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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HPV vaccine concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still "want to do their research" or "have heard things" so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven't done their research, so their child remains unprotected. Sometimes they'll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.

I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough. 

It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).

Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection "to those who do not need it (adolescents)" at all. Yes teens need protection. I'll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It's kind of like saying that kids don't need to brush their teeth because they don't have cavities. If you wait for the cavities to develop, it's too late!

The second argument is based on old version of the vaccine. We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting. If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine. 

The risks listed have all been shown to not be as risky as once shown.

• HPV Vaccine Not Linked To Autoimmune Disorders, Study
• Questioning Whether To Get Your Child the HPV Vaccine? Read This
• Is The HPV Vaccine Safe? v 2.0
• Gardasil HPV Vaccine Safety Assessed In Most Comprehensive Study To Date

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage. There are so many things wrong with this. First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship. Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry. Or there could be infidelity in marriage. There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not. And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage. Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don't always protect against HPV transmission.  And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

They argue it hasn’t been tested in males. It has. And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

This article is several years old. It didn’t yet know that the cancer rates in Australia would fall like we now know. We’ve learned much more information than they knew in 2011 when it was written. We know the HPV vaccine is safe. It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely. It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn't worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn't need protection.

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can. If I had any concerns about its safety I would not have given it to my own children. I don't think I can list any study or give any argument stronger than that.

Help! I'm sick and I have a baby at home.

When we have newborns we don't want to expose them to germs. We avoid large crowds, especially during the sick season. We won't let anyone who hasn't washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

• Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting. Wash Baby's hands after diaper changes too. Make this a habit even when you're not sick... you never know when you're shedding those first germs!

• Wipe down surfaces. Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect. Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area. 

• Avoid touching your eyes, nose and mouth - these are the "doors" germs use to get in and out of your body. Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
• Resist kissing Baby on the face, hands, and feet. I know they're cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too. 
• Cover your cough. I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs. When you're responsible for a baby, the baby's head is often in your elbow, so I don't recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren't available.
• Vaccinate. If you're vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you're less likely to bring those germs home. Encourage everyone around your baby to be vaccinated. If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity. See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.
• Breastfeed or give expressed breast milk if possible. Mothers frequently fear that breastfeeding while sick isn't good for Baby. The opposite is true - it's very helpful to pass on fighter cells against the germs! Again see Jody Segrave-Daly's blog for wonderful explanation of how breast milk protects our babies. 
• Limit contact as much as possible. If possible, keep Baby in a separate area away from sick family members. Wash hands after leaving the area of sick people. If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.
• Insist on a smoke-free home and car. Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production. These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors. Change your shirt (or remove a coat) and wash your hands before holding Baby.

It's never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too. As with everything, you must take care of yourself before you can help others. Drink plenty of water and get rest! Most of the time medicines don't help us get better, since there aren't great medicines for the common cold. Talk to your doctor to see if you might need anything. Don't be falsely reassured that you aren't contagious if you're on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing. You need to be vigilant against sharing the germs!

Great News About the HPV Vaccine!

The HPV vaccine has been a controversial vaccine on social media, but anyone who knows me knows that I agree with the recommendations and wholeheartedly endorse it for the reasons given in my favorite HPV Vaccine article.

Photo Source: Jan Christian via Wikimedia

To add to the confusion and misinformation that circulates regarding the safety of the vaccine (which I don't have room to go into here, but is discussed here, here, here, and visually here), the vaccine itself has changed (covering 9 strains now compared to the initial 4 strains) and the dosing schedule is changing.

Don't presume the change in vaccine schedule is to answer the calls of the anti-HPV vaccine crowd. That isn't needed because their claims have been debunked (see all the articles referenced above).

Dosing schedule ~ Happy News!

HPV vaccines were initially approved to be administered as a 3-dose series: dose #2 given two months after the first and the 3rd dose at least 4 months after the second. Giving doses later is acceptable, but they cannot be given too early.

There is research that supports giving just two doses at least 6 months apart. A two dose schedule was approved earlier in Europe and this week was approved by the FDA in the US for children 9 to 14 years of age. The two doses should be given 6-12 months apart, which means for most kids they can get the vaccine at two regularly scheduled well visits (such as the 11 year exam and the 12 year exam) and not have to come in for additional visits.

The data support continuing a 3 dose series in those 15 years and up. This means they can get the 2nd dose 2 months after the 1st dose and then a 3rd dose at least 4 months after the 2nd dose and 6 months after the 1st dose.

The official ACIP Meeting Information is not yet available, but will be posed within 90 days of the October 19-20 meeting. (Note: I originally stated this was an October 11 meeting.)

I know that the two dose series will make many kids happy ~ one less shot for the same protection!

If two doses have already been given at less than 6 months apart or if the teen is 15 years and older, the third dose will still be needed.

Addendum: 

I don't want to confuse everyone... the FDA has approved a new schedule, but the Advisory Committee on Immunization Practices (ACIP) will need to give their input before the schedule actually changes. That will be decided at their October 19-20 meeting.

One last addendum:

The ACIP approved the changes! Talk to your doctor about your child's vaccine needs. In short, the new recommendations state:

• Kids who get the first HPV vaccine before their 15th birthday need two doses 6-12 months apart.
• Kids who have turned 15 years old before the first dose should use the 3 dose series.
• Kids who have gotten a 2nd dose less than 6 months after the first (regardless of age) need the 3rd dose.

Meningitis Risks and Preventions

Meningitis is thankfully uncommon, but when it happens it can be deadly. Meningitis is an inflammation in the membranes around the brain and spinal cord (meninges). It is usually caused by a virus, but many bacteria and fungi can also infect the meninges. Symptoms include headache, fever, and stiff neck and may include other symptoms depending on the organism causing the infection.

I wanted to write about meningitis because with the newest vaccine against meningitis, I am concerned that parents don't recognize what exactly their children are protected against and what risks remain after vaccination. I will break down meningitis by type of organism causing the inflammation, and include any vaccines and treatments available for that type within that grouping.

Bacterial Meningitis

Bacterial meningitis is a medical emergency. Even with early treatment with antibiotics, it can be devastating. If a person survives, many of the bacteria can cause permanent brain damage, hearing loss, learning disabilities, and loss of limbs. Anne Geddes, a photographer famous for her pictures of infants and children, has worked with Novartis Vaccines and the Confederation of Meningitis Organizations (CoMo) to create Protecting Our Tomorrows: Portraits of Meningococcal Disease, a book that is available for a free download on iTunes that shows people who have survived meningitis.

Photo by Mikael Häggström

The type of bacteria causing meningitis varies by age group. Fortunately the bacteria that cause meningitis are not as contagious as things we more commonly see, such as the common cold, but whenever there's a case of bacterial meningitis the health department will identify risks and help treat contacts at risk. The bacteria don't always lead to meningitis, but may be found in healthy people or cause other types of infections as well, such as ear infections, pneumonia, and urinary tract infections. 

• Newborns tend to be infected with bacteria that can be a part of the mother's urogenital tract. Group B Streptoccous (GBS), Escherichia coli, and Listeria monocytogenes are most common. Pregnant women are screened for GBS and treated with antibiotics prior to delivery if possible. Pregnant women should handle foods properly and avoid certain foods to protect against Listeria.
• Infants and children are most at risk from Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcal), Haemophilus influenzae type b (Hib). Thankfully starting at two months of age infants can get vaccines against Hib since 1985. A vaccine against 7 strains of pneumococcus became available in the year 2000, and it was improved to protect against 13 strains of pneumococcus since 2010. There are over 90 known strains of pneumococcus, but the vaccine covers the majority of strains that cause severe illnesses. Vaccination against N. meningitidis is not routinely given to infants at this time.
• Teens and young adults are at risk from Neisseria meningitidis and Streptococcus pneumoniae. Younger teens who are up to date on vaccines have been vaccinated against S pneumoniae, but since the vaccine was introduced in 2000, older teens might have missed this vaccine and it is not recommended to do catch up unless they are in a high risk group, such as if they are immune compromised or missing a spleen. 

• Vaccines are now available that help protect against all three serogroups (B, C, and Y) of meningococcal disease that are the most commonly seen meningococcal subtypes in the United States: 

• Meningococcal conjugate vaccine (Menactra®- which covers A, C, W, Y subtypes, Menveo®- which covers A, C, W, Y subtypes and MenHibrix®- which covers C, Y, and Hib) is recommended as part of the routine vaccine schedule at 11-12 years of age with a booster at 16 years. It is also recommended at younger ages for high risk people (immune compromise, spleen issues, and certain travel).

• Meningococcal polysaccharide vaccine (Menomune®- covers A, C, W, Y) is given to people over 55 years of age.

• Serogroup B meningococcal vaccine (Bexsero® and Trumenba®- both cover subtypeB). This is only recommended with a permissive use status, meaning it is not highly recommended for any age group, but it is allowed to be given to anyone over 16 years of age and is encouraged for high risk people, sometimes down to 10 years of age, depending on the risk. High risk people are those with known immune problems, specific chronic diseases, or who have no working spleen. High risk might include when there is a known outbreak, so if your college student hears of meningitis on campus don't let them think they don't need it due to vaccination with one of the vaccines that covers A, C, W, and Y. Some colleges require vaccination against meningitis B in addition to A, C, W and Y. 

Viral Meningitis

Viral meningitis is much more common but less deadly than bacterial meningitis. There are many types of viruses that cause meningitis, and usually there is no specific treatment for viral meningitis, just like other viral illnesses. Most people who get viral meningitis completely recover on their own within 7 to 10 days. People with meningitis caused by certain viruses such as herpesvirus and influenza may benefit from treatment with an antiviral medication. If there are symptoms of meningitis, it is important to quickly get the proper testing done to determine if treatment is needed or not. Prevention with standard hand washing and other measures to prevent the spread of viruses is important. Some vaccinations can protect against diseases that can cause meningitis, such as measles, mumps, chickenpox, and influenza. Since mosquitoes, other insects, and rodents can spread disease, avoiding bites can help prevent infection.

Fungal Meningitis 

Fungal meningitis is very rare and does not spread from person to person. It occurs when a person with a weak immune system is infected with a fungus that spreads to the brain or spinal cord.

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. 

How To Keep Your Family Healthy This Winter

This blog is short and sweet about avoiding illness this sick season, but has links to dig deeper as desired.

It's not a big secret. We know the best ways to stay healthy, but it takes everyone to participate to make it work.

Practice the following routinely and help stop the spread of illness!

1. Wash hands or use hand sanitizer (sanitizer is not helpful at eliminating all germs - see the link for more information on how and when it is appropriate) 
2. Eat healthy and drink water (infants under 6 months should drink breast milk or formula)
3. Sleep
4. Get vaccinated
5. Don't touch your face - this is where germs enter our bodies!
6. Probiotics might help (recent meta analysis)
7. Wipe down objects regularly: learn the difference between cleaning, disinfecting, and sanitizing.
8. Safely prepare and serve food 
9. Cover your cough and sneeze with your elbow.
10. Avoid sick people
11. Stay home when sick

Things that haven't been shown to help:

1. Mega doses of vitamins
2. Cough and cold medicines have limited benefits, if any at all
3. Homeopathic medications
4. Essential oils
5. Antibiotics for viral illnesses (most cold and coughs)
6. Using an improper medication dosing device

Related blogs:

How Long Will a Cough or Cold Last?

Cough Medicine: Which one's best?

My Child's Cough Sounds Like...

But the snot is green...

Sick, sick, and more sick

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

To Tamiflu or Not to Tamiflu?

Tamiflu: Guest Blogger Dr. Mark Helm

Adenovirus Infections

Evolution of Illness

Fever Is...

New High Risk Child RSV Prevention Guidelines

What are the most common risks after shots?

Parents want to keep their kids as healthy as possible, but with the overwhelming amount of information found in media these days, it is hard to know what is safe and what risks really are when it comes to vaccines.

Nothing we do is without risk. The most risky thing most of us do daily is to get in a car and drive somewhere. We can minimize the risk by wearing a seat belt and putting our kids in the proper sized car seat, obeying the traffic laws, and adjusting our driving to the road and weather conditions, but there is always the chance of an accident. For most of us, the risk of an accident is outweighed by the benefits of getting to where you need to go. 

Vaccines are no different. The benefits are many, including preventing early death from infection. The risks are often overblown, but do exist.

You might have read somewhere that you should read the package insert of vaccines before allowing your child to get a vaccine. This advice is somewhat misguided. The package insert has a lot of information, but it is designed for legal reasons, not consumer information sharing. Anti-vax groups encourage the reading of them to learn risks of the vaccines, but this can lead to undue fear and confusion. Not all problems recorded in the adverse reactions section of the package insert are due to the vaccine. If someone fell out of a tree and broke his leg after a vaccine and reported it during vaccine trials, "broken leg" will be listed as a reaction. It does not mean that the vaccine broke the leg or caused the broken leg in any way, but it is reported in a way that can make it look like there is a cause and effect relationship. For a more detailed description of package inserts, see Package Inserts - Understanding What They Do (and Don't) Say. 

The risks of all vaccines are similar. Specific risks can be found on the Vaccine Information Sheets (which are designed to educate consumers about risks and benefits), but in general the risks of any vaccine may include:

• Pain with injection. This is very subjective. Most babies cry, but typically as soon as they are cuddled by a parent they quickly calm down. Toddlers are more prone to longer crying times, but that often starts unrelated to the vaccine and is not solely due to pain. It is often due to their frustration and/or fear of being in the doctor's office. Older kids often will say the pain was less than they feared, but some do complain for several minutes. Moving the arms or legs that were injected can help ease this pain. 
• Fever. A mild fever can occur for a day or two after many vaccines. Most kids do not need any fever reducers for this. The fever reducers might even reduce some of the effectiveness of the vaccine, so are not routinely recommended after vaccines. If the temperature is over 102F or the child is very fussy with the fever, it is okay to use a fever reducer. These higher fevers are not common after vaccines, but are possible.
• Fussiness or feeling mildly ill. Infants can be fussy for a few days and older kids might say they feel tired or have a headache. Some kids (and adults) will feel like they're getting sick, but it never evolves into an illness and it stays mild. Extra sleep would be beneficial, but typically no treatment is needed. 
• Non-stop crying. While unusual, it is possible that an infant will cry for hours after one or more vaccines. If this occurs, you can try a pain reliever. If the crying doesn't stop, it might be wise to have your child examined since it might be that something significant is going on causing the crying. 
• Seizure. It is not common to have a seizure after a vaccine, but whenever a child under 5-6 years of age has a fever, it is possible to have a fever seizure. Most fever seizures are from viral illnesses, some of which are prevented by vaccines. Vaccines rarely cause fever seizures, but if the temperature increases rapidly after a vaccine in a susceptible child, it is possible. If a child has a fever seizure, it is scary to watch but does not lead to permanent brain damage.  
• Pain, tenderness and swelling of the injection site for several days after the injection. Some vaccines, such as DTaP and Tdap, are more prone to swelling and redness than others. The most swelling tends to happen after several doses of these vaccines, such as with kindergarteners, tweens, or adults. My son's arm was so swollen after kindergarten shots that he couldn't fit into some of his shirts with narrow arms, but it was a normal shot reaction. With a shot reaction the inflammation begins a few hours after vaccination, peaks 24 h to 48 h afterward and resolves within one week. Tenderness is usually at its worst during the first few hours and resolves as the reaction enlarges. The amount of swelling and redness is more significant than pain or tenderness with a classical vaccine reaction. 
• Infection of the injection site. Very rarely the area can become infected (cellulitis) but this is exceedingly rare now that most childhood vaccines come in single dose syringes. Cellulitis can evolve rapidly -- often within 12 h to 24 h. Diagnosis is based on the symptoms of redness, pain, swelling and warmth, usually with fever and ill appearance. Most redness and swelling is a normal shot reaction and not a sign of infection, but if your child seems ill along with a painful red and swollen area where the vaccine was injected, it might be wise to have your doctor take a look at it. 

It's hard to see, but this is my arm 2 days after a Tdap. The area was swollen, warm and red. The redness has irregular borders, looking lacy in appearance, which is common in shot reactions. I didn't take any pain relievers. I tried moving my arm around a lot and that helped.