Issue: February 2019
February 22, 2019
10 min read

Bad flu seasons test US hospitals

Issue: February 2019
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Hospitals in the United States have implemented new policies based on last year’s severe influenza season, but infectious disease experts agree that America’s health care systems would still be seriously challenged by another bad influenza season.

Tight resources and underfunding mean hospitals are ill prepared for “surge” events, such as last year’s influenza season, they said.

The 2017-2018 influenza season was the first to be classified as “high severity” across all age groups, according to the CDC. There were high levels of outpatient clinic and ED visits for influenza-like illness (ILI), high rates of influenza-related hospitalizations and geographically widespread influenza activity, the agency reported. ILI was at or above the national baseline for 19 weeks, which made it one of the longest influenza seasons in recent years.

In the U.S., an estimated 959,000 people were hospitalized and 79,400 people died because of influenza last season, according to figures released by the CDC. The number of cases of influenza-associated illness that occurred last season — an estimated 48.4 million people — was the highest since the 2009 H1N1 pandemic, when an estimated 60 million people became sick with influenza.

Paul D. Biddinger, MD, director of the Center for Disaster Medicine at Massachusetts General Hospital, said the severity of last influenza season reinforced the need to recommend vaccination to patients. “If the flu season were much worse,” he said, “hospitals could easily be pushed beyond their capacity.”
Paul D. Biddinger, MD, director of the Center for Disaster Medicine at Massachusetts General Hospital, said the severity of last influenza season reinforced the need to recommend vaccination to patients. “If the flu season were much worse,” he said, “hospitals could easily be pushed beyond their capacity.”
Source: MGH Photography Department

“Last season was the worst season we have had in many, many years,” Infectious Disease News Editorial Board member William Schaffner, MD, professor of preventive medicine at Vanderbilt University Medical Center and medical director for the National Foundation for Infectious Diseases, said in an interview. “Based on our local experience and my conversations with colleagues, it was my impression that hospitals were often very stretched during last year’s influenza season and that, on occasion, patients were backed up in emergency rooms.”

Schaffner said hospital capacity across the country was “stretched but not broken,” and most hospitals were able to manage because they had a pandemic preparedness plan in place.

“That plan probably was, at least in its early stages, put into operation last year in many hospitals,” he said.

Among other plans of action, notice went out to all medical providers that patients needed to be discharged as promptly as medically appropriate to make sure there were enough beds available to accommodate the influx of patients with influenza, Schaffner said.

The CDC noted that the estimated number of hospitalizations during the 2017-2018 influenza season exceeded the number of staffed hospital beds in the United States — 902,202.

William Schaffner, MD
William Schaffner

Other experts agreed with Schaffner’s assessment that hospital staff and preparedness levels have been stretched to the limit. Although this influenza season does not appear to be as severe as last year’s, experts agreed that U.S. hospitals and health care systems would again face major challenges if another severe influenza season were to occur. And hospitals may not be prepared for an influenza pandemic.

“You cannot be perfectly prepared for any large pandemic, whether flu or otherwise,” Schaffner said. “Our nation is tight on hospital beds. Intensive care unit facilities are finite, ventilators are finite, the staff that is knowledgeable about managing patients on ventilators is finite, so if we were to be hit in the United States and around the world with a major new pandemic influenza virus, I think our medical care facilities would be very, very challenged.”


Surge capacity a challenge

According to Michael T. Osterholm, PhD, MPH, regents professor and director of the Center for Infectious Disease Research and Policy at the University of Minnesota, hospital capacity is a concern not just in severe influenza seasons, but during any major health care crisis.

“Very few institutions anywhere in the country have surge capacity, meaning unused capacity just sitting there waiting for a crisis to happen,” Osterholm told Infectious Disease News. “It would be like a manufacturing plant overbuilding its manufacturing capacity so that once a year when they get a potential short-term increase in order numbers, they can use that capacity. That just doesn’t make sense for them, financially. It is the same thing with health care. We worry all the time about the need for surge capacity.”

Last year’s influenza season “brought preparedness issues to the surface,” he said.

“We are constantly dealing with shortages and a limited capacity to respond to a surge situation, and that’s the reality of health care today. Influenza is probably the one thing out of all the diseases we deal with that challenges that surge capacity issue, short of a localized crisis, like terrorism or a mass shooting. Flu is in some ways the disease that is a barometer that tells us how capable we are.

“When you hear about patients being in the hallways and not having room for them, that really is not necessarily a function of the influenza season, it is a function that we just hit capacity.”

Federal funding cuts to blame

Federal funding cuts to hospitals and the public health system are a major reason for the lack of surge capacity, according to Jeffrey S. Duchin, MD, health officer and chief of the communicable disease epidemiology and immunization section of public health for Seattle and King County, Washington, and a professor in the division of infectious diseases at the University of Washington.

Jeffrey S. Duchin, MD
Jeffrey S. Duchin

“Our hospitals are struggling with the ability to meet medical surge events, even in the absence of a severe flu season,” Duchin told Infectious Disease News. “Even before flu season in the Puget Sound region, we have experienced EMS diversion, long ED wait times, caring for patients in untraditional spaces, like hallways, and having higher than usual patient-to-staffing rates. What this tells us is that there is a clear need for health care systems to better operationalize medical surge strategies. Hospitals have lost a lot of funding, as have public health departments related to emergency preparedness.”

For example, Duchin noted that the Hospital Preparedness Program (HPP) — the only federal source of funding for hospital preparedness — has been more than halved since 2003. HPP appropriations were cut from $514 million in fiscal year 2003 to $255 million in fiscal year 2017, according to the nonprofit Trust for America’s Health.

“The bottom line is we do not have an adequate source of steady funding for hospital or public health preparedness, and the result of that is that hospitals struggle with even moderate surge events, so a severe flu season could be very challenging for many of our health care facilities,” Duchin said. “This is really any type of emergency — a bioterrorist attack, a train derailment, an infrastructure catastrophe, such as a bridge accident, flood, landslides, which would include lots of injuries with people requiring hospital care.”


Mandatory staff vaccinations

Hospitals may not be completely prepared for a bad influenza season, but one thing that can lessen the burden is for more people to get vaccinated. That includes health care workers.

“More hospitals are introducing mandatory influenza vaccination programs for their staff, which improves preparedness and decreases transmission, and that is an improvement,” Paul D. Biddinger, MD, director of the Center for Disaster Medicine at Massachusetts General Hospital (MGH), said in an interview. “It’s pretty clearly documented that the higher vaccination rates decrease transmission of influenza, and of course, the vaccine isn’t perfect, but it is an important step. I think that hospitals really do appreciate the importance of preparedness for flu season, and hospitals, including my own, have recently taken bigger steps, such as mandatory employee vaccination.”

Biddinger said MGH did not have a mandatory vaccination policy last year, and the campaign to move to mandatory vaccination predated last year’s severe influenza season. But the severity of last season has reinforced the need to recommend vaccination to patients.

“I think it has made it easier for primary care physicians and others to have conversations with their patients about the importance of flu vaccinations,” he said. “Numbers like 80,000 deaths are heartbreaking, but they are also motivational for some patients to understand why they need the vaccine, and it is helpful for providers to explain why they are recommending vaccination for everyone.”

Biddinger said there are still myths about the influenza vaccine — such as patients getting influenza from the vaccine, or that healthy people do not need it — and sometimes patients will respond to recommendations only when there are large numbers of illnesses, like there were last season.

“Unfortunately, when you see how bad the flu season was last year, and even tragically this year there have been some deaths from influenza, you can get people to understand that if you are healthy, you are less likely to get the flu just by getting the vaccine, and if you get sick, you are less likely to die if you have received the vaccine. Those are very important messages.”

According to the CDC, patients most likely to experience severe influenza-related complications that can lead to hospitalization include older adults, young children and pregnant women. Studies have shown that vaccination halves the risk for influenza-related hospitalization in adults and reduces the risk for influenza-related pediatric deaths by 65% among healthy children, and 51% among children with high-risk medical conditions.

Fast Facts

Duchin emphasized that physicians still need to tell patients that it is important to get vaccinated if they have not done so already, because the influenza season is expected to last until March.

“The other key point is that many people forget that there are antiviral drugs available that are critical in helping people who have underlying high-risk conditions to avoid severe illness,” Duchin said. “That could be hospitalization. It could be the intensive care unit. It could be death.”

Recent practice guidelines from the Infectious Diseases Society of America emphasized the need to test and promptly treat patients at high risk for seasonal influenza-related complications, including pregnant women, young children, patients who are extremely obese and those who have a weakened immune system. Recommendations from the IDSA include testing and beginning antiviral treatment in patients if they are sick enough to be hospitalized with influenza symptoms, and that antivirals should be prescribed to patients at high risk for influenza-related complications, even if they have been sick for more than 2 days.


“Antiviral drugs can do a lot to relieve the stress on health care systems if they are used appropriately in the outpatient population,” Duchin said. “Fewer people will require ED visits and hospitalizations.”

He added that “early antiviral treatment is most effective in preventing serious illness and produces the most benefit. For patients hospitalized with influenza, antiviral treatment should be initiated even if beyond the optimal initiation period.”

One of the main strategies for dealing with the health care overload “is to treat people as outpatients, and that means you have to treat them early with antiviral drugs before they get sick enough to need hospitalization,” Duchin said.

H1N1 predominant this season

Through mid-January, up to 11.4 million Americans had been sickened with influenza this season, between 4.6 million and 5.4 million had seen a doctor because of their illness, and as many as 136,000 had been hospitalized, the CDC reported. Through Jan. 19, 22 influenza-associated pediatric deaths had been reported to the CDC, compared with 183 pediatric deaths associated with influenza last season. The CDC noted that approximately 80% of pediatric deaths in the 2017-2018 season occurred in children who had not received an influenza vaccination for the season.

This season, the percentage of outpatient visits attributed to ILI crossed the national baseline of 2.2% in late November and climbed weekly through the end of the year. Last season, the number peaked at 7.7%, matching the highest level recorded during the 2009 influenza pandemic. Influenza A(H3N2), which causes relatively severe illness, was the predominant subtype last season, whereas influenza A(H1N1) has caused most illnesses so far this season.

Kristen Nordlund, spokeswoman for the CDC, told Infectious Disease News that influenza numbers began to rise over the holiday period and into the new year. The Southern U.S. has seen sharp increases in activity.

“At this time, hospitalization rates in children younger than 5 years old (14.5 per 100,000) are the highest among all age groups,” Nordlund reported in early January. “Flu activity is unlikely to have peaked and is expected to continue nationally for many weeks.”

Schaffner said it is fortunate that the predominant virus so far this year is H1N1, because it tends to produce less severe disease than H3N2. He said there was hope that the Southern Hemisphere’s very mild H1N1 season would be repeated in the Northern Hemisphere, but that does not appear to be the case.

“My crystal ball suggests that we are going to have a rather typical influenza season,” he said.

Duchin stressed that a bad influenza season is “rather unpredictable,” and late-season activity with influenza B can be significant.


“It is way too early to judge how severe the season will be ultimately,” he said. “Although, in broad-brush terms, we are happy that we have not had as many of hospitalizations and deaths at this point, as we sometimes do.”

Although it is too early to tell how this influenza season will turn out, the curve of ILI so far in the Boston region is almost identical to the tracking at the same time last year, according to Biddinger.

“The majority of our cases, however, were later, in January and February, which is somewhat typical for us,” he said. “Through December, the graph looks almost typical from this year to last year. That clearly does not predict the season will be the same, but so far, we have been very similar.

“However, if the flu season were much worse, and caused an increase in hospitalizations by even just a few percentage points, hospitals could easily be pushed beyond their capacity,” Biddinger added.

Duchin said responses to another severe influenza season “will vary from one system to the next,” but hospitals would find it “more challenging and disruptive than if they were better resourced, prepared and rehearsed in implementing medical surge strategies.” – by Bruce Thiel

Disclosures: Schaffner reports serving on the data safety monitoring committees on behalf of Merck and Pfizer and serving as an occasional consultant for Dynavax, Sutrovax and Shionogi. Biddinger, Duchin, Nordlund and Osterholm report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “Should physicians prescribe antivirals to patients at high risk for flu-related complications more than 2 days after symptom onset?”