Flu shot anyone?

The flu vaccine.  What do we need to know to decide if we want to get it for ourselves and for our kids?  I am going to be honest.  This is a difficult post to write.  There are strong emotions associated with vaccinating and not vaccinating our children.  

Children, even healthy children, can die from the flu.  How many die each is year varies with the circulating virus and the severity of the flu season.  The worse season was the 1918-1919 pandemic when more than 20 million people died. 

Some day I should write an "Immune System 101" post.  But here is a quick description.  The immune system has two kinds of "troops" for fighting a virus or a bacteria.  It had general or non-specific troops and it has specialized or specific troops.  The general troops are the first responders.  They catch a virus.  If the body has seen it before it usually will have specialized troops that are more efficient at killing the virus.  If it has these specialized troops, the immune system will send them out and quickly make more for the fight.  If you have enough of these troops you don't get sick.

If you don't have specialized troops, you body develops them so it can fight the virus.  But this takes time and the general troops may not be able to keep up.  That is when you get sick. 

Usually, adults' immune systems have seen a flu virus and have some specialized troops available to attack a flu virus, but in the 1918 virus "looked" different enough that for most people specific immune system did not recognize it .  And that is why so many people died that season.

You have heard the phrase use it lose it?  That applies to your specialized troops.  If your body doesn't ever use the specialized troops for flu, it may stop making them.  So based on all of this information about the flu, it is thought that by getting the vaccine each year, people will not only be able to avoid getting the flu this year, but the immune system may become better at recognizing it.  Possibly even strains that are not in the vaccine. 

Worst Case Scenario

So, to basically make an informed decision about the flu shot, we need to have an idea of what is most likely to happen if you or your child gets the flu and look at the worst case scenario.  I discuss this more here.  But depending on your child’s health and age, most likely he would be sick for a week or two with fever, cough, runny nose, and sneezing.  He could get an ear infection, pneumonia, or other complication. He could be hospitalized.  You could be hospitalized if you catch it as well.  Worst case scenario is death. But the risk of catching the flu depends on your environment.  

I have a relatively high risk of catching the flu as a healthcare provider seeing sick kids during flu season with my own children attending public school.  Someone else who works from home and homeschools their children is going to have much less exposure to the flu virus.

The h1n1 Swine Flu virus vaccine shot for Emilio. Side effect symptoms: "Squeal like a Pig", a photo by Dj Crazy Gabe on Flickr

 

Effectiveness

We also need to know how effective the vaccine is and what all the possible consequences or side effects of the shot are.   From my review of the literature there is not a clear answer to how effective the vaccine will be.  This is because effectiveness changes each year depending on the circulating virus and the match of the vaccine.  And it depends on how old the people receiving the vaccine are and whether they get the TIV or LAIV.

Oops, I just threw some abbreviations at you.  Let me explain.  The TIV stands for the trivalent (or three strain) inactivated (killed) vaccine.  LAIV stands for live attenuated influenza vaccine.  It is a nasal spray.  The only live flu virus that is FDA approved in the United States is FluMist. According to the CDC,

“the nasal spray flu vaccine does contain live viruses. However, the viruses are attenuated (weakened) and cannot cause flu illness. The weakened viruses are cold-adapted, which means they are designed to only cause infection at the cooler temperatures found within the nose. The viruses cannot infect the lungs or other areas where warmer temperatures exist”.

Back to effectiveness.  Overall, the flu shot is effective approximately 50-70% of the time.  Meaning, your immune system responds to the vaccine enough to protect you from the virus slightly better than half of the time.  The flu shot effectiveness is higher for kids under 6, and slightly better for FluMist in this age group.  The injection seems slightly better for healthy adults.  And there is not enough evidence for effectiveness in adults over age 65.  Actually, in reading the evidence, numbers seemed to vary greatly.  In fact, some meta-analyses showed the effectiveness at less than 50% for healthy adults.  And many of the studies are funded by the pharmaceutical company who manufactures it.  I agree with the call for more publicly funded (not potentially biased) studies at each age group.  I will list links to the research I looked at following the post.

Reactions and Side-Effects

OK, on to reactions to the vaccine.  All the vaccines are made with eggs, so an allergy could cause an allergic reaction to the vaccine. "Although," according to Children's Hospital of Philadelphia (CHOP),

"the influenza vaccine is made in eggs and some people are severely allergic to eggs, the quantity of egg proteins in the vaccine is insufficient to cause a severe allergic response. But just to be sure, people with severe egg allergies should remain at their provider's office for about 30 minutes after receiving the influenza vaccine."

There may be an extremely small chance of experiencing Guillain-Barre syndrome after immunization, but this has not been shown in current studies. Most people have soreness at the injection site if they receive a shot.  People who get FluMist could have cold symptoms: runny nose, fever, fatigue, aches, chills, or sore throat. There is no evidence of death as an adverse reaction to the flu shot or FluMist.  However, according to the recent Lancet article more research is necessary on "potential harms".

Recently, the CDC has been investigating whether there is an increased risk for seizures following a influenza shot.  It appears that in children under 5 who also receive a Prevnar shot on the same day, there may be an increased risk for febrile seizure.

Many people also consider the preservative and other components in the vaccine.  Thimerosal (mercury-based) is used as a preservative in some flu shots and is left over from the process of creating the flu vaccine in other shots.   If the flu is in a multi-dose vial, it will have a preservative in it.  If it is in a single dose it usually does not have Thimerosal.  Fluvirin single dose has trace amounts  .FluMist is always prepared as a single use and does not have a preservative in it. To see which vaccines have Thimerosal look here and to learn more about it look here.  By the way none of the the flu vaccines have aluminum in them.

Formaldehyde.  Yes there is a small amount of formaldehyde is all flu vaccines.  But, small amounts of formaldehyde is present in the human body already.  According to CHOP,

"First, formaldehyde is essential in human metabolism and is required for the synthesis of DNA and amino acids (the building blocks of protein). Therefore, all humans have detectable quantities of natural formaldehyde in their circulation (about 2.5 ug of formaldehyde per ml of blood). Assuming an average weight of a 2-month-old of 5 kg and an average blood volume of 85 ml per kg, the total quantity of formaldehyde found in an infant's circulation would be about 1.1 mg, a value at least five-fold greater than that to which an infant would be exposed in vaccines."

Finally, in my research on the flu shot I came across a great post from healthyfellow with more options for preventing the flu.

References

Look at the CDC, FDA, and CHOP sites for more information.
 
Jefferson T, Di Pietrantonj C, Rivetti A, Bawazeer GA, Al-Ansary LA, Ferroni E. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD001269. DOI: 10.1002/14651858.CD001269.pub4.

Manzoli L, Ioannidis J, Flacco M, De Vito C, Villari P. Effectiveness and harms of seasonal and pandemic influenza vaccines in children, adults and elderly: A critical review and re-analysis of 15 meta-analyses. Human Vaccines & Immunotherapeutics 2012; 8:851 - 862; PMID: 22777099; http://dx.doi.org10.4161/hv.19917.

Osterholm MT, Kelley NS, Sommer A, Belongia EA.  Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis.  The Lancet Infectious Diseases - 1 January 2012 ( Vol. 12, Issue 1, Pages 36-44 ) DOI: 10.1016/S1473-3099(11)70295-X  

10 things to prevent the flu, pt 2

1.       Get a flu shot.

2.       Wash your hands frequently.  Teach your children to wash their hands frequently at school or use hand sanitizer.

3.       Keep hands away from eyes, nose, and mouth.

4.       Cough and sneeze into your elbow.

5.       Clean hard surfaces

6.       Get enough sleep

7.       Exercise just enough

8.       Reduce stress and Laugh!

9.       Eat a nutritious diet

10.    Avoid sugar

Yesterday we talked about  1-5 and today we are continuing with last 5.
6.  Get enough sleep.

This one is one of the hardest for me.  With four kids, one teen who wants to stay up late and a baby that is up to nurse during the night…well, you get the picture.  But studies (including Bryant PA; Trinder J; & Curtis N. and Teodorescu MC; Teodorescu M.) continue to show a correlation to between illness and either not getting enough sleep or getting too much sleep.  So how much sleep do you need?  And what about your kids?  Here is a chart from the National Sleep Foundation.

7. Exercise just enough

  In nurse practitioner school I learned that if you don’t exercise at all, you are more likely to get sick.  And if you exercise too much, you are more likely to get sick.  So, like sleep, the trick is to get just enough.  When I looked at the current research, it is still showing the same thing.  Moderate exercise most days leads to an improved immune system, while prolonged or intense exercise suppresses the immune system.  According to the Cleveland Clinic the general idea is to get 20-30 minutes of moderate exercise about 5 days a week.  So, what if you are an athlete?  Or if you have a child who is an athlete and exercises hard several days a week?  Take a look at the BASES guidelines.

8.  Reduce stress and Laugh!

According to Glaser and Kiecolt-Glaser, “Several studies have provided convincing evidence linking stress-induced immune dysregulation with morbidity and mortality.  Animal models that involve viral infections have confirmed that stress can exacerbate morbidity that is associated with a viral infection.”  That means that when someone is under stress their immune system works differently and this has been linked with people being more ill and also with death.  Another study shows the flu vaccine did not create immunity as well in individuals who were experiencing moderate stress.

There are many different healthy ways to reduce stress.  Try to notice if your children are under stress and help them find ways to unwind.  Exercise, yoga, an enjoyable activity, prayer, meditation are all good ways to reduce stress that our children can learn.  Besides preventing the flu, they will have learned a skill that will serve them for life.

Laughing has been shown to reduce stress and improve immune system function.  It doesn’t even matter why you are laughing.  You can laugh for no reason at all and it still has the same effect.  One of the ways we have used this in my family is by having “Laugh fests”.  One of us would declare a laughfest and then we would all laugh for no reason at all.  When we first started the laugh was fake, but after a few minutes the laughs became real and everyone had a good time.  It was so much fun and we all enjoyed it.

9.  Eat foods high vitamins and minerals

Zinc, selenium, iron, and antioxidant vitamins have all been shown to have an effect on children’s immune systems and infections. Lack of protein and or zinc can also affect the immune system.   (Look at this study).  The best way to get the vitamins and minerals is by eating foods that are high in these vitamins.  You might consider a supplement in some cases.  I personally supplemented Miss Froggie off and on when she was two and three with Vitamin C and Echinacea.  From what I understand Echinacea does not speed recovery from a virus, but may prevent getting one in the first place.  It seems to work best when used on and off instead of daily.

If you are feeding your family whole, real foods with plenty of fruits and vegetables you have this one covered.  One of the great things about eating local foods in season is that the foods are fresher and have more vitamins and minerals in them.  If you are looking for online resources for teaching kids about nutrition check out Departing the Text.

10.  Avoid sugar

  To my knowledge, there is only one study from 1973 that has been done investigating the role of sugar on the immune system.  100 g of glucose, fructose, sucrose, honey, or orange juice all caused the immune system to consume fewer bacteria.  100 grams of a sugar is about the same as in two 12-ounce sodas.  This is only one study.  Recent studies have found a relationship between a high-fructose diet and increased inflammation.  Inflammation and infection are both regulated or taken care of by the immune system.  Maybe there is a connection.  I’m not sure.  This might be a good time to look at my disclaimer.

As I was writing today’s post, I realized how much more there is to say on each of these 5 topics.  And how many of them are easy to know but hard to put into practice.  Some of them are easier to control for our kids than for ourselves.  And, when I am under stress I am likely to do poorly on the others on the list.  What ideas do you have for encouraging each other to live healthy and teach our kids the same?  Do any of the above five things really interest you? 

10 things to prevent the flu

Yesterday we talked about seasonal influenza and its symptoms. Today we are talking about what to do to prevent the flu at your house and why it works. Originally I was going to explain all 10 today, but the post was HUGE! So I’ve broken it up into two days. Today I’ll cover the first five on our list of ten: How to prevent the flu by keeping the flu virus from making a home in your respiratory tract. Tomorrow, we’ll talk about last, which five prevent the flu by keeping your immune system strong enough to fight off the virus. All of them except the flu shot will also help prevent other viruses during the cold and flu season.

1. Get a Flu Shot.
I know a lot of people object to getting a flu shot for various reasons. This one deserves its own post so I’ll give the flu shot an entire post next week. I’m not going to try to convince you. Just give you the information so you can decide wisely what is best for your family. If you were planning to get the flu shot but haven’t done it yet, now is the time.

2. Wash your hands.
The flu is believed to spread through droplets produced when an infected person coughs, sneezes or talks. If these droplets find their way to the eyes, nose, or throat of another person the virus can grow and cause that person to develop the flu. Studies show that the flu virus can live on your hands for at least an hour after touching the virus. Washing your hands removes the virus. To do this effectively you want to scrub your hands for 20-30 seconds with hot water.

Antibacterial soap is not necessary and may make you more likely to have infection. Because the flu is caused by a virus, and antibacterial soaps kill bacteria not viruses. The antibacterial soaps can also kill the good bacteria on your hands which could leave room for more resistant bacteria. At home good hand washing with regular soap is usually the best solution. Don’t take my word for it, check what the CDC has to say. The guidelines are different if you are a healthcare professional. Again check the CDC article.

If your kids are at school and do not frequently have access to soap and water, than an alcohol based hand sanitizer is the next best choice. In both hand soap and sanitizer avoid products with triclosan because it has been linked with other health problems that you can read more about on the EPA’s site. I just recently became aware of this when I was reading at Kitchen Stewardship.

3. Keep hands away from eyes, nose, and mouth.
If you can keep hands from touching your eyes, nose, and mouth, then you can avoid bringing the virus from your hands to the areas where it can grow and make you sick. This one is a lot easier to say then do. I mean most kids are touching everything including faces.  Theirs and yours. And babies love to grab everything and put it in their mouth. If you have kids that are too young to teach not to touch, that makes the hand washing and cleaning more important.
 If you have bigger kids you might try to make it a game. Maybe something like a reverse chore chart. Start with a number of stars and every time your child touches eyes, nose or mouth take a star away. The kid with the more starts left at the end of the day wins something special.

CC Image courtesy of SCA on Flickr

4. Cough and sneeze into your elbow.
The goal here is to keep the droplets with potential viruses out of the air and off hands. If you cough into your hand and then touch something before you wash your hands then you have left germs somewhere. I think the schools are pretty good about teaching this. At least mine have come home and told me that they were encouraged to cough into their elbows.  If your kids are too little to learn to use their elbow, you might try a tissue.

5. Clean hard surfaces
Cleaning is most important if you have had someone in the house that is ill. The flu virus cannot live very long at all on soft surface, but according to the CDC it can survive on hard surfaces for 2-8 hours. The good news is that alcohol, hand dish soap, and 5% vinegar have all been shown to kill the flu virus. If you clean with a commercial product, check the label to see if it kills the flu virus. Remember, antibacterial does not mean antiviral.
OK, so tomorrow we will be onto the things to do to keep your immune system at its best.
See my disclaimer here.

Flu season has begun

 Seasonal Influenza or "the Flu"

Flu season starts in October and can continue to as late as May. Usually there are the most number of cases in January or February. Wyoming and Minnesota are already reporting cases this year.  So here is what you need to know.

Seasonal influenza, commonly called “the flu” is caused by one of several influenza viruses.  The flu has 

symptoms like fever, headache, body ache or sore muscles, tiredness, cough, runny nose, and sore throat.  Some people also have vomiting with the flu.  The flu is not the same thing as a stomach bug.  So vomiting and diarrhea without sore throat, cough, and/or runny nose is unlikely to be the flu.

I really hate to get the flu.  I have had it twice and it puts me in bed for days. When I see patients who have the flu, they just look miserable.  As a medical provider, I always order a flu test during flu season for fever with headache, body ache or sore throat.   But, sometimes I feel like you can just look at a person and guess they have the flu.

CC Image courtesy of ragesoss on Flickr

You are usually sicker with the flu than with a cold.  You keep fever longer (4 or more days). You feel worse.  And you are more likely to have complications from it.   Each year about 20,000 children are hospitalized from flu complications like pneumonia. You might even need to take your child to the the emergency room for the flu.There are flu related deaths each year.  In the 2011-12 flu season there were 34 pediatric deaths.  That was a mild year.  In 2009-2010 there were 282 pediatric deaths.  That was an extreme year.  Children under 5, adults over 65, pregnant women, Native Americans, anyone with medical conditions such as asthma are more likely to have flu complications.  It is therefore more important for them and their families to take preventive measures from getting the flu.  One of the preventive measures is the flu shot.  In a later post we will talk about the flu shot and other preventative measures in depth.

Seasonal Influenza comes in different strains: Influenza A (H1N1, H3, H3N2v, H5N1) and Influenza B.  Most rapid flu tests will indicate only flu A or B.  A test must be sent to the lab to get more specific information about the strain.  The CDC tracks hospital and clinic information and puts it on the internet so anyone can look and see how many cases have been reported and what type of virus is causing illness.

Viruses adapt and change to their environment.  Most people are aware that one of the difficulties treating HIV comes from how quickly the HIV vaccine adapts. The influenza virus does not change as quickly as HIV, but it does adapt and there are frequently new variants.  H3N2v is one of the new variants.  So was H1N1 in 2009.  Viruses can also become resistant to an antiviral medication, just as bacteria become resistant to antibiotics.

Antivirals

Because influenza is a virus, antibiotics do not speed recovery from the flu.  But, there are two antiviral medications that are FDA approved for the treatment influenza: Tamiflu (oseltamivir) and Relenza (zanamivir).  Tamiflu is for children over the age of 1 year and Relenza is for children over the age of 7 years.  Relenza is not recommended for children with a chronic respiratory disease like asthma.  Both antivirals can have side effects like nausea, vomiting, diarrhea.  Tamiflu can sometimes cause people to be confused or try to harm themselves.  This seems to happen more in Japanese adolescents or adults.  Relenza can cause upper respiratory infections like ear infections, bronchitis, and sinus infections which is part of why it is not recommended for people with chronic respiratory illnesses.

Antivirals can reduce the symptoms of the flu and also the number of days symptoms occur.  Antivirals work best when started within 48 hours of the first symptoms.  For really bad cases of the flu medical providers will sometimes still prescribe antivirals even after it has been 48 hours.

Concluding Thoughts

It stinks to have the flu.  Nobody wants to get it, and we all want to keep our children from getting it.  First, because they feel miserable and it lasts longer than other viral illnesses.  Second, because sometimes it can cause severe illness and cause a hospitalization or worse.  So come back tomorrow when we will talk about how to prevent your families from getting the flu.