Monthly Archives: October 2011

What is Flu Vaccine Anyway?

We spend a lot of time each fall talking about influenza and flu vaccine. A great deal of hard work by very smart people goes into making this magic fluid each year.

'Flu Vaccination Grippe' photo (c) 2010, Daniel Paquet - license: http://creativecommons.org/licenses/by/2.0/

The first thing you need to make flu vaccine is a flu virus. Those come in many different flavors, some old standbys trying to make a comeback, occasionally some new virus. Because the earth is tilted, our summer is the Southern Hemisphere’s winter. They are having this year’s flu season 6 months before we do. The best place to look for new influenza viruses are poor rural areas in Southeast Asia. In these areas, humans and animals frequently live close together. I’m sure you have noticed all influenza viruses have animal names (swine flu, bird flu…) – that is because the virus jumped from an animal to a person.

The World Heath Organization (WHO) is in charge of collecting flu viruses. They culture a bunch of sick people (nasal swab) to find the new and dominant viruses that season. They get pure cultures of the three worst viruses.

Now the magic begins.

Each virus is combined with a harmless standard lab virus. The result is a new virus that looks like the bad influenza virus on the outside, and like the harmless lab virus on the inside. That is important because the human body generates antibodies to the outside of the virus (it can’t see the inside). Now we have a copy of the virus that can’t make people sick, and grows well in chicken eggs. All this happens at the WHO labs.

Next it’s off to the vaccine manufacturers.

This harmless copy virus is injected into fertilized chicken eggs that are 9 to 12 days old. Three days later there are almost countless copies of the virus in the egg white. The virus is then separated from the egg white. Now it’s time to kill the virus with chemicals as we don’t want anyone being infected by this new virus (even though it is harmless). Now the virus is broken up to get a solution of the surface proteins (those on the outside).

This solution, called antigen, is then diluted to the proper concentration for use.

Next, it’s sterilized and packaged in vials and syringes.

There are hundreds of quality assurance tests done at each step of the process.

So your flu vaccine contains just the proteins from the outside of the original bad virus. It doesn’t have the ability to infect you as there is no living virus in the vaccine.

When you get your flu shot, these proteins (antigens) in the vaccine stimulate your body to make antibodies against this interloper. These antibodies will attach to the original virus and destroy it. In about 9 days you have enough antibodies to fight off an assault by the original virus.

It takes six months from finding a new virus to mass-producing the vaccine. That original virus was found in our spring (the Southern Hemisphere’s fall) and is ready for use by our fall season – just in time for flu season.

Producing the new trivalent (3 viruses) vaccine each year is one of the things the human race does very well; it requires worldwide cooperation to pull it off.

So, when you get your flu shot this year (and do it soon to maximize your protection), appreciate the “magic” that half cc of vaccine represents.

Take care

Dr B

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Top Ten Flu Shot Myths: Don’t Fall for Them

It seems most people won’t get a flu shot this year – many turning to what can only be called the Top Ten Flu Myths. Here goes:

'Finally Got A Flu Shot $25.' photo (c) 2010, Jake Metcalf - license: http://creativecommons.org/licenses/by/2.0/
1. The flu shot can give me the flu. No way, no how. Injectable flu vaccine is 100% dead, broken-up virus – it is not infectious.

2. I won’t get the flu. That is Russian roulette. How often this winter will you be in the same room/elevator/auto with someone who is coughing, sneezing and doing their best to infect everyone? You will find yourself trapped like a rat.

3. I’m healthy, so getting the flu is no big deal. Influenza hits even the strong and healthy like a Mack Truck. Think 104 fevers and every muscle in your body screaming at you. Not much a doctor can do after you have the flu.

4. The Flu vaccine is dangerous. This is the old argument regarding the preservative Thimerosal. There is zero scientific evidence that this preservative is harmful. Given the hundreds of millions of flu shots given, even a tiny risk would be found. If you still fear this preservative, the flu vaccine is available in preservative free form (no Thimerosal) and the FluMist nasal spray has none. For the record, my children, wife and I had the regular flu vaccine (with Thimerosal).

5. Flu shots are difficult to find and useless after November. The flu season changes every year. Things like air travel spread viruses quickly to far flung places. It takes 9 days to develop immunity after being vaccinated. You will still get immunity whenever you vaccinate. In terms of finding the vaccine, the vaccine is plentiful even late in the season. If you decide a flu shot is a good idea, why risk getting the disease for months before getting a shot?

6. I get sick even if I get the flu shot. Influenza takes a couple of days to develop after you are infected. So you can also get exposed a couple of days after the vaccine, but before you are immune. Influenza vaccine doesn’t prevent colds. So any of those situations can lead people to think the vaccine didn’t work.

7. I don’t have the money. A Canadian study found an average savings of $43 in healthcare expense for every vaccinated person. Doctor visits and work absence were all significantly reduced in the vaccinated population.

8. Only old people die of flu. In normal years, 90% of flu deaths are 65 years and over. H1N1 had the opposite with almost all the deaths in the young. It is your contribution to the public good to not be passing around flu this winter. We call that herd immunity. The sum is greater than the parts.

9. I am still immune from last year’s shot. The flu vaccine is redesigned every year based on the early emerging virus types in Southeast Asia (they have their winter during our summer). When we measure immunity, flu vaccine gives very strong immunity for six months or longer. You don’t still have high antibody levels the next flu season.

10. Flu shots hurt. In my clinic, we use #30 needles that are the thickness of a human hair. The vaccine is not irritating to the muscle. There is very little pain with a carefully given flu shot. If you are needle-phobic, you can always take the nasal spray (FluMist).

We have plenty of vaccine, what are you waiting for?

Dr. B

Careful Steps Need to be Implemented to Avoid Drug Poisoning in Young Children

A recent study published in The Journal of Pediatrics blames greater availability of prescription medications in the household for the rise of accidental drug poisonings in children.

'My Medicine Cabinet' photo (c) 2008, Mr. T in DC - license: http://creativecommons.org/licenses/by-nd/2.0/

The large majority of these accidents, which lead to serious poisonings, hospitalizations and even death, are from young children finding and ingesting drugs by themselves. Failure to poison-proof a household may play a role.

However, the larger problem is simply the increased use and availability of prescription medications, including pain medications, narcotics, sedatives for sleep, muscle relaxants for injury, and cardiovascular prescriptions. Dosing mistakes for pediatric patients account for only a very small portion of the problem.

Past emphasis by FDA and other professionals has minimized therapeutic mistakes and does not account for the rise of serious drug poisoning in children. The offending medications are often not even drugs that are commonly used for children.

The most recent surveys show that 55 percent of adults have taken a prescription medication within the last week and 11 percent have taken five or more prescription drugs within the preceding week. The use of over-the-counter medications such as common anti-inflammatory products and acetaminophen has increased and created more prevalence in the home.

But the largest increase in poisonings remains from prescription medications, resulting in more adult medications around that are toxic to both toddlers and young children. Medications for seniors and grandparents are estimated to be involved in these accidents only 10 to 20 percent of the time. These products are often stored in containers or pill reminders that are not child resistant. The rise of more serious admissions for accidental poisonings and the types of drugs ingested, point to the greater availability of medications in a child’s environment without adequate precautions for protected access.

Some experts believe there are limitations to education about prevention and poison-proofing the home for children. The consensus among behavioral experts is that the best efforts in child proofing will result in prevention 90 percent of the time. Even that would be an improvement over the status quo.

The typical pattern for accidental ingestion is during the period of time that the medications are in use by an adult. They are typically left out for convenience without recognizing the hazard they present to a curious young child. Medication in locked cabinets is generally considered inconvenient, which limits the accessibility, especially when needed two or three times a day.

The recent information sheds light on the prevalence of prescription medications in a household and the serious risks of ingestion by children. Some experts have suggested new types of packaging that would restrict the access to medication by limiting the amount. This means adding flow restrictors for liquid medications and containers that would dispense only one tablet at a time. Such changes would have to be applied to both adult and pediatric products to have any beneficial effect.

Renewed education for all consumers about where the overlooked risks lie is an important first step. More thoughtful storage and access to prescription medications is necessary to restrict access for young children.

In general, the situation should give everyone reason to pause and consider society’s overall increased use of powerful medications such as opiates and sedatives that have clearly been on the rise. In turn, it has indirectly increased the risks to our children.

Preventative measures need to be taken to decrease the immediate risks. The larger picture is evaluating a society that relies too heavily on the use of therapeutic prescription drugs.

Dr. Bruce Kaler, U.S. HealthWorks Medical Group

The Cold Season Diet – Foods that Strengthen Your Immune System

Guest Writer: Timi Gustafson, RD

It is the time of the year again when many of us get the sniffles, wondering when there will be a cure for the common cold at last. Of course, not everybody will fall sick. Some people seem to remain unscathed no matter what, while others succumb as soon as the temperatures drop. It’s a mystery how a chosen few can handle the germ assault so much better than the rest of us. These folks must have an extraordinarily robust immune system that protects them like an invisible shield. But were they born this way or did they acquire their immunity over time. And if so, how?

'Walmart's Healthier Foods Annoucement in D.C.' photo (c) 2009, Walmart - license: http://creativecommons.org/licenses/by/2.0/Humans have three types of immunity: “Innate,” “adaptive” and “passive.” We all are equipped with “innate” or “natural” immunity at birth. It is our first line of defense against the countless health hazards we become exposed to the moment we begin to breath. We also have external barriers, like our skin and the membranes that line the nose, throat and gastrointestinal tract. If any of these outer defense walls break down and an opening occurs, e.g. through an abrasion or cut, immune cells keep pathogens from invading while the wound heals.

By contrast, “adaptive” immunity is a defense mechanism we acquire as we encounter various diseases or become intentionally immunized through vaccinations. It is a process that continues over the duration of our lifetime.

“Passive” immunity only lasts for a limited period. For instance, we receive certain antibodies as infants from breast milk, protecting us initially from the infectious diseases our mother carries anti-bodies against. But that kind of protection is only temporary.

As we get older, our immune system should grow increasingly stronger and more efficient, simply because it recognizes many germs from past encounters and eliminates these faster. Unfortunately, that is not always the case. Immunity disorders and allergies can severely diminish our natural defenses. But if it functions properly, the immune system is a magnificent asset without which we would not survive for long.

Fortunately, we have also means to strengthen the immune system’s capacity. Most people may think in terms of vaccinations. However, one of the most effective ways to boost the immune system is through a healthy, balanced diet. Experts believe that eating lots of fresh fruits and vegetables is probably the single best thing one can do to support the immune system and thereby ward off many infections.

Some of the most important nutritional benefits we can get come from antioxidants. Antioxidants are vitamins, minerals and other nutrients that help to protect cells in the body from damages caused by so-called “free radicals.” These are highly unstable organic molecules, mostly generated by exposure to toxins, which can adversely affect cells and tissues and thereby contribute to diseases and aging. They can also impact the immune system and interfere with its functions. Antioxidants are believed to prevent these free radicals from doing their harmful work. Including lots of rich sources of antioxidants in one’s diet is therefore highly recommended as a preventive measure against colds and other infections.

Certain foods contain higher levels of antioxidants than others. Look for fruits and vegetables that are high in beta-carotene and other carotenoids. You can easily recognize them by their bright colors, like orange, purple, red and yellow. Apricots, cantaloupes, mangoes, nectarines, peaches, grapefruit, tangerines and watermelons are all fruits rich in beta-carotene. So are vegetables like asparagus, beets, broccoli, carrots, bell peppers, kale, collard greens, squash, spinach, sweet potatoes and tomatoes.

You may want to include good sources of essential vitamins and minerals as well. Vitamins A, C, E and the mineral selenium (all antioxidants), B-complex vitamins, iron and zinc are especially beneficial for the immune system. Vitamin C and E are present in many produce items and are readily available for most of the year. Vegetables like broccoli, cauliflower, Brussels sprouts, citrus fruits and berries are loaded with them. Foods that can be found in colder climates during the fall and winter season are prunes, apples, raisins, plums, grapes as well as onions, eggplants, beans, squash, pumpkins and sweet potatoes. The richest Vitamin E sources are wheat, nuts, seeds and also certain fruits and vegetables.

All these foods contain many more varieties of nutrients that work together in support of the immune system and have other health benefits too. Some have important anti-inflammatory properties, which can be used for the treatment of allergies and other inflammations.

With regards to their nutritional value, natural sources of antioxidants are preferable to vitamin supplements. However, in order to avoid deficiencies, I do recommend a daily multivitamin supplement, at least during the cold season. Supplements are never to be considered a substitute for real food, but they can serve as useful additives, especially when your diet is less than balanced. However, I do not advise taking specific immune boosting supplements or medications, unless prescribed by a doctor for therapeutic purposes. The reason is that some vitamins (like A and E) are not as easily eliminated as others (e.g. vitamin C) and may accumulate to the point where they become toxic.

Last, but not least, it needs to be said that good nutrition alone will not guarantee the immune system to function at top level. Stress management and sleep hygiene are also part of the equation. If you are too run down from work or sleep deprivation, the best food in the world will not prevent you from having to pay the price eventually. But with all (or most) of your health needs met, you should make it through the coming winter just fine. Perhaps, this time you will be among the chosen few who stay above the fray, no matter what.

Timi Gustafson RD, LDN. is a clinical dietitian and author of the book “The Healthy Diner – How to Eat Right and Still Have Fun”®, which is available on her blog, “Food and Health with Timi Gustafson R.D.” (http://www.timigustafson.com), and at amazon.com. You can follow Timi on Twitter and on Facebook.

From Everett, WA To Treating Patients in Rural Vietnam

Dr. Randall Franke of U.S. HealthWorks Medical Group in Everett, WA, recently had the opportunity to travel to Vietnam to provide medical services to the poor. Below is an account of his trip.

'SE Asia' photo (c) 2009, Rolling Okie - license: http://creativecommons.org/licenses/by/2.0/

Providing medical attention on a two-week journey into rural Vietnam communities has forever changed my life.

On August 25, the journey began for me and two other physicians along with nurses, dentists and pharmacists. Our medical group also consisted of 30 pre-med, pre-nursing, and pre-pharmaceutical students from the University of Washington; many of whom acted as translators. Also making the trip was my son, Alex, a high school senior. Though missing his first week of school, I knew Alex would benefit from this experience as much as I would.

The two weeks were like nothing any of us had ever experienced. My patient visits were not at my modern U.S. HealthWorks medical center in Everett, WA, but rather in spartan, temporary health clinics that we set up in rural areas both in the north and south.

In preparation for our journey to visit and treat patients in Vietnam, our team had trained weekly for several months to prepare for our trip. Despite the training, it still didn’t totally prepare us for our Vietnam experience.

Our days in Vietnam began in the early morning. We would board a bus at 5 or 6 a.m. and travel 60 miles or more in a very time-consuming drive that typically lasted two to three hours before we reached the people in these outlining areas. Once we reached our destination, set up would take an hour most mornings. We would begin seeing patients between 8-9 a.m. and wouldn’t stop providing medical assistance until early evening.

As we set up our mobile clinics each day, hundreds of Vietnamese people would be lined up eagerly waiting to receive medical attention. The large daily crowds were skillfully managed by our students many of whom were Vietnamese Americans. Patients would be registered, and their vitals signs would be taken by our students.

After the preliminary work was completed, the next step was being seen by one of the three physicians. Once a patient had seen a doctor, they were directed to another part of the mobile clinic for medications, and in some cases, additional treatment including dental care.

Approximately 65 percent of the patients that we saw were senior citizens. Their health issues included chronic hypertension, vision problems, skin conditions and other medical conditions that had gone untreated due to the lack of healthcare access.

In our two-week span, we set up eight mobile clinics and saw an estimated 1,600 patients. It was a heavy work load each day, but providing healthcare to these long lines of patients was well worth it. We were able to provide much-needed medical attention to people who unfortunately don’t have access to regular healthcare. We also had the opportunity to meet with students from Hanoi Medical University. Everyone was extremely friendly.

It was an incredible learning opportunity for all of us and one I would like to repeat. I’m eager to return again and hopefully offer an increasing scope of services to a very appreciative group of patients.

~Dr. Randall Franke, U.S. HealthWorks Medical Group

Plenty of Good Reasons to Get Flu Shot This Year

'Finally Got A Flu Shot $25.' photo (c) 2010, Jake Metcalf - license: http://creativecommons.org/licenses/by/2.0/
So far, it’s been a pretty uneventful flu year with no scary new strains. We picked the right flu virus to make vaccine out of, so it’s a one-shot year.

When discussing the flu, “same old-same old” means 41,000 people will die in this country of the flu this winter. That’s as many people as get killed on U.S. highways in a year. It would be nice to be able to vaccinate against automobile deaths, wouldn’t it?

Most of the flu deaths will be people 65 or older. Most of them will catch the flu from younger people around them.

We get the flu vaccine or not according to our own private equation, weighing our health, the chance of getting the flu, our memory of last winter, and the hassle factor of both illness and getting the vaccine. All this is almost unconscious, and steers us either toward or away from opportunities for vaccination. Public health folks tear their hair out trying to convince us of the benefits of herd immunity.

I recently came across some data that looked at flu vaccination from a different perspective. The study looked at respiratory illness rather than just flu. Respiratory illness includes anything that makes you congested and cough, presumably 20 dozen different cold viruses and the flu. They vaccinated a bunch of healthy working adults and watched what happened. Those vaccinated adults had 25 percent fewer respiratory illnesses, 43 percent less sick days from respiratory illness, and 44 percent fewer visits to a physician for a respiratory illness. The savings on average for each person vaccinated was almost $47.

At first glance it appears that the flu vaccine helps protect you against a bunch of cold viruses as well as influenza. That would be a heck of a flu shot – sign me up. Sadly, it doesn’t.

What it actually means is there are a bunch more cases of flu going around than anybody realizes. And the flu is a much bigger part of what makes us cough in the winter. One would suppose from this data that a third or even a half of our winter respiratory illness is flu based. Who knew?

So maybe you get vaccinated for some noble reason, like saving an elderly person’s life, or trying to keep the kids healthy this winter, or missing less work, or simply to save a buck (or $47) — it all works.

There is plenty of vaccine, and winter is coming, so what are you waiting for?

Take care,

Dr. B

Suture, Glue or Tape – Wound Closure with Choices

'stitches' photo (c) 2008, Sarah (Rosenau) Korf - license: http://creativecommons.org/licenses/by-sa/2.0/

It wasn’t long ago that learning to sew lacerations in the ER was the most fun and useful a medical student ever felt.

Those days the choices were simple – to sew or not to sew, that was the question. Often it amounted to self-selection. The patient needed sutures or he wouldn’t be here. Wound care these days is a little more interesting as we can pick the suture color, thickness or stretchability. We can even put a wound together without sewing.

Wound closure, like most of medicine, is conceptually simple: just put things back together the way they were. One of my surgical professors used to quip: “Anatomic closure doctor, put the insides back in the inside.”

For many wounds that aren’t too deep or in the wrong place, almost anything works. Just get the skin edges back together and hold them there, and healing will occur. Medical stitches, staples, tape or glue all work quite well. After a week or so, the patient is as good as new.

Wounds in areas of greater skin tension or movement present some challenges. Cut the skin over a knuckle, and that repair will be pulled apart every time you make a fist. The chance of the wound staying closed with anything less robust than stitches is unlikely. Put that same wound on the forearm, where the skin doesn’t move much, and there isn’t a lot of tension and tape or glue will work just fine.

Steristrips are 1/8th inch fabric tapes that are used to close wounds. Nothing fancy, simply push the wound edges together and press on these tapes to hold it closed.

Dermabond or medical superglue is the latest innovation in wound closure. This is almost universally misunderstood outside the clinic or ER, which probably is a result of our normal use of superglue to fix nonliving things.

Take your basic broken toy, put a drop of superglue on the parts, and hold them tightly together, usually they stick. Wounds, however, are different. The biggest difference: they’re wet, and it is certainly tough to glue wet surfaces.

Medical superglue is never actually put in a wound; rather, it is put on a wound (outside the wound). Pinch the skin edges together, make sure they are really dry, and put a drop of glue on top of the wound. This special superglue has some tiny threads in it that make it stronger, like fiberglass. Gluing it shut also seals it up, so no bandage is needed.

So when it comes to skin lacerations, where they are is a big determinant of options.

Other determinants are the age of the patient. It is well known that almost any wound in a child can be taped or glued. Young children just don’t hold still when you point a needle at them (and why would they?); sometimes adults, too.

The opposite can occur in working adults. They actually ask to be sutured. Medical superglue or tape needs to be treated gently. No heavy use of the hand. Sutures are a much stronger repair and often allow a worker almost full use of the hand immediately.

So now you know you have choices. A good wound closure can be made using several different techniques. We can accommodate those with needle phobias, workaholics and everything in between.

Take Care.

Dr. B