Influenza Winter 2015 UPDATE: Saturday, January 10, 1PM

Influenza Winter 2015 UPDATE:  
Saturday, January 10, 1PM

The CDC has recently released the latest data on this year's influenza virus epidemic, and the news is very good.

Every week the CDC reports a comprehensive set of data on how many people are infected with the flu virus that week, how many are getting hospitalized ,and how many deaths this virus is causing, especially in children.

As we share this week's information with you, it is once again very important to keep in mind that only a minority of a winter's colds and flus are caused by the influenza virus, in fact about 25-30%.  All the other colds and flus we have are caused by all sorts of viruses, like the rhinovirus, adenovirus, RSV, etc.  So all the news reports and all this data concern only the influenza virus.

The good news is that this winter's influenza epidemic is giving an early sign of weakening, of being past its peak.

Even more striking, the pattern of this year's influenza virus epidemic is matching the pattern of the epidemic of 2012-2013 almost exactly!  This epidemic appeared in December and peaked around New Year's.  The rise and fall of 2012-2013 is so far almost an exact match to this year's epidemic.

That means the worst of this year's influenza epidemic may be over and it is very reasonable to hope that the intensity is already fading.

Here is more good news:  there are far fewer of the most frightening outcomes this year than in years past.  The number of childhood deaths from influenza virus infection by this time of year in the 2012-2013 epidemic (which matches this year so closely) was about 50-60 deaths.  This year that number has dropped to 26, across the whole country.  To put that into further context, influenza virus infection typically kills about 20,000 people in the US every year, and this year that may only include <100 children.="" i="">

These data are especially important to know as the news and reporting on this year's influenza epidemic are giving a needlessly frightening message.  If you read the paper, watch TV, or listen to the radio, the impression is that the United States is under the assault of a historically dangerous influenza outbreak with unprecedented levels of illness, risk of dying, and failure of flu vaccination.

None of these impressions are true.   This year is very much like most others, lots of colds and flus circulating in the winter.  The actual numbers are about the same as in 2012-2013 which was a year the generated almost no comment of worry, and the number of deaths in children is actually much lower than that year.

As for the impact of immunization, it is true that the most widespread subtype of the influenza virus circulating right now is not the exact form of the one in the vaccine, but even so, those vaccinated have a 50% of being protected from that strain.

Finally, to repeat our perspective on Tamiflu.  There are three reasons to be cautious in its use:

1. It is not free of side effects.  Children especially are at risk for developing seizures, and it can cause serious behavioral disturbances.
2. It does not deliver dramatic improvements consistently.
3. If millions of relatively healthy people use it for most colds and flus, we hasten the day when even its limited efficacy is available.

Of course, if a person does develop a dangerous influenza infection, defined as one impairing the ability to get air in and out of your chest, or in some other way impaired in function, the use of Tamiflu is clearly worth the risk of its use despite its impact being limited.

Bottom Lines:

1.  This year's influenza epidemic is actually a rather typical winter flu season.  Its magnitude and timing, so far, nearly exactly match the 2012-2013 epidemic which caused almost no comment at the time.

2.  This year's influenza epidemic is giving early signs of being on the wane.  If this turns out to hold up, we won't have much to talk about influenza in a few weeks.

3.  The scary news reports on this year's influenza virus epidemic are highly misleading.   These infections are overwhelmingly harmless to healthy children, the frightening reports of deadly infections in children fail to discuss just how rare this is.  And, so far this year, fatal illness in children is quite a bit lower.

4.   The flu immunizations have worked, those who got them, even this year, turned out to be less likely to get sick, and when ill had milder illness.

5.  As with any illness, if you have serious troubles such as struggling to breath, severe pain, a stiff neck, dehydration, call for help.

We hope you and your family get through this winter in good health, and that any colds or flus you get- although unpleasant- remain harmless.

Happy and Healthy New Year,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Influenza Winter 2015 UPDATE

Influenza Winter 2015 UPDATE

The rates of infection with the influenza virus in the United States continue to climb, as expected at this time of year.

Before going further, we should repeat that there are many viruses that cause viral respiratory infections, and in fact, so far this year the number of such colds and flus due to the influenza virus has reached 30%, so over 2/3 of all colds and flus still are not from the influenza virus.

Now, on to the latest on the influenza virus.

We have talked before about how the influenza virus changes every spring as it leaves the human community, and every late fall when it returns to us. Sometimes the influenza virus that actually appears completely matches the subtypes in that winter's vaccine, sometimes not so much.

The current data suggest that the dominant strain appearing in the US is indeed the H3N2 strain, and it is different than the H3N2 in the flu spray and flu shot, that is, the flu vaccines for the winter of 2015.

We now know the following details on how well this year's flu vaccines protect against the H3N2 out there:

• About 50% of the H3N2 circulating do match what's in the flu vaccine, and those vaccinated are protected very well against it.
• About 50% of the H3N2 circulating do not fully match what's in the flu vaccine, but match well enough to blunt the severity of the infection.

And, a word on the terribly frightening reports on childhood deaths from the influenza virus of the winter of 2015.  The total across the entire United States is 15 deaths.  Each are horrifying losses, but the fact remains that across a nation of 100 million children, this number actually demonstrates that this terrible outcome is extremely unlikely.

Bottom Lines

1.  If you got or get this year's influenza vaccine, by spray or shot, you will almost certainly reduce the severity of the dominant influenza virus out there, the H3N2.

2.  If you got or get this year's influenza vaccine, by spray or shot, you have a 50% chance of full protection against the main influenza virus circulating right now.

3.   If you got or get this year's influenza vaccine, by spray or shot, you have a 50% chance of only partial, but still significant protection against the full severity of the main influenza virus circulating right now.

4.  If you haven't gotten a flu vaccine for the winter of 2015, it is not too late, we anticipate another month or two of lots of influenza virus causing lots of illness.  The flu vaccine only takes 2 weeks to provide its protection.

5.  Viral respiratory illnesses are a true misery.  And this year's influenza virus is causing very high fevers and much suffering.  But they are not dangerous infections for 99.999 (really)% of our children.   This means that very nearly all children who get these infections will do what very nearly all children do when they get colds and flus- recover without hazard or complication.  This year is still really not much different than others in that regard.

A Happy and Healthy New Year to all,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

The best source of data on the influenza virus- http://www.cdc.gov/flu/weekly/

The Best source of Data on the Influenza Virus-  

http://www.cdc.gov/flu/weekly/ 

We have gotten such a wonderful and enthusiastic response to recent posts about infectious diseases, that I thought it would be of interest to share a great source of information- the CDC.

In particular, I want to share how the information about the influenza virus is presented every week by the CDC.

Keep in mind that viruses, like animals, are classified into a variety of species, each of which are different in many important ways.  The influenza virus is one species of virus, that comes in many subtypes.   Colds and flus are caused by many different species of viruses, including RSV, rhinovirus, adenovirus, coronaviruses, etc.  Influenza virus causes only about 1/3 of winter-time respiratory colds and flus.

The CDC actually tracks the presence of the influenza virus in America, in great detail, for all sorts of reasons.  The primary one is actually to specify which varieties are in circulation so that the right types enter each year's vaccine, and to monitor this major cause of illness.

This webpage:   http://www.cdc.gov/flu/weekly/  gives anyone access to a veritable gold mine of data on the influenza virus.

Here is a brief tour of the six types of trends this web page follows on this virus:

First of all, all the data are reported weekly and usually lag 1-2 weeks behind.  Today for example the page reports on Week 50 of 2014, and we are in week 52.

Viral Surveillance

This is a very interesting report, as it tells us what percentage of respiratory swabs in people with colds and flus are positive for influenza.   It also tracks which subtypes are in the swabs- Type A, Type B, and subtypes like the now famous H3N3.  Note that as of December 13, 2014,  about 25% of people with colds and flus had influenza.  This means that even in the thick of the influenza onslaught, 75% of us with a cold or flu do not have an influenza infection.

The graph in this section is a bar graph with green, red, and yellow bars, color coded for the subtype of influenza virus on the swabs.  Bar graphs going up means more swabs are positive for the influenza virus.

Pneumonia and influenza mortality

This is a jagged red line going up and down between two wavy black lines.

The red line is the percentage, every week, of deaths in 122 American cities due to pneumonia and influenza.

Even without an influenza virus epidemic happening, about 6-7% of all American deaths are due to pneumonia, usually in the elderly.  That number goes up in the winter and down in the summer.  When the red line goes above the top wavy black line, that means pneumonia and influenza deaths have reached epidemic proportions, they have not yet done this in the US as of December 13.

Influenza Pediatric Deaths

These are the green bar graphs, and they track a very sad set of facts, how many children die of influenza in the US each week.  The numbers here, thankfully, are very small.  About 20,000 people die of influenza infection in the US every year, but only 100 or so each year are children, so far this year that number is 11.  A terrible loss, but quite rare.

Influenza associated hospitalizations

This line graph has many colored lines, one each for an age range, that tells us how many people, per 100,000, are hospitalized for influenza virus infections each week.  Note that by far the most hospitalizations occur in the elderly, and as expected these rates go up in the winter.

Outpatient Illness Surveillance-  This is the section I refer to most to report the progress of each winter's spread of all viral respiratory illnesses.  

This is a set of different colored lines set against a dashed black line.  Each line traces the percentage of visits to a doctor in the US for a fever of at least 100.0 with cough and/or sore throat. 

Note how the typical year really takes off in December, peaks around New Years, and slowly fades across January and February.   2014-2015 is the red noted by the red triangles, and seems to be following a course very similar to  2012-2013.  

Geographic spread of influenza virus, state-by-state

The final two graphics are state maps of the US that report levels of all viral colds and flus (green and red) and levels of influenza virus activity (Yellow and brown) for the week being reported.

BOTTOM LINES:

1.  Respiratory colds and flus do indeed peak in the winter.

2.  This year is not exceptional in the rate of illness, as of December 13.

3.  We are in the midst of the great peak of respiratory colds and flus for this winter.

4.  Even in this peak season, about 75% of the respiratory colds and flus are from viruses other than influenza virus.

5.  The detail does indicate a large proportion of the influenza virus actually circulating, unfortunately, is a subtype not included in this year's influenza vaccine.  Keep in mind this vaccine is manufactured every spring and as such, has to be a prediction of what subtypes will circulate the following winter.  This year the mismatch was significant.  FluMist offers more protection across varying subtypes than the injected flu shot.

6.  MOST importantly.  As with most years reported, infection with influenza in healthy children, although a miserable experience, tends to be quite harmless.   At it's worst, so far this year, about 99.99% of children who get this infection recover without need of hospitalization.

Again, we offer this guide to the CDC data, since we find it helpful and reassuring.  We will continue to report the trends for colds and flus, and the influenza virus, as the season progresses.

Here is to a Happy and Healthy New Year,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Croup- What is It, When to Worry?

Croup-  

What is It, When to Worry?

What is Croup?

Croup is a variety of a cold that presents the greatest worry and perhaps the greatest risk of all forms of a cold.

The word croup is actually derived from ancient root words that mean "to call out, to cry, to shout hoarsely"

Like all colds, croup is an infection of the respiratory system by a virus.  What makes this respiratory infection croup is not the germ as much as the geography.

When a virus causes a cold or respiratory flu, what happens physically is that the virus burns the lining it attacks.   If the virus attacks the nose, the lining of your nose gets burned and you develop a sore, runny nose.  If the virus attacks the throat, you get a sore throat, and if it burns the lining of the lungs you get the all too familiar cough of a cold.

Croup happens only when the virus attacks a very specific area of the respiratory tree- the vocal cords and voice box.  What is so special about this area?   Think about narrowing and where narrowing counts.   If your nose gets very swollen and clogged with mucus, you can always get around that by breathing through your mouth.   And if some part of the lungs gets swollen and filled with mucus, you can always get around that by having the air go in and out of other parts of the lung.

But, if the vocal cords get badly swollen, so swollen that the gap between them is closed, then no air can flow, and that is very bad.

So, croup is a cold that has landed on the vocal cords, and caused enough swelling there to create some problem with air flowing, usually a barking cough.

When to Worry

As with all infections, the amount of irritation, swelling, and mucus production varies from mild to severe.

The sequence of severity for croup is as follows:

1.  Croup always starts off as a barking cough with no trouble breathing when not coughing.

2.  The next stage, if it gets more severe, is some difficulty breathing noted by a whooping sort of sound on breathing in.  This is called stridor.  It is a sharp, moaning sound on breathing in.

3.  If croup gets even worse, then not only is there a barking cough, and stridor, but now you can see your child tugging and pulling air hard to get it into their chest.

4.  At the most severe, it becomes truly challenging for the child to get air in their chest.

Fortunately, the vast majority of cases of croup we see never go beyond the mildest stage, simply having a barking cough.  If your child has a barking cough, but breathes easily and without that sound we call stridor, there is no danger, this croup is too mild to cause any harm.

A small number of children we see go on to have stridor, but not many go beyond that.

So, when looking at your child with a cold, if you hear a barking cough but hear no stridor and see that he or she is breathing comfortably, no reason for worry.

And, of course, if you hear stridor or see any difficulty getting air in and out of the chest, that is when to be concerned and contact us.

In very, very instances, breathing is really very hard for the child and there is a great deal of struggle.  This is the situation that truly is emergent and indicates the need to call 9-1-1.  

What to Do?

If your child's croup is mild, only the barking cough, there is not much to do.  As with other colds and coughs, there is no medication that will actually change the cough. Comfort measures may help, such as sipping comfort foods and drinks.

If the cough goes on to stridor, give us a call.  While at home, you can sit in a steamed-up bathroom which will dissolve some mucus around the vocal cords and ease breathing.  And/or, you can step outside which will allow cold air to shrink some of the swelling around the vocal cords.

If the stridor is mild, we can start a prescription of oral steroid for a short time which will shrink the swelling around the vocal cords and restore easy breathing.

Again, if trouble breathing is pronounced, the right course of action is to call 9-1-1.

Bottom Lines

Croup is a cold with a specific location, the vocal cords.  We see croup every cold and flu season.

It tends to be mild, with only a barking cough, but can be more severe.

If it is mild with only a barking cough, not much to do.

If it starts to make breathing difficult, then you need to call.

Here is to a happy and healthy holiday season,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Influenza 2014-2015 UPDATE December 19, 2014

Influenza 2014-2015 UPDATE  

December 19, 2014

The influenza epidemic of the winter of 2014-2015 continues to evolve, here is what we know as of today.

No one needs a doctor to know that respiratory viruses are infecting many, many people right now.

In the Greater Cleveland area, it seems almost everyone is sick with a cold or flu, or knows someone who is.  The numbers are so great that absences have forced at least 3 area schools to close for one or more days in December.

Here are some key facts about this year's epidemic:

The infections

1.  Many of these cases are caused by one species of virus, the famous influenza virus, but not all.

For an entire winter, about 1/3 of all colds and respiratory flus (that is not stomach flus) are caused by the influenza virus.

2.   We are in a period of lots and lots of influenza virus activity.  The CDC tracks this carefully.  We are on track to have this virus cause most of its havoc in its typical time period, namely, appear in December, peak in middle to the end of December (now), and fade slowly through February, vanishing by spring.

3.  As many know, the flu vaccine is always a prediction.  Typically about 3-4 subtypes of influenza virus circulate every winter, but the subtypes vary year to year, and so in making a vaccine in the spring for use in the winter, a prediction has to be made.  We always hope the subtypes that are in the community turn out to match those in the flu vaccines.

4.  This year, one strain, called A-H3N2, is different in our community than in the vaccine.  That means the vaccine will not protect so well, or in some cases, at all, if the A-H3N2 that is circulating infects you.   The influenza vaccine given this year does protect against the other 2-3 strains.

5.  Putting all this together, we are seeing a big burst of influenza virus activity, much of which is not protected against by this year's influenza vaccine.  These two facts combine to explain why so many of us are sick.

The course of this infection

Influenza viral colds and respiratory flus are very much like all viral colds and flus- you feel awful, fever, lots of mucus, sneezing, prolonged coughing, sore throat, and a variety of other experiences like headache, stomach ache, neck ache, achiness.

This year the fever is especially high, more in the 103-105 range than the more usual 99-102 range.

Like all such viruses, the illness itself typically lasts about 8 days, but if the cough is intense, it can go only without complications for 2-3 weeks.

When to Worry

Fever itself is a harmless, if miserable and agonizing, experience.  That is, once fever ends, there is never any sign of ongoing harm caused by it.  The normal range of fever in humans is 100.4-105.8.  Now high fevers of 103-105.8 are miserable to experience, but even these high fevers are harmless.

So when to worry?  If one of these four symptoms occur:

• Stiff neck (not sore neck or achy neck).  A stiff neck means you can't bend your neck.  If you can touch your chin to your chest, your neck is not stiff.
• Trouble breathing when not coughing.   Simply look at your child and if he or she is breathing comfortably in and out of their mouth when not coughing then they are not having trouble breathing.
• Severe pain anywhere.
• Fever, 106 and beyond.  Temperatures below 106 are harmless.

Treatment

Medical science has very limited options to treat viruses, including influenza.  So most treatments that are safe and helpful are comfort measures, like using ibuprofen, comfort foods, back rubs, ice cream, soup, tea, etc.

A word on three medications:

Tylenol or acetaminophen

Acetaminophen has been associated with increasing the risk of a child developing asthma, so we do not recommend its use.  People should also know that if you give your child ibuprofen, adding tylenol does not tend to control the fever any better.

Tamiflu

This has been a very good year for those who sell Tamiflu.   A run on the drug has been ignited by the widespread use of rapid influenza testing and recommendations to use this drug.

There are two issues with the use of Tamiflu in children.

1.  Particularly in children, the risk of Tamiflu causing a child to have a seizure is increased. This risk is strong enough that TV ads for Tamiflu actually feature this risk as one to be especially concerned about.   Tamiflu is also known to cause delirium and behavioral disturbances, and propel those who take it to commit acts of self-injury that at times can be quite serious.  This pattern of side effect- seizure, delirium, and serious behavioral disturbance all point to Tamiflu having some effect on brain function.

2.  Tamiflu sometimes works well giving people relief, we all know those who have had this experience.  But many people, including most people in careful studies of the drug, don't really have much relief from Tamiflu, especially children.

Given that nearly all influenza infections in healthy children cause no lasting harm, exposing children to a drug that can cause significant impact to the brain seems to be causing more harm than good.

If Tamiflu is not used, there is no benefit to testing for the influenza virus, since if the test is positive, no change in treatment will be made.

Over the counter cough and cold remedies.

With the exception of ibuprofen, the hundreds of cold and cough remedies, including decongestants, expectorants, and cough syrups, don't work.  This is based on many, many studies, and reflects consensus statements from many professional societies.  The FDA is currently investigating 500 of these medications for fraud!

BOTTOM LINES

1. Every winter influenza virus comes to make us ill, usually in December.
2. True to form it is here in December
3. This year, a dominant subtype sadly does not match its subtype in this year's flu vaccine, so a lot more people than usual are ill.
4. Influenza, like all respiratory viruses, causes much misery, but in healthy children, not much harm.
5. Tylenol may increase the chance of developing asthma and is not recommended.
6. Tamiflu causes more harm to children, particularly to their brains, than adults, and often has little benefit, so it is not recommended in routine cases of flu in otherwise healthy children.
7. This year's flu is a high fever flu, but fever is harmless at 105.8 and below.
8. It is important to call if fever reaches 106 or above, if significant pain is present, if there is trouble breathing, or if there is a stiff neck.

Here is to a happy and healthy holiday season,

Dr. Arthur Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Winter Cold and Flu Virus Update- December 9, 2014

Winter Cold and Flu Virus Update- A word on Fever and Cough

December 9, 2014

The Cleveland community is being hit hard with a blast of viruses that is causing very high fevers, prolonged coughs, and much suffering.

Part of this onslaught is clearly the annual winter arrival of influenza virus, which typically appears every December, so it is showing up as expected.   But the high fevers and coughs are not just from the influenza virus, which tends to cause only about 1/3 of all such illnesses.

Fever

Whatever the virus causing our children's fevers and coughs right now, these viruses are giving everyone lots of very high fevers.  So here is a reminder on the key points to keep in mind with regard to fever:

• Fever, although very unpleasant, is completely harmless in the setting of these viral fevers and coughs.   Fever is unfortunately an experience that every single person will have, many times in their life.   The normal range of fever is 100.8-105.8.  Temperatures in this range are common and safe.  
• The temperature over which fever becomes abnormal or of any concern is 106.0.   It is important to note that going to 106.0 and beyond is an extremely rare event.  As universal as fevers in the range of 100.8-105.8 are, fevers beyond that range are never seen in most people.  Fever often seems to be something out of control, but in fact, the body is very careful in setting the higher temperature.  The fact it stays at 105.8 and lower shows that fever is actually a very controlled and safe event. 
• The main problem with fever is the discomfort it causes, and it is clear that the higher the fever, the more discomfort.  So it's a good idea to use ibuprofen to reduce fever to make your child more comfortable.  
• The main question fever raises, from our point of view, is what is causing it, not how high it is.  Fevers always indicate that some inflammation is present.  In the vast majority of situations, the inflammation is due to a viral infection that will come and go without causing any harm, despite all the discomforts.  
• How do you know if your child's fever is from a simple viral infection that will be harmless,or a more serious cause?  Three key items that tell us something more serious than a simple viral infection is happening are important to look for.  If you don't have any of these three problems, you are likely dealing with a simple viral infection that should be harmless:
• A stiff neck in older children
• Severe pain
• Trouble breathing
• Ibuprofen and acetaminophen.   These are the key medications available to reduce fever.  They don't always work.  It is very important not to give too much of these medications when they don't fully eliminate the fever.  As noted, fever is harmless, but overdose with either of these medications can be harmful. Here are some key points on use of fever medications:
• We recommend using ibuprofen as some studies raise concern that acetaminophen use is associated with greater risk of developing asthma. 
• Ibuprofen is a helpful drug and should be used properly.  The safe interval for children is using it every 6-8 hours.  Occassionally, during the peak of a round of fever, it is safe to give ibuprofen every 4 hours, but there should never be more than 5 doses in a 24 hour period.
• If you give your child ibuprofen every 6-8 hours, there is no further reduction in fever, and therefore no benefit, to adding acetaminophen between doses 

Cough

No symptom of viral respiratory illnesses causes as much suffering as cough.  Fever is very uncomfortable and causes tremendous distress, but cough truly is a misery.

Cough is the result of inflammation of the airways.  That means the lining of the lower throat, voice box, upper lungs, and lower lungs gets red, swollen, and irritable.  When air passes over this inflamed tissue, the tissue is quite bothered and you cough.

Airway inflammation is usually due to one of three causes:  viral infection, bacterial infection, and allergies and asthma.

Bacterial infections are the least common cause of cough in children.   When a serious bacterial infection of the lungs is present, usually the person is struggling to breathe or breathing very rapidly, even when not coughing.

Most coughs in children with fever involve viruses.  Some of these children will also have some asthmatic inflammation with their colds and flus.  

How do viral coughs and asthmatic coughs differ?

Viral inflammation is like a burn of the airway lining.  The lining gets destroyed by the virus and the inflammation remains in place until the burn heals.  It is entirely the result of the damage done by the virus.

Inflammation from asthma is from our own body's immune attack.

But the main difference is that if your airway inflammation is from asthma, medications like inhaled albuterol or inhaled steroids can get rid of the inflammation and the cough.

But, if the inflammation and cough are purely from a virus, no treatments actually can make the cough better or go away, only healing the burn from the virus will help, and only the body can do that.

So if a cough lingers and there is no reason to think bacteria are present, it makes sense to try Albuterol.  If it works there is an element of asthma present and the cough can be alleviated.  If it does not work, it is more likely a viral cough and not much will make it go away any faster than healing will.

One word on over the counter cough remedies:  they do not work.   Like any intervention, about 30% of the time it will appear to help, due to the power of the placebo effect.  But, in study after study, cough syrups do not better than water in comforting or treating a cough.   The FDA is currently investigating 500 of them for fraud.

BOTTOM LINES:

1.  Fever is a normal and universal experience, and although very uncomfortable, quite harmless.  

2.  The normal range of fever is 100.8-105.8, all temperatures in this range are harmless.

3.  Ibuprofen is the preferred medication for fever, adding acetaminophen offers little if any help.

4.  Cough in the setting of fever is usually the result of a viral infection.  For prolonged coughs a trial of Albuterol will tell if there is a component of asthma.

5.  Over the counter cough syrups don't work.

6.  The key signs to watch for to tell you if your child with cough and/or fever has an illness of concern are:

• Stiff neck
• Severe pain
• Trouble breathing when not coughing

If these appear, call us right away.

If these worrisome symptoms aren't present, you are still welcome to call, but what your child will need is to be comforted as they go through the viral infection.

To your health,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.

Flu Vaccines 2014-2015- Update on What Works

Flu Vaccines 2014-2015- 

Update on What Works- December 5, 2014

The influenza virus feels very familiar, who hasn't had the flu, or knows it comes in the winter and goes in the summer?

But it also seems to throw surprising dangers our way.   In 2009 it was the spring pandemic, in other years it is very mild, and in some years it seems to target unusual populations in upsetting ways, like the 2009 pandemic susceptibility of pregnant women.

And now this year, we are hearing reports about mutations of the influenza virus for 2014-2015, and that this year's influenza vaccines may not work.

So, what is the story with influenza?  Why is it a different problem every year?  How can a vaccine work one year and not another? Will your child's influenza immunization work this year?

Here are some answers.  The bottom line is that this year's influenza immunizations should work very well, and do far more good than not getting one.

Why is influenza a different story every year?

The influenza virus, as familiar as it is, is actually unusual, perhaps unique.   Almost all viruses can only infect one species.  Chickenpox only infects humans, and the same is true of measles, colds, stomach flus.  Dogs have their own viruses that do not infect us.

But the influenza virus infects humans in the winter and barnyard animals every spring and summer, every year.  To go from human to cows/horses/pigs requires the virus to change in each direction.  So it has to change to go from humans to pigs, and again from pigs to humans.

As such, influenza is the only common virus that changes every year.

What changes?

Every virus is a string of genes wrapped in a protein coat. The protein coat contains patterns that allow the virus to open a cell and get their genes inside.   The patterns differ from species to species.

So when the influenza virus enters a human cell, it needs a different protein coat than when it enters a cow cell.

So every spring the protein coat changes to go from human to animal, and every winter it changes again to come back to humans.

It turns out there are just two main types of chemicals on the coat of an influenza virus:  an chemical called H and one called N.  There are a whole bunch of H types, and a whole bunch of N types.

One famous combination is H1N1- the spring pandemic version of the influenza virus in 2009, and still around.

Making a Vaccine Work

Most vaccines are made against an unchanging virus, so they work forever.  The polio vaccine was created in 1953 and still works fine, since the polio virus has not changed at all.

But since the influenza virus changes every year, returning with a new H and N combination to pick our cell's locks, the vaccine must change too.

To make an influenza vaccine that will work, every spring the World Health Organization and the CDC actually sample influenza viruses in cows and pigs and horses around the world, to see how the H and N combinations are shifting.  They then take their best guess as to how the influenza virus will change and reappear in humans the upcoming winter.  Tens of millions of doses of influenza shots and mist are made.

Every year, no one knows until the influenza virus returns in the winter, just how the H and N combinations will be, and if the vaccine matches it for real.

In almost every winter there are three to four types of influenza virus that hit humanity, and so the vaccine contains 3-4 strains.

We only give the vaccine that has 4 strains.

Mist versus Shot

The big difference between Flu Mist (the nasal spray) and the flu shot is that the mist has live virus and the shot has dead virus in it.  They are the same viruses, with the same 4 combinations of H and N.

The major result of this difference is that the shot only protects against the four influenza viruses in it.

This year, the combinations are:

A/H1N1

A/H3N2

B/Yamagata/16/88

B/Victoria/2/87

(NOTE- the H and N system fully describes the A strains of influenza, a second group of influenza the B strains use a different system to describe combinations on the protein coat, but it's the same idea)

So the flu shot will protect against these four influenza viruses, none else.

The flu mist will protect against these four influenza viruses, but since it is live virus, the immunity is stronger and can protect against other combinations.

How are this year's influenza vaccines doing against the actual influenza viruses now in circulation?

As with most years, the answer to this has some details.

For both the flu mist and flu shot, the A/H3N2 combination placed in the vaccine turns out not to match the A/H3N2 combination actually infecting people across the US this winter, now.

This is not a failure of the vaccine, missing the exact match is inherent in the process.   Since the influenza virus changes every year when it goes into animals and when it comes back to humans, there is no choice but to guess every spring, and find out every winter how the virus will be.

For the other three combinations, the shot is a 100% match and direct hit.  

The flu mist has a twist this year all its own.  For some reason it's version of the A/H1N1 is not working in the A/H1N1 circulating across the US this winter.  The good news, though, is that of these four versions and combinations now circulating, there is not much A/H1N1 around as of now, so the flu mist is working very well.

BOTTOM LINES

1.  The influenza virus is highly unusual in changing every year.

2.   It changes as it goes to animals in the spring and back to humans every winter.

3.  This means every winter we need a new version of the flu vaccine to contain our best guess version of the flu viruses that will be here in the winter.

4.  All the flu vaccines we offer contain 4 strains.

5.  The flu mist nasal spray is live and therefore gives protection to more than just the 4 strains in it.

6.   The flu shot is dead and so only can protect against the 4 strains in it.

7.   Both the flu mist and flu shot for this winter contain an A/H3N2 combination that does not match the actual A/H3N2 in circulation.

8.   The flu mist's A/H1N1 does not work well, but there is not much of this A/H1N1 version of influenza virus actually in the community.

9.  Final thought:  influenza viruses cause about a third of all colds and flus in the winter.   Despite some misses on the guesses about what should be in them, you will get fewer colds and flus if you get a flu vaccine- mist or shot.  None of the variance between the guessed virus in the vaccine and the actual virus in circulation present any danger or increased side effect, they just may not work as well.

Here is to a happy and healthy holiday season,

Dr. Lavin

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*Disclaimer* The comments contained in this electronic source of information do not constitute and are not designed to imply that they constitute any form of individual medical advice. The information provided is purely for informational purposes only and not relevant to any person's particular medical condition or situation. If you have any medical concerns about yourself or your family please contact your physician immediately. In order to provide our patients the best uninfluenced information that science has to offer,we do not accept samples of drugs, advertising tchotchkes, money, food, or any item from outside vendors.