A virus. There is A, B and C. Influenza is brought to you by the alphabet.
They are identified by the hemagglutinin (the H) and the neuraminidase (the N) and these are the proteins recognized by the immune response to both disease and vaccination. Some H's and N's are found in humans, some, like H7, are found in bird flu strains.
And besides the human strain, various bird influenzas (H7N9 etc)(PubMed) are just waiting to jump to humans and kill us.
And kill us it will. Depending on the season, flu kills between 30,000 and 645,000 people a year (PubMed).
Every year as the virus replicates there is the increasing accumulation of mutations (drift) in the the hemagglutinin and the neuraminidase, taking the virus away from prior immunity, the vaccine, and making PCR tests less reliable (PubMed). Shift, as occurred with H1N1, is when a whole new strain hits.
Breathing next to someone with influenza. It is also spread by contaminated hands and, in an experiment I would not participate in, through the eye when sprayed in the face. So wear a mask with eye protection. Highly infectious.
"...two-fifths of fine-particle aerosol samples from subjects with community-acquired influenza virus shed infectious virus during normal breathing. Aerosol particles ≤5 μm, in contrast to larger aerosol particles or droplets, may remain suspended in ambient air for prolonged periods of time and may serve as a source of air-borne transmission beyond the 6-foot droplet perimeter and well after an infected individual leaves the area (PubMed)." So don't inhale; worked for the POTUS to be (YouTube).
One poster demonstrated that infected patients can spew infectious influenza at least 6 feet with a cough (PubMed).
We are still waiting for the next pandemic, either avian or human, to sweep the world and kill large numbers of humans. Don't kid yourself. It will happen.
How long are people infectious? With H1N1, and allow me to quote "Of 43 persons with PCR-confirmed pandemic (H1N1) 2009 from whom a second specimen was collected on day 8, 74% remained PCR positive and 19% were culture positive. If the 73 symptomatic household members without PCR- confirmed illness are assumed to have pandemic (H1N1) 2009, a minimum of 8% (6/73) of case-patients shed replicating virus on day 8. Self-isolation only until fever abates appears insufficient to limit transmission (PubMed)."
14% of them what have detectable seasonal influenza by PCR can be asymptomatic but have low viral loads (PubMed) and are probably not that infectious. Still, do not lick their nose.
About half of healthcare workers have no fever before diagnosis (PubMed).
And people can have no or little symptoms and be shedding virus (PubMed).
The effects of the flu vaccine are wide ranging, depending on the population studied: decreased infection, decreased hospitalization, decreased transmission and decrease in stroke and heart attack. While efficacy hovers around 50%, its benefits are undeniable to everyone except the Atlantic and the Cochrane review.
And should unvaccinated HCW's have to mask? As of 2018 I am against it. There is no information to show benefit if neither the HCW and their patients have influenza. And think about it. Say you have 80% vaccinated and the vaccine is 60% percent effective. Out of every 100 employees 20 will be at risk from no vaccine, but 32 will be at risk from vaccine failure. So it is vaccinated group who should wear a mask. To my mind it is everyone or no one.
Worried about that coughing idiot on the plane? "Passengers were at 3.6% increased risk of contracting pandemic (H1N1) 2009 if they sat in the same row as or within 2 rows of persons who were symptomatic preflight. A closer exposed zone (2 seats in front, 2 seats behind, and 2 seats either side) increased the risk for post-flight disease to 7.7%" (PubMed). But wearing a mask on the plane is protective (PubMed) and a lot easier than holding your breath for the entire flight.
Face masks and hand hygiene reduces respiratory illnesses in shared living settings like dorms (PubMed).
Be wary of pigs. Pigs at fairs may have influenza A and not be ill, although I am uncertain how to tell is a pig is ill and pigs do not like wearing N95 masks (PubMed). And those that work with swine are also at risk.
When flu first hit Europe 500 years ago it was called the 'gasping oppression' (PubMed). I think we should still use the term.
High fevers, headache, severe cough, way bad myalgias. Whether or not you die may be due to a genetic predisposition (PubMed).
The manflu is the real deal. Men "...have weaker immune responses to viral respiratory viruses, leading to greater morbidity and mortality than seen in women" (PubMed).
For H1N1, it is the obese (of 92 case patients who died (17%), 56 (61%) had BMI ≥30 and 28 (30%) had BMI ≥40 (PubMed) and the pregnant who are likely to die.
Secondary bacterial pneumonias are very common (at least a fifth of patients) with influenza, including the 2009 H1N1: "Of 3,110 (29.3%) samples positive for pandemic (H1N1) 2009 virus, 28% contained >1 other pathogen, most commonly Staphylococcus aureus (14.7%), Streptococcus pneumoniae (10.2%), and Haemophilus influenzae (3.5%)(PubMed)." They are more likely to have not been on prior antivirals, to go septic and to die (PubMed)(Pubmed). Your threshold for adding antibacterial should, as a result, be low.
"For patients with influenza who were immunocompromised, incidence of invasive pulmonary aspergillosis was as high as 32%, whereas in the non immunocompromised influenza case group, incidence was 14% (PubMed)."
Pregnancy and obesity are risk factors for dying from influenza; with H1N1, about 6% had a vascular thrombotic event (PubMed).
If you are a HCW, you can protect yourself and other with vaccination and proper PPE. You know, wear a mask around coughing patients.
Independent factors associated with mortality were hospital-acquired influenza A (H1N1)pdm09 infection (odds ratio: 1.63), like getting flu from an unvaccinated HCW (PubMed).
"For patients exposed to at least 1 contagious HCW compared with those with no documented exposure in the hospital, the RR of HA-ILI was 5.48; for patients exposed to at least 1 contagious patient, the RR was 17.96; and for patients exposed to at least 1 contagious patient and 1 contagious HCW, the RR was 34.75 (PubMed)." But I presume those that do not use PPE have lots of children and syphilis, being too dense to understand contraception.
Besides acute influenza and secondary infections, flu is associated in increased risk of MI (PubMed), pulmonary embolism (PubMed), stillbirths (halves the still birth rate (Pubmed), smaller babies, dumber babies, and acute worsening of chronic medical problems.
There is a suggestion that H1N1 is evolving to be more virulent (PubMed).
Influenza C causes about 0.3% of URI's (PubMed), most commonly kids.
The risk for heart attack or stroke after flu is maximal in the first week after infection (PubMed).
For H3N2, a 2-day combination of clarithromycin 500 mg, naproxen 200 mg, and oseltamivir 75 mg twice daily, followed by 3 days of oseltamivir resulted in a lower 30-day mortality, less frequent high dependency unit admission, a shortened hospital stay and a decrease in viral titers. (PubMed).
Combination therapy with oseltamivir, amantadine, and ribavirin (PubMed) had NO added clinical benefit.
If you think a little is good than a lot is better: wrong. That would be beer and ice cream. When it comes to oseltamivir, more only increases cost and toxicity without clinical benefit (PubMed).
There is an argument made that for severe influenza combination therapy may be needed. This is an argument not (yet) based on clinical trials (PubMed).
Treatment of flu will decrease the symptoms by a day in healthy OUTPATIENTS. Usually given within 48 hours, but quasi-beneficial effects can occur up to 5 days in some populations (PubMed)
Treating also decreases chance of being hospitalized (PubMed).
For HOSPITALIZED patients prompt therapy shortens hospitalization (PubMed) and for those at risk (AIDS, elderly, cancer, pregnant, transplant) and in the severely ill decrease the risk of dying. Got that? Prompt treatment decreases the odds of DYING. There is a lot of brouhaha/BS about the worthlessness of olsetamivir. It may be a waste time for the outpatient with no comorbidities, but for everyone else there is benefit. For a nice discussion see (Debate Regarding Oseltamivir Use for Seasonal and Pandemic Influenza) or any number of my rants linked below.
Severe H1N1 may be associated with a IgG subclass 2 deficiency (PubMed).
In nursing home outbreaks (2 or more) start universal chemoprophylaxis in less than five days: "LTCFs that initiated chemoprophylaxis > 5 days after outbreak onset had significantly longer duration of outbreaks (18.3 vs. 6.7 days), higher incidence rates (10.5 cases per 100 residents vs. 6.2 cases per 100 residents; ), and higher case-fatality rates (3.3 deaths per 100 residents with influenza A vs. 0.45 deaths per 100 residents with influenza A; ) than did LTCFs that initiated chemoprophylaxis 5 days after outbreak onset" (PubMed)."
Macrolides, which are mild anti-inflammatories, may hasten the resolution of symptoms. I am a big fan of macrolides as anti-inflammatories (PubMed).
And Tylenol does nothing either (PubMed).
There is a vaccine which, if you are a dumb ass, you might avoid. The vaccine is reasonably effective, overall it decreases the risk of flu about 50% depending on the year.
The vaccine is better against H1 than H3, in part due to the antigens becoming more glycosylated over decades. As the virus grows in eggs it looses that glycosylation and so the vaccine lacks proper antigen. The virus also has become more human adapted over time and does not grow well in eggs and to grow in eggs the virus alters to be different from the circulating strains. As a result, the antigens in the vaccine do not completely match the wild type.
The high dose flu vaccine for the elderly decreases the risk 24% compared to the standard dose vaccine. And if you get the vaccine and still get the flu, it will be milder case, with decreased odds of hospitalization, ICU admission and death. And for asthma patients it decreases asthma attacks by two thirds (PubMed). Likely better in old vets (PubMed) and solid organ transplant patients (PubMed).
And it may be better to the vaccine in the morning than in the afternoon (Pubmed).
Being immune to influenza leads to less influenza, less secondary infections, less death from flu and its complications, fewer cardiovascular events (PubMeds)(as an example, they estimate 16,514 fewer MACE related hospitalizations and 2764 premature deaths in Korea (PubMed), fewer strokes (PubMed), (PubMed), less loss of pregnancy (1 in 10 pregnancies were lost in the 1918 pandemic), and the birth of larger, smarter, wealthier babies. Really. Although, as is always the case, there is contradictory data (PubMed).
And flu vaccine halves the mortality rates in patients with CHF
Flu during pregnancy: "Mothers with influenza had a higher rate of stillbirth, and their offspring had low 5 minute APGR Scores. Furthermore, the rate for birth weight less than 2500g was increased." (PubMed).
In RA patients, holding the methotrexate increases the immunogenicity of the vaccine.(PubMed).
The H1N1 vaccine did not increase the risk of Guillian-Barre even a hair of a whit and the disease has 15 x the GBS rates as the vaccine (PubMed). The data all suggests the risk of GBS from the disease is far worse than the vaccine (Review). Prior post vaccination Guillain Barre Syndrome is NOT a risk for subsequent GBS (PubMed).
If you think, after reading the steaming pile that is the Annals, that Maxingshigan– Yinqiaosan is of utility, see my SBM analysis of that farce.
Oscillococcinum? You are joking right? Do you know what that is?
"In to a one litre bottle, a mixture of pancreatic juice and glucose is poured. Next a Canard de Barbarie is decapitated and 35 grams of its liver and 15 grams of its heart are put into the bottle. Why liver? Doctor Roy writes: “The Ancients considered the liver as the seat of suffering, even more important than the heart, which is a very profound insight, because it is on the level of the liver that the pathological modifications of the blood happen, and also there the quality of the energy of our heart muscle changes in a durable manner.”
After 40 days in the sterile bottle, liver and heart autolyze (disintegrate) into a kind of goo, which is then “potentized” with the Korsakov method where the glass containing the remedy is shaken and then just emptied and refilled", and the process of filling and emptying is repeated 200 times. If you were cleaning a glass in the sink how any times short of 200 would you rinse the glass before declaring everything gone and the glass clean?
"Moreover, at "200C" (or "200K" or "200 CK") the concentration of the original substance would be 1 part in 100200 ;which is a 1 followed by 400 zeroes. A 1 followed by 100 zeroes is called a googol. The estimated number of particles in the universe that we can see is a googol, give or take a few zeroes. So in order for one of the original molecules to be present in a container of Oscillococcinum, the mass of that container would have to be about a googol googol googol times our world, which would be incomprehensibly larger than the visible universe."
If you really think Oscillococcinum could possibly have any effect on influenza, I worry for your grasp on reality.
The downstream complications of influenza are not inconsequential: worsening of cardiopulmonary diseases, more vascular events like MI (PubMed) and increased focal and bloodstream bacterial infections (PubMed). Flu season is bad for pregnant females: increased stillbirth and smaller, perhaps stupider, children. Vaccination decreases the odds for this.
MI risk increases markedly the first week of influenza (PubMed).
The vaccine lasts the whole season. It is a myth that there is a significant decline in antibody over the flu season (PubMed)(Pubmed). I wrote a whole essay on it (here). The vaccine efficacy does fade during the season, about 7% decline in effectiveness a month (PubMed).The decline is more for H3 and B than for H1 (PubMed).
There is this odd suggestion that repeat yearly vaccination decreases the effectiveness of the vaccine (PubMed). But still better than getting the flu.
Get the damn vaccine, you fool. Anyone who can take the vaccine and doesn't is a moron. Period. End of story. Well, more on that story follows.
And be happy when you get the vaccine; it will lead to a better response (PubMed).
It is clear. Egg allergy means nothing. From the Guidelines (PubMed) "All patients with egg allergy of any severity, including anaphylaxis, should receive (influenza vaccine) annually, using any age-approved brand of (vaccine) in an age-appropriate dose. Such patients can receive the vaccine as a single dose without prior vaccine skin testing."
You can't get the flu from the vaccine (its dead) and it will not protect you from the 1000 and one viruses out there that are not influenza. But it will prevent you and, more importantly, your patients, from dying from not only influenza but community acquired pneumonia as well (PubMed). Few medical interventions provide more bang for the buck.
The vaccine is safe and effective in HIV-positive patients, patients with cancer, and transplant recipients but not as effective as in immunocompetent (Pubmed).
And there is no such thing as a stomach flu. God, that irritates me. And it equally pisses me off when people call febrile illnesses the flu when there is no cough. Flu is, above all else, a coughing illness.
How long will H1N1 cough last? "The duration of cough was as following: <1 week (73.0%); 1-2 weeks (7.8%); 2-3 weeks (7.8%); ≥3 weeks(8.5%). Twelve (8.5%) patients had cough lasting more than 3 weeks (postinfectious cough), 4(2.8%) patients developed chronic cough (>8 weeks) (PubMed)."
A few words about the Swine flu. Eat bacon. It will decrease the spread of the disease. Do not rely upon the rapid test, it is only useful if positive (MMWR). So far it kills mostly kids and pregnant females as a significant number of adults born before 1950 have preexisting cross reacting antibody from strains circulating before 1950. So far it is sensitive to oseltamivir. and early use in at risk populations increases survival. That will not last. Many of the deaths are due to bacterial superinfections and, with all the MRSA circulating in the US as well, I expect a fair number of deaths from MRSA as it is not an organism I can treat. I sure hope it does not 'mate' with H5N1 and we end up with a highly infectious and highly virulent influenza A. And get the damn vaccine; given that we have a near perfect match between the vaccine and the H1N1 it should be highly efficacious in preventing H1N1.
Avian influenza: the H5N1 strain that is slowly sweeping across the world. Currently (12/23/06) only those that have close contact with ill birds are at risk. This is due to the fact that human receptors for H5N1 are only in the lower respiratory tract; therefore you need to snort in a big load of virus to get infected. IF it mutates to acquire an affinity for upper airway human receptors and IF it retains its virulence, it is estimated it will kill 68 million world wide. Treatment would be zanamivir or oseltamivir (resistance increasing as the organism moves across the world) if you could get it in fast enough. I am not optimistic that should the time come for human to human spread we will be able to diddly.
People say they have the quote flu unquote when in fact they have another of the innumerable viruses that cause a febrile or coughing illness. Real flu makes you sicker than stink. Doctors also use the term too freely: stomach flu for example. Stop it. Precision of thought is demonstrated with precision of speech. I will let someone else comment of precision of writing.
I reproduce here my yearly Medscape blog entry, A Budget of Dumb Asses:
This essay is, I would like to clarify, directed at healthcare providers, not patients. Healthcare providers have no excuse to avoid the flu vaccine: they have access to the world's medical knowledge and should be able to rise above superstition and ignorance. The data is reasonably clear: HCW vaccination decreases patient death (PubMed).
Yes, I too am a Dumb Ass, but for different reasons.
I give you, slightly rewritten for 2011, a Budget of Dumb Asses.
I wonder if you are one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine (most are not when tested), you may have had Guillain-Barre, in which case I will cut you some slack. But if you don't have those conditions and you work in healthcare and you don't get a vaccine for one of the following reasons, you are a Dumb Ass.
1. The vaccine gives me the flu. Dumb Ass. It is a killed vaccine. It cannot give you the influenza. It is impossible to get flu from the influenza vaccine.
2. I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass. I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool.
3. Only old people get the flu. Selfish Dumb Ass. Influenza can infect anyone, and the groups who are more likely to die of influenza are the very young, the pregnant, and the elderly. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. You can help prevent your old, sickly Grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Flu, by the way, is highly contagious, with 20% to 50% of contacts with an index case getting the flu. However, Granny may be sitting on a fortune that will come to you, and killing her off with the flu is a great way to get her out of the way and never be caught. That would make a good episode of CSI.
4. I can prevent influenza or treat it by taking echinacea, vitamin C, oOscillococcinum or Airborne. Gullible Dumb Ass cubed then squared. None of these concoctions has any efficacy what so ever against influenza. And if you think oscillococcinum has any efficacy, I would like you to invest in a perpetual motion machine I have invented. None of the above either prevent or treat influenza. And you can't "boost" your immune system either. Anyone who suggests otherwise wants you money, not to improve your health.
5. Flu isn't all that bad of a disease. Underestimating Dumb Ass. Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 20,000 people (depending on the circulating strain and year) and leads to the hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach 'flu'? No such thing.
6. I am not at risk for flu. Denying Dumb Ass. If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Former President Clinton, who evidently doesn't inhale. Michele Bachmann. Wait, that's the HPV vaccine. And people who want to be safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.
7. The vaccine is worse than the disease. Dumb Ass AND a wimp. What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough.
8. I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass. Each year new strains of influenza circulate across the world. Last year's vaccine at best provides only partial protection. Every year you need a new shot.
9. The vaccine costs too much. Cheap Dumb Ass. The vaccine costs less than a funeral, less than Tamiflu, and less than a week in the hospital.
10. I received the vaccine and I got the flu anyway. Inexact Dumb Ass. The vaccine is not perfect and you may have indeed had the flu. More likely you called one of the many respiratory viruses (viri?) people get each year the flu. Remember there are hundreds of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.
11. I don't believe in the flu vaccine. Superstitious, premodern, magical thinking Dumb Ass. What is there to believe in? Belief is what you do when there is no data. Probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.
12. I will wait until I have symptoms and stay home. Dangerous Dumb Ass. Despite often coming to work ill, especially second year residents, about 1 in 5 cases of influenza are subclinical, hospitalized patients are more susceptible to acquiring influenza from HCW's than the general population, and 27% of nosocomial acquired H1N1 died. And you will never realize that you were the one responsible for killing that patient by passing on the flu.
13. The flu vaccine is not safe and has not been evaluated for safety. Computer illiterate Dumb Ass. There are 1342 references on the PubMeds on safety of the flu vaccine, and the vaccine causes only short term, mild reactions. All health care requires weighing the risks of an intervention against the benefits. For the flu vaccine all the data suggests huge benefit for negligible risk. And as a HCW, it could be argued that we have a moral responsibility to maximize the safety of our patients.
14. The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesn't work since it is part of a big government sponsored conspiracy to keep Americans ill, fill hospital beds, line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable. Paranoid Dumb Ass.
So get the vaccine. And pass this essay on to someone else. The life you may save may be your own. Or be a Dumb Ass.
And if you and yours are admitted to the hospital or visit a HCW during the flu season, ask if your provider has had the vaccine. If not, ask for a new provider. Who wants their health care provided by a Dumb Ass?
My Extensive Rants on SBM
- https://www.sciencebasedmedicine.org/scam-stud – Scam Stud
- https://www.sciencebasedmedicine.org/the-tamiflu-spin — The Tamiflu Spin
- https://www.sciencebasedmedicine.org/yes-but-the-annotated-atlantic — Yes, But. The Annotated Atlantic.
- https://www.sciencebasedmedicine.org/cochrane-reviews-the-food-babe-of-medicine — Cochrane Reviews: The Food Babe of Medicine?
- https://www.sciencebasedmedicine.org/one-flu-into-the-cuckoos-nest — One Flu Into the Cuckoo’s Nest*
- https://www.sciencebasedmedicine.org/uneasy-lies-the-head-that-wears-the-flu — Uneasy Lies the Head That Wears the Flu
- https://www.sciencebasedmedicine.org/what-are-words-for — What are words for?
- https://www.sciencebasedmedicine.org/why-get-a-flu-shot/ Why Get A Flu Shot?
- https://www.sciencebasedmedicine.org/i-refute-it-thus — I refute it thus
- https://www.sciencebasedmedicine.org/uneasy-lies-the-head-that-wears-the-flu — Uneasy Lies the Head That Wears the Flu
- https://www.sciencebasedmedicine.org/protect-yourself – Protect Yourself
- https://www.sciencebasedmedicine.org/drinking-from-the-fire-hose-odds-and-ends-on-the-gasping-oppression — Drinking from the Fire Hose: Odds and Ends on the Gasping Oppression
- https://www.sciencebasedmedicine.org/random-flu-thoughts — Random Flu Thoughts
- https://www.sciencebasedmedicine.org/ososillyococcinum-and-other-flu-bits — Ososillyococcinum and other Flu bits.
- https://www.sciencebasedmedicine.org/influenza-vaccine-mandates — Influenza Vaccine Mandates
- https://www.sciencebasedmedicine.org/nine-questions-nine-answers – Nine Questions, Nine Answers
- https://www.sciencebasedmedicine.org/flu-vaccine-efficacy — Flu Vaccine Efficacy
- https://www.sciencebasedmedicine.org/more-flu-woo-for-you-boo-boo — More Flu Woo for You Boo Boo.
- https://www.sciencebasedmedicine.org/herd-immunity — Herd Immunity
- https://www.sciencebasedmedicine.org/flu-woo-hodgepodge — Flu Woo Hodge Podge
Relevant links to my Medscape blog
Last Update: 10/06/18.