Should I get the flu vaccine?

Tis the season!

Flu season that is. The flu vaccine is ready and out for administering, so in the usual fashion Erin and myself are having to answer the daily questions: “Should I get the flu shot?” “Does it really work?” “What kind of side effects should I expect?” “But my friend told me I shouldn’t get it because of X,Y,Z.”

This week’s blog post will answer any questions you may have regarding what exactly the flu is, who should receive the vaccination, and what side effects are expected. In the end, you will have to make the decision to accept or decline the flu vaccine from your healthcare provider (or even make the decision while you are shopping at various grocery/supermarkets). And it’s your duty to make sure you have ALL of the facts before making that decision.

What is “The flu”?

“Between 1990 and 1999, seasonal influenza [influenza A+B] caused an average of 36,000 deaths and 226,000 hospitalizations per year in the United States.” (1)

Did you know there are 4 types of the influenza virus? They are A,B,C, and D.

Influenza (Flu) A and B are the viral strains that most commonly affect the human population and are considered “seasonal” (mostly fall and winter months). However, in hot and humid South Florida we tend to see positive flu tests in our clinic/office even during the summer months! These are the strains that are being swabbed for in primary care offices, urgent cares, and emergency rooms, and Flu A tends to be more prominent than Flu B.

Flu A is “further classified into subtypes according to the combinations of the hemagglutinin (HA) and the neuraminidase (NA), the proteins on the surface of the virus. Currently circulating in humans are subtype A(H1N1) and A(H3N2) influenza viruses. The A(H1N1) is also written as A(H1N1)pdm09 as it caused the pandemic in 2009 and subsequently replaced the seasonal influenza A(H1N1) virus which had circulated prior to 2009. Only influenza type A viruses are known to have caused pandemics.” (2) Flu B viruses are not broken down into these subtypes.

Flu C is less frequent and causes only mild symptoms, while Flu D primarily affects cattle and does not seem to be a threat to the human population. (2We will not be addressing these two strains of Influenza in this blog post.

The Flu (both A and B) can sometimes mimic symptoms of the “common cold,” in which case you may try natural remedies to treat (FYGMDNP Blog–Natural Cold Remedies). But what makes the flu different from the common cold virus is the sudden onset of intense symptoms. These symptoms include, but are not limited to:

Sudden high fever > 101

Cold sweats/intense chills

Overall muscle aches/weakness/joint pains

Malaise (severe fatigue)

Vomiting and diarrhea

Feeling and looking like you have been hit by a semi-truck (this one is NOT listed on any website or textbook, but this is how our patients often present in the office)

Symptoms usually last about a week, but can linger for several. This obviously can cause financial stressors (you can NOT work with the flu- trust me!), make you more susceptible to other opportunistic infections (pneumonia primarily), and can affect your physical, emotional, and mental state as you are not able to function even at sub-par levels.

Treatment DOES NOT include antibiotics, as the flu is a virus. If you are diagnosed within a certain period of time, your healthcare provider can determine if a prescription for an anti-viral medication such as Tamiflu or Relenza is appropriate. Unfortunately, our patients are usually outside of this window of treatment time when they are diagnosed. We are then left with only the option to treat the symptoms rather than the virus itself because replication has gone too far (meaning the anti-viral medications are pretty worthless at that stage).

Who is considered “high risk” for contracting the flu virus?

There are two flu vaccines that you should be aware of for the 2018-2019 flu season. The trivalent vaccination is indicated for those under the age of 65 and contains 2 influenza A viruses (H1N1 and H3N2) and one B virus. The Quadrivalent contains these three strains along with an additional B virus strain.

Adults over the age of 65

This patient group is particularly susceptible to the flu due to a multitude of reasons including chronic medical conditions and poor immunity. They have the highest rate of morbidity and mortalityImmune function decreases with age causing “immunosenescence”, which not only prevents the patient from fighting the virus effectively, but prevents the standard dose vaccination from protecting adequately. (3)In a 2014 article in The New England Journal of Medicine, researchers conducted a trial in over 30,000 patients from 126 centers across the US and Canada to compare the effectiveness of a standard trivalent dose of the flu vaccine against a high-dose vaccine. The results concluded that patients over the age of 65 years old had a significantly higher antibody response with the high-dose versus the standard dose, meaning the high dose protected much better than the standard dose in this patient group. (4)The International Journal of Clinical Practice will be releasing an article on October 7th recommending a new vaccination method for this patient group. In this article they recommend the high-dose trivalent vaccine (containing higher antigen content than the standard) and MF59 adjuvant trivalent influenza vaccine to be administered. It is claimed that this is safe, well-tolerated, and assists in enhancing the immune system response to the flu. (5)

Children between the ages of 6 months- 5 years

The American Academy of Pediatrics (AAP) provides their clinical recommendations in regards to the flu vaccine in children/adolescents on an annual basis (6)The flu vaccine is recommended in 6 months and olderThe primary recommendation is either the inactivated trivalent or quadrivalentThe trivalent one contains protection against 2 strains for influenza A and 1 strain for B, but the quadrivalent contains an additional B strain The live vaccine (intranasal) can be used in healthy children over the age of 2 Considered less effective than inactivated so live vaccine has limited useCould develop actual flu from itNot indicated for children with chronic medication conditions

Pregnant women

The American College of Obstetricians and Gynecologists (ACOG) continues to strongly recommend flu vaccination (through inactivated formation) as part of pre-pregnancy, prenatal, and post-partum care. Vaccinating has shown protection against the flu in children under the age of 6 months due to passive immunity (antibodies from the mother passed to the baby in utero)Recommendations are backed with clinical studies that show effectiveness/efficacy along with safety of vaccinating They concluded that pregnant women are particularly high risk group due to the fetus’s lack of immunity defenses (7)The AAP continues to recommend pregnant women vaccinate themselves against the flu during anytime of the pregnancy. They also recommend postpartum vaccination and while breastfeeding.There is debate in regards to the flu vaccine’s effectiveness and safety for pregnant women due to a “lack of evidence,” specifically in randomized controlled trials (RCTs). The argument is that the data for recommendation usually comes from observational studies, “which are notoriously prone to confounding by indication and healthy-vaccine bias. The latter type of bias leads to an overestimation of the effectiveness and safety of the vaccine, which may be what occurs in pregnant women.” (8). In a Cochrane review of studies, they concluded that the inactivated flu vaccine had very limited protection in women in pregnancy. Some of the observational studies suggested possible adverse reactions from the flu vaccine due to inflammation. They still recommend offering flu vaccination during the 2nd and 3rd trimester, but advised educating the patient that uncertainties exist, thus encouraging informed choice. First trimester vaccination is still debatable. Overall, they stress that this does not mean to leave pregnant women “defenseless,” rather to look at other behavioral and environmental measure that can reduce the risk of being infected. (8)

Patients with underlying chronic medication conditions

The Center for Disease Control (CDC) defines patients of chronically medical conditions as Adults and children who have chronic pulmonary (including asthma) or cardiovascular (excluding isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus)Patients who are immunocompromised due to any cause (either medication or HIV infection)Patients who are extremely obese (body mass index >40)These patients are identified as “high risk” and are most likely to require hospitalization due to complications of the flu, therefore are in need of the vaccine prior to those who are not in this categoryTo be placed into this category you only have to be diagnosed with one of the aboveChronic illness taxes the immune system. The “defense system” (aka the immune system) is compromised as it continues to battle the underlying chronic condition, therefore allowing the flu to infect the host (the patient)

Healthcare workers

Obviously healthcare workers come into contact with ill patients quite frequently, including those infected with influenza. Vaccination is mandatory in some facilities, and, if refused, the medical professional may be required to alter how they care for patients, ie. wearing a mask for the entirety of their shift. Others provide incentives for vaccination or even give the vaccine to their staff for free. This is not only to avoid spreading the flu amongst patients, but amongst themselves. A systematic review and meta-analysis was performed this year (2018) to look at the direct economical effects that seasonal flu vaccination has on healthcare workers and their productivity. “While the overall incidence of absenteeism was not changed by vaccine, [influenza-like illnesses] ILI absenteeism was significantly reduced. The duration of absenteeism was also shortened by vaccination. All published economic evaluations consistently found that the immunization of [healthcare workers] HCW was cost saving based on crude estimates of avoided absenteeism by vaccination.” (9)

People who live with or care for high risk patients

The CDC also remarks the importance of annual vaccination of people who live with or care of patients who are at high risk for influenza-related complications.Healthcare workers as they potentially can bring home and infect their loved ones due to their high risk of caring for patients infected with the fluPeople who live with children less than the age of 5 or over the age of 50, and most importantly are in contact or live with children < 6 months old

People who live with patients affected by chronic medical conditions

We recommend that patients with chronic diseases, such as Multiple Sclerosis, and on medications that significantly suppress the immune system have a dialogue with their specialist in regards to the flu vaccination prior to administration, as there could be certain limitations.

Lastly, according to the most recent CDC recommendations, patients with an egg-allergy may receive the age-appropriate flu vaccine. I have attached the site with the recommendations and potential limitations from the CDC click here. As stated above, I recommend that you discuss this with your healthcare provider prior to having the flu vaccine administered and discuss the literature along with the risk and benefits of the vaccine, as this is case by case basis.

What are the potential side effects of the flu vaccine?

The most common question that we receive other than “Do you think I should get it?” is “Are there any side effects?” In the end, it is an intramuscular (in the muscle) injection and it is a vaccination. The latter means that affects the immune system and can cause an immune response. NO, YOU WILL NOT GET THE FLU FROM THE FLU SHOT, but the intranasal mist is a live vaccine, so you do have potential of “getting the flu” with that option. Also, there is absolutely has been no clinical data showing an association between the flu vaccine and autism.

The most common side effects of the flu vaccine are:

>Reaction at the injection site

May result in soreness, redness and swelling

You can apply ice to site and/or take ibuprofen (if there are no contraindications)Usually will go away within 2-3 days

>Muscle aches

Due to the systemic response to vaccination (“revving the immune system up”)

Can take Tylenol or ibuprofen (again if not contraindicated)Usually goes away within 1-2 days

>Dizziness

This is not so much from the flu vaccine itself, but more of a reaction that a patient has to receiving an injection in generalThe patient subconsciously bears down (kind of like having a bowel movement) on vagus nerve due to stress/anxiety of the injection, causing blood pressure and heart rate to drop. This leads to dizziness, lightheadedness, and even fainting If you have a history of this, inform the injector as they can have modalities ready to assist if this occurs

>Mild fever

A fever < 101 could occur and lasts about 2 daysAgain, this is a reaction to the immune system being given the vaccination to build the necessary antibodies

Can take Tylenol and/or ibuprofen (if not contraindicated)

>Fatigue

If this does occur it will usually only last 1-3 days

Due to an immune system reaction

No treatment but hydrate properly, rest, healthy diet are recommended

Serious side effects include:

>High fever

A fever > 101 occurs is not a common side effect and you should inform your healthcare provider right away

Could be part of an allergic reaction to vaccination

>Severe allergic reaction

If hives, severe swelling, trouble breathing, weakness, or fast heart rate occurs we recommend seeking medical attention right away

This usually will occur within a few hours of receiving the vaccination

This can happen with any vaccination, drug, food etc that you ingest so keep this in mind

>Guillain-Barre syndrome (GBS)

Very rare but potentially fatal autoimmune diseaseMost common etiology is due to Campylobacter jejuni

GBS is a neurological condition that causes generalized weakness and paralysis of your body

Can occur from other vaccines as well, such as meningococcal, polio, and rabies If you have a past history of (GBS), it is not recommend to receive the flu vaccine

What are other ways to prevent being infected by the flu?

Erin and I are both conventionally-trained practitioners, so we understand the importance of vaccinations and follow necessary guidelines in regards to administering them. However, we also have patients who either do not fall into the groups listed above for vaccinated or those who should be vaccinated that refuse to have the vaccine administered. Either way, we have to not only educate about the vaccine, but advise patient on other modalities to help decrease their risk of contracting the flu virus. It’s all about the issue of protection, either of you from others or of others from you.

>Regular hand washing

Hand washing with soap and water has been shown to reduce the number of bad bacteria and viruses on one’s hands better than alcohol-based hand disinfectants (10) (11)

Make sure that you lather well, scrub hands for at least 20-30 seconds, and rinse with warm water

>Proper respiratory hygiene

One way the flu is passed to others is via respiratory droplets

When you sneeze, try to sneeze onto your shirt sleeve or inside your blouse versus onto your hands as this is a vehicle that spreads the virus

Do not sneeze with your mouth wide open (this should be common sense but you’d be surprised!)

If you do end up sneezing into your hands, wash your hands immediately

>Early isolation of self away from other contactsIf you do begin to develop symptoms of the flu or are diagnosed, you should isolate yourself away from others in order to avoid spreading the virus

According to the CDC, you are most contagious with the flu within the first 3-4 days after symptoms begin, but you can infect others at day 1 when the symptoms have not even started. You can continue to infect for 5-7 days after becoming ill. If you are a professional mom like me, this is not much of an option unfortunately.

One of the ways that I try to prevent spreading the virus to my husband and children is wearing a mask- yes even in my house! If I am too ill to work, I do stay home, but as a medical provider it is pretty difficult to avoid working (even when you are considered “contagious”) so I do wear a mask. I also hand wash frequently, hydrate, rest from high-intensity workouts, and, if the flu is the cause, start an anti-viral medication right away.

>Avoidance of close contact

As I stated above, the flu is spread through respiratory droplets, but also via saliva and eye secretions If you suspect you have the flu (or if a loved one does) avoid kissing, sharing food or drinks, and close snuggling (I know, so difficult).

Also, don’t touch any eye secretions as this is also a vessel that can infect a host.

Proper diet and hydration

Making sure you are consuming a diet high in micronutrients including B vitamins, vitamin C, and zinc ensures that you are boosting your immune system as much as possible Please refer back to our previous blog post “Natural Cold Remedies” as I go into depth on the clinical benefits of certain vitamins and minerals and their immune-boosting properties

Ensure you are drinking at least half your body weight daily. Hydration can actually boost your immune system when you are “coming down with something,” whether it is a cold or the flu, so prevention with adequate water intake is essential. Make sure that you check out the blog post “Hydrate Your Life” where we give tips and tricks for ensuring that you get your necessary water intake in

>Adequate rest

“Sleep is a physiological process that has been proposed to have restorative and regulatory properties. Although it remains unknown what its exact function is, sleep has garnered particular interest in recent years due to its potential influence on the immune system” “For example, intranasal inoculation with influenza virus in mice enhances non-rapid eye movement sleep (NREM) and decreases rapid eye movement sleep (REM) [the sleep we actually need], despite body temperature declining” (12)The recommended amount of sleep is about 7-8 hours per night

Sleep hygiene is important as well, which includes your routine before bed time. This should start occurring within 1-2 hours prior to actually laying down in bed. If you have issues with sleep, we recommend reading our previous blog post “Natural Sleep Remedies” and review the recommendations with your healthcare provider before trying them

>Exercise routine

We recommend our patients get 30-45 minutes of cardiovascular activity (includes cardio, but also weight training) a day, 5 days a weekMany studies show the benefits of physical activity on the immune response (13) (14). Also, check out our blog posts in regards to the benefits of weight lifting in women and ways to fit in your fitness. These are helpful resources when it comes to figuring out what fitness routine works for you. “Single bouts of moderate intensity exercise are “immuno-enhancing” and have been used to effectively increase vaccine responses in “at-risk” patients” (15)

Reducing oxidative stress via exercise allows your immune system to thrive If you are infected with the flu, obviously the intensity of your regular workout routine will need be cut down drastically. This gets back to the last point of adequate rest. If you must “do-something” in regards to physical activity, exchange your heavy weight routine for a light walk or swap out your high-intensity regimen for yoga or pilates. Stress controlIt’s not so much acute stressors that cause depletion in one’s immune system, rather its the chronic stressors.

Chronic stressors are anything from caring for a dependent loved one to trying to balance work, motherhood, school, social life, and everything else in between. These chronic types of stress cause “negative effects on almost all functional measures of the immune system. Both natural and specific immunity were negatively affected, as were Th1 (e.g., T cell proliferative responses) and Th2 (e.g., antibody to influenza vaccine) parameters.” (16)“The most chronic stressors were associated with the most global immunosuppression, as they were associated with reliable decreases in almost all functional immune measures examined.(16)

Last week, Erin posted a beautifully-written blog in regards to stress and how to manage it naturally. I HIGHLY encourage you to read this post as she gives some great tips and tricks on how to manage your stress more effectively.

This blog post may be a bit more lengthly than normal, but I wanted to try and provide you with as much information as possibly regarding to the flu vaccine. This will be a continuing hot topic as the season is in full swing and will continue to peak. As always, speak with your healthcare provider prior to having the flu vaccine administered. If you have any additional questions or concerns, don’t hesitate to contact us via email or through our various social media sites (instagram, facebook, or twitter).

We hope you guys have a safe and “flu-free” season!

Continue to Follow Your Gut,

Jaci

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