Skip Navigation LinksHome > October 2010 - Volume 110 - Issue 10 > Lessons Learned from the 2009 H1N1 Pandemic Flu
AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000389664.17370.d9
AJN Reports

Lessons Learned from the 2009 H1N1 Pandemic Flu

Jacobson, Joy

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A look back as nurses prepare for a new flu season.

At the height of the 2009 H1N1 pandemic influenza outbreak, the demand for nurses in Missoula County, Montana, became so acute that nurses there compared the response required to "an uphill climb followed by a marathon." Ellen Leahy, MN, RN, director of the Missoula City–County Health Department, said that in her role as incident commander for pandemic response in a county larger than the state of Delaware, she saw nurses come out of retirement, volunteer at weekend clinics, establish infection-control procedures, and supervise call-response teams. "Nurses really shined," she said of the local response.

Figure. Wendy Rainey...
Figure. Wendy Rainey...
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Assessment of the response to the pandemic has begun in recent months, now that global H1N1 activity has diminished, the World Health Organization has declared the pandemic to be over, and clinicians are preparing for another flu season. (See H1N1 on the Global Front.)

The Centers for Disease Control and Prevention (CDC) sought comment over the summer on its interim document providing guidance on infection control in health care settings for both H1N1 and seasonal influenza, in part because the risk of hospitalization and death from H1N1 infection "is now known to be substantially lower" than had been assumed. (Go to for updates.) Of the issues the CDC addresses, two have been particularly contentious among nurses: the H1N1 vaccine and the use of respirators (as opposed to face masks).

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The CDC surveyed health care personnel and found that by January only 37% had received the H1N1 vaccine, whereas 62% had received the seasonal flu vaccine, a higher than usual rate. The CDC found a "wide variation" in H1N1 vaccine rates in the general population, with a mean rate of 24%. Consequently, one-quarter of the H1N1 vaccines made last year have expired and will be incinerated this year, at a loss of $260 million, the Associated Press reported in July (usually, 10% of seasonal flu vaccine is discarded). For the upcoming flu season, the CDC recommends that everyone six months of age and older get the 2010–2011 vaccine, which will offer protection against three influenza viruses, including the 2009 H1N1 pandemic virus.

Why the low rates among health care workers? Lori Rhudy, PhD, RN, and colleagues interviewed U.S. nurses who said they would not or might not get the seasonal flu vaccine (the report was published in the second-quarter 2010 issue of Worldviews on Evidence-Based Nursing). "For the most part, nurses knew that immunization is recommended for health care providers," Rhudy, a nurse researcher at the Mayo Clinic and clinical assistant professor of nursing at the University of Minnesota, told AJN. "They just didn't interpret it in light of protecting their patients. They felt young and healthy," and didn't feel at risk for getting influenza, she said.

Although the CDC found higher vaccination rates among staff at facilities that required it, mandating the H1N1 vaccine is extremely controversial. When New York State ordered all health care workers to receive the vaccine in the fall of 2009, four Albany nurses and two unions sued the state health commissioner, and a state judge issued a restraining order blocking the mandate.

Another solution, said Linda Greene, MPS, RN, CIC, director of infection prevention and control at Rochester General Health System in New York, is to offer the option of "informed declination," which allows a clinician to refuse the vaccine after talking with an infection preventionist or other expert about the reason for opting out. "We mandated that everyone who refused for other than medical reasons had to go to a seminar on why the vaccine is important," Greene said. "Those strategies can work."

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The American Hospital Association and the Association for Professionals in Infection Control and Epidemiology (APIC) have both endorsed the CDC's recommendation that surgical face masks be used instead of N95 respirators by personnel working with patients with influenza. In a letter commenting on the CDC's interim guidance document, APIC wrote that face masks "are more readily available, more practical, more comfortable, more likely to be worn, and less costly" than respirators (see the APIC comments at But the American Nurses Association (ANA) doesn't agree and urged the CDC to keep its prior recommendation that fit-tested N95 respirators be "the first line of protection." Katie Brewer, MSN, RN, an ANA policy analyst, said that although the ANA acknowledges that N95 respirators are more costly and uncomfortable for the wearer, "until there is significant evidence [that face masks are adequate], we don't feel comfortable with the decreased level of protection." Study of the issue has begun: a randomized controlled trial of nurses treating patients with flu symptoms by Loeb and colleagues (published in the November 4, 2009, issue of JAMA), suggests that face masks are "noninferior" to respirators.

Leahy said that the respirator–face mask issue is "pretty confusing," and that she found much to praise in the Missoula County nurses' response to H1N1. She hopes that what was learned can be applied to more chronic illnesses. "Conditions like obesity, because they don't slap us in the face and scare us, we're slower to respond to," Leahy said. "But I've seen that when we're called upon, we can come together, as a country and as a community."—Joy Jacobson

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H1N1 on the Global Front

The WHO under fire; vaccination rates suffer internationally.

By late July more than 18,000 people had died worldwide from H1N1 infection, and on August 10 the World Health Organization (WHO) had declared the pandemic to be over. But a report by Cohen and Carter published on June 3 in BMJ "raises troubling questions" about how the WHO "managed conflicts of interest among the scientists who advised its pandemic planning," and on June 4 the Council of Europe issued a report citing "overwhelming evidence that the seriousness of the pandemic was vastly overrated" by the WHO. A WHO spokesperson told the Washington Post ( that the allegations were "inaccurate and downright irresponsible." An independent team headed by the Institute of Medicine's Harvey Fineberg is investigating the WHO's response to the 2009 H1N1 outbreaks, as well as to other emergencies, and will issue a report to the World Health Assembly in May 2011.

U.S. nurses aren't the only ones with low H1N1 vaccination rates. In August, To and colleagues reported in the American Journal of Infection Control (published online ahead of print) that of 812 Hong Kong RNs responding to a 2009 survey, only 13% were considering getting the H1N1 vaccine; 45% said they would reject it, and 41% were undecided, mainly because of "perceived ineffectiveness and potential adverse effects of the vaccine." Only 38% said they would receive the seasonal flu vaccine.—Joy Jacobson

© 2010 Lippincott Williams & Wilkins, Inc.


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