Flu Vaccination

Background
Influenza is an acute respiratory illness caused by Influenza A or B viruses, which occurs in outbreaks and epidemics worldwide nearly every year, mainly in the winter season.  The Influenza virus is remarkable for its high rate of mutating its genes, thereby changing its biochemical characteristics.  Another way of putting this is that the Flu virus changes it's "look" pretty much every year.  This makes it very hard for our immune systems to fight and the reason that the Flu causes so many problems.  As a consequence, new vaccines are produced each year to try and match the best vaccine to produce resistance to the upcoming year's infecting virus.

Antigens can be thought of as pieces of the virus or pieces that are similar to the virus for which our immune system recognizes as "foreign."  Antigens are what stimulate our immune system into action.  Our immune system "remembers" antigens and on the second go-around is better armed to defend.   This means either not getting sick or not getting as sick.  This is the basic principle of vaccinations.

The decision of which influenza antigens to include in a vaccine is made in advance of the Flu season.  It is based upon global surveillance of influenza viruses and the emergence and spread of new strains.  The U.S. Centers for Disease Control and Prevention in collaboration with the World Health Organization track this and ultimately predict what goes into that year's vaccine.

Vaccinations
There are two different vaccines licensed for use in the U.S.  One is the tr-ivalent inactivated influenza vaccine and the second is the tri-valent live-attenuated vaccine that is given intranasally.

The first is the one we typically think of when we hear the term "vaccine."  It is an intramuscular shot.  The vaccine is inactivated in terms of its components.  Specifically, it contains inactivated influenza virus or smaller pieces called subvirion components.  These "pieces," or antigens, stimulate our immune system to produce immune proteins called antibodies that lead to destruction of the real virus when the patient is later exposed to it.  Also, new for this year is an intradermal form of this vaccine that is given under the skin like diabetics give their insulin.

The second is a live influenza virus, but attenuated.  This is actually a live influenza virus that has been stripped of it's ability to cause real disease.  It will still stimulate your body's immune system to "remember" the real virus if it comes along in the same exact way as the inactivated vaccine.  This vaccine is given as a mist inhaled through the nose.

Effectiveness
Among healthy adult patients the inactivated vaccine produces a substantially reduced probability of Flu A or Flu B infection, a reduction in cumulative days of respiratory illness, and a reduction in work absentees.  Among patients that received the live attenuated vaccine there were significant reductions in severe febrile illnesses, febrile upper respiratory tract illnesses, and days of work lost.

In our elderly patients the data was a little less convincing looking back at past studies involving residents of long term facilities and those patients living out in the community.  However, a recent study in 2012 evaluating patients out in the community revealed that the vaccination was associated with a reduction in the hospitalization for pneumonia, influenza, and death during the influenza season.

In children vaccination against the flu produced a significant reduction in the amount of confirmed influenza illness, upper respiratory tract illnesses, and school days missed.

Who Should Receive It
In 2010 the CDC's  Advisory Committee on Immunization Practices and the American Academy of Pediatrics expanded the recommendation for influenza vaccination to include every individual older than 6 months.   
Although vaccination is recommended for all patients, special efforts should be made to immunize those more at risk of developing complications from the Flu: 
--These include children 6 months through 4 years of age.
--Patients that are 50 years old and older.
--Children with chronic pulmonary conditions, such as asthma, any ongoing long-term cardiovascular, kidney, hematologic or metabolic disorder. 
--Also, patients that are immunosuppressed, residents of chronic care facilities, native Americans and morbidly obese. 
--Women who are or will be pregnant during the influenza season.  Household contact and out-of-home caregivers and adolescents who are at high risk for severe or complicated influenza.
--Children who may transmit influenza to a high-risk household member.
--Adult patients with Diabetes, Kidney dysfunction, Chronic Liver disease, Chronic Pulmonary disease, Spinal Cord injury, Neurodevelopmental disorders(Cerebral Palsy, Muscular Dystrophy), Intellectual and Developmental delay.
--Patients with HIV.
--Patients that are on medications that can cause immunosuppression.

Which Vaccine
There are many questions about who should  receive which vaccine.  Basically, the inactivated vaccine can be given to everyone with a higher dose form sometimes given to our patients 65 years and older.  Starting with infants 6 months or older the inactivated form can safely be given every year for however long the patient wishes to be immunized.  The only thing that changes is the amount of the vaccine injected.  There are very few situations when this vaccine absolutely should not be given.  The first is any type of significant reaction to a previous Flu vaccine, such as shock requiring resuscitation, being place on a ventilator, or admitted to the hospital for these sxs.  Another is the development of a disease called Guillain Barre Syndrome within six weeks of a previous flu vaccination.  Patients with egg allergies can receive this vaccine.  This was once a contraindication, but has been relaxed somewhat.  It is now recommended by the American Academy of Pediatrics the CDC,  and the Advisory Committe on Immunization Practices that the inactivated vaccine can be given only with a period of observation and the presence of resources and medications to perform emergent resuscitation if shock occurs.  Be sure and let your doctor know if you have allergies to eggs before being given any vaccinations, in fact, any medications whatsoever.

There are many more limitations on the live attenuated vaccine (Flumist).  Again, this is the vaccine that is given inhaled through the nose.  The USDA has licensed this vaccine for use in healthy individuals age 2 y/o and older to 50y/o old.
 Furthermore, the Intranasal vaccine should NOT be given to:
--Children with asthma and children 2-4y/o with a history of recurrent wheezing conditions.
--Children with medical conditions that increase risk for severe or complicated influenza infection
--Children who are contacts of severely immunocompromised patients.
--Immunocompromised patients, including HIV and Chronic Hepatitis.
--Patients with certain chronic conditions, such as; Emphysema, Asthma, Congestive Heart Failure, Coronary Artery Disease, Diabetes, Kidney Disease, Hypertension.  There are others, but these are the more familiar ones.  Patients need to inform their physician of any ongoing illness before receiving any vaccine.
--Pregnancy
--Patients with a history of an illness called Guillain-Barre Syndrome
--Patients with a history of egg allergy
--Long-term aspirin or salicylate therapy
--Receipt of another live virus vaccine within the previous 4 weeks
--Residents of  chronic care facilities

Thimerosal
Thimerosal is a mercury-containing antibacterial compound used as a preservative in multi-use vials of flu vaccines.  It is not present in all the vaccines.  Although mercury can be toxic to the human body, the small amount found in some of the inactivated vaccines poses no risk.  The risk is both theoretical and unproven.  Thimerosal was implicated as a contributing factor in autism and the idea seemed to gain some momentum in the press and some circles.  There was never any scientific proof of this nor any relationship between mercury and autism.

Infection and Withholding
Immunization with both the inactivated and live vaccines should be withheld with moderate to severe acute illness with fever until symptoms have resolved.  However, minor illnesses with or without fever should not prevent vaccination.  The live vaccine can be administered with minor acute illnesses with or without fever.  Since this vaccination is given intranasally sometimes the Flumist vaccine is withheld if patients have  a upper respiratory track infection resulting in significant nasal congestion.  You and your doctor can decide.

Which is Better?
In children the live attenuated vaccine has been shown to provide better immunity than the inactivated form.  It was shown to provide immediate protection during an outbreak and may provide better long-term protection.  In adults it seems that most of the studies show somewhat the opposite.  Studies in adults specifically show that the inactivated vaccine protects about the same or better than the live attenuated vaccine.  Also, some patients have a phobia to shots.

Schedule/Frequency and When?
Annual vaccination is recommended.  It should be administered as early as possible during the fall of each year.  Ideally as early as October and throughout the fall and early winter until December in the U.S.  There are certain situations when two doses should be given.  This usually applies to patients first receiving the vaccine and then those patients that have not had two doses of the vaccine after 2010.  You and your doctor can help determine how many doses you may need.

Side Effects
The most common side effect with the inactivated vaccine is arm soreness at the site of injection.  Low grade fever is common and it is also common for  patients to have mild fatigue and general muscle soreness for 24-48 hours.  The Flumist also causes fever, in addition the intranasal live vaccine has a higher incidence of nasal congestion and a higher incidence and intensity of influenza-like symptoms.  These symptoms can occur up to 72 hours after administration.

Our Recommendations
>>Get vaccinated, there is overwhelming evidence that you can keep yourself well, miss fewer workdays and decrease the risk of infecting household member and loved ones.
>>Always, always, before being given any medication or vaccination tell your doctor or whoever is giving the vaccine all of your allergies to food, drinks, drugs, or any other substance that has caused a "reaction" in the past.
>>Talk to your doctor about which vaccine is better for you, the Inactivated or the Live Flumist.
>>Talk to your doctor about any household members or loved ones that you live with that have any chronic disease or illnesses requiring treatment or medicines on a daily basis.
>>Of course, considering some of these important things mentioned above we will always recommend getting your Flu vaccination at a Doctor's Office to discuss some of these important issues.
>>With all this in mind, we have both versions of the flu vaccine at Hello Wellness, call now it will take no time: 279-249-6362.  Stay tuned for more information, thank you.