Flu Vaccine 2013: The story unfolds

photo source: Shutterstock

I wrote about this year's flu vaccine new twist last month (Flu Shot Information 2013-14 Season).

Since that time I've learned some frustrating things.

Although it is not new news that companies are making two types of injectable flu vaccine this season (trivalent and quadrivalent), there are signs that we won't be able to start using it. The quadrivalent vaccine was not approved by the FDA until after the CPT coding book was published for this year, so no currently recognized code exists for the quadrivalent vaccine. Since every service and procedure a physician's office does is reported to the insurance company with a CPT code, the quadrivalent vaccine can't be given and appropriately documented with appropriate notification to the insurance company. The codes (90685 for 6-35 months and 90686 for 36+ months) are now assigned for the quadrivalent vaccine in CPT 2014, but insurance companies have until January to recognize them (with a retroactive time of 90 days possible- so possibly as early as October they can be used, but with a question of reimbursement for this very real cost, many businesses will be hesitant to use it).

There is only one type of FluMist, so there is only one code, allowing it to be used when in stock. (For more on CPT codes: What Are CPT Codes?)

You might wonder why this is important. First, CPT codes are used to document which vaccine is given and to send it to the insurance company. We must report the code accurately for inventory, billing, and proper documentation reasons. Insurance companies value each code differently, so the vaccine reimbursement will be different from code to code (and also varies among various insurance companies). The quadrivalent vaccine is of course more expensive than the trivalent vaccine, but it also covers another strain of virus, which makes it a better vaccine.

Our office received notice that our first shipment of quadrivalent injectable vaccine would soon be shipped. Since we won't be able to use it, we were forced to cancel that order. (It was only a small fraction of our overall order, so we hope to have more coming later when this mess is sorted out.)

My biggest frustration is that I want my most at risk patients vaccinated with the quadrivalent vaccine because it covers an additional strain of influenza. They can't wait until January. Many of these kids are not able to get the FluMist because they are under 2 years of age. I will be forced to give kids the less-preferred (though still good) vaccine, fully knowing that the only reason is tied to coding and billing. I've had parents mention that they would pay cash to avoid the delay, but that gets complicated with insurance contracts.

And what about the companies that have made all of their pre-ordered quadrivalent vaccines? If we all cancel our orders, they will have invested time, money, and resources into an entire line of product that will go unsold. Over the years many manufactures have gotten out of the vaccine market due to it being a money loser (despite what some anti-vaccine people state of us being in it only for the money). For a historical review of why companies stop making vaccines, leading to shortages over the years, please see this article: Why Are Pharmaceutical Companies Gradually Abandoning Vaccines? I worry that this type of craziness will lead to future flu vaccine shortages, resulting in more people getting sick and dying from influenza.

That all being said, the FluMist recommendations have become more relaxed as we gain experience in how it affects at risk groups of people. Because it is a live attenuated vaccine, initially higher risk people were not eligible to get the vaccine out of fear it would lead to wheezing. It is still not recommended for children under 2 years of age, but other groups for whom it used to be not recommended now may consider it. Children over 2 years who have a history of wheezing, a weakened immune system, diabetes, and other higher risk conditions MAY be eligible for this vaccine. Pregnant women also used to not be eligible, but many OB's are now recommending it because of its superior protection, which helps protect the newborn as well. You will need to talk with your provider if you feel your child should get the FluMist but has historically been unable due to higher risk status.

So, in a nutshell: this flu season follows suit with the fact that there is always something crazy that happens with flu vaccines. This is the most frustrated I've been though. In years past it usually has to do with shortages and trying to get mass numbers vaccinated within a relatively small window of time. Things that really are beyond what anyone can do. We can't anticipate the need, so ordering (and manufacturing) isn't always matched to demand. Proper codes for a new vaccine that had been announced is something that should have been anticipated. These coding problems are due to something people should have addressed, not unknown issues, which is why I am more frustrated than ever!

Stay tuned...

Common Sleep Myths - by guest blogger Kerrin Edmonds

made at www.quickmeme.com

Social Media really is shrinking the world. How else would I be able to keep up with my friends without leaving my living room? I've realized that people I know from different aspects of life somehow know each other because they are friends of friends. I can easily share great information with hundreds of people with one easy click.

Business networking through social media is a wonderful tool. I have recently been contacted by a number of sleep consultants who found me through Facebook. Since there are always so many questions about sleep, I'm excited that many of these certified sleep consultants have offered to share articles when they write them. Some have been published on other sites, and I have (or will) post those articles on my Social Media sites. For those who have great information to share but don't have a website to link, I will have them guest blog here.

I'm excited to introduce my first ever guest blogger, Kerrin Edmonds.

Kerrin grew up on California’s Central Coast and has lived there her whole life.

Growing up with a Mom who owned and ran her own preschool, as well as being the oldest of three kids, Kerrin has always been around children from the start. But her passion for babies and more particularly, for baby sleep issues, was born with her first baby. After weeks of crying and sleepless nights, she felt there had to be a better way……So she started her journey to a better sleep for her whole family. After graduating from the Family Sleep Institute, and becoming certified with the International Sleep Consultants Association, Kerrin founded “Meet You in Dreamland,’ where she helps families find and keep their restful nights sleep.

Kerrin also works with a local group called Pickles and Tickles, a organization that offers early intervention services to families with children under the age of three.

Kerrin lives in California's San Luis Obispo North County with her husband, daughter, son, funny looking little dog and sweet kitties.

Common Sleep Myths

By Kerrin Edmonds

As we parent our children in regards to sleep, there is a myriad of information, recommendations, myths, rules and even legends! It can be tough to sort through and make sense of it all. In this article I will respond to 5 of the most common Sleep Myths.

1. Putting Rice Cereal in a Babies Bottle will help them Sleep Longer-

This one has been around for decades! Many studies have  proven that babies who were given rice cereal in their bottle did not sleep any longer than those who did. Some parents have even found the opposite to be true….that babies who were given too much rice cereal or were given rice cereal at a young age suffered from indigestion and tummy upset.

2. Keeping a baby/child up later at night will make them sleep in.

This one couldn’t be further from the truth. While on the surface this makes sense, we must think biologically not logically when it comes to our child’s sleep. If we allow our children to become overtired they release a hormone called Cortisol, which is similar to adrenaline. This hormone makes it very hard for them to fall and stay asleep. Babies sleep better, longer, and cry less if they are put to bed early in the evening. Babies who go to sleep late in the evening are often "over tired", even though they seem to have energy. A typical and healthy bedtime, depending on how they napped during the day is between 6-8 pm.

3. A Baby should sleep through the night at 12 weeks-

While this would be nice, and does happen in some cases with some babies, it can be an unrealistic expectation and just cause stress if it doesn’t happen for you. It isn’t unreasonable for a baby to “need” a feeding during the night till around 9 months of age.

4. My child doesn’t need as much sleep as other children-

I hear this one a lot in my profession and while this might make a parent feel better about how little their child sleeps, it really isn’t true. It is true that some kids need/love sleep more than others but usually this varies by only an hour or two, not huge amounts that I tend to see. It is not uncommon for children to fight sleep but that doesn’t mean they don’t need it.  I am confident that all children can be taught to be good sleepers…..and isn’t that what we want?!

5. You can sleep train a newborn-

In all reality you can’t sleep train or schedule a newborn. Sometimes an infant might appear to be on a schedule until it suddenly changes. This is because our babies Circadian Rythmn or body clock is not biologically mature yet. This maturing starts around 4-5 months of age and this is when we can start scheduling naps, etc.

Most basic baby sleep myths can be busted by remembering to think biologically instead of logically in regards to our children’s sleep.  Respecting and encouraging our children’s need for sleep is something every baby deserves!

Flu Shot Information 2013-14 Season

Dr. Mellick getting FluMist

Dr. Stuppy getting a flu shot

Many parents are already asking about this year's flu vaccine, which means we've done a great job in the past making them aware that they need to think about getting the vaccine before they start seeing people get sick!

We feel so strongly that the vaccine is effective at protecting not only the person vaccinated but also the community around them that our office requires all staff to get a vaccine. We made the Honor Roll for Patient Safety from the Immunization Action Coalition for this requirement!

What's new this year?

Every year scientists predict which strains of Influenza A and Influenza B will likely be prevalent. The World Health Organization makes the recommendations for the vaccine based on these predictions. The strains chosen are the same for every company that makes the vaccine. The difference this year is that some will have three strains (trivalent) with two A and one B, others will have four strains (quadrivalent) with two A and two B.

Flu shot season causes headaches for doctor's offices. 

We must anticipate our need many months in advance and get our orders in. Each year the vaccine demand varies (a lot based on press reports on how badly people are getting sick, which we don't know when ordering). As more places offer vaccines (such as offices and pharmacies) the numbers of people getting vaccines at their doctor's office might go down. (I am biased, but of course believe getting them at your doctor's office is superior since we keep all your medical records in one place.)

From a business perspective, no one wants to be stuck with thousands of dollars of unused vaccine-- we can't stay in business if we lose money. We also don't want to have kids at risk of disease because they're unprotected and unable to find an appropriate vaccine when we run out. We certainly don't want parents yelling at our staff because we run out. Sometimes we've ordered enough overall, but our shipping allotments don't come fast enough for the demand. Shortages have happened over the years, something beyond anyone's control.

Scheduling mass flu vaccine clinics is often the best way to vaccinate large numbers of patients, but they are fraught with complications: how many people will show up, what flu vaccine (injectable vs nose spray) will they need? How many doses do we need on hand to hold a clinic? In times of shortages or low stock, how do you prioritize who gets the vaccine -- or do you want to just keep giving to anyone until it is gone so the office isn't stuck with unused vaccine at the end of the season? Do you give one dose to a 6 month old who you know won't be able to get the 2nd dose due to your supply running out?

This year there's a new spin to the variety of headaches: different vaccines will be available. Not just injectable vs nose spray. There will be some with 3 strains of virus, others with 4 strains. (For a review of how strains get into vaccine and how this year is different, see Quadrivalent Flu Vaccines: Four Means More Protection.)

So this year we have new questions: How are we supposed to order the different types, who gets which type, and are they interchangeable? How will the public perceive the difference and will they demand one or the other? Will insurance companies reimburse the cost appropriately, given that one is more expensive than the other? While in health care our goal is to keep everyone as healthy as can be, no office can afford to lose money on vaccines and stay in business.

What kinds of vaccine will be available this season?

There are many companies that make influenza vaccine, each with their own indications. For a complete list, see the chart on the CDC website. Our office has pre-ordered the FluMist and the Fluzone products (both forms) in part because we didn't know which would be available at the start of the season. We do not purchase the brands that are only available for older children or adults. Ask your doctor what they order.

All FluMist will be quadrivalent (4 strains) and is for children over 2 years without high risk conditions, such as asthma (presumed based on previous recommendations, this year's statement has not been released yet). It is expected to start shipping in July or August, though any individual office may not receive their order with the first shipping dates.

Fluzone Quadrivalent (4 strains) is an injectable vaccine for everyone over 6 months of age. It has already sold out  based on pre-season orders and will be available in limited quantities. Shipping dates will begin in August or September.

Fluzone Trivalent (3 strains) is an injectable vaccine for everyone over 6 months of age. It is expected to begin shipping in July and August. I have not heard of shortages.

Is adding a new strain dangerous?

Based on the chaos in the year of H1N1, I know that many parents fear "new" strains added to a flu shot. In actuality, every year the vaccine changes with very rare exception. That is because the flu strains predicted to cause disease change year to year. Adding a new strain does not make the vaccine less safe, just more effective.

Who needs the flu vaccines and how will they be given?

As of today, the finalized recommendations have not been approved. The preliminary recommendations  continue to recommend flu vaccine for all people over 6 months of age. (The link should update to the final recommendations as they become available.)

Last year it was recommended to start giving the vaccine as soon as it was received (previously it was suggested to wait until October so it remained effective throughout the season, but the vaccine is effective longer than previously thought so earlier vaccine is effective.) I presume this will remain the same.

If a child under 9 years of age has not had flu vaccine before, they need 2 doses in the same season to "prime" and "boost" immunity. If only one vaccine was given, the next season the child needs 2 doses unless they have gotten 2 of the same strain before. (This was easier last year because it was a rare year that the vaccine didn't change, so they could have gotten one the season prior, and the booster last year.) For children over 9 years, only one dose is needed, even if never received previously. After that first year of 2 doses, each year everyone just needs one dose unless it dramatically changes (as in the H1N1 year). I suspect since 3 of the 4 strains are the same this year, if a child needs 2 doses because they have not had 2 doses of the same strains, the vaccines are interchangeable. We will all find out when the final recommendation is given.

At this point I have not heard if high risk people should get preference for the quadrivalent vaccine. I don't think this will be possible in many cases, since many of the high risk are under 2 years old, and not eligible for FluMist. The injectable quadrivalent vaccine is in short supply, and many offices are likely to not get it at all. I personally feel it would be bad to wait for the quadrivalent vaccine if we have the trivalent vaccine in stock and an eligible patient is in the office. I'd rather vaccinate than potentially miss the opportunity all together. I'm sure others will differ in opinion since the quadrivalent vaccine is better protection. Talk to your pediatrician about their preference.

Although we cannot require all patients to get vaccinated, we certainly encourage it and try to make it as painless as possible (though the kids who get shots don't always agree). We will once again allow any patient in the office to get a flu vaccine (even if just there with a sibling for an appointment) and we will offer on line sign up for our clinics. On line sign up has proved very popular, both among our nurses and the families who come. It has really made the process run much more smoothly. There will not be a co pay collected at those clinics. (After we submit the claim to your insurance company if they tell us differently we will send a bill, but do not expect that in most cases.) Be sure you have registered for our e-Newsletter so you will be among the first to know when sign ups are ready for our patients. (No dates are set yet because we have not gotten verification on shipping dates. Please don't call the office to ask-- staff have no idea.) We will put information on our website as it becomes available in addition to posting on our Facebook page and sending the e-Newsletter.

We will all have to wait to see how this plays out! Every year something is new with the flu vaccine. What will be next?

Updated Sinusitis Guidelines

photo source: Shutterstock

This month the American Academy of Pediatrics updated the guidelines for management of sinus infections in children (1-18 years of age) in the June edition of Pediatrics, available online.

Many parents bring kids in to the doctor for green or yellow runny noses because they're worried about bacterial sinusitis. Sinuses can be infected with viruses or produce mucus from allergies, so not all sinus infections are bacterial. Most of these kids do not need antibiotics to get better, but the guidelines help determine who might benefit from them and when to change an antibiotic if not improving. The guidelines are based on duration of symptoms and severity, not the color of the drainage, how much drainage there is, or fancy testing. Only infections caused by bacteria need antibiotics. Overuse of antibiotics can lead to resistance (so when there is a severe infection it becomes more difficult to treat), side effects (such as diarrhea), or allergic responses.

Unfortunately, a physical exam is not helpful in distinguishing a simple viral cold and cough from a bacterial sinus infection, but is needed to identify other problems that might complicate the picture, such as pneumonia or an ear infection. The inside of the nose can be swollen and various shades of pink, red or blue in sinus infections from bacteria or other causes. How often have I palpated those sinuses to see if tender, yet I know from personal experience that mine hurt when my allergies flare-- certainly not a reason for antibiotics!

I wish there was a simple test, but nose swabs for culture have not been found to be accurate in predicting bacterial cause of the infection. Imaging studies are not needed to help diagnose sinusitis because the inflammation seen in pictures can be from other causes, not just bacterial.

Most cases of runny nose, fever, and/or cough are due to a viral illness. The nasal discharge usually starts clear, but can become thick and discolor over time for several days. It often goes back to a thinner, clear color before resolving without antibiotics. Fever in a typical viral illness tends to be the first several days, and may precede the other symptoms. Fever usually resolves by day 3, when the nasal discharge and cough tend to worsen.  Symptoms tend to peak between the 3rd and 6th day, then resolve after about 10 days. (Though some studies show longer.) Back to back infections are common in kids, especially during the winter months, which can be confused with one prolonged sinus infection.

Guidelines to diagnose and treat acute bacterial sinusitis in a nutshell:

• Symptoms in a child with upper respiratory infection suggest acute bacterial sinusitis if: 

• there is persistent illness (nasal discharge or daytime cough) of 10 days without improvement. This persistence can be difficult to distinguish from back to back viral illnesses, so a careful review of symptoms is important.

 or

• there are worsening symptoms (nasal discharge, cough, fever) after initial improvement. (New in the 2013 guidelines.)

or

• there is severe onset (fever over 102.2F and discolored nasal discharge for at least 3 consecutive days). Several viral infections, notably influenza, can cause severe onset of symptoms, but a clue to the bacterial nature is the combination of fever with mucus in the initial days, since the fever usually comes before the mucus in many viral illnesses. 

• Observation without antibiotic is acceptable with a persistent infection over 10 days for another 3 days if there was not a severe onset or worsening of symptoms. (This differs from the 2001 guidelines to use an antibiotic for symptoms of 10 days.)
• Imaging is not recommended to diagnose routine sinusitis. Plain x-rays, computed tomography (CT), magnetic imaging (MRI), and ultrasounds (US) cannot distinguish between viral, bacterial, or allergic nature of the inflammation. 
• If there is a suspicion of extension of the infection outside of the sinus cavities, such as into the eye orbit or central nervous system, a contrast-enhanced CT scan is indicated. These might be suspected if the eyelid is swollen and the mobility of the eye is decreased, sensitivity to light, severe headache, seizures, or other neurologic changes. 
• When antibiotics are indicated, amoxicillin or amoxicillin with clavulanate (Augmentin) is the first line choice unless there are documented allergies to penicillins. If there are allergies or failure to respond to the amoxicillin, a cephalosporin may be used. There are other good choices, but studies do not show that azithromycin (Zithromax) or trimethoprim sulfamethoxazole (Bactrim) are good choices because they aren't effective against the most common bacteria of bacterial sinus infections. The duration to take an antibiotic is not well identified. Recommendations vary from 10 to 28 days, or 7 days from the time symptoms go away. This will vary by prescriber's preference and experience.
• If there are worsening of symptoms or failure to improve within 72 hours of initial visit, a repeat evaluation is recommended. If no other source of symptoms is found on physical exam, adding an antibiotic (if not previously initiated during the observation period) or changing the antibiotic is recommended. 
• There was not enough evidence to support other treatments, such as decongestants, antihistamines, nasal corticosteroids, or saline rinses. More studies in children are needed to validate whether these are effective or not. There's always more to learn!

Bicycle Safety

I like the simplicity of picture blogs. They make it easy to share a lot of information in an easy to see format, so when I decided to do a blog on bicycle safety, it was an obvious choice.

Bicycle Safety Tips

Teach kids to use hand signals to alert others where they are going:

From: http://www.nhtsa.gov/Bicycles

Use a properly fitted helmet:

From: http://www.nhtsa.gov/Bicycles

Help your kids learn about bike safety with these fun activities from the National Highway Traffic  Safety Administration.

Swimmer's Ear

Summer's here and that means we will soon start seeing a lot of older kids with earaches.

Swimmer's ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

Swimmer's ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin. Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer's ear.

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear. Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though -- it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Both Good and Bad.

Swimmer's ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal. Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer's ear due to canal irritation). Sometimes there is drainage of clear fluid or pus from the canal. If the canal swells significantly or if pus fills the canal, hearing will be affected. More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck. Swimmer's ear can lead to dizziness or ringing in the ear.

Prevention of swimmer's ear is possible for most people.

• If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. (Wax does help keep your ears clean, so you don't want to clear it too much!)
• Never put anything solid into the ear canal.
• Dry the ear canals when water gets in. 

• Tilt the head so the ear is down and hold a towel at the edge of the canal. 
• Use a hair dryer on a cool setting several inches away from the ear to dry it. 

• If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal. DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.

• If your child has a scratch in the ear or a current swimmer's ear infection, avoid swimming for 3-5 days to allow the skin to heal. 
• Avoid bubble baths and other irritating liquids that might get into ear canals.
• If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming. 

Treating swimmer's ear:

• If you think your child has swimmer's ear, start with pain control at home with acetaminophen or ibuprofen per package directions. Heating pads to the outer ear often help, but do not put any heated liquids into the ear. 
• Most often swimmer's ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days. Bring your child to the office for an exam, diagnosis, and treatment as indicated. 
• If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at our office or another urgent/emergent care setting. 
• Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal. Never attempt this at home!
• The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day. Have the patient lie on their side, put the drops in the ear and remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. Symptoms generally improve after 24 hours and the infection clears within a week.
• Oral antibiotics are usually not required unless the infection extends beyond the ear canal.
• If pain is very severe, ask about prescription pain relievers when your child is being seen and evaluated. Most often they are not needed, but if they are it is best to get them at the time of your visit so risks of these medications and how and when to use them can be discussed.
• If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection, which requires an anti-fungal medication. 
• No swimming until the infection clears. 
• Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection. Visit your doctor early if you suspect a problem.

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Lawn Mower Safety

This time of year a lot of us must mow twice a week to keep the grass under control.

I have already seen kids in my neighborhood who are far too young to safely mow pushing the lawn mower. Each year I cringe at the sight of kids taking on this responsibility too soon! 

I often see a parent mowing with kids playing near by. 

Thousands of children are injured by lawn mowers each year. They lose limbs and life. This is entirely preventable.

Last week I drafted this picture to quickly show a few safety tips.  It was popular on our Facebook page, so I wanted a more "permanent home" for it. 

Please feel free to share!

For more tips, see the American Academy of Orthopedic Surgeon's page on Lawn Mower Safety.

Original picture altered from Shutterstock.