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Flu

Fall 2016 Note:

The Nasal Flu Vaccine “Flumist” was not very good over the last several years.  It was only 17% effective.  The shot is 67% effective most years.  So the CDC and AMA and American Academy of Pediatrics recommends only the shot this year.  There probably will be a shortage of injectable shots for flu since everyone should be getting shots and not nasal vaccine.  I recommend the vaccine and I would suggest getting it as early as you can since I think there will be a shortage.

 

 

 

Here is the incidence of flu as of Jan1, 2016.

This last year cases of flu is started out slow.
Like all illnesses, it waxes and wanes with high and low years.
See my article on West Nile... some years it is high and some low.
The news media loves to scare you and as you can see we have a big increase every few years.
I do recommend the flu vaccine.

 

This year 2015-16 is in Red triangles.
very similar to the last several years... Less than many years past and arrived late.
The news like to scare the dickens out of us.

 

 

Thank goodness we did not have a high pediatric death rate last year.  Not like the H1N1 in 2009.
This chart shows you how many kids died of the flu as on Summer 2016
Do not be alarmed by the national news who likes to scare you.
Google CDC Weekly Flu and you can keep up with these numbers.

 

 

 

Realize that this is 10 deaths a month out of 50 million children.  They are children with serious health issues.
Rare healthy children die but rare.  Some years there are more or less deaths in each age group.  I wish this was zero!

 

And the over all death rates from pneumonia and flu.  Low this last year because low rate of flu.   

  

 

Most of the deaths were in the elderly and those with health issues like cancer and such.
Sad to say some are the infants below 2 years old.
 

The effectiveness of the flu vaccine was not good in 2014. 
Many years it protects us 70% of the time
and in rare years it has been as low as 30%. 
Even though the vaccine is not perfect, I recommend it since it does decrease your chances of getting the flu. 
Especially in children below 2 yr, who are at higher risk,
and in Middle/Senior High School where they miss a week of school.

 

How should we diagnose and treat the flu?

Finally what I have been telling my paitients for years is shown by more modern studies on treating the flu:
http://www.smh.com.au/federal-politics/political-news/antiviral-drug-stockpile-a-waste-of-money-says-study-20140410-zqt3i.html

 The average accuracy of the Rapid Flu Tests is 50%.  See: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6143a3.htm

 CDC Quote:

RIDTs (Rapid Tests) may be used to help with diagnostic and treatment decisions for patients in clinical settings, such as whether to prescribe antiviral medications. However, due to the limited sensitivities and predictive values of RIDTs, negative results of RIDTs do not exclude influenza virus infection in patients with signs and symptoms suggestive of influenza. Therefore, antiviral treatment should not be withheld from patients with suspected influenza, even if they test negative. Testing is not needed for all patients with signs and symptoms of influenza to make antiviral treatment decisions. Once influenza activity has been documented in the community or geographic area, a clinical diagnosis of influenza can be made for outpatients with signs and symptoms consistent with suspected influenza, especially during periods of peak influenza activity in the community.

So basically the CDC said to approach the patient as if they have the flu regardless of the test.  Therefore many cases where I am sure they clinically have the flu I do not test them.  The test will not change what I do for the patient.

 

Do you need to be treated with Tamiflu?

The medication has to be started in the first 24-48 hours since it only shortens the illness by one day.  Studies showed that the medication only shortened the illness by 12 - 24 hours.  Resistance can be a worry.  In a study from April 2012 from the National Institute, 27 cancer patients who were hospitalized for the flu.  They found 2 of the viruses were resistant to Tamiflu before treatment and 4 developed resistance at the end of therapy with Tamiflu.

 Not everyone should be treated with Tamiflu.  Here is a quote from the CDC:

"It’s very important that antiviral drugs are used early to treat hospitalized patients, people with severe flu illness, and people who are at higher risk for flu complications based on their age or underlying medical conditions. Other people also may be treated with antiviral drugs by their doctor this season. Most otherwise-healthy people who get the flu, however, do not need to be treated with antiviral drugs."

Following is a list of all the health and age factors that are known to increase a person’s risk of getting serious complications from the flu:

·         Asthma

·         Neurological and neurodevelopmental conditions

·         Blood disorders (such as sickle cell disease)

·         Chronic lung disease (such as chronic obstructive pulmonary disease [COPD] and cystic fibrosis)

·         Endocrine disorders (such as diabetes mellitus)

·         Heart disease (such as congenital heart disease, congestive heart failure and coronary artery disease)

·         Kidney disorders

·         Liver disorders

·         Metabolic disorders (such as inherited metabolic disorders and mitochondrial disorders)

·         Morbid obesity (body mass index [BMI] of 40 or higher)

·         People younger than 19 years of age on long-term aspirin therapy

·         Weakened immune system due to disease or medication (such as people with HIV or AIDS(http://www.cdc.gov/flu/protect/hiv-flu.htm), or cancer, or those on chronic steroids)

Other people at high risk from the flu:

·         Adults 65 years and older

·         Children younger than 5 years old, but especially children younger than 2 years old

·         Pregnant women and women up to 2 weeks after the end of pregnancy 

·         American Indians and Alaska Natives

 Study showing Tamiflu did not decrease the mortality of flu in children.

When I tell the patient I am not treating their child since they are not high risk, they look worried at me.  So I ask them do you want to shorten your child’s illness by one day and then grandma dies of the flu in the years to come when the medication does not work?  Too many clinics give out Tamiflu like bubble gum to everyone and they are not supposed to do that. 

Another study came out in Spring of 2014 showing Tamiflu had very little affect on hours of fever and did not change hospitalizations or secondary pneumonias.
http://pipeline.corante.com/archives/2014/05/16/the_real_numbers_on_tamiflu.php

Should you get Tamiflu to prevent the flu?

Again we worry about resistance.  If someone in the family has the flu, we could give Tamiflu to everyone in that house in order to try and prevent others from getting it.  The first person in the family who developed the flu did not catch it from a family member.  They caught it from someone outside the home.  So if we give the Tamiflu to others in the family for a few days, they will still be exposed to the flu for the rest of the winter at school, friends, church, and stores.  Are you going to give them Tamiflu the whole winter?  I recommend Tamiflu to prevent the flu for a pregnant mommy who is at bed rest and not going out, a small infant who is not going out in public, or elderly relatives with cancer and other diseases and they are not going out in public.  I do not think the average child who is going to school needs medication to prevent the flu.

Whether you get Tamiflu or not, watch out for fever after day 5 of the illness.  Fever is during the first 3-4 days and pretty much gone by day 5.  Fever after that is bronchitis, sinus or pneumonia bacterial infections that can be deadly. Please call if that occurs.

Dr. Knapp

p.s. Opinions expressed here are my personal ones and does not take the place of recommendations from your doctor. 

Discussions on Flu and treatment 2015

Weijen Chang, MD: Recently, Thomas Frieden, MD, director, US Centers for Disease Control and Prevention (CDC), in response to criticism about the reduced efficacy of this season's influenza vaccination, has been prominently advocating use of antiviral medications (oseltamivir [Tamiflu®] and zanamivir [Relenza®]) for the treatment of influenza infections in adults and children. In short, his philosophy can be paraphrased as, "Treat early, treat late, treat often." This treatment recommendation, however, seems to be swimming upstream against a growing river of evidence that questions the efficacy of influenza antiviral medications, especially in light of an unfavorable adverse effect profile.[1]

The current CDC recommendations advocate treatment with antivirals for all children hospitalized with influenza infection, despite recent studies showing lack of efficacy in otherwise healthy children.

Based on my concerns as a pediatric hospitalist with the recommendations and the lack of evidence, I decided to touch base with two other pediatric hospitalists, Matthew Garber, MD, and Ricardo Quinonez, MD, and I asked them about the use of antiviral medications in the treatment of pediatric influenza infections.

Drs Garber and Quinonez, what do you think is driving Dr Frieden's strong, perhaps non-evidence-based, recommendations for antiviral treatments in influenza infection?

Matthew Garber, MD: This is a difficult question, especially because I don't know Dr Frieden and am unaware of his life experiences, general approach to medicine, how he understands and deals with risk, or various outside pressures he may be under.

I can speak to some underlying psychological biases that most of us share and other issues in evidence-based medicine that may be at play. First you have the original CDC,[2] World Health Organization (WHO),[3] and American Academy of Pediatrics (AAP)[4] recommendations that advocate use of antivirals pretty broadly. If you were to take those recommendations at face value, without critically looking at the evidence and the Cochrane review,[1] you could logically conclude that because this season is predicted to be severe, and the vaccine is not very effective, we need to rely even more heavily on these medicines.

As you know, the best evidence we have—systematic reviews and meta-analyses of randomized controlled trials—including data from methodologically sound, industry-sponsored trials that were withheld from the Cochrane respiratory group for 5 years[5] and tells us that these medications reduce symptoms by about 1 day if given very early in the course of infection. However, there is no evidence that they prevent complications, hospitalizations, or deaths from influenza. Furthermore, even though prophylaxis with antivirals can prevent symptomatic disease in a contact, prophylaxis has not been shown to decrease transmission of the virus (the main impetus for stockpiling these medicines in order to halt an epidemic).

So did the Cochrane review prove that antivirals do not prevent complications, hospitalizations, and death? That is the evidence-based medicine issue I'm talking about. It is very hard to prove a negative. Except in extreme extenuating circumstances, we generally require proof that a drug works before using it—we do not require proof that a drug does not work to avoid using it.

Then there are the psychological issues to take into consideration. People, and perhaps especially doctors, like to help other people. Doctors have been trained that when a patient is sick, we find out what is wrong with him/her and then find the best treatment and administer it. It is very hard for us to say, "Thank you for coming to see me and paying for this visit, but there is really no effective therapy for this condition other than symptomatic relief." We'd much prefer to say, "Aha! You have the flu, and here is the drug that will make you better." Then of course, especially in pediatrics, the patients do get better, which reinforces our behavior. The placebo effect is large, especially in children,[6] which also encourages this type of behavior.

Finally, unfairly, we treat errors of omission differently from errors of commission. If someone complains of nausea and vomiting after receiving oseltamivir, we say, "Well yes, that is a known side effect of that drug." Basically it is the cost of doing business. If we don't give an antiviral and the person becomes very sick, we are often faulted for failing to provide the right treatment and may even be sued. Even our language contributes to overtesting and overtreatment saying things like, "To be conservative you better get that chest x-ray. And just to be safe, let's start that antibiotic or antiviral." When in fact one could argue that the conservative path in the face of uncertainty would be to intervene less, not more. This is partly explained by our failure to consider the harms of our interventions (finding an innocent lesion on the chest x-ray that leads to an invasive procedure; Clostridium difficile infection following antibiotics).[7]

Dr Chang: Given the recent Choosing Wisely® campaign started by the American Board of Internal Medicine (ABIM) and joined by major professional societies (AAP, Society for Hospital Medicine [SHM], etc), should one of the major societies balance the voice of the CDC with their own recommendations?

Ricardo A. Quinonez, MD: The short answer is yes, particularly those societies that use strong evidence-based decisions for their own guidelines. My view is that they should adhere to the highest standard both when they write their own guidelines and endorse others' recommendations. I really think that is not the case currently. To be fair, though, it is going to be extraordinarily difficult for a medical society to contradict decisions made by one of the highest medical authorities in the land, such as the CDC.

Where it really should start is with those medical experts within our government to have a measured response to ongoing health crisis and not swing the pendulum so far that they are ignoring science. I understand they want to seem proactive given the initial criticism the CDC received for handling of the Ebola crisis. However, the failure of this year's vaccine to completely cover the flu represented yet another crisis. The unmeasured response was to support, in an extraordinary way, medications for which evidence is not just lacking but also has a clear track record of manipulation of data by its industry supporters.

I would direct readers to well-documented instances of this behavior with oseltamivir by the British Medical Journal.[8] I think the CDC and others should take an unbiased approach to recommendations even in times of crisis. The US Preventive Services Task Force (USPSTF) framework for making recommendations is a great example to follow. If evidence is not there to support a particular therapy or test, no recommendation is made. It allows clinicians to use their judgment to make clinical decisions in those instances in which the evidence is equivocal or highly biased, as is the case for antivirals in influenza. The CDC's strong stance on this has really put conscientious physicians in a difficult spot.

Dr Chang: The reality of practicing hospital-based pediatrics is that it is a team effort and, as physicians, we are not immune to the "peer pressure" of others when it comes to treatment selection. How much antiviral use by hospitalists is due to a fear of being second-guessed (especially if the patient subsequently "crashes")?

Dr Quinonez: This is a fantastic point, and I could not agree more with your assessment. I think pediatricians and other physicians have been placed in an extraordinarily difficult situation. Those of us who like to make decisions based on evidence when treating children feel extremely uncomfortable with the CDC's recommendations. On the one hand, the latest meta-analysis of neuraminidase inhibitors not only found insufficient evidence to support an effect on complications in patients with influenza but also found that the harm has been severely understated. These medications may actually put children at risk of developing important neuropsychiatric symptoms and significant emesis.

CDC defends its decisions by pointing to single studies showing decreased complications and mortality but ignores the higher-level evidence (meta-analysis) that should drive recommendations. The US Food and Drug Administration (FDA), an agency that has indeed reviewed the full study data on Tamiflu® during its approval process, has actually contradicted the CDC's recommendations and has forced the makers of oseltamivir to include in its labeling language that effectively states that Tamiflu has not been shown to prevent complications like serious bacterial infections.

On the other hand, not following the CDC recommendation puts practitioners at a very significant risk for legal exposure. It is not hard to imagine that a patient who presents with influenza-like symptoms and is not started on antivirals and later develops a complication (which, again, the evidence does not support antivirals being able to prevent) could result in the physician being dragged into a painful legal proceeding based solely on the strong recommendation from the CDC that seems to be using antivirals as the solution to the inefficacy of this year's flu vaccine.

Dr Chang: Does the severity of the current influenza season, coupled with the lower-than-expected efficacy of the seasonal vaccine, warrant increased antiviral usage by hospitalists?

Dr Garber: I don't think it does. But to be fair, this argument is not completely without merit. As I discussed before, it's hard to disprove a negative, but with the large number of patients studied, I think we can rule out a large effect size of the antivirals. While antivirals may have a small effect size to prevent complications in a limited group of patients, there is currently no high-quality evidence supporting this. The clinician must weigh several factors when considering interventions for her patients.

Let's pretend, just for the sake of argument, that a particular antiviral was shown to have absolutely no side effects and was free (maybe it's derived from a pesky weed that homeowners would be happy for us to pluck and ingest). Let's also pretend that this year's influenza season is much worse than the 1918 Spanish flu epidemic (imagine Ebola that spreads like the flu). In this imaginary scenario, prescribing the antiviral makes sense. No side effects and it's free. It may help some people avoid complications, but even if it doesn't, what's the harm? Unfortunately, no such medicine exists. They all have side effects, and current recommended antivirals are quite pricey. We know that oseltamivir has a significant rate of emesis and, though rare, occasionally causes severe neuropsychiatric symptoms, even suicide. So those need to be added into the equation, and the more prescriptions we write, the more potential harm we cause.

While harms resonate with doctors and patients more than costs, we also must consider costs. Because the United States does not have unlimited resources, money spent in one area of healthcare will not be available in another. That is the reasoning behind the statement, "Waste is unethical." We need to be good stewards of our country's healthcare dollars and should not allocate large resources to unproven therapies as there will undoubtedly be patients who will be denied effective therapy as a result.

So there is a balancing act. We must weigh the severity of the disease and the evidence supporting the potential of the therapy to improve important outcomes (such as mortality) against potential harms and costs of the therapy. Right now we do not have strong evidence that antivirals improve important outcomes, but they do have significant side effects and high costs. So at this time I don't think the severity of the season coupled with the poor efficacy of the vaccine warrant increased use of antivirals by hospitalists.