between 1915 and 1923. Overall, these populations had roughly the same rate of heart attack year to year — about 200 heart attacks per 1,000 people — when they were studied some 60 years later. But among the subset of people born between October 1918 and June 1919, when the flu pandemic was at its worst, the number of heart attacks increased more than 20%.

The study’s authors, including Caleb Finch, a professor of gerontology at the University of Southern California, also combed through U.S. Army enlistment data for about 2.7 million men born between 1915 and 1922 and found other trends among flu babies. "Men born in 1919 were shorter by about 0.05 in. relative to surrounding cohorts," says Finch. That’s only about a millimeter’s difference, or the thickness of a credit card, but he thinks that’s significant and somehow related to maternal flu exposure. "I am confident because it’s only restricted to that one year," Finch says. (See what you need to know about the H1N1 vaccine.)

In the past decade, there have been several similar studies in the U.S., Britain, Brazil and elsewhere that have come to comparable conclusions. Children born just after flu pandemics have higher rates of physical disability, perform worse in academic tests and have lower income compared with babies born before or after pandemics. "The cohort [born in 1919] has shorter height and lower weight as teenagers, a higher percentage of various health issues," wrote economist Ming-Jen Lin of National Taiwan University in a soon-to-be-published paper looking at the long-term effects of the 1918 flu in Taiwan.

Perhaps the most commonly cited paper is one by researchers at Columbia University, which associated a mother’s influenza with her child’s risk of mental illness. In that landmark study, researchers collected blood samples from 12,000 pregnant women in Alameda County, California, between 1959 and 1966 and monitored their sons and daughters for more then three decades. Children born to women who had been infected with flu were three to seven times more likely to develop schizophrenia later in life, the study concluded. (See the top 5 swine flu don’ts.)

So what is the link between a mother’s influenza and her child’s cardiac health, physical stature or risk of mental illness? Well, we don’t really know. What we do know is that it’s probably not the flu virus itself. There is no known biochemical mechanism that links heart disease or other health outcomes to prenatal exposure to flu. And the flu virus, unlike the pathogens that cause herpes, German measles and syphilis, is not teratogenic — that is, it doesn’t cause malformations in the fetus, says Dr. Ellen Harrison, the director of obstetrical medicine at the Montefiore Medical Center in the Bronx, N.Y.

Researchers’ best guess is that a flu infection causes stress in the mother, which might in turn affect fetal development. During pregnancy, a woman’s heart and lungs are working substantially harder than usual, and her immune system is compromised, so a few infections (like influenza) may potentially become more intense. Although most pregnant women who get the flu survive with no serious problems, they are still more likely than other healthy adults to also develop respiratory failure and secondary bacterial infections like pneumonia — potentially fatal conditions that may require hospitalization and mechanical ventilation. "It is these severe cases that are dangerous for both the mother and her baby," said Harrison in an e-mail message.

The idea that environmental conditions in the womb may have lifelong effects on the fetus is certainly not new. British epidemiologist D.J. Barker first proposed his theory of fetal origins in 1992, arguing that when the fetus doesn’t get enough nutrition in utero, for example, an increased risk of future heart disease and diabetes somehow gets "programmed" into his or her development. There wasn’t very much data to back Barker’s theory at the time, but over the decades, a wealth of animal and human data has suggested it’s true. Maternal conditions like high blood pressure and diabetes and behaviors like smoking and drinking have all been identified as factors that can harm the fetus. Each risk factor may lead to various long-term consequences, including mental retardation, low birth weight or an increased risk of heart disease, diabetes or schizophrenia. (See how not to get the H1N1 flu.)

But the flu-stress theory is still just a theory. There is only epidemiological evidence to support it; a clinical trial measuring the effects of flu-induced maternal stress would, of course, be unethical. And the link could involve any number of unknown variables: in the new study co-authored by Finch, it’s not even clear which of the survey respondents’ mothers actually caught the flu, because that information was not available.

Still, the study’s authors argue that there are few other immediately obvious alternative hypotheses, given the cluster of outcomes among babies born at certain times. "Why is it that only those born in 1919 showed the spike [in heart disease]?" asks study author Douglas Almond, a professor of economics at Columbia University and a pioneer in applying the fetal-origins theory to economics. "People who were born just before and after the flu should be affected as well."

Whatever the exact biological pathway, for obstetricians like Harrison, the findings have immediate relevance: they reinforce the importance of getting a flu shot, especially for pregnant women, many of whom say they are reluctant to receive the new 2009 H1N1 vaccine. "I am already 37 weeks into my pregnancy and haven’t fallen sick and have been healthy all along, and I don’t see the point of introducing a foreign body into my body," says first-time mother Laurie Koch-Smith, 41, in Westchester County, New York, who says she thinks the risk of H1N1 infection has been overhyped.

But even if pregnant moms avoid catching the H1N1 flu, the vaccine has other benefits, says Harrison. "The baby of a woman who got the influenza vaccine [during pregnancy] will be born with antibodies to influenza," she says, adding that immunity — albeit temporary — would greatly reduce the chances of the infant coming down with the flu during the first few months of life.


Dear All:

CDC is asking every provider to assist with the monitoring of the safety of H1N1 vaccine by reporting any suspected adverse events promptly and accurately. See attached letter describing this process.

This document can also be found on the DPH website at

Please share this with your colleagues.


Face Masks for Patients May Leak, Spread Germs Health-care workers should take precautions, especially given H1N1 pandemic,
experts say   


Friday, October 9, 2009

FRIDAY, Oct. 9 (HealthDay News) — Health-care workers, take note: Hospital patients using positive pressure ventilation masks to help them breathe may be spreading germs every time they exhale, a new study finds.

The masks can leak exhaled air up to one meter from patients receiving treatments, spreading contagious respiratory illness within a hospital, researchers say. This may be of particular concern if the patient has the highly contagious H1N1 swine flu.

"Health-care workers should take adequate respiratory precautions — wearing N95 masks and personal protective equipment — when providing noninvasive ventilatory support to patients with pneumonia of unknown etiology complicated by respiratory failure, including patients with pandemic H1N1 influenza," said lead researcher Dr. David S. Hui, from the department of medicine and therapeutics at the Chinese University of Hong Kong.

The report is published in the October issue of Chest.

For the study, Hui’s team measured air leakage from two commonly used positive pressure ventilation masks, the Respironics ComfortFull 2 mask and the Image3 mask. The test was done on a patient simulator, which mimicked a patient with lung injury.

These masks fit over the patient’s nose and mouth and provide a continuous flow of air at a steady pressure to help the patient breathe. They are used for patients with heart failure, chronic obstructive pulmonary disease (COPD), asthma and sleep apnea in addition to pneumonia.

With both models and using negative pressure, the researchers found substantial exposure to exhaled air occurs within one meter of patients receiving non-invasive ventilation in an isolation room. But far more leakage and room contamination occurred from the Image 3 mask, especially at higher pressures, Hui said.

Hui said the study results argue for avoiding the use of high pressure, which will lead to more exhaled air dispersion, and "exhalation devices, which will lead to widespread exhaled air dispersion."

Dr. Roland Schein, professor of medicine in the division of pulmonary, critical care and sleep medicine at the University of Miami Leonard M. Miller School of Medicine, said it is well-known that these masks can spread contagious germs.

"The concern has always been with open systems and highly infectious pathogens. People within a certain range are at risk and need to take precautions to reduce those risks," Schein said.

This study has defined how far those germs can spread, he added.

Health-care workers caring for patients using these masks should take precautions, including face masks and protective clothing, Schein said. This is especially important now with "the concerns about H1N1 and other respiratory pathogens," he said.

SOURCES: David S. Hui, M.D., department of medicine and therapeutics, the Chinese University of Hong Kong; Roland Schein, M.D., professor, division of pulmonary, critical care and sleep medicine, University of Miami Leonard M. Miller School of Medicine; October 2009 Chest


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