Less than two weeks after Chinese officials released the genetic sequence of a new type of bird flu, U.S. vaccine experts are well on the way to making a vaccine to protect people against it.

There’s no evidence the H7N9 virus would ever threaten the U.S. It’s been diagnosed in fewer than three dozen people, all restricted to eastern China. People don’t appear to be infecting one another, at least not in large numbers.

But it’s already killed nine of them. Scientists said Wednesday that the virus seems to have been the result of genetic reassortment of wild birds from east Asia and chickens from east China, Xinhua, the official Chinese news agency reported. Still, it doesn’t seem to be making birds sick -- which means authorities don’t have tell-tale die-offs of poultry to warn them when it’s circulating.

And it takes months to make influenza vaccines, so every day may count.

“It puts flu back on people’s minds,” said Dr. Amesh Adalja, an emergency physician at the Center for Biosecurity at the University of Pittsburgh Medical Center.

It’s just the kind of situation that flu experts have been been rehearsing for. They hope to do better than in 2009, when it took until October to deliver the first vaccines against the pandemic of H1N1 swine flu.

“The virus was identified in March,” notes flu expert Dr. Arnold Monto of the University of Michigan. Six long months ticked by with the virus spreading and no vaccine against it.

The U.S. government was battered by criticism from confused Americans who tried hard to get flu vaccine but couldn’t, and then gave up trying just about the time that vaccines started being produced and delivered in quantity.

Vaccine makers ended up throwing away about 70 million doses. “We can do it faster,” Monto said.

Two seasonal flu vaccines that use new technology approved within the past six months should help speed up the process. That same techonology can be used to make other vaccines, including one to protect against H7N9. And Dr. Robin Robinson of the Biomedical Advanced Research and Development Authority (BARDA), part of the Health and Human Services Department, says H7N9 is giving his department the chance for what he hopes will be a dry run.

“I think we are in a much better place than we were before the pandemic of 2009,” Robinson told NBC News. “We have some ongoing initiatives that are starting to provide real results.”

Most flu vaccines are made using technology that dates back to the 1940s. Doctors isolate the virus from a patient, combine it with another virus used to make the a “seed” for the vaccine, grow it in specially fertilized chicken eggs, strain it out and purify it – a process that takes months and that is fraught with dangers, not the least of which is contamination of the eggs.

Newer technology dumps the eggs. One new vaccine is grown in insect cells, and another is grown in cells taken from a single cocker spaniel’s kidney decades ago. That speeds things up a bit. And now scientists can make vaccine based on the genetic sequence, because they can make artificial genes in the lab.

So they can go straight from a genetic sequence published online to starting to make a vaccine. This method, called recombinant technology, shaves a few weeks off the process. Last summer, when a new strain of swine flu called H3N2v infected about 300 people and killed one, mostly via state fairs, drug maker Novartis and experts at the J. Craig Venter Institute in California made a seed virus for the vaccine in a week, Robinson says.

“Now with the H7N9 outbreak in China, the nucleotide (genetic) sequence was available Saturday, March 30,” Robinson said. Scientists at Novartis, with the federal government and the Venter Institute synthesized the necessary genes by the following Tuesday. By Wednesday, they had inserted the artificial gene sequences into dog cells and were growing new virus.

“Now we are characterizing that … virus to see if we have the right seed strains,” Robinson said. If they are, they’ll be tested and prepared to make a vaccine.

“We have been able to shave weeks off the method,” Robinson said.

When samples of the actual virus are released later this week, vaccine makers using old-fashioned methods will go to work on those, Robinson added.

“We have talked to all the manufacturers that make egg- based, cell-based and recombinant-based vaccines to ask what their manufacturing capabilities are,” Robinson said. HHS will know by the end of this week how much vaccine the companies can make and when they could have it ready, he says.

In any pandemic, the goal is to vaccinate every American. What's not clear is how many doses would be needed for protection and whether manufacturers could create enough in time.

The United States has invested heavily in vaccine technology since about 2004, when it became clear that H5N1 bird flu was a threat. So far, H5N1 has been an expensive nuisance, forcing the culling of hundreds of millions of birds, and killing 60 percent of the 600 or so human victims who have been infected.

But it could mutate into a form that passes easily from human to human. So could H7N9. Or another type of flu could emerge. Seasonal flu vaccines provide no protection at all against these new strains.

Some people have criticized the U.S. government’s reliance on commercial flu vaccines. It’s spent $147 million in five years to help companies that were struggling to develop new vaccine technology.

Seven companies make flu vaccines for the U.S. market, and the CDC and HHS are heavily invested in encouraging people to get vaccinated each year, not only to protect themselves from flu, but to keep a market incentive for companies to make flu vaccine.

But Monto says it’s the only way. “If the companies were not involved in producing a vaccine and taking risks each year, we wouldn’t have vaccines,” he says. And seasonal flu is nothing to sneeze at -- killing upwards of 40,000 people in a bad year.

Robinson says these preparedness efforts have been spared so far from budget cuts hitting other areas of government.

“We plan for these kinds of things to happen,” he said. “So far we are OK in developing the actual vaccine candidate. Where we get into trouble and will have to ask Congress for more money is if we have to have a large vaccine campaign like we had in 2009.”

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New virus not transmitted person to person

Flu vaccine barely worked in elderly this year

Brian Snyder/Reuters

Chihn Ha, 8, gets an influenza vaccine injection from nurse Nho Nguyen, right, during a flu shot clinic at Dorchester House, a health care clinic, in Boston, Mass., in January 2013.

The longer-than-average flu season finally appears to be ending, federal officials said on Friday, but it’s not quite done yet. Only six states, mostly in the Northeast, are now reporting widespread influenza.

The deaths of another five children were reported this past week, bringing the total for the season to 110, the Centers for Disease Control and Prevention reports. That’s just around the unfortunate average for influenza in any given year, the CDC says, although it varies a lot.

The viruses circulating this year were especially hard on people 65 and older and CDC is still trying to work out just how well vaccines may or may not have protected people, especially the elderly, against serious illness and death from flu. So many adults die of flu every year that the CDC can’t keep a precise count, but estimates that it ranges from a low of 3,000 to as many as 49,000.

This year was a “moderately severe” flu year, CDC says in a review of the 2012-2013 influenza season.

“This season, influenza activity started about 4 weeks early and was intense. Influenza-like-illness rose quickly to well above the baseline of expected activity and remained elevated for 15 consecutive weeks, making this season slightly longer than average,” the agency says in a statement.

“Flu-associated hospitalizations began to rise in mid-December with sharp increases seen among people 65 years and older.”

Half of the patients sick enough to be hospitalized with flu were 65 or older, CDC said. “While hospitalization rates have leveled off, this is the highest proportion of persons 65 and older hospitalized for flu that has been measured since this kind of record-keeping began during the 2005-2006 season,” it said.

Sadly, a few were children, and most had not been vaccinated, CDC said. “CDC reported an additional five pediatric deaths this week for a total of 110 to date for the 2012-2013 season. The number of pediatric deaths is likely to climb further as additional deaths are reported,” CDC said. Reports of deaths can take weeks to collate -- some of the five deaths reported this week dated back to December.

Experts have done a batch of studies to see how well the flu vaccine worked this year. That varies from year to year and scientists still are not sure why flu vaccination protects more strongly in some years than in others.

Flu vaccines have to be formulated freshly each year to protect against the most common circulating strains of virus. This year’s vaccine protected against three strains – one called H3N2, one called H1N1 – a descendant of the H1N1 “swine flu” that emerged in 2009 – and one influenza B strain.

Next year’s vaccines are just being formulated now, based on what’s circulating, and some will protect against four strains of flu.

“February results showed the 2012-2013 flu vaccine reduced the risk of flu-associated medical visits from influenza A (H3N2) viruses by one half and from influenza B by two-thirds for most of the population,” the CDC said.

 “This means that vaccinated people reduced their risk of having to go to the doctor for influenza by more than half, thus providing significant benefit to the person getting vaccinated and to public health in general.”

But it only prevented the risk of severe disease by 27 percent among people 65 and older this year. “It’s possible that some people 65 and older did not mount a good immune response to H3N2 from vaccination,” CDC said.

Related:

• Flu kills 105 kids; most not vaccinated
• Why it's so hard to get the flu vaccine supply right
• Flu spreads to all 50 states

A new study adds to years of research showing that childhood vaccines do not cause autism, despite worries among a growing number of parents that their young children receive “too many vaccines.”

Researchers from the Centers for Disease Control and Prevention concluded that even when multiple inoculations are given on the same day, children are at no higher risk of developing autism, according to the report published in the Journal of Pediatrics Friday.

“This study looked into the concern that receiving too many vaccines at one doctor’s visit or too many vaccines during the first two years of life may be linked to the development of autism,” the report’s lead author, Dr. Frank DeStefano told NBC chief medical editor Dr. Nancy Snyderman. “We found they’re not related.” 

The CDC researchers conducted the study by reviewing the vaccination histories collected between 1994 and 1999 of 256 children with autism and 752 children who did not have the disorder. They calculated the number of antigens – the substances in a vaccine that stimulate disease-fighting antibodies – that infants are exposed to either on one doctor’s visit or overall during the first two years.

“We did not find any relationship between the number of antigens and the risk of autism,” said DeStafano, Director of the Immunization Safety Office at the CDC.

The CDC study comes amidst reports that increasing numbers of parents are delaying or skipping childhood inoculations, fearing side effects or the risk of autism and other learning disabilities.

A 2012 study, which examined medical records for 97,711 Portland, Oregon children, found an almost four-fold increase between 2006 and 2009 in the percentage of parents who delayed or skipped vaccinations, researchers reported in the journal Pediatrics. Experts say that by delaying certain vaccinations, parents may be putting their children -- and those of others -- at a far greater risk of contracting deadly diseases, such as pneumonia and whooping cough, also known as pertussis. In 2012, the US experienced the worst epidemic of whooping cough in 50 years

That’s a real concern for Dr. Tanya Altmann, an assistant clinical professor at Mattel Children’s Hospital at UCLA.

“Some parents ask about waiting on vaccines and using an alternative or delayed schedule,” because of worries about autism, Altmann told Snyderman.

Altmann tries to remind parents that while they may worry about the unknown, there are real risks to skipping vaccinations or delaying them: outbreaks of severe, sometimes deadly, illnesses.

“The bottom line for parents is that these outbreaks are real and they will come back,” Altmann said.  “These are serious illnesses, meningitis, whooping cough. This study is just one more piece of evidence to reassure parents that vaccines are safe.”

Although inoculation contents and schedules have changed since the study data was collected, Snyderman sees the findings as applicable to today's children since CDC researchers tallied the total amount of antigens  -- bits of protein in a vaccine that spark an immune response -- that each child was exposed to.

“While the CDC now recommends more vaccinations than it did in the 90s, the level of antigens in today’s vaccines is markedly lower than it was when this data was collected,” Snyderman said.

DeStefano hopes the new research will convince parents that it’s safe to follow CDC vaccination schedules.

“The number of vaccines in the current immunization schedule is what’s needed to protect children,” he said. “It’s not too many for a child’s immune system.”

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Despite evidence, parents' fears of HPV vaccine grows

This year's flu kills at least 110 children; most weren't vaccinated

Jerry Lampen / Reuters file

A young child is vaccinated against the H1N1 flu virus in 2009. A new report says the US childhood vaccine schedule is safe.

It sounds plausible. The average baby gets 24 jabs in 24 months -- needle after needle piercing tender little thighs. Some get as many as five shots in a single doctor’s visit. Surely all this immune stimulation is overloading their little bodies, right?

It’s a seductive idea and one that makes sense, but only to people who don’t study the human immune system. A new report released on Wednesday suggests parents can let go of such concerns.

Nonetheless, government officials need to take these and other worries into account when they design future studies into vaccine safety, the Institute of Medicine committee advised.

“Our committee found no evidence that the childhood immunization schedule is not safe,” Ada Sue Hinshaw, Ph.D, dean of the graduate school of nursing at the Uniformed Services University of the Health Sciences and chair of the committee, told reporters in a conference call.

The Institute, one of the independent National Academies of Science, was asked to look at studies involving not the vaccines themselves, which have been shown numerous times to be safe, but at the schedule for their delivery.

Babies are vaccinated against diphtheria and tetanus, whooping cough and measles, chickenpox and bugs that cause meningitis, pneumonia and diarrhea. Some shots have to be given multiple times over a period of months to fully protect a child, and the schedule is based on when a child becomes vulnerable to infections, as well as when their immune system is developed enough to respond the vaccines.

“A number of concerned parents say the sched­ule is too ‘crowded’ and have requested flexibil­ity, such as delaying one or more immunizations or having fewer shots per visit,” the committee says in its report.

“Some parents have rejected the vaccines outright, arguing that the potential harm of their child suffering a side effect from the vaccine outweighs the well-documented benefits of immunizations preventing serious dis­ease. Other parents delay or decline immuniza­tions due to worries that family history, the child’s premature birth, or an underlying medical condi­tion may make them more vulnerable to compli­cations. Some simply distrust the federal govern­ment’s decisions about the safety and benefits of childhood immunizations.”

And delaying or refusing vaccination can cause harm -- not only to the children who are not fully vaccinated, but to those around them, the committee noted. “States with policies that make it easy to exempt children from immunizations were associated with a 90 percent higher incidence of whooping cough in 2011,” the report says.

The Centers for Disease Control and Prevention says the U.S. is having one of its worst outbreaks of whooping cough in 50 years and that 18 people, mostly very young babies, have died. 

Furthermore, the vaccines have been fine-tuned. "Although the number of vaccinations recommended is greater than ever before, the vaccines used in the current immunization schedule actually have fewer antigens (inactivated or dead viruses and bacteria, altered bacterial toxins, or altered bacterial toxins that cause disease and infection) because of developments in vaccine technology. From 1980 to 2000, the immunization schedule’s total number of antigens decreased by approximately 96 percent," the report reads.

More than 90 percent of U.S. children are fully vaccinated by the time they start kindergarten, but some states, cities and towns have rates below that. Depending on the infection, having less than 80 percent to 90 percent of the population vaccinated can cause outbreaks that endanger infants too young to be vaccinated, the elderly, and people such as cancer patients with suppressed immune systems.

And the report notes that most new parents today are too young to remember disease outbreaks of the 20^th century. More than 16,000 Americans children were paralyzed by polio in the 20^th century. None was last year, thanks to vaccines, the report notes. Smallpox, which once killed a third of its victims, has been completely eradicated by vaccination.

But the National Vaccine Program Office, the Health and Human Services Department agency that commissioned the report, needs to listen more to worried parents, said Dr. Albert Berg of the University of Washington in Seattle, who served on the committee.

“We recognize that parents have some concerns. We should understand those concerns,” Berg said in a telephone interview.

“We should be all on the same side on this topic. We all want a safe and effective vaccine supply.”

Related stories:

• Whooping cough epidemic worst in 50 years
• How about a needle-free vaccine?
• Flu and fever linked with autism

Mario Tama/Getty Images

Phamacist Prakash Deshpande injects Judith Echevarria with influenza vaccine at a Manhattan pharmacy. Americans are clamoring for influenza vaccine thanks an an unusually early flu season this year.

Drugs stores running out of vaccine. One company’s supply nearly sold out. An unusually early flu season has Americans clamoring for vaccines and all of a sudden they are scarce.

Yet back in September, public health officials were begging people to get vaccinated. Why the disconnect?

There are four main reasons:

• Flu vaccine is hard to make and it takes months
• Americans are ambivalent about vaccines in general and only want flu vaccines when they are scared (like now)
• Doctors are not paid to encourage and remind patients to get a flu shot, and they are afraid to order too much in case they’re stuck with the extra
• Vaccine makers only want to make as much as they can sell and last year the U.S. threw away 30 million doses

It may be 2013, but the United States still uses technology developed in the 1940s to make flu vaccines. In fact, the process for making next year’s flu vaccine is just starting to gear up right now, even though this year’s flu season is nowhere near to being over.

Experts have to first predict which strains of flu virus will be circulating next year. Influenza mutates all the time and there are different strains, so this is tricky. It’s also the reason people have to get a new flu vaccine every year.

The virus must be isolated from patients’ blood, purified, and injected into chicken eggs to grow. These aren’t just any chicken eggs, either – they have to be fertilized, have a chicken embryo inside and they need to be a certain size. The process is fraught with danger and often breaks down if eggs don’t develop right or if there’s contamination.

Then the virus is purified and made into vaccine. New technology is in the works and Novartis now makes flu vaccine at a factory in Holly Springs, North Carolina, using dog cells instead of eggs—a process that’s slightly faster, easier to control and that can be scaled up more quickly.

The hope is for a universal flu vaccine – one that would work against all strains of flu and protect people for years at a time, but progress is slow.

“A vaccine that would provide protection against all of the known strains of influenza has been a goal since flu vaccine was discovered,” says Dr. John Treanor, a vaccine researcher at the University of Rochester in New York. “It’s not going to be a straightforward, easy shot.”

In the meantime, companies predict how much demand there will be months before flu season even starts, and there’s no way to ramp up production when a season like this one hits and there’s suddenly a surge in demand.

This leads to the next problem: Americans don’t like getting flu shots. It’s the main reason demand is hard to predict. About 128 million people, or about 42 percent of the U.S. population, got immunized against influenza last year. That’s even though the Centers for Disease Control and Prevention says everyone over the age of six months should get a vaccine – every year. More than 30 million doses of flu vaccine never got used and were almost certainly thrown away, according to CDC.

“If people followed the recommendations every year, there would be no shortages,” says Dr. Walter Orenstein of Emory University’s Emory Vaccine Center and a former head of the CDC’s immunization program.

“The first issue is that Americans are pretty deeply divided on whether they think flu vaccination is a good idea,” says Katherine Harris, a RAND Corporation economist who studies flu vaccine issues.

“There are the people that get it and the people that don’t, and the people that don’t get it have pretty bad attitudes about it.”

And people aren’t afraid of the flu, even though it kills as many as 36,000 people in a bad year, including 100 children every year. Flu puts as many as 200,000 people into the hospital every year. But in some years it may be a mild season and kill 4,000 people. This variation lulls people into thinking flu isn’t a problem. “Many people who don’t get flu vaccine don’t get it because they don’t feel they, personally, are at risk,” Treanor says.

The flu vaccine isn’t perfect, either, leading many to think it’s a waste of time to get one. This year’s is only 62 percent effective. On top of that. lots and lots of viruses act like flu – causing coughing, headache, muscle aches and so on – so  many people believe they have flu even if they don’t. But Orenstein says if 80 percent of Americans got vaccinated with this vaccine, it would provide “herd immunity” against flu.

“I have had in the last three weeks two respiratory illnesses,” Orenstein says. “And I was vaccinated. But even if one was the flu, the other one was not. Maybe neither of them was flu.” But such uncertainty can make people doubtful about the value of vaccination.

The belief that flu vaccine causes flu is still rampant, although doctors all agree it’s not true. Many people also fear side-effects from the vaccine. Vaccine regulators and public health experts still remember the 1976 swine flu debacle, when the U.S. government rushed out a mass immunization against a swine flu virus that never spread off one military base.

Several hundred cases of a rare neurological disease called Guillain-Barre syndrome were reported afterward and the incident made many people mistrustful of immunizations.  More recent fears center on a mercury-based preservative called thimerosal, which was taken out of most vaccines after activists claimed it could cause autism. The link is discredited by many scientific studies but suspicion persists among some parents and activists.

Harris says people do trust their personal physicians, but doctors are not usually paid by health insurance companies to talk people into getting flu vaccines, and they aren’t paid much to administer them. Doctors have to compete with pharmacies, big companies that buy up vaccine to give to their employees, and large stores like Wal-Mart and Target to even get vaccine to stock, and they have to eat the cost if they don’t sell all the vaccines they buy to patients.

“It is a cost that comes right off their books,” Harris says. So many don’t even bother.

“We don’t really have a way for compensating health care providers for encouraging us to take preventive steps,” she said. The 2010 Affordable Care Act does have provisions for rewarding preventive medicine, however, which take effect in 2014.

Harris believes that if doctors’ offices worked harder to remind people to get a flu shot, more people would get it, vaccine makers would provide more supply, and flu shot shortages would ease up.

The Trust for America's Health agrees. It recommends that insurers be required to cover flu vaccines under public and private insurance without cost-sharing.  "For instance, currently, 12 states and Washington, D.C. do not require Medicaid to cover flu shots with no co-payment requirements for beneficiaries under the age of 65," the group said in a statement released Tuesday.

The federal government is trying to help in other ways, too. Ten years ago, just four companies made flu vaccines. This year, the U.S. government has licensed vaccines made by seven manufacturers. They include a nasal spray that’s been shown to work especially well in children and a special formulation for older people, whose immune sytems don’t respond as well to vaccines.

The idea is to spread the risk as well as to increase availability. Sanofi Pasteur, which provides about half of the flu vaccine in the U.S., says it has sold out of four of its six formulations of its Fluzone seasonal flu vaccine because of late-season demand.

Companies are wary of making too much vaccine, however, because they can’t re-sell it next year. The flu strains will likely have changed enough to make this year’s vaccine out of date for next year. “It’s not like you can carry it over if you don’t use it,” says Orenstein.

In 2008-2009 the U.S. government shipped 162 million doses of vaccine, but only 90 million were used. And last year 30 million doses or more went unused – most at a loss to the drug makers.

As a result, this year the seven companies made 135 million doses of flu vaccine. So far 128 million have been distributed to pharmacies, doctors’ offices and other providers.

“We have received reports that some consumers have found spot shortages of the vaccine,” Food and Drug Administration commissioner Dr. Margaret Hamburg says in her blog. “We are monitoring this situation and will update you at our Website and at www.flu.gov.” There’s a flu vaccine finder on those websites.

“The flu season usually peaks in January or February, but can extend as late as May,” Hamburg adds – meaning it’s not too late to get a vaccine if you can find one.

“All of us should be encouraging our friends, our neighbors – everyone – to get vaccinated,” Orenstein said. 

• Related links:
• Nasty flu season sparks shortages
• Flu shot isn't perfect
• Flu shot still a hard sell
• Teen death shows flu can kill

Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won't get flu shots, with some workers losing their jobs over their refusal.

"Where does it say that I am no longer a patient if I'm a nurse," wondered Carrie Calhoun, a longtime critical care nurse in suburban Chicago who was fired last month after she refused a flu shot.

Hospitals' get-tougher measures coincide with an earlier-than-usual flu season hitting harder than in recent mild seasons. Flu is widespread in most states, and at least 20 children have died.

Most doctors and nurses do get flu shots. But in the past two months, at least 15 nurses and other hospital staffers in four states have been fired for refusing, and several others have resigned, according to affected workers, hospital authorities and published reports.

In Rhode Island, one of three states with tough penalties behind a mandatory vaccine policy for health care workers, more than 1,000 workers recently signed a petition opposing the policy, according to a labor union that has filed suit to end the regulation.

Why would people whose job is to protect sick patients refuse a flu shot? The reasons vary: allergies to flu vaccine, which are rare; religious objections; and skepticism about whether vaccinating health workers will prevent flu in patients.

Dr. Carolyn Bridges, associate director for adult immunization at the federal Centers for Disease Control and Prevention, says the strongest evidence is from studies in nursing homes, linking flu vaccination among health care workers with fewer patient deaths from all causes.

"We would all like to see stronger data," she said. But other evidence shows flu vaccination "significantly decreases" flu cases, she said. "It should work the same in a health care worker versus somebody out in the community."

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CDC reports flu in 47 states
Bioethicist says: Don't be selfish, get the shot

Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

Medical ethicist Art Caplan says health care workers' ethical obligation to protect patients trumps their individual rights.

"If you don't want to do it, you shouldn't work in that environment," said Caplan, medical ethics chief at New York University's Langone Medical Center. "Patients should demand that their health care provider gets flu shots — and they should ask them."

For some people, flu causes only mild symptoms. But it can also lead to pneumonia, and there are thousands of hospitalizations and deaths each year. The number of deaths has varied in recent decades from about 3,000 to 49,000.

A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

At Calhoun's hospital, Alexian Brothers Medical Center in Elk Grove Village, Ill., unvaccinated workers granted exemptions must wear masks and tell patients, "I'm wearing the mask for your safety," Calhoun says. She says that's discriminatory and may make patients want to avoid "the dirty nurse" with the mask.

The hospital justified its vaccination policy in an email, citing the CDC's warning that this year's flu outbreak was "expected to be among the worst in a decade" and noted that Illinois has already been hit especially hard. The mandatory vaccine policy "is consistent with our health system's mission to provide the safest environment possible."

The government recommends flu shots for nearly everyone, starting at age 6 months. Vaccination rates among the general public are generally lower than among health care workers.

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Bridges said.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Starting this year, the government's Centers for Medicare & Medicaid Services is requiring hospitals to report employees' flu vaccination rates as a means to boost the rates, the CDC's Bridges said. Eventually the data will be posted on the agency's "Hospital Compare" website.

Several leading doctor groups support mandatory flu shots for workers. And the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes; elderly patients are particularly vulnerable to flu-related complications. The American Nurses Association supports mandates if they're adopted at the state level and affect all hospitals, but also says exceptions should be allowed for medical or religious reasons.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work — partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

While not 100 percent effective, this year's vaccine is a good match, the CDC's Bridges said.

Several states have laws or regulations requiring flu vaccination for health care workers but only three — Arkansas, Maine and Rhode Island — spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization policy and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

__

Online:

R.I. union lawsuit against mandatory vaccines: http://www.seiu1199ne.org/files/2013/01/FluLawsuitRI.pdf

CDC: http://www.cdc.gov

Giving kids and teens in a New York community a third dose of the measles, mumps, rubella (MMR) vaccine likely helped halt a mumps outbreak in late 2009 and early 2010, according to a new report from the Centers for Disease Control and Prevention.

U.S. guidelines call for kids to get two doses of the MMR vaccine, one at age 12-15 months and the other at 4-6 years. But as evidence from the Orange County, New York, community shows, mumps can spread in very close quarters even when most young people have received both recommended doses.

The study covers a mumps outbreak in the Orthodox Jewish community, which researchers say began at a religious camp in the Catskill Mountains and was spread by a method of schooling involving close one-on-one contact between study partners, known as chavrusas.

In September through December 2009, close to 400 people became ill in one Orange County village and was concentrated at three local schools.

"Most of these outbreaks of mumps occur in very crowded settings," said Dr. Preeta Kutty, a CDC researcher who worked on the report. "Although the majority of the children (who got mumps) had received two doses of the vaccine, the intensity of exposure overcame that protection."

Because it can take a few days for mumps to cause symptoms, Kutty said infected students may have been exposing their study partners without knowing they were sick.

When other outbreak-control methods such as isolating sick children failed, public health workers stepped in and offered village students in grades 6 through 12 a third dose of the MMR vaccine in January and February 2010.

In their report on that intervention, Kutty and her colleagues found the rate of new mumps attacks in that age group dropped from almost 5 percent of kids in the three weeks before vaccination to 0.13 percent a few weeks after the extra doses were given.

Village-wide, mumps attacks fell from 0.86 percent to 0.21 percent, the research team reported Monday in Pediatrics.

The most common vaccine side effects were redness and swelling from the shot and achy joints and muscles.

Mumps is caused by a contagious virus that causes salivary glands to swell, as well as fever, headache and tiredness. Complications of a mumps infection include inflammation in the brain, testicles or ovaries.

Kutty said even among people in the New York village who didn't get a booster dose of the MMR vaccine, so-called herd immunity likely kept them protected. Out of 2,178 students who had already received two doses of the vaccine, more than 80 percent chose to receive a third during the outbreak.

Still, the researchers can't prove the vaccine was responsible for the drop-off in mumps cases. It's always possible the outbreak had already hit its peak and was on the decline anyway. They emphasized that the study doesn't mean everyone should get a third dose of the MMR vaccine. But in outbreaks, booster shots could be one tool when other infection-control strategies fail, they said.

"We have learned that providing a third dose may be effective in stopping an outbreak," Kutty said.

Dr. Saad Omer, from the Emory Vaccine Center in Atlanta, said that's an important lesson for dealing with future mumps outbreaks, both in the U.S. and elsewhere.

"The vaccine is so safe and the evidence is very reasonable now," Omer, who wasn't involved in the new study, told Reuters Health. "I think (a third vaccine) should be on the list of first-line options for decent-sized outbreaks."

Mumps outbreaks are most common in crowded settings such as college dorms and prisons, he added. So the recent outbreak in religious schools "is not all that unique."

Pediatrician and vaccine researcher Dr. Amanda Dempsey from the University of Colorado Denver said the Orange County outbreak was probably due to a combination of big families and crowded schools as well less than 100-percent MMR vaccine coverage.

She, as well as the study's authors, said the report also highlights the importance of following vaccination recommendations in early childhood.

The boy who first introduced mumps into the Catskill Mountain camp had himself contracted the disease during an outbreak in Britain, where concerns over vaccine safety had led to low vaccination rates. The boy had previously received the standard two doses of mumps vaccine.

"The main way that vaccine-preventable diseases get propagated is through people who aren't fully vaccinated," Dempsey said. "Even small drops in vaccine coverage can have major implications."

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NEW YORK — Colorado doctors mostly support local efforts to give kids their flu shots and other vaccines at school — but they also have misgivings, a new study shows. 

In particular, they threw more support to school flu shots, versus other vaccinations. They were also worried about how school vaccinations would affect their record-keeping and their bottom line.

The study, reported in the journal Pediatrics, looked at doctors' feelings on so-called school-located vaccination — one-day "clinics" where local health officials and school districts offer kids flu shots or other vaccinations.

The programs are seen as a potential way to bring more kids up-to-date with government-recommended vaccinations.

Since 2010, the U.S. has advised nearly all Americans age six months and up to get an annual flu shot.

Even though only a minority follow that advice — about 43 percent of Americans did during the 2010 flu season — that still translates to more than 100 million people clambering for the flu vaccine within the space of a few months.

"To get all of those people into the doctor's office is impossible," said Dr. Judith Shlay of the Denver Public Health Department, the senior researcher on the new study.

In Denver, a project funded by the Centers for Disease Control and Prevention has provided in-school flu shots, as well as vaccinations recommended for older kids and teenagers: the meningococcal meningitis vaccine, the human papillomavirus (HPV) vaccine and the "Tdap" vaccine against tetanus, diphtheria and pertussis (whooping cough).

For the current study, Shlay's team wanted to know how pediatricians and family doctors felt about school vaccinations.

Of the 584 doctors who responded to the survey, most supported in-school flu shots.

About two-thirds were in favor of their privately insured patients getting the shot at school, while around three-quarters liked the idea for their patients on Medicaid.

A financial consideration likely factors in there, since the federal government provides free vaccines for kids on Medicaid, but doctors may have a tough time being reimbursed for the administration costs. Shlay's team found less support for kids getting other vaccinations at school. Half of pediatricians and 59 percent of family doctors were for it when it came to patients with private insurance; 59 percent and 67 percent, respectively, supported it for Medicaid patients.

One concern was that if older kids get all their vaccinations at school, they won't come in for routine checkups. Many doctors also were worried they'd have a hard time keeping their patients' records straight.

"If we give vaccinations in schools and the doctor doesn't know about it, then that's a concern," Shlay said.

There is a way to address that, though. Colorado, and all other U.S. states, have computerized immunization registries that offer a consolidated record of children's vaccination histories.

"That's a really important tool," Shlay said.

But of the doctors in this survey, about one-third were not participating in Colorado's immunization registry.

If more providers get involved in state registry systems, that could help ease worries over record-keeping, Shlay's team writes.

Many doctors were also concerned about their bottom line. Most were at least somewhat worried that if an unpredictable number of patients got their vaccinations at school, their offices would have a tough time estimating how many vaccine doses to have in stock.

Shlay said that's a legitimate concern, since the vaccines for older kids and teens are expensive. (The retail price of the HPV vaccine, for example, is about $130 per dose.)

"If (doctors) end up with unused, expired vaccines, that's a problem," Shlay said. The potential waste, she added, is a concern not only for doctors, but for everyone who needs the vaccines.

So that may mean doctors' offices will need to be more careful in terms of inventory, Shlay noted.

But even if your child gets vaccinated at school, that's not a replacement for checkups with the doctor.

"There's more to health and health care than just vaccines," Shlay noted.

It's important, she said, for doctors, public health officials and schools to all work together to make school vaccination programs effective — and, in the bigger picture, get all kids their appropriate vaccinations.

A government study last year found that that goal is fairly far off: Only 49 percent of U.S. teens had received the first of three doses of the HPV vaccine, while 63 percent had gotten the meningitis vaccine and 69 percent the Tdap shot.

"School-located vaccine programs are an important approach to augment vaccine delivery," Shlay said.

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Just about everyone is supposed to get a flu shot every year, and two groups are particular no-brainers -- pregnant women and health care workers. But new numbers released on Thursday show that fewer than half of pregnant women got vaccinated last year and just two-thirds of health care workers did.

Although they’ve been pushing flu vaccination hard for more than a decade, public health officials admit they are still finding it a hard sell. But it’s not necessarily resistance. It just may not yet be easy enough to get the vaccine. And recent mild flu seasons haven’t helped.

About 128 million people, or about 42 percent of the U.S. population, got immunized against influenza last year. Because flu viruses constantly mutate and evolve, people must get vaccinated with a fresh formula every year to be fully protected. This year’s vaccine protects against the three most common circulating strains.

The best vaccination rates are among babies aged up to 2, with nearly 75 percent vaccinated. That’s because babies make regular visits to pediatricians, and vaccinations are a routine part of those visits. And more than 63 percent of 2- to 4-year-olds were vaccinated last year. But just 29 percent of 18- to 49-year-olds had a flu shot.

Pregnant women are especially vulnerable to flu. Not only do they get sicker, because pregnancy suppresses the immune system, but the infection can lead to losing their babies. The vaccine also protects a woman’s newborn, who cannot get the vaccine until age six months.

“Influenza is five times more likely to cause severe illness in pregnant women than women who are not pregnant,” said Dr. Laura Riley of Massachusetts General Hospital in Boston and the American College of Obstetrics and Gynecology.

But a CDC survey released Thursday showed that just 47 percent of pregnant women had a flu vaccine last year. If their doctors both recommended and provided the vaccine, nearly 74 percent of pregnant women got the shot. Just 11 percent of women whose doctor said nothing got immunized.

Even though doctors have been stressing for years that flu vaccines cannot give people the flu, a full quarter of the pregnant women who refused the vaccine said they believed it would infect them. Another 13 percent thought their babies were at risk.

“Pregnant women worry about everything,” Riley said. “We spend a lot of time in this country talking about you can’t eat this, you can’t eat that. It takes us a little while to get the message out about how efficacious (the vaccine) is. We are preventing a very severe disease potentially and we are protecting your baby.” Vaccination does not raise the risk of miscarriages or birth defects.

Don Emmert / AFP - Getty Images file

A mild flu season last year and memories of the H1N1 pandemic that didn't turn out to be as serious as expected have made flu shots a hard sell to the general public.

Flu may be off many people’s radar because the last two years haven’t been especially bad, and because the 2009 H1N1 swine flu pandemic didn’t turn out to be as bad an initially feared.

Yet, 1,300 children died from H1N1 that year and about 100 U.S. children die every year from flu, half of them previously perfectly healthy, CDC says. The CDC estimates that anywhere between 3,000 to 49,000 people a year die from flu in the United States. A lot depends on the strains circulating.

“Flu is unpredictable. Just because we got off easy last season does not mean we will get off easy this season,” Riley said.

The other group that should have 100 percent vaccination is health care workers. The CDC data show that more than 86 percent of physicians are vaccinated, followed by more than three-quarters of nurses. But the numbers plummet to just half of workers in long-term care facilities, where patients are especially vulnerable to flu.

“I believe that the immunization of the health care provider community is both an ethical and professional responsibility,” said Dr. William Schaffner of Vanderbilt University in Nashville and the National Foundation for Infectious Diseases. “It’s a patient safety issue so that we do not transmit our influenza infection. When an outbreak strikes, we need to be vertical, not horizontal.”

As with the pregnant women, health workers were more likely to get vaccinated if it was easy for them. More than 78 percent of health care workers got immunized if free vaccine was made available for several days at work. And 21 percent of the health workers said getting flu vaccine was now a condition of employment. More employers should consider making it a requirement, said Litjen Tan of the American Medical Association.

This year, 135 million doses of flu vaccine will be available to the U.S. market. People can get vaccinated at pharmacies, at big-box stores, grocery stores, doctor’s offices and often at their places of employment. Most private insurance companies and Medicare pay for the whole cost of the vaccine.

And while the vaccines are not specifically formulated to protect against some new flu strains that a few people have caught from pigs, they may offer some help, health officials said.

So far, the three new variants identified this year --  H3n2v (the little v stands for “variant”), H1N1v and H1N2v -- don’t spread easily from person to person. Almost everyone infected has been close to pigs. One person has died from the new H3N2v virus, but everyone else has recovered.  The CDC’s Dr. Daniel Jernigan says people alive in the 1990s have some immunity to the H3N2 version, and the new H1N1v is close to the strain that the current vaccine targets, although the protection is not perfect.

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