Flu Season Fears: What should you do?

Headlines are making everyone nervous about this year’s flu season. Schools are closing due to high flu numbers. Parents are worried that their child will be the next that dies.

Yes, the risk is real.

But there are things to do.

First: Prevent

Vaccinate

Vaccines are the one of the best inventions to prolong our lives. They really can help. I know the flu vaccine (or any vaccine) isn’t 100% effective, but it does help. Everyone over 6 months of age should get a flu shot.

I’ve heard from many pediatricians taking care of kids hospitalized with influenza, and none of the dying kids were vaccinated.

Kids who were vaccinated this season might get flu symptoms, but generally not as severe.

It does take 2 weeks for the vaccine to be effective, so get it ASAP. Kids under 9 years old who haven’t been vaccinated for flu previously will need 2 doses a month apart. Call around to see where you can get it.

If your kids (or you) are scared of shots, check out these tips.

Not convinced? Check out these 10 Reasons to Get the Flu Vaccine.

Wash hands

Wash hands often. This goes without saying. Whatever you touch stays on your hands. When you bring your hands to your face, the germs get into your body. Teach kids to wash hands well too!

Cover!
cough, cold, urgent care, primary care, medical home
Cover your cough!

Teach kids to cover their cough (and sneeze) with their elbow. This collects most of the germs in the elbow. Hands touch other things, so if you cover with your hands, you need to wash them before touching anything.

The only time I don’t recommend the elbow trick is if you’re holding a baby. Their head is in your elbow, so you should use your hands to cover and wash often!

You can get masks at the pharmacy to cover your nose and mouth to protect yourself from catching something and to prevent spreading an illness you have. We have masks available for anyone who comes to our office. We ask those who are sick to wear them, but those who are well can also put them on to prevent catching something!

In my office you’ll see that most of our nurses and clinicians have opted to wear masks when seeing sick kids even though we all have had our flu vaccine!

Avoid the T-zone

Avoid touching your face. It’s a horrible habit that most of us have. Be conscious of how often you wipe your mouth, eyes, or nose. Those are the portals to our body. Avoid touching them unless you can wash your hands before and after. Show kids how the eyes, nose and mouth make a “T” and teach them to not touch their T-zone.

Stay home when sick.

I’ve heard many angry complaints from parents about exposures. One mother was sick because she was exposed at work and then her illness spread to her family. She was especially upset because the exposure was from a child of a co-worker who brought the child to work because the child was sick and couldn’t go to school.

Keep sick kids home. If you’re sick: stay home.

If you’re sick with a flu-like illnesss, don’t
  • run to the store.
  • send your child to school with ibuprofen.
  • go to work.
  • go to your child’s game.

Stay home unless you need to seek medical attention.

Tamiflu and other anti-virals

My office is getting inundated with phone calls requesting us to call out Tamiflu. In some instances it’s appropriate for us to prescribe it for prophylaxis, but often we want to see your child first. If your child has flu-like symptoms, I do not want to prescribe a treatment without first evaluating your child. I don’t want to miss a more serious case that needs to be hospitalized. I don’t want to treat bronchiolitis or another condition as flu and miss the proper treatment. More on treatment with Tamiflu below.

Prophylactic uses

Tamiflu can be used for prophylaxis after exposure, but don’t rely on it. (If you follow my blog, you know I’m not a Tamiflu fan.)

Newborns

Some of the calls we are getting are from mothers with influenza who have newborns and their OB’s have recommended prophylaxis for the baby. If the baby is under 3 months of age, Tamiflu is not approved for prophylaxis. (See the chart and corresponding footnotes from the CDC below.) If you are sick, try these tips to prevent spreading illness to your kids.

Community exposures

Many calls are from parents worried about a classroom (or other) exposure in a child who is not high risk. Unfortunately we cannot and should not use Tamiflu for routine exposures. Tamiflu itself is not without risk and if overused it will not be available for people who might really need it.

Big event coming soon!

A big birthday party, a big test, a planned vacation, etc do not make your child high risk. We really shouldn’t use Tamiflu inappropriately just because flu will make life inconvenient. Remember that all treatments have potential side effects and if we use them indiscriminately they will not be available when really needed.

Tamiflu prophylaxis is recommended for high risk people who have known exposure.

High risk includes:

  • children under 2 years of age
  • adults over 65 years of age
  • persons with chronic lung (including asthma), heart (except hypertension alone), kidney, liver, hematologic (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury)
  • persons with immunosuppression, including that caused by medications or by HIV infection
  • women who are pregnant or postpartum (within 2 weeks after delivery)
  • under 19 years of age receiving long-term aspirin therapy
  • American Indians/Alaska Natives
  • persons who are morbidly obese
  • residents of nursing homes and other chronic care facilities

Prophylactic and treatment options are summarized in this table from the CDC:

Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza
Antiviral Medications Recommended for Treatment and Chemoprophylaxis of Influenza

Finding Tamiflu

Right now it’s hard to find Tamiflu in many parts of the country, so you might not be able to get it after you’re exposed (or even if you’re sick with flu).

What’s better than Tamiflu?

Flu season can last through April, so taking it for 10 days now won’t help in 2 weeks when you’re exposed again. The flu vaccine protects more effectively and for a longer duration!

If sick: Treat

Most flu symptoms can be treated at home.
Fever and pain reducers

Use age and weight appropriate pain and fever reducers, such as acetaminophen and ibuprofen to keep kids comfortable. It is not necessary to bring the temperature to normal – the goal is to keep them comfortable. Don’t fear the fever – it is the immune system hard at work!

Offer plenty of fluids

Infants should continue their breastmilk or formula as tolerated. Older kids can drink water and it’s okay for them to eat. There is no need to avoid foods if a child wants to eat – I don’t know where the “feed a fever starve a cold” or other common myths started. Of course, appetite is usually down during illness, so don’t push foods. Push fluids.

Saline and suction

Saline and suction can go a long way to help relieve nasal congestion. Noisy breathing isn’t necessarily bad, but if the breathing is labored that’s another story. Check out the Sounds of Coughing to learn how to identify various breathing problems.

Cough medicine?

Pediatricians don’t recommend cough medicines due to high risk of side effects. Kids over a year of age can use honey. Some kids can get relief from menthol products. I’ve previously written all about cough medicines if you want to read more.

Natural treatments?

A lot of parents want to do natural treatments. Learn which have been shown to work and which haven’t.

For more…

For more on treating symptoms, visit my office website’s tips.

when not to go to the doctor

Not every person with influenza needs to be seen by a medical provider. I know we’re all scared, but in most cases there isn’t much doctors and other healthcare professionals can do to help.

Medical offices, urgent care clinics and ERs are overwhelmed with mildly sick people, which makes it harder for those who are really sick to be seen.

If your child is low risk (anyone who doesn’t meet the high risk criteria above) and is drinking well, overall comfortable with support measures, and doesn’t have any breathing distress, you can manage at home. Certainly if the situation changes, bring him in, but coming in before any signs of distress will not “ward off” the development of those symptoms.

When you should bring your child to be evaluated

If you think your child might have another illness, such as Strep throat, ear infection or wheezing, bring him in for evaluation and treatment.

When any signs of distress are noticed in your child: bring him in.

If your child is high risk (as described above) and has sick symptoms, he should be seen to determine if Tamiflu is appropriate. I do not recommend getting Tamiflu called in if a child is symptomatic. A child should have an exam to be sure there aren’t complications before just starting Tamiflu. I’ve seen several kids whose parents thought they had flu, but their exam and labs showed otherwise. They could be properly treated for Strep throat, ear infections, or pneumonias instead of taking Tamiflu inappropriately after an evaluation.

How can you tell if it’s the flu or another upper respiratory tract infection?

I have seen many kids who are brought in with a runny nose just to see if it’s early flu. No. No it’s not. Flu hits like a tsunami: fever/chills, cough, body aches, and fatigue. But the child was playing in the waiting room full of kids who do have flu, so you might recognize flu symptoms soon.

cold vs flu
From the CDC: How to tell if it’s a cold or the flu?

If your low-risk child had the flu vaccine, they may still get influenza disease. But if it’s mild, they can be treated at home. If symptoms worsen, they should be seen. Yes, there is a benefit to starting Tamiflu early, but we shouldn’t use it for low risk people who aren’t significantly sick. Even if you come in early, Tamiflu probably won’t be recommended if your child doesn’t meet criteria. Tamiflu has some significant side effects and is in short supply. We shouldn’t overuse it.

Flu testing

We currently have the ability to do a rapid flu test in the office, but there is a national shortage of the test supplies, so we might choose to not test your child if they don’t meet high risk criteria. I know at least one local hospital is out of rapid test kits and we probably won’t be able to get more this season if we run out.

Don’t come to the office or go to an urgent care or emergency room just to be tested.

Please don’t be upset if we do not test your child, especially if your child is not high risk and we wouldn’t recommend Tamiflu if they are positive.

If your child has classic flu symptoms, the guidelines don’t rely on test results for treatment, so if your child meets criteria for treatment, we can prescribe without a positive test.

Knowing test results doesn’t really help guide treatment when we have such high numbers of flu in the community. It does help early in the season to recognize when flu is coming to town, but we know it’s here. Pretty much everywhere in the US, it’s here.

Let’s work on stopping the spread.

Be healthy!


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The flu shot doesn’t work

I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.

How do they know it isn’t working?

Influenza can be deadly.

Most of the kids I’ve seen with flu who have had the shot aren’t that sick. Yes, they have a fever and cough. They aren’t well.

But they’re not in the hospital.

They’re not dying.

They tend to get better faster than those who have unvaccinated influenza.

Some kids still get very sick with influenza despite the vaccine.

That’s why there’s surveillance to see how it’s working.

When FluMist was determined to not be effective, it was removed from the market.

Studies are underway to make a new type of flu vaccine that should be more effective.

We know the shot isn’t perfect, but it’s better than nothing.

Maybe if you weren’t vaccinated you’d be a lot sicker.

Maybe you were exposed to another strain of flu and didn’t get sick at all.

I think it’s still worth it to get vaccinated each year (until they come up with a vaccine that lasts several seasons).

If everyone who’s eligible gets vaccinated against the flu, herd immunity kicks in and it doesn’t spread as easily. Historically only around 40% of people are vaccinated each year against influenza. We know that to get herd immunity we need much higher numbers.

Shot fears…

If your kids are scared of shots, check out Vaccines Don’t Have to Hurt As Much As Some Fear.

Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.

Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.

Prevention’s the best medicine.

Learn 12 TIMELY TIPS FOR COLD AND FLU VIRUS PREVENTION.

Get your flu vaccine. #fluvaccine #vaccineswork
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It’s not the flu!

I was at the gym today and an otherwise great instructor who seems to know a lot about health was sharing incorrect information about the flu with the class of about 40 people. She said that she had received several texts from other instructors asking her to cover their classes because they were vomiting. Then she went on to say that many at first thought it was food poisoning, but it’s spreading like illness, so it’s the flu, not food poisoning. She made a big deal that the flu is here. Is vomiting from the flu?

She’s only partially right.

Yes…

There’s a stomach bug going around.

It’s not food poisoning.

Influenza is in town.

But this extreme vomiting is not “the flu”

vomiting from the flu
Vomiting can be associated with influenza, but is not the main symptom.

The flu causes predominantly fever, cough, sore throat, and body aches for many days. It can cause vomiting and diarrhea, but those aren’t usually the predominant symptoms. And the flu doesn’t cause just a few hours of extreme vomiting like we’re seeing these days.

Why do I care if people call this stomach bug “flu”?

Runny nose is one of the symptoms of influenza.

The biggest reason I care is that it leads people to make other incorrect assumptions and to get the wrong treatments.

I hear all the time that people had the flu the year they got a flu shot, so they don’t want to get it anymore.

When probed about their illness, it’s usually not consistent with the flu. It was either a cold and cough or a stomach virus.

If they think a common cold or vomiting is from the flu, they’re mistaken.

They need to know that this isn’t the flu.
Cough is one of the most common symptoms of influenza, along with fever, sore throat, and body aches.

Common colds and vomiting are not prevented with the flu shot.

The flu shot has nothing to do with protecting against most cases of vomiting and diarrhea or most upper respiratory tract infections.

Of course there are people who got the flu shot (or FluMist when it was available) who did come down with the flu. They had a positive flu test and symptoms were consistent with the flu. But if they get influenza after the vaccine they tend to have milder symptoms. They tend to not end up in the hospital or dead if they’ve had the vaccine. Yes, even healthy young people can end up very sick from influenza. They can even die. (The FluMist didn’t protect well and was removed from the market due to this.)

We forget about all the times people did get the vaccine and they didn’t catch the flu even with likely exposure. Lack of disease is easy to fail to acknowledge.

We know the flu vaccine is imperfect. But if the majority of people get vaccinated, we can slow the rate of spread and protect us all against influenza most effectively.

We don’t have great treatments for influenza, so vaccinating and using other precautions is important!

Tamiflu: The not-so-great influenza treatment

Over the years I’ve written a lot about Tamiflu because I have strong feelings about its use. Here I’ll summarize what I’ve learned over the years because during flu season I get many requests for Tamiflu (oseltamivir). Understandably parents fear the flu once they see how miserable their kids are when it hits their house, but I don’t like to use Tamiflu because I just don’t think it works well and it has quite a few side effects.

The pressure’s on…

In recent years I’ve felt coerced into writing more prescriptions for Tamiflu due to the powers of the guidelines recommending it. It’s more common in my experience to hear negative feedback about side effects than it is to see patients get better faster. (Note: this is a very biased view, since those who are better would not call, but since so many call with side effects it seems fair to say I don’t like the drug.)

I am not alone in my dislike of Tamiflu. I follow a listserv of pediatricians around the country and many share my views. In a discussion of influenza and antivirals, one doctor suggested watching a TED Talk by Dr. Ben Goldacre: What doctor’s don’t know about the drugs they prescribe.  Dr. Goldacre starts talking about Tamiflu specifically about 10:10, but the entire lecture is done in an entertaining and informative manner if you have the time.

I feel deceived.

When I practice medicine, I follow standard recommendations and guidelines that are based on peer reviewed articles and data. The question is, what important data is left out? There is a movement to solve this problem of unpublished studies. You can see updates at the Tamiflu Campaign of the British Medical Journal.

The WHO has downgraded Tamiflu’s status, but I haven’t seen the CDC or AAP comment on that.

Back to influenza treatment…

First, current influenza treatment guidelines regarding the use of antivirals:

From the CDC’s recommendations for antiviral use for influenza
Summary of Influenza Antiviral Treatment Recommendations
  • Clinical trials and observational data show that early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of complications from influenza (e.g., otitis media in young children, pneumonia, and respiratory failure).
  • Early treatment of hospitalized adult influenza patients has been reported to reduce death.
  • In hospitalized children, early antiviral treatment has been reported to shorten the duration of hospitalization.
  • Clinical benefit is greatest when antiviral treatment is administered early, especially within 48 hours of influenza illness onset.
  • Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who:
    • is hospitalized;
    • has severe, complicated, or progressive illness; or
    • is at higher risk for influenza complications.
  • Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk with confirmed or suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.
That last statement is what really gets me confused.

I know that influenza can be deadly.

And that we should try to do everything in our power to help prevent severe illness and death.

But to treat any healthy person with suspected flu with a medicine that hasn’t been shown to be very effective and has side effects seems unreasonable to me.

Because it’s a guideline, if a physician chooses not to give antiviral treatment and there is a bad outcome, they could be held liable.

Despite the research.

I think this option also encourages people to not get the vaccine because they think they can just treat it if they get the disease. It’s not that easy…

look at what a search for “unpublished tamiflu trials” shows.

For those of you unfamiliar with the Cochrane group: They are a well respected group that reviews all the studies within certain parameters on one topic to evaluate the overall findings of several independent studies.

From the Cochrane Group:

A review of unpublished regulatory information from trials of neuraminidase inhibitors (Tamiflu – oseltamivir and Relenza – zanamivir) for influenza.

These results are from a review of published and unpublished studies that they could find.

From the abstract:

“The authors have been unable to obtain the full set of clinical study reports or obtain verification of data from the manufacturer of oseltamivir (Roche) despite five requests between June 2010 and February 2011. No substantial comments were made by Roche on the protocol of our Cochrane Review which has been publicly available since December 2010.”

They found several problems with Tamiflu from the studies they were able to review:
  • Drug manufacturers sponsored the trials, leading to publication and reporting biases. One of the authors reported that 60% of the data was never published. This is over half of the research, and I suspect it didn’t support use of the medicine (remember the company that benefits from selling the medicine was doing the trials…)
  • There was no decrease in hospitalization rate for influenza in people treated with Tamiflu.
  • There was not enough evidence of prevention of complications from influenza. Design of the trials (again by the people who make the drug) did not report the prevention of complications from influenza, such as secondary infections.
  • There is not evidence in the trials to support that Tamiflu reduces spread of the virus. One of the main reasons people request the medication is after exposure to prevent illness! (Note: this might have changed because the indications on the package insert now say it can be used to prevent illness in those over 1 year of age and they were previously not allowed to mention prophylaxis.)
  • Tamiflu reduced symptoms by 21 hours. Yep. Less than one day of fewer symptoms. For the cost of the drug and the potential side effects, is feeling sick for 1 day less really worth it?
  • There was a decreased rate of being diagnosed with influenza in those randomized to get Tamiflu, probably due to an altered antibody response. The authors suspect a body becomes less able to make its own antibodies against influenza when taking Tamiflu.
  • Side effects were not well documented. A review study done in children exclusively (Neuraminidase inhibitors for treatment and prophylaxis of influenza in children: systematic review and meta-analysis of randomised controlled trials) focused on treatment of disease and prevention of illness after exposure.
Findings included:
  1. Symptom duration decreased between 0.5 and 1.5 days, but only significantly reduced symptoms in 2 of 4 trials. That means in 2 of 4 trials there was no significant reduction in symptoms.
  2. Prophylaxis after exposure decreased incidence by 8% of symptomatic influenza. This means for every 13 people given Tamiflu to prevent disease, one case will be prevented. Not great odds.
  3. Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
  4. Tamiflu was associated with in increased risk of vomiting. About 1 in 20 children treated with Tamiflu had an increased risk of vomiting over the baseline vomiting due to influenza.
  5. There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.
Investigators have documented their discussions with the maker of Tamiflu on Tamiflu correspondence with Roche.

 

Recent studies have tried to compile all that is known about how oseltamivir works:

Results from this study include:
  • In the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.7 hours, 29 hours in children.
  • There was no difference in rates of admission to hospital between treatment groups in both adults and children.
  • Oseltamivir relieves symptoms in otherwise healthy children but has no effect on children with asthma who have influenza-like illness.
  • Using oseltamivir had no significant effect on admissions to the hospital.
  • Oseltamivir causes gastrointestinal disturbances in both prophylaxis and treatment roles. In prophylaxis, it caused headaches, renal events (especially decreased creatinine clearance), and psychiatric effects.

So what do I recommend during the cold and flu season?

    1. Get vaccinated! The influenza vaccines have been shown to help prevent influenza and are very well tolerated with few side effects. If you or your children are due for other vaccines, be sure to get caught up. Even if they aren’t a perfect match, some protection is better than none, and if more people get the vaccine herd immunity helps!
    2. If you get sick, stay home until you’re fever free without the use of a fever reducer for at least 24 hours! Don’t spread the illness to others by going to work or school. The influenza virus is spread for several days, starting the day before your symptoms start until 5-7 days after symptoms start– kids may be contagious for even longer. You are most contagious the days you have a fever.
    3. Wash hands well and frequently. If you can’t use soap and water, use hand sanitizer.
    4. Cover your cough and sneeze with your elbow or a tissue.
    5. Avoid close contact with people who are sick. But remember that people spread the virus before they feel the first symptoms, so anyone is a potential culprit!
    6. Don’t share food, drinks, or towels (such as after brushing teeth to wipe your mouth) with others.
    7. Don’t touch your eyes, nose, and mouth — these are the portals for germs to get into your body.
    8. Keep infants away from large crowds during the sick season.
    9. Frequently clean objects that get a lot of touches, such as keyboards, phones, doorknobs, refrigerator handle, etc.
    10. Avoid smoke. It irritates the airway and makes it easier to get sick.
    11. Remember that many germs make us sick during the flu season. Just because you’ve been sick once doesn’t mean you won’t catch the next bug that comes around. Use precautions all year long!
    12. Did I mention that you should get vaccinated?

Because the guidelines recommend Tamiflu as above, I will probably be forced to prescribe it by worried parents who hope that their kids will feel better. (You’ve heard of defensive medicine, right?)

Key Point:

Influenza is a miserable illness. The key is prevention.

I’ve had my vaccine, how about you?

If you’re worried about the injection, check out Vaccines Don’t Have to Hurt As Much as Some Fear.

A physician’s story of his sister dying of influenza despite being overall healthy and getting good medical care: Even With All Our Modern Medicine, I Watched My Sister Die From Flu

Added 1/14/18: I just saw this story about a girl with very scary hallucinations from Tamiflu. I’ve heard these stories before. It’s not as uncommon as the story might lead you to believe.

Further Reading:

Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children: A link is available to the full text of the study by T Jefferson, MA Jones, P Doshi, CB Del Mar, CJ Heneghan, R Hama, and MJ Thompson.

 

Tamiflu status downgraded!

Those of you who follow my blog or are my patients know that I’ve never been a fan of Tamiflu. I’ve written To Tamiflu or Not To Tamiflu and I’ve posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC’s recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn’t completed because the kids don’t tolerate it well – usually vomiting, but occasionally they’ve had scary hallucinations. I haven’t seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).

WHO Downgrades Tamiflu

The World Health Organization (WHO) has recently downgraded the status of Tamiflu. The CDC and FDA will have to chime in for the US recommendations, but the WHO is a respected source of medical guidelines and I look forward to a response from the CDC.

Risks vs benefits

As I’ve said before, Tamiflu doesn’t seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren’t published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.

2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.

Will the CDC join in?

I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn’t perfect, but it does help keep us from getting sick and it can help save lives!

 

tamiflu
Tamiflu is an antiviral used against influenza, but there are many questions of safety and efficacy.