Posted tagged ‘flu’

A cold, the flu, or sinusitis? Part 3: Myths

October 15, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

You might not like to hear it, but the truth is….

 

Nothing really works well to treat these things

Colds, flus, and sinusitis all share some things in common—and the most important one is that just about all of us get these, and they make us miserable, and we want them to go away. Billions are spent on all sorts of things to treat these conditions, both from pharmaceutical companies and from companies that make supplements and other alternative-health nostrums. We’ll try just about anything. But if clinical studies reliably show that just about nothing really helps, why do we keep buying them?

I think the most important factor is simple human nature, and the way that symptoms change. If you have a cold, the symptoms get better and worse throughout the day—so if you take medicine or supplement XX when you feel really bad, the natural ups and downs average out, and you’ll feel better. But: you would have felt better anyway! Still, human nature, you took the magic beans (that you paid for), then you felt better, so there must be a connection, right?

That happens at the end of an illness, too. Let’s say you’ve had a cold for 6 days, and you go to the local get-me-some-drugs at the QuickieClinic. You get some antibiotics, and a few days later you start to feel better. Boom, QED, there’s all the proof you need. (BTW, docs are pretty much just as bad about giving out unnecessary antibiotics, too.) But: you were going to get better anyway.

Think about this, it’s really important: many symptoms occur like a mountain, with an up and a down. If you try therapy at the top, when you’re feeling bad, you will feel better. But that doesn’t mean that the therapy was why the mountain went downhill.

 

Flu shots work

The effectiveness of flu vaccines varies from year to year, but typically runs ~ 50-75% — that’s pretty good, really, for a health intervention (it’s much better than, say, the effectiveness of taking a cholesterol-lowering drug to prevent a heart attack. And some people take those every day for years.) It does mean, though, that in a family with say four people who’ve gotten flu vaccine, one child may not be well protected. That’s why it’s important for the whole family to get it.

Also: flu vaccines only prevent the flu. They don’t prevent colds. And they take 3 weeks or so to “kick in” – you don’t get instant protection.

 

Flu shots cannot cause the flu

MythsNo. They can’t, and they don’t. They can sometimes cause a little fever or achiness, but that is not the flu—and anyone who’s actually had the flu will tell you that these mild symptoms after a flu vaccine are pretty much nothing. Sometimes, right after a flu vaccine, someone does get the flu—that’s because we’re giving flu vaccines during flu season, and if you don’t get it in advance it can’t protect you. The vaccines take about 3 weeks to work. If you catch influenza right after getting the flu vaccine that’s called “bad luck” or “bad planning”, not “bad vaccine.”

 

Green snot means sinusitis

No, green snot means it’s been sitting around up your nose (you’ll often notice this overnight), and your white cells are busy fighting off the viral infection. Good for your white cells. Go blow your nose, and stop looking at the color—it doesn’t matter what shade it is.

 

Flu tests are needed to diagnose flu

Commercially available flu tests aren’t very good—they give a lot of false negatives (a negative test even in the setting of flu), and some false positives (a positive test in a person without flu.) Many health care facilities don’t even use them. A flu test can be helpful, sometimes, if I’m on the fence about a diagnosis, but they’re really just not very reliable to help make decisions about treatment.

 

Cold weather causes colds

Colds are caused by viruses, one of many from families called “rhinovirus” and “coronavirus” and others. They’re not caused by cold weather. BUT there is a germ of truth here: cold air in the nose can make it more likely that these viruses can be transmitted. Grandma may have been right!

 

I’m sure there are other myths, feel free to add your own in the comments!

 

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

A cold, the flu, or sinusitis? Part 2: Treatment  

October 12, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The previous post was about the symptoms of colds, the flu, and sinus infections—they’re not the same. This time, we’ll cover their treatment. And, surprise, it turns out that treating all of these is pretty much the same.

Style: "Neutral"

The most important part of treatment is rest and comfort. Get more sleep, and stay out of school or work until feeling better. That helps you and your children recover, and hopefully prevents the spread of illness. Drink more fluids, and have some soup.

To treat aches and pains, use acetaminophen or ibuprofen. It’s better to use these around-the-clock for a few days rather than just when symptoms become bad—these medicines are better at preventing pain and fever than treating pain and fever.

Treating nasal congestion is all about drainage. Use a humidifier and/or nasal saline spray. If your child is old enough, sometimes OTC decongestants given orally or as a nasal spray can help some, but they’re certainly not miracle drugs.

Coughs are annoying, but they’re there for a purpose: to get mucus up and out. If a cough is bothering your child, one of the best treatments is ordinary honey (for age 12 months and up.) Older children can sometimes benefit from OTC cough suppressants, but, again, they don’t work great. If your child has asthma, it’s probably a good idea to start up rescue medications during a cough.

There are a few more-specific treatments, depending on the diagnosis. If it’s influenza, a specific anti-viral medication (usually Tamiflu) can help some if started within the first 24-48 hours of symptoms. But the benefits of this medicine are modest at best. Tamiflu does not prevent serious complications, and only reduces symptoms by a little bit. Most people with influenza won’t notice any huge improvement with Tamiflu.

Sinusitis is typically treated with antibiotics, though even then the benefits of antibiotics are often over-stated. Studies looking at populations of both children and adults, comparing active antibiotics versus placebos, have shown really limited benefits to using antibiotics to treat sinusitis, at least ordinary, uncomplicated cases. And, of course, these same studies show that people taking antibiotics are much more likely to experience side effects and adverse reactions than those taking placebos.

The good news is that whatever you do, you’re going to get better. Whether it’s a cold, the flu, or sinusitis, symptoms will get better with or without treatment—though you’re going to be feeling sick for a while. If that’s the case, why does it seem like Tamiflu, antibiotics, OTC supplements, and all sorts of other things “work”? Next up, Part 3: Myths.

 

The whole series:

A cold, the flu, or sinusitis? Part 1: Symptoms and Diagnosis

A cold, the flu, or sinusitis? Part 2: Treatment

A cold, the flu, or sinusitis? Part 3: Myths

Some bad news about flu this year

December 8, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

We could be in for a rough influenza winter.

First, data just released from the CDC shows that a lot of the flu circulating in the USA isn’t a good match for the strains in this year’s flu vaccines. About 82% of flu since autumn is a type A H3N2, one that historically has been associated with more-severe illness. Of those, only about half are closely related to the A/Texas/50/2012 strain that was chosen in February to be included in the vaccine. Unfortunately, current methods of vaccine production take a long time, and manufacturers have to commit early—months ahead of time—to what will be included in the vaccines. In February, when the World Health Organization made their recommendations for the Northern Hemisphere 2014-2015 flu vaccine, they chose the H3N2 that was then in circulation. Since then, it’s “drifted”, or changed, to a related but non-identical type.

What this means is that the current vaccine is well-matched to only about 40% of circulating flu. The vaccine will probably offer some protection against the other 60%– illness will be milder and shorter—but a lot of people who got their flu vaccines are still going to get the flu, and spread the flu. Now, some protection is still better than none, so I’d still go and get that flu vaccine now if you haven’t gotten it already. An imperfect (or, honestly, far-less-than-perfect) flu vaccine is better than none. But it isn’t looking good this year.

And it gets worse. It’s becoming increasingly clear that Tamiflu, the anti-viral medication we rely on to help treat influenza, doesn’t work very well. As summarized by the Cochrane Collaboration earlier this year, studies show that Tamiflu is only modestly effective in reducing the length of influenza illness, and may be only slightly effective at reducing complications. If it does work for treatment of flu, it works best when started very early in the course of the illness. The FDA labeling calls for it to be started within 48 hours, but honestly it seems to barely work if started that late. Better to get it started within 24, or even better, 12 or 6 or 2 hours.

In practice, Tamiflu really doesn’t seem to do much of anything for most of the flu patients seen in hospitals and doctor’s offices, because we usually see patients too late. It does have a role in helping family members at risk for flu. They can start it immediately, at the first symptoms, and will probably get more benefit.

Tamiflu can also be used as a prophylactic, or preventive, agent in people exposed to flu with no symptoms, though again, the benefits are modest at best. Crunching the numbers, we probably have to treat about 33 people on average for just one person to benefit from prophylaxis. That’s not very good, especially considering that all 33 people will have to pay for it and risk the side effects.

And Tamiflu does have some significant side effects. Nausea and vomiting are quite common, but the scarier reactions are depression, hallucinations, and psychosis. Neuropsychiatric side effects are most common in people of Japanese ancestry.

So: the flu vaccine, this year, will probably offer only modest benefits. And Tamiflu really has very limited usefulness. It looks like we’d better prepare for a rough winter, and keep in mind some of the old-fashioned ways to keep from getting the flu:

  • Stay away from sick people.
  • If you’re sick, stay home.
  • Keep your mucus to yourself—sneeze into your elbow, or better yet into a tissue. And then wash your hands.
  • Don’t touch your own face. Flu virus on your hands doesn’t make you sick until you help it get into your body by touching your eyes, nose, or mouth.
  • Wash or sanitize your hands frequently, and especially before touching your face or eating.

Pregnant women should get influenza vaccines to protect their babies and themselves

August 4, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

The kids are heading back to school, and my zucchini vines are withered—that means summer’s almost over, and we’re heading back into flu season. This year, I’m going to try my best to convince as many of you as possible to get yourselves and your children vaccinated.

Why? Because I don’t like to see people suffer and die. We’ve got a good, safe, effective way to prevent influenza—and the more people vaccinated, the better it works. There are very few medical contraindications, and the CDC recommends that everyone aged 6 months and over get the vaccine each year. That helps protect us all.

Today I’m going to focus at the beginning of the life cycle, with pregnancy. We’ve known for a long time that pregnant women are especially prone to complications and death from influenza infection, and ACOG (The American Congress of Obstetricians and Gynecologists) has recommended since 2010 that women receive a dose of injected influenza vaccine during pregnancy. Uptake has been poor, in part because of lingering safety concerns.

There have been several recent studies that provide solid reassurance about the safety and effectiveness of influenza vaccines during pregnancy. In 2013, the New England Journal published a study from Norway that looked at 117,347 pregnancies—vaccinated moms were less likely to get influenza, and less likely to have their babies die. Another study, BMJ 2012, looked at about 55,000 pregnancies in Denmark, showing no increased risk of birth defects, preterm birth, or fetal growth problems after vaccination. That same Danish group published a second study from their data set showing no increased risk of fetal death. The Danish studies looked rigorously for adverse reactions, finding no support for any significant problems, though these studies were not designed to look at the effectiveness of the vaccines.

The effectiveness of these vaccines has already been demonstrated, both to protect mom and to protect baby. Pregnant women ought to make the safe choice: get vaccinated against influenza. It’s the right thing to do for you, and the right thing to do for your baby.

Does the influenza vaccine work? A small observational study

December 30, 2013

The Pediatric Insider

© 2014 Roy Benaroch, MD

Flu season is in full swing here, and I’m seeing dozens of feverish, miserable kids a week. Since it started early this year, maybe that means influenza will burn out and be over soon—but maybe not. Some years we get a “double dip” as a second strain of flu moves through town.

Influenza does a very good job of working its way through our communities each year. The symptoms of flu, including runny nose and cough, make transmission of infected mucus almost guaranteed.  And the virus itself, already very contagious, changes over time– so neither natural infection nor immunizations provide reliable lasting protection.

Though far from perfect, influenza vaccinations should be an important part of your family’s flu prevention strategy. Their effectiveness varies from year to year, but is probably overall in the range of 50-70%. Not great, but if even half of the cases of flu could be prevented, that’s a whole lot less misery, and far fewer people continuing to spread infection. Remember: for every case of influenza prevented, that’s fewer exposures for the rest of us.

I get asked a lot: how’s this year’s vaccine doing? Does it work? So a few days ago I collected data from my practice. I copied out the log book we keep of flu tests from 12-18-2013 to 12-24-2013—this is a list of all of the rapid flu tests we did in one of my two offices, the names of the patients and the results of the tests. Then I went back through their charts to see if they had been fully vaccinated against influenza this year.

Here’s the data, raw, in a “2×2 contingency table”:

Vaccine Yes Vaccine No total
Flu test POS 2 14 16
Flu test NEG 9 9 18
Totals 11 23 34

I’m not going to go into big-time statistics with this—I’m not pretending that this was a full-scale, professional study. This was just a convenience sample of kids who had flu tests done in my office over a few days in December. But what it does show is striking:

  • If you had a flu vaccine, your chance of testing positive for influenza was about 20%.
  • If you didn’t have a flu vaccine, your chance of testing positive for flu was 60%– three times the risk.

For you statistics types, I did plug these numbers into a web-based statistics package, and based on the Chi-Square calculation for a 2×2 contingency table the difference was statistically significant with p<0.05. However: I’m not 100% sure I did that right. I’m not swearing by my statistical chops here. Anyone out there with a good statistics background: if you want to chew on the data, please do, and post in the comments what you’ve determined.

Now, to be honest, there are some big-time caveats to this “study.” We didn’t systematically test people based on certain criteria. Each doc decided who to test, and it’s possible that some of my docs would be more or less likely to test people depending on whether they had had a flu vaccine. The test itself isn’t perfect—though a positive test is quite reliable, it’s possible that a negative flu test misses up to even 50% of true flu cases. The study wasn’t a randomized clinical trial- whether or not each child was vaccinated was up to the parents, and could have been influenced by their individual child’s risks of influenza exposure. And I didn’t look at the timing of the vaccines that were given—it’s possible that some kids in the “Vaccine YES” column received their vaccines too late in the season to be effective, and should have been counted as “Vaccine NO.” Furthermore: I only had access to my own records. Some of the “Vaccine NO” children could have gotten flu vaccines elsewhere.

Still: from this small sample, it looks like flu vaccines were strongly effective at preventing influenza in children at my practice.

More on preventing and treating influenza

Influenza is here

October 31, 2013

The leaves are changing, there’s a nip in the air, and I’m making plans to steal my kids’ Reese’s tonight. And to make Halloween just a little scarier: we’ve got our first case of influenza, right here in Atlanta!

I don’t know if this will be a mild, moderate, or severe flu season—but even in the mildest years, we’re going to see a lot of miserable kids and families in our office, and a handful of really sick, hospitalized children. While nothing can give you 100% protection, one of the best ways to help keep your kids, yourself, and your neighborhoods healthy is for all of us to get the flu vaccine. It’s not too late! Go, now, get vaccines for your family to protect yourselves. Do the safe thing.

If you do get the flu—the aches, the fever, the misery—stay home. The best treatment is rest and fluids and maybe acetaminophen or ibuprofen. Anti-viral medications like Tamiflu are expensive, nauseating, and not very effective. Still, for high-risk cases it’s the best we’ve got.

You know what they say: an ounce of prevention is worth a pound of Tamiflu. Or something like that. Go get your vaccine!

Previously:

How to transmit influenza to your friends and enemies

Preventing and treating influenza

The CDC’s influenza page, including links to maps showing current influenza activity nationwide

Can a face mask prevent flu?

January 14, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

We’re still swamped with flu at the office—this year is bad, bad, bad. I’ve recently written about preventing and treating influenza, and another detailed piece about exactly how flu is transmitted and how to protect yourself.

What about face masks? You see them on TV this time of year, and maybe you’ve seen them at your doctor’s office. Should flu patients wear masks? Should all of us?

There’s some evidence supporting the use of masks to prevent transmission of flu to healthy people. Studies have looked at both household and dormitory transmission of flu, and healthy people who routinely wear masks are less likely to contract flu, even when people sharing living quarters have influenza. The effect is largest when mask-wearing is combined with hand washing, vaccinations, and other steps to limit contagion.

As far as putting a mask on people who themselves have the flu: I could find no studies showing that this actually works. It does make sense to keep flu victims out of the workplace and away from other people, and perhaps putting a mask on them will also help. But it’s not clear that this will really make a difference.

Why would wearing a mask help prevent a healthy person from catching flu? A cough from a flu patient within three feet of your nose or eyes can transmit flu, so perhaps a mask could block that (there is no evidence that this is actually true.) More importantly, wearing a mask will remind you NOT to touch your nose or mouth. So even if you do get contaminated, infectious mucus on your hands, it won’t get you sick.

I’ve covered the best ways to prevent flu before: avoid sick people, wash your hands, don’t touch your face, and get immunized. Perhaps wearing a face mask can also help (I don’t recall these guys getting the flu!) Hopefully, this year’s flu season will burn out soon, and most of us will make it through OK. Next year, be sure to get that vaccine, OK?