10 Reasons Not To Get the Flu Vaccine, Reconsidered: Fight Flu!

Influenza is not a just a bad cold. People sick with with the flu can suffer from fevers, cough, sore throat and body aches. It can lead to complications, many of them severe, and death. Complications include pneumonia, ear infections, and sinus infections. Since 2010, influenza has resulted in between 9.2 and 35.6 million illnesses, between 140,000 and 710,000 hospitalizations and between 12,000 and 56,000 deaths each year. 

There's good news though. There's a vaccine to help prevent the flu.

There are many reasons people don't get the flu vaccine, but many of those reasons deserve a second thought.

1. The flu vaccine doesn't work. 

While it's true that the vaccine has variable efficacy, it's important to get the vaccine each year. The more people vaccinated, the less likely the flu will spread through a community. Take a look at this really cool representation of how herd immunity works. How it was developed is described on IFLS.

No one claims that the vaccines against influenza work perfectly. The influenza virus can mutate by shifting and drifting. Until there's a universal flu vaccine, we must rely on experts to look at the viral patterns and predict the strains that will be most predominant in the upcoming season and make a vaccine against those strains.

Despite not working 100% of the time, the flu vaccine has been shown to lessen the severity of illness and decrease hospitalizations and deaths. Even if there's not a perfect match, it can still help those who are vaccinated have a lesser illness. That's worth something.

2. I got the flu from the vaccine.

The influenza vaccine that is currently available cannot cause the flu. Only live virus vaccines can lead to forms of the disease. The vaccines available in the US this season are either an inactivated or a recombinant vaccine. These do not cause flu symptoms. The vaccines cannot mutate to cause symptoms. They simply don't work that way.

There are many reasons you could have gotten sick after a flu vaccine that were not due to the vaccine.

1. You were exposed to influenza before the vaccine had time to take effect and protect. 
2. You  caught a strain of influenza that wasn't covered in the vaccine. 
3. You caught one of a number of other viruses that cause flu - like illness. 
4. The vaccine did cover the type of virus you have but your body didn't make the proper protection from the vaccine so you were still susceptible. 

In each of these scenarios, you still would have gotten sick if you hadn't had the vaccine, but if you recently had the vaccine it's easy to understand the concern that the vaccine caused the illness.

The FluMist is a live virus vaccine, so it could cause mild symptoms of influenza viruses, but it is not recommended for use in the US this year.

3. I can prevent the flu by being healthy.

It is important to eat right, exercise, get the proper amount of sleep, and wash hands. All of these things help keep us healthy, but they don't prevent the flu reliably.

We cannot boost our immune system with megadoses of vitamins. (Vaccines are the best way to boost our immune system.)

Organic and non-GMO foods don't offer any benefit to our immune system over other healthy foods. If these things did as some claim, people generations ago would have been healthier since they ate locally grown organic foods, got plenty of fresh air, and exercised more in their day to day life than we do these days. Instead of being healthier, they were much more likely to die from infections. The risk of death between the first and 20th birthday had decreased from over 3 in 100 children in 1900, to less than 2 in 1000 children today. One of the major causes of death historically (and still today) is from influenza, but it has been shown that the flu vaccine reduces the risk of death. Why not help your body prepare for flu season with the vaccine?

4. Flu vaccines shouldn't be used during pregnancy -- they've never been tested and can lead to miscarriage.

Pregnancy is considered a high risk condition for severe complications of influenza disease and the vaccine can help prevent those complications. It is recommended that all pregnant women get vaccinated against influenza. If a pregnant mother gets the vaccine, it not only helps to prevent complications during pregnancy, but it also helps prevent influenza in newborns since they can't be vaccinated until 6 months of age.

There are some who assert that since the package inserts state the vaccines have not been studied in pregnancy that they aren't safe, but in the next breath they say that they aren't safe because a study showed a high rate of miscarriage after the vaccine.

The first part of the argument is one of the many ways the package insert is misused. Discussions about using package inserts properly are found at The Logic of Science, another at The Logic of Science, Skeptical Raptor, Harpocrates Speaks, and even this analogy of Package Insert Airline to vaccine package inserts.

Think about it... you can't argue that it's never been studied and then quote a study. It's been studied. A lot. The Vaccine Safety Datalink is a huge database designed to document adverse events associated with vaccination, allowing researchers access to a large amount of data.  

The flu vaccine has been safely given to pregnant women for over 50 years. Despite a recent small study suggesting a potential risk of miscarriage, the flu vaccine has been studied extensively around the globe and found to be not only safe but effective at decreasing the risk of influenza disease during pregnancy and beyond.

5. I have a chronic illness and don't want to get sick from the shot.

People with chronic illnesses (including diabetes, heart conditions, and asthma) are more at risk from serious illness from influenza disease. The influenza vaccine can prevent hospitalizations and death among those with chronic diseases. People with chronic diseases should be vaccinated, as should those around them to protect with herd immunity.

The flu shot cannot make anyone sick, even those who are immunocompromised. You do not need to avoid being around someone who is sick or immunocompromised if you've recently been vaccinated.

6. If I get the flu I'll just take medicine to feel better.

There is no medicine that makes people with influenza feel better reliably.

There is no medicine that decreases the spread of influenza to friends and family of those infected.

We can take fever reducers and pain relievers, but they don't treat the underlying virus. They suppress our immune system so we don't make as much inflammation against the virus, which decreases the symptoms and our body's natural defenses.

Cough and cold medicines simply don't work well.

As for antiviral medicines, I have written about Tamiflu previously and why I rarely recommend it.

Megadoses of vitamin C or other vitamins, homeopathic treatments, essential oils, and other at home treatments have not been shown to significantly help.

It is important if you get sick, you should limit contact with others. This means missed school and work for at least several days with influenza. Prevention with the vaccine simply is better than trying to treat the symptoms.

7. I don't like shots. (Or my child doesn't like shots.)

I'm a pediatrician. Most of my younger patients hate shots. Like really hate shots. They cry, scream, kick, try to run and hide -- you name it, they've tried it to try to avoid shots. They fear shots, but we can help them with techniques that lessen the pain, and they often say "it wasn't that bad" afterwards. For more on how we can help lessen the pain, check out Vaccines don't have to hurt as much as some fear.

8. I have an egg allergy so can't get flu shots.

In previous years there was a concern that people with egg allergy would have a reaction from the vaccine so it was not recommended, but it has been found to be safer and still appropriate to vaccinate with proper precautions.

People who have had only hives after egg exposure can safely get flu vaccines following standard protocols.

People who have symptoms of anaphylaxis with egg exposure that requires epinephrine (respiratory distress, lightheadedness, recurrent vomiting, swelling - such as eyes or lips) should still get the vaccine, but they should be monitored at the appropriate facility (doctor's office, hospital, health department) for 30 minutes to monitor for reactions.

9. Vaccines are only promoted to make people money. Doctors are shills.

Very little profit is made from any vaccine. Really. Some doctors and clinics lose money by giving vaccines. I often tell my own patients that I don't care if they get the vaccine at my office, the local pharmacy, or at the parent's office - whatever works for them best. I just want everyone vaccinated. This in the end will decrease my revenue because they will not come to the office seeking treatments for a preventable illness. But I am a pediatrician to take care of the health of children, not to make money. Pediatricians are consistently on the bottom of the list of physician salaries. If I was in it for the money, I would have gone into orthopedics or another surgical specialty.

There are many things to consider when addressing this argument and the Skeptical Raptor does it well, including links to more information.

10. The flu vaccine contains mercury.

While it is true that some flu vaccines contain thimerosal, not all do. Thimerosal was removed from the majority of childhood vaccines in 2001 due to lawmakers responding to constituent demands, not because it was shown to be a risk medically. Since the flu vaccine is not only for children, there are multidose vials that contain thimerosal. If that really bothers you, ask for a version without thimerosal. But since it was removed because people thought thimerosal caused autism and the rates of autism haven't gone down since it was removed, that's pretty strong evidence that it never caused autism. Just like the scientists said. It's a preservative that is effective. I would gladly get a flu vaccine with thimerosal, and have over the years, but the majority of flu vaccines given to children in the US are thimerosal free. Just ask.

Flu Vaccine Information and Recommendations for the 2017-2018 Season

• Both trivalent (3 strain) and quadrivalent (4 strain) vaccines are approved for use this year. There is no preference officially of one over the other, but the vaccine should be appropriate for age.
• No FluMist Nasal Spray flu vaccine is recommended. The nasal spray did not work well in the last few seasons it was used in the US. Until it is understood why it wasn't effective then how to make it effective, it will not be recommended.
• Pregnant women should be vaccinated to protect themselves and their baby. 
• Everyone over 6 months of age should be vaccinated. Children 6 months to 8 years who have only had one flu vaccine in their past will need two doses this season. This is because the first dose acts as a primer dose, then a booster dose boosts the immune system. Once the body has had a boost, it only needs a boost each year to improve immunity. 
• Infants under 6 months of age can gain protection if their mother is vaccinated during pregnancy and if everyone around them is vaccinated. They cannot get the flu vaccine until 6 months of age.
• People with egg allergy can be vaccinated. If there is a history of anaphylaxis to egg, they should be monitored for 30 minutes.
• The CDC is encouraging everyone to be vaccinated by Halloween if possible, but it's not too late to be vaccinated after that if not yet done this season. It takes up to 2 weeks for the vaccine to be effective. Flu season typically starts in January, but the peak can be as early as November and as late as March.
• It is acceptable and encouraged to give the flu vaccine along with other recommended vaccines needed.

Related blogs

Flu Vaccine Recommendations for the 2016-17 Year

Vaccines don't have to hurt as much as some fear

To Tamiflu or Not To Tamiflu...

Tamiflu: Guest blogger Dr. Mark Helm
Tamiflu Status Downgraded

How To Keep Your Family Healthy This Winter

Evolution of illness

Fever Is...

My Child's Cough and Breathing Sounds Like...

Cough Medicine: Which one's best?

"But the snot is green…" Or "How can we treat cough and colds?"

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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).

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.

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.

A 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.

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!

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Tamiflu

During flu season we have many requests for Tamiflu (oseltamivir) because of flu exposure or disease. I have rarely complied with these requests, though in recent years more often due to the powers that set the guidelines recommending it more. It is 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.)

photo source: Shutterstock

I am not alone in my dislike of Tamiflu. I follow a listserv of pediatricians around the country and many share my views. A recent topic thread on treatment of flu has peaked my interest. 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.

Back to influenza treatment...

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

The current guidelines basically say every child should be considered a candidate for an antiviral treatment. I understand the reasoning behind the first two conditions of antiviral use (except that studies don't really support even those indications), but I am very confused about the third highlighted below.

(from http://aapnews.aappublications.org/content/early/2013/09/02/aapnews.20130902-1)

ANTIVIRALS CONTINUE TO BE IMPORTANT IN THE CONTROL OF INFLUENZA.

Treatment should be offered for:

• any child hospitalized with presumed influenza or with severe, complicated or progressive illness attributable to influenza, regardless of influenza immunization status; and
• influenza infection of any severity in children at high risk of complications of influenza.

Treatment should be considered for:

• any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her pediatrician; the greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset.

Then look at what a search for "unpublished tamiflu trials" shows.

For those of you unfamiliar with the Cochrane group, I need to take a quick sideline. 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:

• 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.
• 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.
• Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
• 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.
• There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.

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.
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!

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?) 

Influenza is a miserable illness. The key is prevention. I've had my vaccine, how about you? 

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.

Update 2016:

The CDC continues to recommend Tamiflu (oseltamivir) and other anti-viral medications. I continue to wonder why.

There continues to be a lot of confusion about unpublished studies. 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:

• Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. 

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.
• 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. 

Prescriptions for Flu Shots

We have started to get requests for pharmacists again this year to give flu vaccines to our patients.

THIS MAKES ME FURIOUS! (Can I be any more clear with this? I am not usually alarmist, but it really is frustrating.) Let me try to explain. I apologize in advance for complaining, but...

Risk

The pharmacy is essentially wanting to put the onus on me to verify that the child is healthy enough for the vaccine and doesn't have any contraindications. Of course this is getting very difficult to do even in my office now that walk in clinics are conveniently located everywhere, so continuity of care is lost. If I haven't seen the child in many months, I might not realize that he had a wheezing episode last week but went to another urgent care center to manage. The pharmacy wants me to spend the time looking at the child's chart to verify the health of the child without seeing the child, write the prescription, and have unused flu vaccine sitting in my office (or waiting to be shipped to my office) that I must pay for but not use. Really???

Cost of care

And all of this for free, since the patient is not coming to my office for a visit, but spending his money at the pharmacy. My time needs to be valued somehow in this. A lawyer would charge for the time spent, but I cannot get reimbursed for this. Pediatricians are famous for being nice and giving free advice and care.

Now don't get me wrong. I didn't go into pediatrics to get rich. Medical students who want to get rich don't go into primary care. But I do need to cover my costs and support my practice by earning income with patients who come into the office. Primary care offices are struggling to survive. Many are selling out to hospitals, which increases healthcare costs. 

Continuity of care in the medical home: special dosing for kids, live viruses, and chronic illness

Flu vaccines in kids, especially under 9 years of age, have different rules than older kids and adults. They must have two vaccines of the same strain once before getting a simple yearly booster. If we don't have proper documentation of previous flu vaccines, they need two doses. Until we have a nationwide vaccine database, the pharmacy is unlikely to have the complete vaccine record for these kids and if they give some of the vaccine, the primary care office might not have records of the vaccines.

Parents often don't remember which of their children have been vaccinated -- let alone the specific dates and which particular vaccines were given. If kids get live virus vaccines, they must be given at least 28 days apart from one another or on the same day. This can cause issues if a child gets the kindergarten vaccines at their doctor's office and then a FluMist at the pharmacy or other walk in center (or vice versa). It is easy to see how mom and dad might each take the child to one of the places and not realize the contraindication. If all vaccines are given in one location (or if a person transfers records to another physician for continuing care at a new location) then this type of mistake can be more likely avoided. I try to remember to warn parents to wait at least 28 days before giving the FluMist to their child at the well visit if they get the MMR and/or chickenpox vaccines around flu vaccine time, but sometimes I forget and parents often forget when the time comes at the pharmacy. These kids don't suffer from harm, but the vaccine is not effective and must be given again. I've seen more than one frustrated family suffering from this scenario...

Another issue with getting vaccines outside the medical home is when there is a chronic issue, such as asthma, and parents don't accurately remember the severity. Even in my office when I've talked to parents and given a written Asthma Action Plan, they sometimes tell my nurse the child doesn't have a history of asthma. The nurse can question further because it's in the chart. The pharmacist won't know to question in a different way, especially if the family hasn't filled medications for that child at that pharmacy.

Inventory issues

We have been ordering and giving flu vaccines for longer than the 16 seasons I have been a part of Pediatric Partners. Each year there has been some frustration with the flu vaccine season.

See here and here and here for some of our headaches -- I wasn't blogging at the time of the novel H1N1 outbreak, but you all remember that, I'm sure.

Now that some kids get vaccinated at the parent's workplace, others at pharmacies, and others not at all it is getting more and more difficult to predict how much flu vaccine to order. If we over order, we are stuck with vaccine that can't be used (in other words, we stand to lose a lot of money). If we under order, parents are upset that we run out. Some years we can get more, others we can't.

We offer flu vaccines in our office, or at least we do when we have the vaccine in our office. For the second year in a row we are experiencing shipping delays. This is frustrating because we love to take advantage of the school aged kids (especially college aged "kids") being in the office in late summer and getting the flu vaccine out of the way. We can't give it at well visits if we don't have it, so we must pay nurses for more overtime having more flu vaccine clinics when we finally get the vaccines in stock. It's much easier for all to get it at an already established visit, but we do not have control of when the vaccine arrives at our office.

Pharmacies giving vaccines is a relatively new thing. I am frustrated that they are getting their supplies before us and offering them to our patients before we even have a chance. We have more and more difficulty ordering flu vaccines because we have no idea how many kids will get them elsewhere versus our office. We must pre-order during the winter before the next season, often when we are still offering vaccine for the current season, so we don't know if we will run out early or have leftovers. That makes it really hard to predict use for the next season.

Prescription requests 

Thankfully when I get a faxed request for such a prescription, I have an easy answer: No.

Our malpractice carrier has advised us to not write prescriptions for over the counter medications unless we are seeing the child in person. We have interpreted vaccine prescriptions to be in a similar category. If we cannot assess how sick or well a child is, we should not make the decision for any medicine (or vaccine) to be given. If the pharmacist wants to do an evaluation and order it, great. Otherwise, we are more than happy to vaccinate our patients.

Another reason to get the vaccine at your doctor's office

I just saw in a Slate article that vaccines might be better covered by insurance by an in network provider: "Pediatrician Walter Orenstein of Emory University, who chairs the National Vaccine Advisory Committee and formerly was the country’s assistant surgeon general, notes that the Affordable Care Act now requires that insurers cover vaccines against flu and several other diseases with “no co-payments or other cost-sharing requirements,” but, again, the catch is “when those services are delivered by an in-network provider.”"

Getting the vaccine

Please be patient with us. It wasn't that long ago that it was recommended to hold off on giving flu vaccines until October, thinking that the vaccine wouldn't last the season if given too early. Now that we know it is okay to give it earlier, that doesn't mean we must give it earlier. It isn't even October yet and people are panicking that they won't be able to get the vaccine. As far as I know, there's plenty of vaccine. It just hasn't all shipped yet. We are getting small allotments and giving it to kids whenever possible if they're in the office when we have stock. Unfortunately we can't schedule any vaccine appointments yet because our stock is too limited and we might run out before that appointment. We will be getting more soon. When we have enough in stock to schedule flu vaccine clinics we will let our patients know.

We're not alone in this. Most pediatricians I've asked are in the same boat. Please be patient with us all.

Dr Mellick got a FluMist in a previous season

What if the flu vaccine doesn't cover the right strains?

Recent news reported that the FluMist nasal spray might not cover the Influenza A H1N1 strain as well as the injectable might. I know this may cause concern for parents whose children have already gotten the FluMist vaccine this season.

Don't panic! (Gee, I've said that a lot this year with the delayed shipments of flu vaccine...)

Why not panic? 

First, this is a theoretical concern. It is based on the findings that the FluMist didn't cover the H1N1 well last season and it is the same vaccine this year.

Second, the main strains of influenza that are starting to circulate this year are NOT that H1N1 strain anyway.

I thought FluMist was preferred this year...

The CDC continues to state that the preferred vaccine for 2-8 year olds is the FluMist because it seems to be more effective than the injectable form against the other strains contained in the vaccines. (This is of course only if the child doesn't have contraindications to the FluMist and the FluMist is available. No one should delay vaccination if one form is available to wait for another form.)

Should we wait to get the shot? I know there are shipping delays...

Both the CDC and the AAP state to give whatever vaccine is available as appropriate and to not delay giving the vaccine to wait for another type. This makes sense. If you can be vaccinated with only one type due to the shipping delays, why risk being completely unprotected when you can get a vaccine that will most likely protect. No vaccine is 100% effective. With influenza we have the additional difficulty that the flu virus changes each year, but there is some protection across types when the flu vaccine is given.

Why doesn't the strain match?

Flu strains change every year and scientists predict what strains will be circulating. The vaccine companies all make vaccine against the predicted strains. This year the main strains that have been identified in people sick with the flu are Influenza A H3N2 and Influenza B. It is still early in the season, so findings might change, but so far both the FluMist and injectable vaccines seem to be effective against those strains. The FluMist appears to offer better protection than the injectable if the strains are not quite matched.

In short: 

Any age-appropriate influenza vaccine should be used as soon as possible to protect as many people as possible against the flu.

Do kids who got the FluMist need to be given a shot this year?

No. It is not recommended to do a second vaccination unless it is the first flu vaccine and a child needs a booster dose this season. It is appropriate to use either form of the vaccine for eligible children over 2 years, and mixing and matching is okay, but there is no recommendation specifically to do that.

The good news: 

We are starting to see shipments of flu vaccine! Hopefully we'll soon be able to vaccinate your children!

Flu Vaccine 2014-15 Season

Every year it's something.

Flu vaccine causes distress every year for physician offices around the country.

I wrote about some of the issues last year here and here.

This year's flu vaccine is identical to the trivalent and quadrivalent vaccines of last season, so it should be easier.

But as always, there's a hitch.

This year there is a delay in shipping but no one really knows why. I've heard pharmacies are starting to advertise they have flu vaccine. From a business standpoint, we start to worry when we hear people say "I'll just do it at the pharmacy." We've already ordered more doses than last year and don't want to get stuck with supplies we can't use. Bad for business...

How flu vaccine makers choose their shipping times to various offices around the country is unknown to me. We order nearly a year in advance so they can make the requested number of doses. We must project how many infant vs child injectable doses of vaccine we will need and how many nasal spray doses we will need. Some years we can add to our order, but other years there are shortages. There are several makers of various brands, but in pediatrics we are limited to what types we order based on the ages for which it can be used.

As soon as we start getting the vaccine we will begin to offer them in the office. Typically we start getting a few doses at a time, so we can't advertise with those first small shipments. It will simply be patients who are in the office and eligible for the type we have will be offered flu vaccine. When we get enough to hold a flu vaccine clinic, we will send out e-newsletters to patients who are registered, as well as post on our website and Facebook page. Our flu clinics run smoothly because parents sign up on line. We will send paperwork ahead of time for you to fill out at home. Bringing that really helps. You will need to have signed our financial policy before the flu vaccine. To keep things running smoothly, we encourage you to do that ahead of time if you have not already done so. We also ask that your child is current on well visits in order to use our flu clinic. If your child needs a well visit, simply schedule one and he can get the vaccine at that visit. We will always give flu vaccine to patients and their siblings who are in the office for a visit (but without significant illness, such as fever) as long as supply lasts.

Who needs a flu vaccine and when should it be given?

It is recommended that everyone over 6 months of age get a flu vaccine each year. As soon as the vaccine is available, it can be given. Ideally the vaccine is given before the influenza season starts. Flu season usually peaks in January, but influenza can occur at any time of the year. I must put a plug in for getting the vaccine in your medical home if at all possible. This keeps vaccine records all in one place and helps support your doctor's office.

Which vaccine should my child get?

Children 6 months to 2 years should get the injectable vaccine. They are not eligible for the nasal spray (FluMist).

Starting in 2014-2015, the CDC recommends use of the nasal spray vaccine (FluMist) in healthy children 2 - 8 years of age, when it is immediately available and if the child has no contraindications or precautions to that vaccine.

Contraindications to the FluMist are:

• Children younger than 2 years
• Adults 50 years and older
• People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
• Young children with asthma
• Children or adolescents on long-term aspirin treatment
• Children and adults who have chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders
• Children and adults who have immunosuppression (including immunosuppression caused by medications or by HIV)
• Pregnant women
• Live virus vaccine (such as MMR or Varicella/chickenpox) within the past 4 weeks. The vaccines can be given together on the same day, but if not on the same day they must be given 28 days apart from one another.
• Most people with the above contraindications can still be vaccinated with the injectable vaccine - ask your doctor

Recent studies suggest that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine.

How many doses does my child need?

In young children who have never received a flu vaccine, two doses of the same strain should be given. If they've had two doses of the same strain previously, they only need one dose. In children over 9 years of age, regardless of previous vaccines, only one dose is needed. This is because it is presumed that by 9 years of age a child has been exposed to the influenza virus previously. Think of it as the first vaccine is the initial body's exposure to the virus in young children, then everyone needs a booster dose for the season, including the first season if a child has never had one before.

The CDC has put together a flow chart of how many doses are needed:

Can a person still get the flu even after getting the vaccine?

Each year experts pick the most likely strains of influenza virus that are expected. Some years they do a great job, other years it is not as accurate. There is some cross-reactivity among strains, so even in years that the wrong strains are in the vaccine, there is some protection against severe flu illness. So yes, it is possible to still get influenza, but usually the illness is mild.

Can a person get the flu from the vaccine?

No. I have heard many people say they get the flu from the vaccine, but this is not possible. People who get the nasal vaccine can get mild congestion (cold like symptoms), but they do not get the flu from the vaccine. It is possible that they were exposed to the actual flu virus and get sick before the vaccine has a chance to provide protection. Or they have a viral illness that isn't the flu. People with influenza often say they feel like they were run over by a train. They are sick. It is not just a cold.

Can I get the flu vaccine even though I have an egg allergy?

The following recommendations come from the Advisory Committee on Immunization Practices (ACIP):

People with a history of egg allergy who have experienced only hives after exposure to egg should receive the injectable influenza vaccine. Because there is limited data in the use of live attenuated influenza vaccine (FluMist) in egg allergic people, inactivated influenza vaccines (shots) either the IIV or trivalent recombinant influenza vaccine (RIV3) should be used.

Where can I get more information? 

Each year the CDC provides summary information about the current influenza vaccine season. You can read about the 2014-15 season, information on flu vaccine myths and misconceptions, and you can even see where the flu has hit.

 

Tamiflu: Guest blogger Dr. Mark Helm

Those of you who have spoken with me about Tamiflu or who have read my blog, To Tamiflu or Not To Tamiflu, know where I stand on Tamiflu. My online friend, Dr. Mark Helm, has written about Tamiflu in a very say-it-like-it-is way. Take the time to read and share!

photo source: PRWeb.com

Tamiflu is probably not going to help you.

Like all prescription medicines, Tamiflu (oseltamivir) can cause many complications. A large number of people who take oseltamivir have side effects which actually feel a lot like the flu (belly problems, headache, etc.). These side effects can be so bad that some people decide they want to stop taking the medicine and take their chances with the flu! Using oseltamivir in kids is very challenging. Children often can not understand or report that the medicine is making them feel bad or altering their thoughts or behaviors.

Almost all of what we know about the safety of this medicine comes from the company which makes and sells it. Doctors know only what that company has revealed. When objective researchers have tried to discover if it actually helps, they have generally found that oseltamivir does very little, if anything, to treat the flu. Even the company concedes that the drug MAY shorten symptoms of the flu by one to one and a half days. Oseltamivir has not been proven to change the outcomes (death, hospitalization, loss of time from work,) of having the flu. It also has not been well-studied in people with significant chronic diseases - who are exactly the people we most worry about when it comes to flu infections. If the medicine is started very early (less than 24-40 hours after symptoms begin), then it may shorten the length of time a person is sick by an average of about 31 hours. Again, this medicine does not seem to affect the need for hospitalization or risk of death that comes from being infected by the flu virus.

Oseltamivir is expensive. It may or may not be covered by your health plan's pharmacy benefit. If it is covered you may only have to pay a co-payment, but your employer or insurance company will have a much larger bill to pay. They will pass those costs on to you next year with premium increases (or cuts in benefits).

A helpful and well-reasoned pamphlet regarding the flu and Tamiflu (oseltamivir) is here. Here's more good stuff on Tamiflu (oseltamivir), including a helpful tab outlining side effects and their frequency.

The challenge for physicians and other prescribers on deciding when oseltamivir may be helpful is balancing the relatively low risk of any individual developing the flu (maybe 1 in 20) against the facts that more like 1 in 10 people taking the drug will have significant side effects, and that there is not likely to be any difference in outcomes for the patient.

So, if you can’t count on Tamiflu, what should you know and what can you do?

Flu will hit you like a ton of bricks, and make you feel horrible. It generally will flatten anyone for about 5-7 days. It is particularly dangerous for "high-risk" people - that is people who have other chronic illnesses, the very young or the very old. However, for health professionals, the more scary illness is the “second sickness” that may follow the flu. If a person with the flu starts to get a little better but then starts feeling worse, they should be seen by a doctor as soon as possible. Additionally if a person with the flu starts to gets worse after 2-3 days of the start of symptoms this is also very concerning.

Flu is a very serious disease every year. 2014 is no exception. The flu strain that is most common this year is the same variety that caused the global epidemic in 2009.

Fortunately, flu is largely preventable with immunization - this is why we try to immunize everyone we can. Despite what some say, the flu vaccine - particularly the injectable vaccine can not give you the flu. The flu shot contains no live virus - only proteins made by the virus. The small dose of these proteins in a flu shot are enough to train our immune system to recognize and fight off the flu. The nasal vaccine does contain a live virus, but it is altered so that it can only reproduce and spread at temperatures lower than in the human nose. Both vaccines teach the immune system to recognize and kill the flu virus.

The vaccine is adjusted each year to match the strains which are believed to be most likely to circulate in the coming season. The vaccine for the 2013-2014 season contains proteins which match the “H1N1” strain that is causing 90% of the disease. People who received the flu vaccine this season have a much lower risk of catching the flu than those who did not get vaccinated - but even for vaccinated people, the risk for flu is not zero. It generally takes at least two weeks after a flu vaccination for the body to develop a good, fighting response. So plan ahead for your vaccine next year… Anytime between Halloween and Thanksgiving is a good time to get vaccinated for the flu.

If you have not had your flu shot this season, and you are worried about the flu, ask to be vaccinated. Assuming that there is still some vaccine supply left, vaccination, avoiding prolonged close contact with people with the flu, and washing your hands are your best defenses against the flu. If you already had your flu shot this year, you should not be worried - you have already taken your best chance to avoid the flu.

About Dr. Helm:

Mark E. Helm, MD, MBA, FAAP is a general pediatrician in Oregon at Childhood Health Associates of Salem. He is active with the state and national American Academy of Pediatrics, involved with the Section on Clinical Pharmacy and Therapeutics, and the Section on Administration and Practice Management. He is currently a member of the Committee on Child Health Financing. Prior to becoming a pediatrician, Mark was a pharmaceutical industry “insider” working in market research. After training at Arkansas Children’s Hospital, Dr. Helm worked with the Arkansas Medicaid program to develop an evidence based “preferred drug list” and to establish policies which promoted safe and responsible use of medications, including psychotropic medication for children. Dr. Helm gets his flu shot every year.

Top 10 Posts of 2013

My last post of 2012 was my Top 10 Posts of 2012. I think I'll keep the tradition going with the Top 10 of 2013.

photo source: Shutterstock

This past year I have written about everything from insurance to illnesses to common parental concerns. My most influential blog has been about the generic formulations of Concerta, with 11,875 readers. It has been shared on ADHD blogs, various Facebook and Twitter feeds, and found on Google searches. I never thought over 1,000 people would read one of my posts, let alone over 10,000! Thank you to all who are reading and sharing!

If you don't want to miss a post, be sure to sign up for an e-mail subscription on the right!

From #10 to #1:

10. My Child's Cough and Breathing Sounds Like… is a collection of videos I compiled to help parents describe their child's cough.

9. Allergy Tips reviews ways to avoid allergens when possible and how to treat symptoms.

8. Flu Vaccine 2013: The Story Unfolds discusses how coding and billing issues impacted our office use of flu vaccines this season.

7. But the Snot Is Green… once again argues why the color of mucus does not make the diagnosis of bacterial sinusitis and gives information on treating colds and coughs.

6. To Tamiflu or Not to Tamiflu  might be a little intense for some readers because it reviews the research on Tamiflu risks and benefits. I am happy it is among the top 10 because I want people to see that Tamiflu isn't that miraculous of a drug for influenza. I get far too many requests for it this time of year. 

5. Flu Shot Information 2013-14 Season explains the different types of influenza vaccine available for the season. 

4. Help! My Child Has ______ Up His Nose! shares a "secret" tip I use to get some unwanted objects out of a child's nose. 

3. Screen Free Week is a challenge to readers to go Screen Free for a week. I have no idea why it is ranked so high. That is a surprise to me. 

2. Cough Medicine: Which One's Best reviews various cough medicines and other treatments of cough.

1. Generic Concerta Not Working Like the Brand Used To?  was read about 10 TIMES as much as any other post. It was found most often by a search engine, not direct shares, which tells me that many families are struggling with this issue. This is the post I am most passionate about. Any of my ADHD patients who are treated with Methylphenidate ER/Concerta know how angry I am that the FDA allows this substitution. I am thankful that the blog can help spread the word so that parents who are concerned about their child's sudden altered response to a medication can learn what might be the cause. I had so many updates to the original post, I wrote a follow up: Update on generic Methylphenidate HCl ER.

Blogs that missed the Top 10 that I wish more people would read include: 

Evolution of Illness - I wish people would read this because we often fall into the trap of wanting a quick fix. Too many parents bring kids into the doctor for a fast remedy only to find that there isn't one.  Resolution of illness takes time. Sometimes kids get worse, only to have the parent accuse a doctor of missing something. It happens to all good docs once in awhile…

First Period Q&A with a Tween - I wish people would find this one because it has questions every young lady thinks about but is often afraid to ask.

It's [Sports, School, Camp, Yearly] Physical Time - I wish people would read this so they understand the value of well exams and the scheduling constraints most pediatricians face. Don't call at the last minute!

Insurance Confusion - I wish people would read this because dealing with insurance is one of the most stressful parts of my job. I want people to learn about insurance to avoid financial surprises and to be responsible with insurance use.

Private Discussions with the Pediatrician - I wish people would read this because I am often uncomfortable (and sad for a child) when a parent wants them to leave the room for us to discuss something privately. Pre-planning with a quick phone call or secure message before the visit can save the child from excess worry.

What kids need to be able to do to leave the nest - This is one of my favorites because it was written at a very emotional point of my life. My kids are growing up and I reflected on what I really want them to know.

New Ideas

While most of my blogs were article-style writings, I introduced a few different types of blog this year. 

My first (and to date only) attempt at a video blog was Nutrition For the Picky Eater. It was born from a talk I gave at an ADHDKC.org parent meeting. 

I also did a picture blog with Lawn Mower Safety. 

I had one guest blogger. Sleep expert, Kerrin Edmonds, wrote Common Sleep Myths. 

Busy times…

April was my busiest month blogging. Seven posts that month. It tends to be a slow month in the office.  Ironically it was also Screen Free Week, a time I should have been off the computer!

• Allergy Tips

• Generic Concerta Not Working Like the Brand Used T...

• Screen Free Week April 29-May 5, 2013

• Help! My child has ___ up his nose!

• Group Teaching With Physicals

• Waiting times...

• Feeding Your Newborn

"But the snot is green…" Or "How can we treat cough and colds?"

This time of year it seems everyone is at least sniffling. Many have annoying coughs. Coughs are annoying to others who wonder why that cougher isn't staying at home keeping his germs to himself. They are annoying to the cougher who is up all night coughing (and his parent who also hears it all night long.)

And then there's all the mucus. We normally make about a liter of mucus a day. Yes, a liter of the stuff. On a good day. It helps moisturize our airway and collects the dust and germs that enter our body. It has antibodies that help fight off the germs it catches. We swallow most of what is made, but when we're sick we make even more. When we're sick it plugs up our noses and makes our head hurt. It drains down the back of our throat, causing us to cough. In kids it drips down the face. It changes color from clear to yellow to green. Sometimes it even gets bloody. It can be thin or thick and sticky. Don't be fooled that the color or thickness means it is for sure "just allergies" because it's clear, or a sinus infection because it's green. These change based on how long it's been in the sinuses, how dry the air is, and other factors. Yellow or green color does not come from bacteria or guarantee that antibiotics will help get rid of the mucus.

Colds and coughs seem to continue forever. Especially since kids get recurrent viral infections this time of year, and they each run into the next illness. I often joke that it doesn't matter if kids get sick in October or January, it will go away by April. Bad joke, but it often seems that once kids start getting sick for the season, they stay sick most days until April.

Here's a graph from way back in 1967 that shows the timeline of a typical upper respiratory illness in an adult:

Remember that kids tend to stay sick longer (and are contagious longer) than adults, so if 20% of adults are still coughing on day 14, you can bet at least that many kids still are coughing with a cold or the flu.

So what can you do to help make kids feel better? As I always say: water, water water.

Water in the air helps thin the mucus, so increase the humidity in the bedroom during the dry winter months. Use a humidifier or vaporizer in the bedroom during illnesses even if your home has a humidifier attached to the heater. Humidifiers with a cool mist are safest with young children. Be sure to follow package directions for cleaning and changing the filter. Vaporizers are generally less work to use, but the steam comes out very hot and can burn young children. Again, follow package directions for proper cleaning and use. Allow it to dry out a bit during the day to avoid build up of mold. 

Water in the nose in the form of saline can really help. The salt in the saline draws the fluid out of the swollen nasal passageways, decreasing the swelling and opening the airway to allow more mucus to be blown (or sucked) out.

Increase fluids that kids drink. Really push water. And unless a child is allergic to milk, it is an old wive's tale that milk will make the mucus worse. If that's what they want, they can have milk with a cold. 

I think what really needs to happen is to get the mucus out. Using saline along with a strong blowing (or suctioning) of the nose is important.

For infants and younger children it can be hard to blow forcefully to get the mucus out. I have been disappointed in the use of a bulb suction because it is very difficult to make a seal and to have enough air to really get a good suction. They tend to cause trauma to the nose because you need to stick it up so high to make a seal. I like nasal aspirators that seal outside the nose and have a continuous flow of air. Check out How to use the Nosefrida. A similar nasal cleaner is available from Nasopure. (Note: I am not tied to either of these companies and do not get any payment from either company.)

For kids over 2 years old, washing the nose is one of the best ways to treat (and prevent) nasal congestion. Check out this video from Nasopure for an easy how to use. (Note: I do not get payment from this company, I simply love the Nasopure company. Not only does the product work well, it is also an all American company. Bottles are made in Kansas City and assembled by disabled adults in Columbia, Missouri.)

What medicines work?

If you choose to use medicines, pick one that has a single active ingredient. Many cold and flu medicines include several active ingredients to treat different symptoms. This increases the likelihood you will use a medicine that isn't needed (because you don't have that symptom) as well as increases the risks of side effects. Also if there is an allergic reaction, you won't know which component was the culprit.

I don't recommend decongestants most of the time. They can make the mucus more thick, which plugs the nose more. If a child is old enough to say if it helps or not (generally over 6 years) and it helps, then it is okay to use a decongestant for a short term. Side effects are trouble sleeping, shakiness, nervousness, increased blood pressure and increased heart rate.

Antihistamines block the histamine that is triggered from allergies. It helps decrease the amount of mucus made when allergies flare, but don't help with the typical cold. Side effects are drowsiness, impaired coordination, excitability in children, and dry mouth.

Guaifenesin is supposed to help thin out mucus to help cough it up. Some studies say it works, others disagree. Again, if a child is old enough to say it helps and it does, use it. Otherwise don't. Side effects can include dizziness, drowsiness, confusion, blurry vision, or lightheadedness.

Studies do not show that any cough suppressant works very well. Honey has actually been shown to help better. Use honey only in kids over 1 year of age due to risks of botulism.

For influenza many people request Tamiflu. Here's my blog on Tamiflu describing why I will be forced to use a medicine I don't like. (It's too long to explain here.)

Another blog going in depth on cough medicines is Cough Medicine: Which one's best?

Holidays and family spoiled by illness... It's that time of year!

It is Thanksgiving morning as I write this. I am enjoying my quiet time as the family sleeps in. Extra time to blog because I'm not cooking today ... more on that later.

Wash hands to help prevent illness!

Yesterday was a typical day in our office for a day before a holiday. Sick kids came in with parents hoping for an insta-cure so they could enjoy the holiday with the extended family. A few wanted to fly back home with a febrile child and wanted our okay -- but of course didn't get it because even on an antibiotic they could spread illness if it is a virus, which most illnesses are. Some parents just called in because they were already out of town when their child got sick and they wanted to know what will make them better before the turkey celebration.

I'm sure most parents knew deep down that the answer would be "time". There is no insta-cure for most illnesses. Anyone with fever, cough, sore throat, or other ill symptoms should be kept away from the festivities. Even if the fever goes down with a fever reducer. Even if the last fever was before bed last night and it's down this morning. Fever can wax and wane and one needs to be fever-free (without a medication to bring it down) for 24 hours before we really consider it gone. People are most contagious when they are running a fever and the first few days of illness.

It stinks. I know. As a parent with a teen who has had a cough for over a week and is sleeping a disrupted 16-18 hours a day, I will miss Thanksgiving with extended family to avoid the spread of illness. Could we go? Sure. He hasn't run a fever all week. He's old enough that he can wash hands, cough into his elbow, and stay out of everyone's way. But he'd be miserable. And if one of the little ones got sick, I'd feel awful. Even if they got it elsewhere, I'd wonder if it was from him.

So I get it. It really stinks. Family from Tennessee and California are in town. We rarely see them and I want the cousins to get to know one another. But my teen isn't feeling well and I don't want the cousins to feel this way. I haven't started him on antibiotics to make him better faster because I know they wouldn't work. We are using a humidifier, lots of sleep, and waiting. He's refusing the nasal wash unfortunately... but I keep offering it!

This holiday season I wish everyone health, but if someone is sick, stay home. Don't spread the germs.

For more information on treating illnesses, see these links:

Fever
Cough and colds
Ear pain and infections
Wheezing in infants
Croup
Influenza
Tamiflu
Vomiting and diarrhea
Pink eye and other red eyes
Strep throat
Painful urination
Cough Medicines: Which One's Best?
Evolution of Illness

To Tamiflu or Not To Tamiflu...

photo source: Shutterstock

During flu season we have many requests for Tamiflu (oseltamivir) because of flu exposure or disease. I have rarely complied with these requests, though in recent years more often due to the powers that set the guidelines recommending it more. It is 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. A recent topic thread on treatment of flu has peaked my interest. 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.

Back to influenza treatment...

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

The current guidelines basically say every child should be considered a candidate for an antiviral treatment. I understand the reasoning behind the first two conditions of antiviral use (except that studies don't really support even those indications), but I am very confused about the third highlighted below.

(from http://aapnews.aappublications.org/content/early/2013/09/02/aapnews.20130902-1)

ANTIVIRALS CONTINUE TO BE IMPORTANT IN THE CONTROL OF INFLUENZA.

Treatment should be offered for:

• any child hospitalized with presumed influenza or with severe, complicated or progressive illness attributable to influenza, regardless of influenza immunization status; and
• influenza infection of any severity in children at high risk of complications of influenza.

Treatment should be considered for:

• any otherwise healthy child with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his or her pediatrician; the greatest impact on outcome will occur if treatment can be initiated within 48 hours of illness onset.

Then look at what a search for "unpublished tamiflu trials" shows.

For those of you unfamiliar with the Cochrane group, I need to take a quick sideline. 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:

• 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.
• 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.
• Treatment was not associated with an overall decrease in antibiotic use, suggesting it did not alter the complication of bacterial secondary infections.
• 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.
• There was little effect on the number of asthma exacerbations or ear infections by treating influenza with Tamiflu.

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.
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!

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?) 

Influenza is a miserable illness. The key is prevention. I've had my vaccine, how about you? 

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.

Update 2016:

The CDC continues to recommend Tamiflu (oseltamivir) and other anti-viral medications. I continue to wonder why.

There continues to be a lot of confusion about unpublished studies. 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:

• Oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments. 

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.
• 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. 

Update 2016/2017 Season:

The CDC recommendations for the use of antiviral medications remain essentially unchanged.

I have heard early reports that this year's flu vaccine is about 60% effective, but it is too early in the season to be sure. For up to date information on this season's flu, check out the CDC website.