Free
Special Communication  |   May 2010
Seasonal and Avian Influenza Knowledge Base of Attending Physicians in a Community-Based Hospital: A Survey-Based Study
Author Notes
  • From the Department of Emergency Medicine at Henry Ford Wyandotte Hospital in Michigan and from the Department of Internal Medicine at Michigan State University College of Osteopathic Medicine in East Lansing. 
  • Address correspondence to Kevin M. Boehm, DO, MSc, Associate Program Director, Henry Ford Wyandotte Hospital, Department of Emergency Medicine, 2333 Biddle Ave, Wyandotte, MI 48192-4668. E-mail: kboehm1@hfhs.org 
Article Information
Preventive Medicine
Special Communication   |   May 2010
Seasonal and Avian Influenza Knowledge Base of Attending Physicians in a Community-Based Hospital: A Survey-Based Study
The Journal of the American Osteopathic Association, May 2010, Vol. 110, 285-289. doi:10.7556/jaoa.2010.110.5.285
The Journal of the American Osteopathic Association, May 2010, Vol. 110, 285-289. doi:10.7556/jaoa.2010.110.5.285
Abstract

Context: Influenza remains a serious threat and is the most frequent cause of death from a vaccine-preventable disease. Physicians' understanding of influenza and its management and prevention can potentially reduce the spread of disease in the community.

Objective: To ascertain physicians' knowledge of the prevention, identification, and treatment of seasonal and avian influenza.

Methods: A 14-question survey regarding seasonal and avian influenza was distributed to emergency physicians at a medical staff meeting in 2005.

Results: The survey was given to 360 physicians, of whom 54 (15%) submitted completed surveys. Of the 51 physicians (94%) in favor of vaccines, only 32 (59%) received the influenza vaccine and only 21 (39%) always received the yearly vaccine. Eight physicians (15%) washed their hands before seeing patients, 18 (33%) washed their hands after seeing patients, 21 (39%) washed their hands before and after seeing patients, and 7 (13%) stated they only wash their hands sometimes. Seven (13%) always “alcohol” their stethoscope between patients; 28 (52%) responded “sometimes;” and 4 (7%), “never.” When taking patient histories, 31 (58%) stated that they always or sometimes ask about travel history; 15 (28%) stated that they never ask about travel history. Thirty-six respondents (67%) would take oseltamivir phosphate if they had avian influenza.

Conclusion: This survey-based study reveals that physicians may lack information in the domains of influenza prevention, identification, and management. Emergency physicians must take the lead in the hospital to ensure that we as a profession are aware of emerging pathogens, how to recognize those pathogens and treat infected patients, and how to protect ourselves.

Since the 1950s, manufacturers have been using egg technology to mass-produce influenza vaccine.1 Despite an adequate vaccine, influenza is the most frequent cause of death from a vaccine-preventable disease in the United States, with nearly 36,000 influenza-associated pulmonary and circulatory deaths each influenza season.2 Morbidity is even greater, with more than 200,000 hospitalizations per year.2 In the United States alone, influenza costs are up to $167 billion annually, $76.5 million of which is for the treatment of children with influenza.1-5 
In addition to seasonal influenza, there has been a growing concern of the H5N1 strain of avian flu becoming more of a human pathogen.1-3,6 Initially, in 1997, this strain did little more than ruffle feathers among infected flocks of chickens, resulting in decreased egg production much like other ubiquitous avian viruses. However, the H5N1 strain quickly mutated and killed nearly 100% of infected birds within 2 days of contracting the disease.6 As quickly as the disease was recognized, it also disappeared—at least for a short time. For 6 years, there were no reports of birds contracting this virulent strain. Suddenly, in 2003, veterinarians in Asia became alarmed at the large number of deaths within flocks of commercial poultry farms. Before long, these deaths were attributed to the H5N1 strain. 
Unlike most avian influenzas, the H5N1 strain began crossing into a new host: humans.6 The spread of H5N1 within humans has been attributed to direct infection of the respiratory tract through fomites, inhalation, or direct contact with the mucosa. The ingestion of improperly cooked or handled poultry meat, blood, or eggs has been linked to the spread of human cases of H5N1 influenza, but no cases have been reported through the proper handling of poultry.2 Unlike seasonal influenza, there are limited cases of human-to-human cases of H5N1 influenza.2 As of May 2010, 498 confirmed cases of H5N1 influenza in humans were reported to the World Health Organization, with 294 of these cases ending in death—a mortality rate of nearly 60%.7 
In my opinion, physicians' understanding of influenza and its treatment and prevention can potentially impact the spread of disease in a community. Therefore, I conducted a survey of a hospital's medical staff in a Detroit, Michigan, suburb to ascertain their knowledge of the prevention, identification, and management of seasonal and avian influenza. 
Methods
The institutional review board at Bicounty Hospital reviewed the study protocol and granted “exempt” status for this project in June 2005. Statistical analysis was performed using Microsoft Office Excel 2007 (Microsoft Corporation, Redmond, Washington). 
Participants and Setting
The participants for the present survey-based study comprised multidisciplinary medical staff comprised of osteopathic and allopathic physicians at a large community hospital (344 beds, 75,000 annual emergency department visits) in Wyandotte, Michigan, during a quarterly general staff meeting. Inclusion criteria was active membership on the medical staff. There were no exclusion criteria. 
Survey Instrument
A cover letter informed potential participants that the survey was anonymous and confidential. Respondents were advised that by completing and returning the survey, they were providing consent to participate in the study. In addition, if respondents had questions regarding the survey or the use of data, contact information (telephone number and mailing address) was provided. 
The survey, which was not validated externally, comprised 14 questions regarding seasonal and avian influenza and related topics. Some questions were related to the physician's knowledge and personal use of influenza vaccines. Other questions concerned the prevention of the disease through sanitization practices, identification of patients with potential avian influenza (eg, history-taking about patient travel), and physician knowledge of treatment options for patients with seasonal or avian influenza. The survey questions appear in the Table. 
Table
Seasonal and Avian Influenza Knowledge Base of Emergency Physicians in 2005: Survey Questions* and Responses (N=54)

Question

No. (%)
1. Did you get flu shot this year?
□ Yes 32 (59)
□ No22 (41)
2. Are you concerned about avian flu?
□ Yes35 (65)
□ No 19 (35)
3. If you got the avian flu, what medication would you take?
□ There isn't anything that works 17 (31)
□ Tamiflu (oseltamivir)36 (67)
□ Symmetrel (amantadine) 1 (2)
□ Cipro (ciprofloxacin)0
4. The typical flu vaccine contains:
□ Two influenza viruses—one A virus, one B virus29 (54)
□ Three influenza viruses—one A virus, one B virus, and one C virus 8 (15)
□ Three influenza viruses—two A viruses and one B virus15 (28)
□ Three Influenza viruses—one A virus and two B viruses 2 (4)
5. Regarding the annual flu shot, before 2003:
□ I always received the vaccine (100% of the time) 21 (39)
□ I usually received the vaccine (more than 50%, less than 100% of the time)11 (20)
□ I sometimes received the vaccine (more than 0%, less than 50% of the time) 6 (11)
□ I never received the vaccine16 (30)
6. Regarding the annual flu shot, since 2003:
□ I have received the vaccine twice34 (63)
□ I received the vaccine in 2004 only 1 (2)
□ I received the vaccine in 2005 only2 (4)
□ I never received the vaccine 17 (31)
7. [Does] our hospital [have] a preparedness plan for events like avian flu?
□ Yes 33 (61)
– I've seen the plan3 (9)
– I've used the plan in a drill, real life 0
– I've never used the plan16 (48)
– I've never seen the plan 14 (42)
□ No21 (39)
8. When taking a patient history I _____ ask about travel history.
□ always 10 (19)
□ sometimes21 (39)
□ rarely 8 (15)
□ never15 (28)
9. Generally I am _____ vaccines.
□ in favor of51 (94)
□ against 3 (6)
10. I alcohol my stethoscope between patients _____.
□ always 7 (13)
□ sometimes28 (52)
□ rarely 15 (28)
□ never4 (7)
11. I wash my hands _____ each patient.
□ before8 (15)
□ after 18 (33)
□ both before and after21 (39)
□ sometimes 7 (13)
□ never0
12. My hospital has hand cleaner foam readily available throughout the facility.
□ Yes 9 (17)
□ No45 (83)
13. I _____ use(d) a travel clinic before going out of the [United States].
□ have/would26 (48)
□ have not/would not 28 (52)
14. I've had natural chickenpox.
□ Yes 52 (96)
□ No2 (4)
14a. If no, have you or would you get chickenpox vaccine?
□ Yes2 (100)
□ No
0
 *Survey questions have been modified for minor editorial preferences only.
 A space was provided for respondents to explain why they did or did not get the flu shot.
Table
Seasonal and Avian Influenza Knowledge Base of Emergency Physicians in 2005: Survey Questions* and Responses (N=54)

Question

No. (%)
1. Did you get flu shot this year?
□ Yes 32 (59)
□ No22 (41)
2. Are you concerned about avian flu?
□ Yes35 (65)
□ No 19 (35)
3. If you got the avian flu, what medication would you take?
□ There isn't anything that works 17 (31)
□ Tamiflu (oseltamivir)36 (67)
□ Symmetrel (amantadine) 1 (2)
□ Cipro (ciprofloxacin)0
4. The typical flu vaccine contains:
□ Two influenza viruses—one A virus, one B virus29 (54)
□ Three influenza viruses—one A virus, one B virus, and one C virus 8 (15)
□ Three influenza viruses—two A viruses and one B virus15 (28)
□ Three Influenza viruses—one A virus and two B viruses 2 (4)
5. Regarding the annual flu shot, before 2003:
□ I always received the vaccine (100% of the time) 21 (39)
□ I usually received the vaccine (more than 50%, less than 100% of the time)11 (20)
□ I sometimes received the vaccine (more than 0%, less than 50% of the time) 6 (11)
□ I never received the vaccine16 (30)
6. Regarding the annual flu shot, since 2003:
□ I have received the vaccine twice34 (63)
□ I received the vaccine in 2004 only 1 (2)
□ I received the vaccine in 2005 only2 (4)
□ I never received the vaccine 17 (31)
7. [Does] our hospital [have] a preparedness plan for events like avian flu?
□ Yes 33 (61)
– I've seen the plan3 (9)
– I've used the plan in a drill, real life 0
– I've never used the plan16 (48)
– I've never seen the plan 14 (42)
□ No21 (39)
8. When taking a patient history I _____ ask about travel history.
□ always 10 (19)
□ sometimes21 (39)
□ rarely 8 (15)
□ never15 (28)
9. Generally I am _____ vaccines.
□ in favor of51 (94)
□ against 3 (6)
10. I alcohol my stethoscope between patients _____.
□ always 7 (13)
□ sometimes28 (52)
□ rarely 15 (28)
□ never4 (7)
11. I wash my hands _____ each patient.
□ before8 (15)
□ after 18 (33)
□ both before and after21 (39)
□ sometimes 7 (13)
□ never0
12. My hospital has hand cleaner foam readily available throughout the facility.
□ Yes 9 (17)
□ No45 (83)
13. I _____ use(d) a travel clinic before going out of the [United States].
□ have/would26 (48)
□ have not/would not 28 (52)
14. I've had natural chickenpox.
□ Yes 52 (96)
□ No2 (4)
14a. If no, have you or would you get chickenpox vaccine?
□ Yes2 (100)
□ No
0
 *Survey questions have been modified for minor editorial preferences only.
 A space was provided for respondents to explain why they did or did not get the flu shot.
×
Participants were asked to return the survey at the end of the meeting. No follow-up period occurred. 
Results
Of the 360 medical staff members who could have responded, 60 (16.7%) returned the survey. Of the 60 returned, 6 surveys were excluded because they were not fully filled out, leaving 54 surveys (15%) for data analysis (Table). 
Despite 51 physicians (94%) being in favor of vaccines, only 32 (59%) received the influenza vaccine in 2005 and only 21 (39%) always received the vaccine annually. For those who did not get the vaccine, reasons cited included time contstaints (3 [6%]); fear of Guillain-Barré syndrome (2 [4%]); and not believing it works (3 [6%]). The majority (10 [19%]) choose not to identify why they did not receive it. Thirty-five respondents (65%) were “concerned about avian flu,” though only 3 (9%) had seen the hospital's “preparedness plan for events like avian flu.” In fact, 21 physicians (39%) were unaware that the hospital had such a plan. 
In addition to personal influenza vaccination, prevention through hand washing and stethoscope cleaning were asked. Eight respondents (15%) washed their hands before seeing a patient, 18 (33%) washed their hands after seeing a patient, 21 (39%) washed their hands before and after seeing a patient, and 7 (13%) stated they only washed their hands sometimes throughout the day. When it came to cleaning their stethoscopes with alcohol, 7 (13%) always cleaned it using alcohol swabs between seeing patients; 28 (52%), sometimes; 15 (28%), rarely; and 4 (7%), never. 
When taking histories of their patients, 31 respondents (57%) stated that they “always” or “sometimes” ask about travel history, whereas 15 (28%) stated that they never ask about travel history. Finally, when it came to the management of avian influenza, 36 (67%) said they would take oseltamivir phosphate if they had avian influenza. Seventeen physicians (31%) responded “there isn't anything that works,” and 1 (2%) would take amantadine hydrochloride. 
Comment
Patients seen in the community have the potential to be misdiagnosed, mistriaged, or even come in contact with the influenza virus because of practice patterns (eg, not washing hands or sanitizing stethoscopes). The present survey-based study reveals that this small cohort of physicians lack knowledge and practice of disease prevention, identification, and treatment when it comes to seasonal and avian influenza. 
Emergency physicians have the unique opportunity to see disease processes in all stages of development. As a result, emergency physicians need a wide differential diagnosis when approaching their patients. The emergency physician must have a functional knowledge of not only how to diagnosis and treat disease, but also how to protect themselves, their staff, and their community. Seasonal and avian influenza are prime examples of this type of situation. 
In the realm of prevention, person-to-person spread can be limited with triage of patients to isolated areas or having atrisk patients don surgical masks in triage.8 In addition, physicians and staff should practice diligent hand-washing, liberal use of gloves, and sterilization of equipment (eg, stethoscopes) between patients.2 Ofner-Agostini et al9 found that improper staff training regarding the importance of personal protection and hand and equipment cleansing contributed to the spread of respiratory viruses such as severe acute respiratory syndrome (SARS) in Toronto. Although the use of alcohol-based cleansing pads have not been shown to reduce the viral load on stethoscopes, they substantially reduce bacterial loads.10 Furthermore, alcohol-based cleansers as well as soap and water have been shown to effectively lower the viral load of influenza on human hands.11 Although logic dictates that alcohol-based cleansers will reduce the viral load on stethoscopes, and recommendations are to clean stethoscopes with alcohol-based cleansers,2,8 further research is needed in this area. In addition, hospitals can potentially increase physician use of alcohol-based hand sanitation by putting hand hygiene agent dispensers in conspicuous locations (eg, suspended proximate to hospital beds).12 
Limiting the spread of influenza and other respiratory infections begins outside the emergency department with proper hand washing and proper cough etiquette (eg, looking away and covering one's mouth and nose when coughing or sneezing).13 In the past, poster campaigns in the waiting room have been effective in educating patients on how to limit the spread of respiratory infections.14 
Vaccines are also important not only for hospital staff but also for at-risk patients. It is important to note, however, that identifying an at-risk patient and providing follow-up with primary care may not be enough. Pilot studies showed that such follow-up vaccination programs resulted in approximately 10% of the eligible population receiving vaccines,15 whereas another study showed that an emergency department–based influenza vaccination program was able to increase vaccination rates among at-risk individuals from 16% to 83%.16 Current practices in many emergency departments may not include updating influenza vaccination status, yet it is well engrained in emergency physicians to check for and update other vaccines, such as tetanus.17 
With the culture of updating immunizations already engrained in emergency physicians, and with pilot studies15,16 showing success in these programs for updating influenza vaccines, perhaps more research is needed. Although immunization to seasonal influenza may not provide immunity to avian influenza, immunization very well may be the key to preventing genetic assortment and thus the possibility of human-to-human avian influenza strains.2 The three factors that allow a new strain of influenza to become a pandemic strain is when the host has no immunity, when it spreads rapidly from host to host, and when no vaccine is available.2,6 Even without the threat of avian influenza or another pandemic strain, the yearly seasonal influenza vaccine helps everyone have fewer sick days during cold and influenza season.18,19 
As a result of the increasing occurrence of avian influenza in certain parts of the world, it is vital that emergency physicians are able to delineate seasonal influenza from avian influenza and that they take travel histories when warranted.7 Emergency physicians need to recognize that a patient who has traveled to an endemic area within the past 14 days and presents with high temperatures, dyspnea, chest discomfort, and gastrointestinal complaints must be evaluated for avian influenza.2 Although the newest screening test for avian influenza—the Human Influenza Virus Real-Time RT-PCR Detection and Characterization Panel20—can screen for the virus in less than 4 hours, approximately 150 laboratories21 in the United States can perform this test. Therefore, treatment must often be initiated early and without confirmatory studies.2,3 
Mainstays of antiviral therapy are neuraminidase inhibitors like oseltamivir and zanamivir. When used for seasonal influenza, oseltamivir is typically prescribed at 75 mg orally twice a day for 5 days. For patients with avian influenza, doses of 150 mg orally twice a day for longer periods have been recommended.2 For those who have been exposed to avian influenza but have not yet shown symptoms, it may also be given as a prophylactic medication at 75 mg orally once a day for 7 days.2 
Zanamivir has not been shown to be effective in treatment but may be a better choice for prophylaxis because it is a neuraminidase inhibitor that is not systemically absorbed. In the setting of a pandemic, however, Zanamivir should remain available for use.2,22 In recent years, the number of seasonal influenza strains resistant to oseltamivir has grown.23,24 Although the H1N5 strain has not shown resistance to oseltamivir as of yet, other antivirals (eg, peramivir, ribavirin, and interferon alpha) are being studied.2 
Although the present study dealt with physicians' knowledge of seasonal and avian influenza, the emergence of a novel influenza A (H1N1, or swine influenza) strain in April 2009 demonstrated how important it is to recognize and treat pandemic influenza.25 On June 1, 2009, the World Health Organization reported that 62 countries reported more than 17,400 cases of H1N1 infection and 115 deaths.25 Nearly 9000 of those cases and 15 deaths occurred in the United States.25 Nearly 1 year later, H1N1 has been reported in more than 214 countries and overseas territories with more than 18,000 deaths.26 Although the impact that this pandemic will have on primary care physicians' offices and emergency departments has yet to be seen, the current pandemic reiterates the need for clinicians to understand how to prevent, identify, and manage influenza. 
Limitations
The present survey-based study has several limitations, including the use of an unvalidated survey tool, small sample size, moderate response rate, and data limited to one geographic area. As a result, I present these data not as conclusive but instead to encourage discussion and highlight an area in which further research is needed in disease prevention, detection, and treatment as well as in development of effective emergency department–driven vaccination programs. 
Conclusion
Although the present survey-based study was conducted in one large community-based hospital with a small sample of physician responses, it highlights some areas of concern for the general medical community. Emergency physicians must take the lead in ensuring that we as a profession are aware of emerging pathogens, how to recognize and treat them, and how to protect ourselves against them. In the case of seasonal and avian influenza, as well as other pandemic influenzas, the necessary course of action would include diligent hand washing, yearly vaccines, and travel histories when warranted. Of course, disease identification, prevention, and treatment go beyond the emergency department. 
 A copy of the survey instrument and accompanying cover letter are available upon request.
 
 Financial Disclosures: None reported.
 
Osterholm MT. Preparing for the next pandemic. N Engl J Med. 2005:352 (18): 1839-1842.
McFee, RB, Bush LM, Boehm KM. Avian influenza: critical considerations for the primary care physician. Johns Hopkins Adv Stud Med. 2006 :10(6):431-440.
Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, et al; Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC). Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. 2007;56(RR-6):1-54. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm. Accessed May 12, 2010.
Influenza (seasonal). World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs211/en/index.html. Accessed May 12, 2010.
Hassan F, Lewis TC, Davis MM, Gebremariam A, Dombkowski K. Hospital utilization and costs among children with influenza, 2003 [published online ahead of print February 5, 2009]. Am J Prev Med. 2009;36(4):292-296.
Jong-wook L. Avian influenza: assessing the pandemic threat. World Health Organization Monograph. January 2005:5-18. http://www.who.int/csr/disease/influenza/WHO_CDS_2005_29/en/. Accessed May 17, 2010.
Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. World Health Organization Web site. May 6, 2010. http://www.who.int/csr/disease/avian_influenza/country/cases_-_2010_05_06/en/index.html. Accessed May 17, 2010.
Rothman RE, Irvin CB, Moran GJ, Sauer L, Bradshaw YS, Fry RB Jr, et al; Public Health Committee of the American College of Emergency Physicians. Respiratory hygiene in the emergency department [published correction appears in Ann Emerg Med. 2007;49(1):61] [published online ahead of print August 23, 2006]. Ann Emerg Med. 2006;48(5):570-582.
Ofner-Agostini M, Gravel D, McDonald LC, Lem M, Sarwal S, McGeer A, et al. Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control precautions: a case series [published online ahead of print April 26, 2006]. Infect Control Hosp Epidemiol. 2006;27(5):473-478.
Lecat P, Cropp E, McCord G, Haller NA. Ethanol-based cleanser versus isopropyl alcohol to decontaminate stethoscopes [published online ahead of print January 28, 2009]. Am J Infect Control. 2009;37(3):241-243.
Grayson ML, Melvani S, Druce J, Barr IG, Ballard SA, Johnson PD, et al. Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. Clin Infect Dis. 2009;48(3):285-291.
Thomas BW, Berg-Copas GM, Vasquez DG, Jackson BL, Wetta-Hall R. Conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit. J Am Osteopath Assoc. 2009;109(5):263-267. http://www.jaoa.org/cgi/content/full/109/5/263. Accessed May 17, 2010.
Sherman FT. Learning to EXHALE: don't catch the flu this season! Geriatrics. 2008;63(10):2-3.
Ward K, Hawthorne K. Do patients read health promotion posters in the waiting room? A study in one general practice. Br J Gen Pract. 1994;44(389): 583-585. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1239083/pdf/brjgenprac00025-0047.pdf. Accessed May 17, 2010.
Manthey DE, Stopyra J, Askew K. Referral of emergency department patients for pneumococcal vaccination. Acad Emerg Med. 2004;11(3):271-275.
Rimple D, Weiss SJ, Brett M, Ernst AA. An emergency department-based vaccination program: overcoming the barriers for adults at high risk for vaccine-preventable diseases [published online ahead of print August 10, 2006]. Acad Emerg Med. 2006;13(9):922-930.
Tetanus immunization for adults and children in the emergency department [information paper]. American College of Emergency Physicians Web site. www.acep.org/WorkArea/DownloadAsset.aspx?id=8990. Accessed May 17, 2010.
Nichol KL, D'Heilly SJ, Greenberg ME, Ehlinger E. Burden of influenza-like illness and effectiveness of influenza vaccination among working adults aged 50-64 years. Clin Infect Dis. 2009;48(3):292-298.
Nichol KL. Cost-benefit analysis of a strategy to vaccinate healthy working adults against influenza. Arch Intern Med. 2001;161(5):749-759. http://archinte.ama-assn.org/cgi/content/full/161/5/749. Accessed May 17, 2010.
FDA Clears New CDC Test to Detect Human Influenza. US Department of Health and Human Services Web site. http://www.hhs.gov/news/press/2008pres/09/20080930a.html. Accessed May 17, 2010.
Facts about the Laboratory Response Network. Centers for Disease Control and Prevention Web site. http://www.bt.cdc.gov/lrn/factsheet.asp. Accessed May 17, 2010.
Monto AS. Vaccines and antiviral drugs in pandemic preparedness. Emerg Infect Dis. 2006;12(1):55-60. http://www.cdc.gov/ncidod/EID/vol12no01/05-1068.htm. Accessed May 17, 2010.
Gulati S, Smith DF, Air GM. Deletions of neuraminidase and resistance to oseltamivir may be a consequence of restricted receptor specificity in recent H3N2 influenza viruses. Virol J. 2009;6(1):22. http://www.virologyj.com/content/6/1/22. Accessed May 17, 2010.
Kramarz P, Monnet D, Nicoll A, Yilmaz C, Ciancio B. Use of oseltamivir in 12 European countries between 2002 and 2007—lack of association with the appearance of oseltamivir-resistant influenza A(H1N1) viruses. Euro Surveill. 2009;14(5):19112. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19112. Accessed May 17, 2010.
Pandemic (H1N1) 2009 - update 42. World Health Organization Web site. http://www.who.int/csr/don/2009_06_01a/en/index.html. Accessed May 17, 2010.
Pandemic (H1N1) 2009 - update 100. The World Health Organization Web site. http://www.who.int/csr/don/2010_05_14/en/index.html. Accessed May 17, 2010.
Table
Seasonal and Avian Influenza Knowledge Base of Emergency Physicians in 2005: Survey Questions* and Responses (N=54)

Question

No. (%)
1. Did you get flu shot this year?
□ Yes 32 (59)
□ No22 (41)
2. Are you concerned about avian flu?
□ Yes35 (65)
□ No 19 (35)
3. If you got the avian flu, what medication would you take?
□ There isn't anything that works 17 (31)
□ Tamiflu (oseltamivir)36 (67)
□ Symmetrel (amantadine) 1 (2)
□ Cipro (ciprofloxacin)0
4. The typical flu vaccine contains:
□ Two influenza viruses—one A virus, one B virus29 (54)
□ Three influenza viruses—one A virus, one B virus, and one C virus 8 (15)
□ Three influenza viruses—two A viruses and one B virus15 (28)
□ Three Influenza viruses—one A virus and two B viruses 2 (4)
5. Regarding the annual flu shot, before 2003:
□ I always received the vaccine (100% of the time) 21 (39)
□ I usually received the vaccine (more than 50%, less than 100% of the time)11 (20)
□ I sometimes received the vaccine (more than 0%, less than 50% of the time) 6 (11)
□ I never received the vaccine16 (30)
6. Regarding the annual flu shot, since 2003:
□ I have received the vaccine twice34 (63)
□ I received the vaccine in 2004 only 1 (2)
□ I received the vaccine in 2005 only2 (4)
□ I never received the vaccine 17 (31)
7. [Does] our hospital [have] a preparedness plan for events like avian flu?
□ Yes 33 (61)
– I've seen the plan3 (9)
– I've used the plan in a drill, real life 0
– I've never used the plan16 (48)
– I've never seen the plan 14 (42)
□ No21 (39)
8. When taking a patient history I _____ ask about travel history.
□ always 10 (19)
□ sometimes21 (39)
□ rarely 8 (15)
□ never15 (28)
9. Generally I am _____ vaccines.
□ in favor of51 (94)
□ against 3 (6)
10. I alcohol my stethoscope between patients _____.
□ always 7 (13)
□ sometimes28 (52)
□ rarely 15 (28)
□ never4 (7)
11. I wash my hands _____ each patient.
□ before8 (15)
□ after 18 (33)
□ both before and after21 (39)
□ sometimes 7 (13)
□ never0
12. My hospital has hand cleaner foam readily available throughout the facility.
□ Yes 9 (17)
□ No45 (83)
13. I _____ use(d) a travel clinic before going out of the [United States].
□ have/would26 (48)
□ have not/would not 28 (52)
14. I've had natural chickenpox.
□ Yes 52 (96)
□ No2 (4)
14a. If no, have you or would you get chickenpox vaccine?
□ Yes2 (100)
□ No
0
 *Survey questions have been modified for minor editorial preferences only.
 A space was provided for respondents to explain why they did or did not get the flu shot.
Table
Seasonal and Avian Influenza Knowledge Base of Emergency Physicians in 2005: Survey Questions* and Responses (N=54)

Question

No. (%)
1. Did you get flu shot this year?
□ Yes 32 (59)
□ No22 (41)
2. Are you concerned about avian flu?
□ Yes35 (65)
□ No 19 (35)
3. If you got the avian flu, what medication would you take?
□ There isn't anything that works 17 (31)
□ Tamiflu (oseltamivir)36 (67)
□ Symmetrel (amantadine) 1 (2)
□ Cipro (ciprofloxacin)0
4. The typical flu vaccine contains:
□ Two influenza viruses—one A virus, one B virus29 (54)
□ Three influenza viruses—one A virus, one B virus, and one C virus 8 (15)
□ Three influenza viruses—two A viruses and one B virus15 (28)
□ Three Influenza viruses—one A virus and two B viruses 2 (4)
5. Regarding the annual flu shot, before 2003:
□ I always received the vaccine (100% of the time) 21 (39)
□ I usually received the vaccine (more than 50%, less than 100% of the time)11 (20)
□ I sometimes received the vaccine (more than 0%, less than 50% of the time) 6 (11)
□ I never received the vaccine16 (30)
6. Regarding the annual flu shot, since 2003:
□ I have received the vaccine twice34 (63)
□ I received the vaccine in 2004 only 1 (2)
□ I received the vaccine in 2005 only2 (4)
□ I never received the vaccine 17 (31)
7. [Does] our hospital [have] a preparedness plan for events like avian flu?
□ Yes 33 (61)
– I've seen the plan3 (9)
– I've used the plan in a drill, real life 0
– I've never used the plan16 (48)
– I've never seen the plan 14 (42)
□ No21 (39)
8. When taking a patient history I _____ ask about travel history.
□ always 10 (19)
□ sometimes21 (39)
□ rarely 8 (15)
□ never15 (28)
9. Generally I am _____ vaccines.
□ in favor of51 (94)
□ against 3 (6)
10. I alcohol my stethoscope between patients _____.
□ always 7 (13)
□ sometimes28 (52)
□ rarely 15 (28)
□ never4 (7)
11. I wash my hands _____ each patient.
□ before8 (15)
□ after 18 (33)
□ both before and after21 (39)
□ sometimes 7 (13)
□ never0
12. My hospital has hand cleaner foam readily available throughout the facility.
□ Yes 9 (17)
□ No45 (83)
13. I _____ use(d) a travel clinic before going out of the [United States].
□ have/would26 (48)
□ have not/would not 28 (52)
14. I've had natural chickenpox.
□ Yes 52 (96)
□ No2 (4)
14a. If no, have you or would you get chickenpox vaccine?
□ Yes2 (100)
□ No
0
 *Survey questions have been modified for minor editorial preferences only.
 A space was provided for respondents to explain why they did or did not get the flu shot.
×