Each fall, health providers in the central San Joaquin Valley try to anticipate when doctors' offices and hospital emergency rooms will be filled with flu patients.
But guessing this year's flu arrival could be a particularly thorny challenge and require the use of some new electronic tools, including Google Flu Trends that can give a "real time" map tracking the spread of the illness.
Doctors generally get an idea of the flu's due date by following the federal Centers for Disease Control and Prevention's weekly FluView report, which tracks the influenza virus as it moves across the country. This year, however, the health agency has been hobbled by furloughs forced by the partial government shutdown. The CDC has not updated its flu report since mid-September.
Valley doctors say the report is an important tool in spotting flu trends, such as a new emerging strain or the virulence of a virus. Last year, for example, the weekly monitoring gave county health departments a heads-up that the flu season was coming early and hitting patients hard.
The CDC also plays a big role in promoting flu vaccination, and doctors say this year there's a vaccine option for the elderly and a four-strain vaccine that the public needs to know about.
"We really will be at a disadvantage if the flu season starts without the national government being back in operation," said Dr. Randy Bergen, the clinical lead for Kaiser Permanente Northern California's flu campaign and a pediatric infectious disease specialist.
But while the CDC's FluView is idled, there are other resources available that give a nationwide picture of flu activity, one of which predicts the arrival of the flu using a tool that most people associate with checking a movie time, buying a concert ticket or finding a restaurant.
Googling the flu
Probably the best known of the new trackers is Google Flu Trends, which takes search engine data -- people using search terms related to flu or influenza -- to map flu activity.
The site follows search queries from across the country and a number of countries and gives daily updates of flu activity.
Google launched the site in 2008. It's a complement to surveillance systems used by the CDC and public health agencies, said Kelly Mason, a Flu Trends spokeswoman.
"The goal is for Flu Trends to help both public health officials and the public make more informed decisions about preparing for and responding to the flu season," Mason said.
But the new tracking tools have limitations, health experts said.
Any mechanism to signal the beginning of flu season is welcome, Bergen said. Web-based surveillance programs, however, rely more on anecdotal information than scientific surveillance, he said. "It's not something you can be as confident about as the rigorous surveillance that goes on in our lab and the national lab with the CDC."
David Luchini, assistant director of the Fresno County Department of Public Health, said he looks at Flu Trends, but doesn't rely on it. "Our epidemiologist doesn't feel like it's very accurate."
Flu Trends was criticized for overestimating the severity of the disease in the 2012-13 season. But, Mason said, "the model worked well to show the start, duration and peak of flu season."
Flu Trends analyzes its performance each year and updates are made to the model, if needed, she said: "Stay tuned for more information on that update later this month."
Using medical records
Electronic medical records have made another flu-tracking resource available to public health officials.
Last week, athenahealth, an Internet-based health information technology and services company in Massachusetts, announced it would share its flu findings with public health agencies. The company says it has nearly 44,000 medical providers and 40 million patient records in its network.
The company knows when a doctor sees someone and suspects influenza, said Josh Gray, vice president of athenaResearch at athenahealth. "We're monitoring diagnoses as they occur."
Gray said the company's data on flu vaccinations correlates closely with CDC data. But the research is not meant to supplant the CDC's surveillance methods, he said. "They are the gold standard."
County health departments and the state keep tabs on flu activity, collecting information from doctors and hospitals. State surveillance, however, offers only one snapshot, said Dr. Gil Chavez, deputy director for California's Center for Infectious Diseases and state epidemiologist at the Department of Public Health. "In real time, we know what is happening, but we don't have that early warning that we would have from the CDC."
So far, flu activity has been limited across the country, and health experts hope the CDC's FluView will be back before an influenza outbreak occurs.
Promoting the vaccine
For now, the biggest concern is how the government shutdown has curtailed promotion of the flu vaccine, which is the best defense to stop the spread of the influenza virus.
"It may not be flu season, but it is flu vaccine season," Bergen said.
This year the public has several vaccine choices, which can be confusing.
Among the products is a stronger dose of vaccine for people age 65 and older.
Health experts know that the flu vaccine works better to protect younger people than older ones and suspect it's because the elderly have weaker immune systems. The higher-dose vaccine is supposed to address that.
The vaccine is available largely for health providers who serve a lot of seniors, Chavez said. The higher-dose vaccine is not offered by county health departments, and the elderly may have to request the vaccine from their doctors. Larger chain pharmacies such as CVS carry it.
At a Fresno County flu-shot clinic at the Senior Village in southeast Fresno last week, people lined up for a regular flu shot. Tom Booth, supervising public health nurse, said the higher-dose vaccine's effectiveness has not been proven and studies continue. "There's no evidence that it works any better in seniors," he said.
Grace McCoy, 81, a Senior Village resident, was taking advantage of the county clinic and was confident the vaccine she got would protect her. She said she never misses getting the vaccine: "I don't want to get the flu." McCoy said her sister died of the H1N1 "swine flu" in 2009.
There's also a four-strain vaccine available this year that includes protection from two influenza B strains instead of one, and also from two influenza A strains. But the supply of "quadrivalent" vaccine is not as great as a three-strain "trivalent" vaccine, which has protection for one influenza B strain and the two influenza A strains. The state has provided county health departments with the three-strain vaccine, and officials believe it will provide sufficient protection.
"When you go to your doctor to get a vaccine, some providers will have the trivalent available and some may have the quadrivalent -- and some may have both," Chavez said.
The main point medical providers want patients to know is the importance of getting a flu shot, Chavez said -- no matter which kind. "Influenza can be a very serious illness and this is the time to get vaccinated, and by taking that very easy step, you can give yourself and your family peace of mind."
Nereida Romero, 37, of Fresno, heeded that advice and got a flu shot at the Senior Village. She has children -- and she works for two seniors -- both vulnerable groups for flu complications.
Seeking proof that flu shots work? "I have to get a flu shot every year," Romero said -- adding that she's never had the flu.
Flu-shot clinic information
• Fresno County: county web page or (559) 600-3200
• Kings County: county web page or (559) 852-2579
• Madera County: county web page or (559) 675-7893
• Merced County: county web page or (209) 381-1200
• Tulare County: county web page or (559) 624-8000
The reporter can be reached at (559) 441-6310, email@example.com or @beehealthwriter on Twitter.