At press time, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices was expected to release recommendations for immunizing target populations against the novel 2009 H1N1 (pandemic) virus and for setting priorities in the likely event of a limited initial vaccine supply. Even with that guidance, though, I'm sure a lot of questions will remain about how this is really going to work.

Rolling out the pandemic influenza vaccine to appropriate high-risk groups, while also keeping up with seasonal influenza immunizations, is going to be highly challenging and complex.

For starters, if the virus continues to be less virulent than expected for a pandemic, it may be difficult to convince even high-risk populations to get vaccinated. And should the virus mutate and become more virulent, how can we get people to stick to the priorities advised by ACIP, especially when the vaccine is likely to be administered in a variety of settings outside of physician offices? And, as additional vaccine supply becomes available, how can we quickly alter the public health message to match the epidemiology of the pandemic and encourage the right people to get their shots?

The only thing that seems clear at this point is that the future of the 2009 H1N1 pandemic virus is unpredictable. The fact that it has persisted through the summer is in itself unusual, and we should be prepared for infection rates to increase this fall when school is back in session.

So what can primary care physicians do right now to prepare their offices?

Make sure that you and your staff are vaccinated, as soon as vaccine is available, against both seasonal and pandemic influenza. The immunization of health care providers should be considered high priority, so set up a system for following up with your staff to make sure that everyone receives vaccine against both seasonal and pandemic flu. Remember that the pandemic vaccine will probably require two doses. Don't assume that everyone is immunized. Data show that up to one-half of health care providers are not immunized against the seasonal flu.

Chemoprevention strategies will change depending on the resistance pattern and availability of antiviral medications. Offices could stock oseltamivir (Tamiflu) or zanamivir (Relenza) to use as chemoprevention for staff until they are fully immunized, but that would be an expensive strategy and the added value over rigorous infection control practices is unknown.

It's probably wise to call your local pharmacy and ask if there is likely to be a problem getting the amount of antiviral medication you would need to treat yourself and your staff, should that become recommended.

Chemoprevention of health care staff might be recommended if the virus becomes more virulent as health care workers are waiting to finish a two-dose schedule of vaccine. Make a few calls now to see where supplies could be located should you need chemoprevention drugs quickly.

If patient volume has tapered during the summer months, use the time to do some in-service training on hand washing (wash-in, wash-out practices) for all staff with patient contact. Proper hand washing or sanitizing reduces the risk of infection and needs to be performed correctly and consistently. Teach your staff members by showing them what you want them to do. While the public health message on hand washing has been stressed, the reality is that many clinical settings have become somewhat lackadaisical about enforcing infection control practices.

Also take the time now to check on the supply of personal protective gear such as gloves, masks, and eye protection and review with your staff appropriate use of protective gear for all routine procedures that can lead to exposure to the virus. This includes collecting oropharyngeal and nasopharyngeal specimens for the laboratory.

Stock up on tissues and hand sanitizer and delegate the job of keeping those items in plentiful supply in the patient waiting area and exam rooms. Put up signs instructing patients to use respiratory hygiene in the clinic and instruct staff to politely point out to patients when they are not covering their coughs and sneezes.

Take some time now to do some strategic thinking about how you could maximize your office space to triage and separate potentially infectious patients should the pandemic hit your local region particularly hard. Consider rearranging the appointment schedule so that patients with infectious conditions are seen toward the end of the day.

Finally, delegate someone on your staff to check the local health department Web site regularly, as well as the site of the Centers for Disease Control and Prevention (www.cdc.gov/h1n1flu/

▸ Who should receive the vaccine in order of priority.

▸ Who should be treated with antivirals if ill (and what antivirals to use).

▸ Who should receive antivirals prophylactically (and what antivirals to use).

Preparing for H1N1's Uncertain Future