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Protect Yourself

Flu season is upon us. If there is such a thing as flu season. H1N1 started at the furthest point in time you could get from the traditional start of the flu season. It is an interesting question as to whether global warming will alter the flu season, as it has the RSV season. Classically influenza is a fall/winter disease and fall started today.

It is perhaps worthwhile to review what is known about influenza.

1) The disease influenza, the gasping oppression, is a disease that has been plaguing humans for about 500 years. It is a predominantly respiratory infection, causing a protracted cough with fevers and myalgias. The term flu is used loosely to cover almost any febrile illness, and I remain uncertain as to what a stomach flu might be. I tend towards the picky side; flu is due to the influenza virus. There are many viri that can cause a flu like illness, but only the influenza virus causes the flu.

2) The flu is due to a virus, the influenza virus. There is influenza A and B and C. There are them what deny germs as a cause of disease, and I will admit that as an infectious disease doctor I have a vested interest in germs causing disease. After all, my job is me find bug, me kill bug, me go home.

3) Not every flu like illness is due to the influenza virus. In a given season the influenza virus may account for around 10-15% of flu like illness in the community, although during epidemics influenza can account for 60% of flu like illnesses.

4) Influenza kills. It kills directly, it kills by acute secondary infections, it kills by worsening underlying diseases like heart failure, it kills long term by increasing vascular events such as heart attacks and stroke. Influenza kills the young, the old, the obese and the pregnant. Deaths by influenza also depend on the virulence of the circulating strains. Some strains, such as H5N1 (the bird flu) or H3N2, are more likely to kill (60% for H5N1)  than strains like H1N1 which was of moderate virulence. Influenza deaths, both direct and indirect, are difficult to measure and are at best an estimate.  As an example somewhere between 151,700 to 575,400 people died worldwide from H1N1 the first year, with a mean of about 250,000.

5) When exposed to influenza, either as an infection or as a vaccine, the body responds in part by making antibody. Roughly, the better the antibody response to the influenza antigens, the better the protection to that strain of influenza. I say roughly as it depends on what part of the antigenic structure the body responds to: antibody to some antigenic sites offer better protection to influenza than others. If you are lucky enough to respond to some highly conserved sites on the virus you could conceivably be immune to all strains of influenza.

6) The influenza vaccine offers moderate protection against influenza. Unfortunately the antigens of the virus change year to year (antigenic drift) and decade to decade (antigenic shift), while the vaccine strain are fixed prior to a given season and may not optimally match the circulating strains. If there is a good match between vaccine and circulating strains in a healthy population, the protection from  the vaccine can be high: for H1N1 it was 87%.

7) Unfortunately those who need to be protected from the influenza virus are those most likely not to respond to the virus vaccine: the obese, the pregnant, the elderly and those with chronic medical diseases.

Eight)  (When I use the ’8′ and the ‘)’ I get a happy face like this 8) ) The benefit of the vaccine extends beyond prevention of flu. Of course, if you don’t get influenza, you cannot spread it to others. If you do not get influenza, then, of course you can’t die of its complications, like pneumonia and heart attack. Influenza vaccination could potentially reduce the occurrence of sudden death, AMI, and stroke by 50%. Babies born to vaccinated mothers have fewer cases of influenza. Vaccinated mothers are less like to have have stillborn or small babies. Not getting influenza or being vaccinated against flu has many short term and long term benefits.

9) Influenza spread can be decreased by mechanical/environmental interventions: hand washing and masks, although these interventions have variable efficacy depending on the population studied. They are not as effective as not getting the virus.

10) Health care workers are particularly problematic. For a variety of reasons they are likely to come to work ill, influenza can be potentially infectious before people are symptomatic, and spread in the hospital occurs, leading to true stories such as this:

Patient Story: Spreading the Flu 4-2012

As a reminder, we have added patient stories to meetings as a way of “bringing the patient into the room,” clarifying the context for our quality plan, and emphasizing the complexities and the importance of the work we are undertaking.

Today’s story is about a group of patients, a nurse, and influenza. It starts with Patient #1, a 57 year-old woman admitted through the emergency department (ED) to one of our hospitals in mid-March with fever and shortness of breath. She was transferred to an inpatient unit with a mask on, which triggered the staff on the receiving unit to implement droplet precautions. Initially thought to have pneumonia, testing confirmed her symptoms were the result of influenza type A, H1N1. After four nights in the hospital, she was discharged home after an uneventful hospital stay and a flu shot.

Patient #2, next door to Patient #1, is a 58 year-old man who was admitted in early March for a GI bleed with multiple co- morbidities. His progress was steady until nine days after admission, when he developed a new fever and respiratory symptoms. These symptoms developed on the same day of Patient #1’s admission. Influenza was suspected two days following the development of his fever, and staff implemented droplet precautions. Lab testing confirmed influenza type A. He remained hospitalized for two more days and received a flu shot before being transferred to a skilled nursing facility.

Down the hall, Patient #3, a 77 year-old man, was admitted two days after Patient #1 for acute stroke and urinary tract infection. On day 3 of his hospitalization, he developed a fever and cough. Lab testing confirmed influenza type A. Droplet precautions were ordered with the lab test for influenza. He remained hospitalized an additional four nights and received a flu shot before being discharged.

Patient #4, a 76 year old man, down the hall from the first two patients and around the corner from Patient #3, was admitted on the same day as Patient #1 following a fainting event at home. Due to his long-standing heart issues, he was kept overnight for observation and discharged the following morning. However, he returned to the ED three days later with continued symptoms. He was discharged from the ED only to return the next day with shortness of breath. Six hours after being readmitted, staff suspected influenza and ordered droplet precautions. His lab tests returned positive for influenza type A. After spending three nights in the hospital, he was discharged home after receiving a flu shot. The following day, he was admitted to the intensive care unit and continued receiving treatment as an inpatient for secondary pneumonia, a complication of his influenza type A infection.

The fifth person in our story is a nurse on the unit where these four patients were admitted. She works on a nursing unit whose hand hygiene performance is currently 67%, and where 85% of the unit staff were vaccinated for this year’s seasonal flu. The particular nurse in this case, however, was 1 of only 9 on the unit who chose not to be vaccinated. Her manager stated that the reason the nurse gave for not receiving the vaccine was that she “was not convinced of the evidence that the vaccine protects patients from transmission … she said she would get the vaccine if she truly believed it protected her patients, but that she didn’t.”

This nurse cared for Patient #1 on her first day of admission. She cared for Patient #2 on the eighth and ninth day (when he developed flu symptoms) of his stay. She also cared for Patient #3 on the first two days of his inpatient stay. There does not appear to be any direct contact with this nurse and Patient #4.

The nurse in our story developed symptoms consistent with influenza three days after working with Patient #1 and Patient #2 (which is the usual 1- to 4-day incubation period for influenza). Due to symptoms, she only worked a partial shift that day. Suspecting her symptoms may be influenza, she used a mask until relief staff was available. She returned home and was able to care for herself without medical intervention. She was not tested for influenza and remained off work for one week. She is still undecided about receiving the flu vaccine.

11) Because those in the hospital are particularly vulnerable to the ravages of infections, mortality from hospital acquired influenza is remarkably high: 25%.

12) Influenza vaccine is safe as well as effective.  There have been some rare complications to the vaccine: Guillian-Barre in the 1970′s and the recent reports that prior vaccination may have made disease from H1N1 worse. Biologic systems are complex, but I look at vaccines as much safer than seat belts and air bags, both of which can cause injury and death. I would still prefer to be in a car accident with seat belts and air bags and work during the flu season with vaccination.

13) Influenza vaccination for health care workers runs at best 70% in the US, which if it were my kids math grade would be cause for some ‘splanin. Doctors and nurses run a bit higher, with an 80% influenza vaccination rate in some institutions.

14) It would be nice to prevent the spread of influenza from health care workers to patients. There is no data for hospitals, although there are nursing home studies to suggest that when staff is vaccinated against flu there is a decrease in flu in the inmates, er, nursing home patients. One retrospective study suggested that units that had higher vaccination rates had fewer cases of flu, but the definitive study has yet to be done. There is buckets of biologic plausibility to suggest that vaccinating health care workers would be of benefit to patients under their care.

15) I have little (actually none) respect for HCW’s who do not get vaccinated. We have a professional and moral obligation to place our patients first.  I think those who do not get vaccinated, except for a minority with a valid allergy, are dumb asses. Here is a copy of my yearly screed over at Medscape:

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. Yes, I too am a Dumb Ass, but for different reasons.

I give you, slightly rewritten for 2012, 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 (most can be vaccinated safely), 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, oscillococcinum 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 are 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 dozens 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 usually 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 instead of the flu. The life you may save may be your own. Or be a Dumb Ass.

15) And this leads to my final thought. There is a tremendous amount of medical literature pointing to the safety and wide ranging benefits of the influenza vaccine as well as the morbidity and mortality that influenza inflicts on humans every year.  Despite that information, when you are admitted to the hospital you have a greater than one in three chance that the HCW taking care of you is ignoring that information and going unvaccinated.

I have long been of the opinion that you judge a person by the company they keep. If your health care worker is a big enough dumb ass to avoid the flu vaccine, what other areas of medicine are they equally incompetent in? Do you want to drive in a car with no seat belts or air bag, whose brakes are of uncertain maintenance? Do you want you or your loved ones to be cared for by someone who is dumb ass enough to not get the flu vaccine, putting you  and yours at risk when most vulnerable?  Can you expect that person to do the rest of their job correctly when they cannot understand and implement a core competency of medicine? Not me.

Here is my suggestion. When you and yours are in the clinic or the hospital, request care only from practitioners that have had the flu vaccine. Put a sign on your hospital room door: No entry unless you are influenza vaccinated or put a copy of this essay on the door. You do have the right to refuse care, especially from a dumb ass.

I know this idea is a non-starter. Sick, vulnerable people are in no condition to potentially antagonize their providers. No one is likely to want to piss off their HCW, especially if that person holds the key to the morphine.

There is a bankrupt idea that it is OK for patients to ask their provider if they washed their hands. It never worked. I took an informal poll of patients on one of my medical floors and asked if they would ever tell their doctor or nurse to wash their hands and not a one said they would. It would be like asking your pilot if he put the wheels down as they stated a landing.  Patients need to trust trust that we are doing what is in their best interests.  When it comes to influenza vaccination, you can’t.

I do not really expect anyone will actually ask to be cared for only by influenza vaccinated providers.

But I can dream.

References

Of sorts.  I had the opportunity to play gold with my brother and son and the time I would normally spend linking to references was spent on the links.  I hope to update it, but really, you can’t search the Pubmeds?

Dolan GP, Harris RC, Clarkson M, Sokal R, Morgan G, Mukaigawara M, et al. Vaccination of health care workers to protect patients at risk for acute respiratory disease. Emerg Infect Dis [serial on the Internet]. 2012 Aug [date cited]. http://dx.doi.org/10.3201/eid1808.111355

J Hosp Infect. 2012 Jul;81(3):202-5. Epub 2012 Jun 1.
Nosocomial H1N1 infection during 2010-2011 pandemic: a retrospective cohort study from a tertiary referral hospital.

http://www.ncbi.nlm.nih.gov/pubmed/22658238

 

 

Posted in: Science and Medicine, Vaccines

Leave a Comment (120) ↓

120 thoughts on “Protect Yourself

  1. Epi Ren says:

    I got my flu shot last night, and my doctor threw in an MMR and Tdap for good measure. It’s only a matter of time until I have to investigate a whooping cough or measles outbreak where I work. I’d be laughed out of the office if I were to catch a vaccine-preventable infection.

    Yes, I got three shots against seven pathogens, and I’m doing just fine.

  2. Brilliant – I will share this widely. I’m currently in a discussion with somebody who has used a couple of the Dumb Arse points, so it’s timely that I can post this link – thank you.

    It baffles and terrifies me that anyone involved in healthcare could remain unconvinced of the necessity of influenza vaccination.

    A small and annoying note – in point seven, you talk about those “most likely not to respond to the virus” – perhaps you meant “vaccine”.

    Kudos on an excellent post. :)

  3. dreixel says:

    “Some strains, such as H5N1 (the bird flu) or H3N2, are more likely to kill (60% for H5N1) than strains like H1N1 …”

    I suppose you don’t mean that H5N1 kills 60% of those infected, right? Perhaps “60% more likely to kill”?

  4. windriven says:

    Each year I offer to pay for flu shots for all of my employees. Incredibly, only about half take the deal. Alternatively, virtually 100% eat the free pizza or donuts when I provide those. Go figure.

    This year I will make it mandatory. And with your permission (and probably without it) I will hang a copy of your “You Know You’re a Dumb Ass IF…” on the break-room door.

  5. BillyJoe says:

    Your northern hemisphere bias is noted. :l

  6. DevoutCatalyst says:

    So develop an oral pizza delivered vaccine, Windy. Do let us know how the mandatory thing works out.

  7. Jann Bellamy says:

    About five years ago, I had a young (in his 30s, I’d say) chiropractor tell me that the flu doesn’t kill people. I guess he’s a # 11.

  8. Skeptico says:

    Really good article, especially summarizing the anti-vax talking points.

    One small typo, I think:

    “7) Unfortunately those who need to be protected from the influenza virus are those most likely not to respond to the virus”

    I think the second “virus” should be “vaccine.”

  9. Scott says:

    My five-month-old would be happy her daddy is getting his flu shot today. If she understood. Oh well.

  10. mousethatroared says:

    “Each year I offer to pay for flu shots for all of my employees. Incredibly, only about half take the deal. Alternatively, virtually 100% eat the free pizza or donuts when I provide those. Go figure.”

    Good for you. Back when I was working in an creative department, someone got word that the local public health service was offering free flu vax in a neighboring office, most of the creative department (some were traveling or crunching under a very tight deadline) trooped over to get a shot…pretty much on the grounds that free is good and blowing off work for a half hour to watch someone stick needles into your friends is even better.

    My instinct says that mandatory vaccines at work are more likely to ruffle feathers. In my experience, people love free, but dislike and rebel against mandatory. But I’ve only managed artists. Your employees may be different.

  11. mousethatroared says:

    That was a windriven quote, by the way. need more coffee.

  12. mousethatroared says:

    Scott, I remember awhile ago you mention contemplating parenthood. Congratulations!

  13. Janet Camp says:

    Last time I was at my clinic, the nurse used some hand-sanitizer before taking my BP. Having just read something about this not being as effective as hand-washing (was that you Dr. C?), I blurted this out. She went all pale and said, “I can wash my hands if you prefer but we are allowed to use the sanitizer for eight (I think?) times before we actually wash hands”. She again offered to wash if I wanted her to. I said to do whatever the policy says, but she kept offering to wash. Then she had to go get her stethoscope, so did wash her hands because she then felt it was required. She didn’t wash as long as I have been told (two repetitions of Happy Birthday To You), though and I (being a cranky old bitch) said so. She laughed, as if I was kidding, and I let it go. Why do these people not want to wash their hands?

    I’m going to find out for sure what their policy is on flu shots. What’s the point of me going there to get one if they are not?

  14. Scott says:

    Thanks! She’s a absolute darling.

  15. rork says:

    Outstanding. Need nicely formatted versions of the anti dumb ass manifesto to post everywhere.

    I’m particularly offended by irresponsible and selfish dumb asses. I try for a statistical summary about selfish: Not vaxing means you can expect to be responsible for the sickness and death of others – you are part of the problem. It’s the technical use of “expect” though, and doesn’t imply “it’s almost certain to happen”. P(kill others)>0. If the cost of avoiding that is small, it’s unethical not to help out, according to my (howling atheist) ethics. I’m amazed at how many people can get around that calculation, by one of the rationalizations listed in today’s article.

    At my health center (U of Mich) you get the flu vax, or get shamed by filling out a form, having to wear a mask constantly, and not having a special mark on your ID that everyone else has. You’ll get people looking upon you with contempt too. And I think we should go further and just get rid of those dumb asses, as we’d do if you refused to be vaxed for some other things. You can have any beliefs you want, but if it means you are picking pockets or harming others heath, work elsewhere.

  16. mousethatroared says:

    @Janet Camp – regarding hand washing. I have a family member who was a hospital floor nurse for a number of years and has an autoimmune skin disorder. The problem with hand washing when you are seeing patients every ten to fiffteen minutes is that it causes painful skin problems, meaning rashes, cracks, sores, especially to those prone to skin problems such as ezema, etc. I believe some of the hand sanitizers are much easier on the hands. Gloves can help, but she became allergic to the latex pretty quickly. Luckily, She works primarily in surgery and OB now, where the times between scrubbing in is much longer and hospitals are providing latex free gloves.

    Here’s a little link that covers the effects of various hand cleansing methods from a dermatological standpoint.

    http://www.dermnetnz.org/treatments/antibacterial-soap.html

    here’s another link on the effectiveness of hand sanitizer versus hand washing in a neonatal unit. Of course this is just one study.

    http://www.ncbi.nlm.nih.gov/pubmed/15809394

  17. Jeff says:

    I’m not sure what category of dumb-ass Dr. Crislip would put me in – maybe #11. I don’t discount the value of all vaccines, but the flu vaccine doesn’t seem to have a strong track record of success. I’ve received no vaccinations of any kind since 1965, and I never get the flu. In #4 the post doesn’t mention the nutrient having the strongest association with flu prevention: vitamin D.

    1. http://ajcn.nutrition.org/content/91/5/1255.abstract
    2. http://www.sciencedaily.com/releases/2010/03/100307215534.htm

  18. I work in a veterinary hopsital with 25 doctors and roughly 100 support staff. Every year, the management offers free flu vaccination. About 15-20 employees get the vaccine each year.

    Granted most of our patients can’t get the flu from us, but certainly our clients, children, and elderly parents can. And every year I have the same arguments with the same people over the points listed in the Dumb Ass Manifesto. *sigh* Keep tilting, Mark, ‘!ause there are plenty of windmills out there.

  19. Robb says:

    Mark,
    What do you think of the effectiveness of elderberry (Sambucus nigra) against influenza? Natural Medicines
    Comprehensive Database rates it as possibly effective with a number of positive clinical trials so far backing up traditional use. I agree for echinacea there isn’t much evidence to support it for influenza, with most trials, positive or negative in result, focusing on the common cold.

    Speaking of us searching PubMed though, I’m curious why you wouldn’t cover or at least cite this 2010 Cochrane Review that did not have such a favorable take on the efficacy of influenza vaccines:
    http://www.ncbi.nlm.nih.gov/pubmed/20614424
    If you really are convinced of the efficacy and usefulness of it, could you comment on this review? There is often quite a difference, both in terms of results and notoriety, between industry funded and publicly funded research on the influenza vaccine.

    I’m also a little confused by your statement that it is not possible to “boost” the immune system and that people who say so just want your money. Is that not how the influenza vaccine works? The FDA does use the phrase “enhance” rather than boost in their description linked below, but it’s basically synonymous. I would agree though that influenza vaccine manufacturers do want money too.
    http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm195483.htm

    By the way, I am not trying to make any sweeping statements like the vaccine is bad, take elderberry instead! I am simply asking questions rather than starting with conclusions because you seem to have very strong and firm conclusions already. I live in British Columbia and for the first time this year, our health authority is trying to enforce mandatory influenza vaccinations on health care workers (I’m not one but my wife is). In Canada, vaccination rates amongst health care workers are around 30-40%, probably comparable to in the US. You seem convinced that they are all dumb-asses but I don’t think that they share your perception on the effectiveness of the vaccine preventing the current season’s virus.

  20. Mark Crislip says:

    If you look though my prior posts, which you can get to by clicking my name, you will find multiple entries re: the flu vaccine including one on the Cochrane review as it was reported in the Atlantic

    As to meta analysis in general, look to one one my early quackcasts.

  21. Todd W. says:

    My work is having a flu vaccine clinic this whole week: free shots for all employees. Got mine the first day. Today, two of my colleagues asked if they should get it. I suggested that it would be a good thing; if not for themselves, then at least so they don’t spread it to others. Both went over and got their shots.

  22. Thanks for the great information; I’ll do my best to spread it instead of the flu. And I’ll take myself and my kids to the flu clinic on the day it opens.

    A couple typos in your annual post, maybe worth fixing for future years:
    “pass it one” should be “on”.
    “what so ever” is usually “whatsoever”.
    “wants you money” should be “your”

    Also, the logic of the “safe from zombies” bit seems to be a bit backwards: it’s not that you shouldn’t get the vaccine if you’re safe from zombies, but rather that your safety from zombies might be an explanation of why you made such a bonehead decision.

    And as long as I’m picking nits, “Remember there are dozens of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.” should probably have a semicolon rather than a comma after “circulating”.

  23. Janet Camp says:

    @mousethatroared

    I am aware of the dermatological concerns of handwashing, and that is why I accepted the nurse’s explanation of the clinic policy that she didn’t need to wash with each patient. I never asked her to wash, just asked a question when she used the hand-sanitizer. I just was curious about the policy. My concern was that when she DID wash the hands, she did it too casually. I’m not sure if the dermatological problems come from length of washing or from the contact with the soap itself. I have every sympathy having once seen a nurse suffering from such severely cracked and bleeding hands that she had to wear gloves to do her paperwork and everything else. I think these reactions vary and for those who have severe reactions, perhaps they should move away from direct patient contact if possible–or wear gloves?.

  24. ConspicuousCarl says:

    Robb on 21 Sep 2012 at 12:50 pm
    I’m also a little confused by your statement that it is not possible to “boost” the immune system and that people who say so just want your money. Is that not how the influenza vaccine works?

    Vaccines teach your immune system to recognize the virus. It’s about providing information, not some kind of fuel additive for more power.

  25. stanmrak says:

    It’s disturbing to witness the contempt Dr. Crislip has towards his colleagues and fellow employees who disagree with his opinion. Hopefully, this doesn’t extend to the patients under his care. There is no excuse for someone in his position to have this attitude, but that’s why doctors have the reputation they do. You will certainly not make any converts this way.

  26. Jan Willem Nienhuys says:

    If you want to use Latin plurals, you should do it correctly. “viri” is Latin, and it means “of the man” or “men”, plural of vir. The Latin “virus” means slime or poison and the plural is virus (in Latin). So better stick to viruses for the plural, because you can’t erxpect your readers to know any Latin, especially if you yourself don’t know it either. This applies to all efforts to use fancy Latin, of course.

  27. Robb says:

    @ConspicuousCarl,
    So my immune system does not work well without a “teacher” to help it? I would describe it more as provoking a response, rather than providing information but that’s just me being nit-picky.

    I was and am being a little facetious though. My point is really that “boost” “enhance” “stimulate” the immune system, whether it’s the FDA saying it about vaccines, or manufacturers of herbal extracts saying it about their products, is a marketing simplification. There are also perfectly plausible, already known pharmacological mechanisms for how other substances besides vaccines interact with our immune system. This is just a minor point I was quibbling with but I see it repeated often enough.

  28. Quill says:

    Excellent article! I think the Dumb Ass Categories are an especially nice enhancement while as Jan Willem Nienhuys notes the incorrect use of Latin plurals diminishes. Caveat lector.

  29. Mark Crislip says:

    stanmrak: Yes. It is hard to have respect for those who ignore a vast medical literature on the safety and efficacy and willfully place their most vunerable pateints at risk for an infection that has a high chance of killing them. I feel the same way about those that do not wash their hands, do not follow infection control proceedures etc etc. I have a career in infection control and quality and know all too well the morbidity and mortaltiy we inflict upon patients when we do not practice best practice in infection prevention. I have contempt for those whose subopimal practice can and does kill people.

    I, on the other hand, always place the well being of my pateints first. I do hope other physicians have the same reputation I hope I have: always my patients avocate first and always based on the best best medical science available.

    As to viri, I usually joke that if more than one elvis is elvi, then more than one virus is viri, but did not this time. Sigh.

  30. ConspicuousCarl says:

    Jeff on 21 Sep 2012 at 11:31 am

    I’m not sure what category of dumb-ass Dr. Crislip would put me in – maybe #11. I don’t discount the value of all vaccines, but the flu vaccine doesn’t seem to have a strong track record of success. I’ve received no vaccinations of any kind since 1965, and I never get the flu. In #4 the post doesn’t mention the nutrient having the strongest association with flu prevention: vitamin D.

    1. http://ajcn.nutrition.org/content/91/5/1255.abstract
    2. http://www.sciencedaily.com/releases/2010/03/100307215534.htm

    Citing a press release republished by Science Daily ought to have its own category, but I notice that it seems to be saying that immune responses don’t work at all if you LACK normal vitamin D levels, which is way different from saying that a buttload of extra vitamin D is a replacement for a vaccine.

    Citation #1 is interesting, though it does seem to have a hint of the same thing. A difference was found, but it was notably greater among those who were not getting vitamin D from other sources. Do the Japanese still not fortify any of their foods with moderate amounts of vitamin D because their high fish consumption is supposed to be enough? I would want to see more research among people with similar existing diets to our own, but I am too lazy to do the reading.

  31. ConspicuousCarl says:

    Robb on 21 Sep 2012 at 2:38 pm

    @ConspicuousCarl,
    So my immune system does not work well without a “teacher” to help it? I would describe it more as provoking a response, rather than providing information but that’s just me being nit-picky.

    Yes, and it can learn either the easy way or the hard way what a flu virus looks like.

    The key here is that it matters which vaccine you get. The provoked response is to a specific virus’s protein structure. Often too specific, or else we wouldn’t have to get new flu shots every year. It’s like teaching curse words to little kids. They already know how to shout loudly when they are mad, it’s the information they are lacking.

    a marketing simplification.

    You’re right, that does give it a connotation of accuracy.

    interact with our immune system.

    I approve of that one.

  32. mousethatroared says:

    @Janet Camp – Sorry, I think I sounded more abrupt than I meant to in my comment. I was trying to answer your question on why do health care workers have a problem washing hands.

    In regards to your comment that traditional hand washing with water being superior to sanitizer. I can’t find any information that indicate that sanitizer is inferior for infection control. Out of curiosity, I googled Mark Crislip Sanitizer and came across this article

    http://www.sciencebasedmedicine.org/index.php/epiphany/

    that says.
    “The first intervention was the use of alcohol foam instead of hand washing. I have in my mind, and cannot find the reference, that if a nurse would wash her hands appropriately after every contact, he would spend 80% of their shift washing hands. Soap and water, it turned out, was not a practical solution to keeping hands clean. It is too time consuming in a busy work day, despite it’s proven efficacy in preventing infections.

    Alcohol foam can be used in a fraction of the time with superior results since it is much easier to foam frequently. And once I discovered it was not to be used orally like cheese whiz, the results were even better.”

    Do you remember what article you are referring too? It would be a shame to lose good nurses to desk jobs just because they have delicate skin.

    Sorry to be such a nuisance on the issue. Just want to get the facts straight for my own info as well as others.

  33. windriven says:

    @stanmrak

    “It’s disturbing to witness the contempt Dr. Crislip has towards his colleagues and fellow employees who disagree with his opinion. ”

    An opinion is whether strawberry is a better jello flavor than lime. The efficacy and safety of influenza vaccines are scientifically demonstrable. Do not conflate an evidence based judgment with a frivolity. It makes you look, well, contemptible.

  34. ConspicuousCarl says:

    windrivenon 21 Sep 2012 at 5:41 pm

    @stanmrak

    “It’s disturbing to witness the contempt Dr. Crislip has towards his colleagues and fellow employees who disagree with his opinion. ”

    An opinion is whether strawberry is a better jello flavor than lime. The efficacy and safety of influenza vaccines are scientifically demonstrable. Do not conflate an evidence based judgment with a frivolity. It makes you look, well, contemptible.

    Yeah, but you’re talking to a guy who is of the opinion that, all other things being equal, we should expect dead bodies to have as many heart attacks as living people. Good luck trying to work any logic on him.

  35. DavidRLogan says:

    Great post Dr. Crislip.

    BTW I’m going to use your Elvis joke and pretend I invented it. Whoops I’m posting non-anonymously :)

    Thanks again for the great post.

  36. windriven says:

    @DevoutCatalyst

    Mandatory might have been a bit strong. Apparently this would be a legal minefield. So this year it will be “strongly recommended” with any abstainers needing to submit a written exemption request to their file.

  37. DevoutCatalyst says:

    Let us know the compliance rate if you get a chance, sincerely interested.

    In reference to some of you others, not knowing Mark’s Elvis shtick prior to today tells me that the world really does need more Mark Crislip. Now I’d make as good a doctor as Jethro Bodine, yet I listen attentively to all your Puscasts, Mark, because I just love to hear you say Linezolid. Mmmm, Linezolid.

  38. physicsgal says:

    So, I used to get the flu vaccine every year when I was a grad student and stressed and not sleeping well and just generally not living healthfully. Now that I’m not a grad student, I hadn’t really thought I would need it. I don’t work in healthcare, I don’t have children or really spend much time around children or old people (I love my nieces by they all live in CA so I only get to see them 1-2 times a year. Same with my 94 year old grandma.)

    Should I get the vaccine? I guess it’s a “better safe than sorry thing” as far as possibly spreading it to others. I’m young and healthy so I don’t think the flu would harm me other than being annoying. Actually, the only time I got sick in the last year was when I visited my sister and her whole family was sick so I could argue that they need to do a better job of protecting me than vice verse ;)

    Anyways, thanks for reminding me that the reason vaccines work is not necessarily to keep healthy people from getting sick, but to keep infections from spreading so that sick/at risk people don’t get the infection. Actually, my work is doing a wellness checkup on me soon and I think I can get it for free then…

    1. Harriet Hall says:

      @physicsgal,

      If enough healthy people like you got the vaccine, it would reduce the spread in the community and help protect people like your 94 year old grandmother. So you can think of it as something you are doing for grandma.

      Compare your argument to: “I used to wear seat belts when I was younger and drove more and took more chances, but now that I’m older and a more cautious driver and drive fewer miles, I’m much less likely to have an accident, so why should I bother wearing a seatbelt? Even if I had an accident, I would probably survive, and broken bones and lacerations heal.”

      I know that’s not a very good analogy, but maybe it’s enough to make you think. And auto accident injuries DO affect other people, like the emergency responders, the hospitals, the insurance companies, and the rest of us who pay higher rates because of the medical expenses of accident victims who weren’t wearing seatbelts.

  39. BillyJoe says:

    Windriven,

    “Do not conflate an evidence based judgment with frivolity.”

    Good one.

    But I’m glad you changed your mind about the compulsory vaccination, because I don’t think that is evidence based. It might actually reduce vaccination rates! What you could do is give your employees information about vaccines (as contained in this article), and strongly encourage them to be vaccinated, but without any reprisals if they do not do so. That is probably also not evidence based, but it is reasonable and anything more than that requires evidence for effectiveness in my opinion.

  40. Th1Th2 says:

    After all, my job is me find bug, me kill bug, me go home.

    Submit your CV here dumb ass. http://www.bls.gov/ooh/building-and-grounds-cleaning/pest-control-workers.htm

    Good riddance. No patients are harmed.

  41. Th1Th2 says:

    Roughly, the better the antibody response to the influenza antigens, the better the protection to that strain of influenza.

    You’re babbling like an intern. I’ll tell you what the General Rule is:

    The more similar a vaccine is to the disease-causing form of the organism, the better the immune response to the vaccine.

    Now how’s that sound Infectious Disease Promoter?

  42. Th1Th2 says:

    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.

    Germ denialist.

  43. Juan Gervas says:

    Influenza is a very common infection that spread during winter time. In general flu is a lightly disease, but it may complicate the evolution of chronic patients, and even healthy ones. The best answer to stop the propagation is just to wash your hands. But official institutions and private organizations push to introduce influenza vaccine in children, elderly and health professionals, even asking for mandatory vaccination. There are no scientific bases for this proposal. See the text with links to the best evidence about this question, many from Cochrane Reviews.

    A few reasons to say no, thanks, to influenza vaccines. Gérvas, J. Madrid (Spain), September 2012.
    http://www.equipocesca.org/wp-content/uploads/2012/09/flu-vaccine-reasons-no-Sept-2012.pdf

  44. BillyJoe says:

    I see we have been treated to some light relief.
    (Remember, everyone, comedy should not be dissected. A good belly laugh will be sufficient. Thanks.)

  45. Jan Willem Nienhuys says:

    At an earlier opportunity I suggested that the nonvaccinators and the vaccinators should wear different insignia or different clothes. For instance a nice looking golden badge for those whose vaccination is up to date. And then declare certain wards off limits for those without the proper badge. If hospital administrators really wanted, they could think up some arrangement.

  46. windriven says:

    @ Juan Gervas

    Dude. Really? I followed the link you provided. After reading it through I decided to follow the links to the studies from which you drew your conclusions. As I was at the end – the summation of your exposition – so I started there. Your link was:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1626345

    and where did that actually take me? To a notorious BMJ piece ‘coordinated by’ … wait for it …

    Tom Jefferson.

    You have to be kidding. At that point I decided that you are probably a crank and that following the rest of your links would be a stroll through the land of pseudoscience and paranoia. Sorry, but at 6:15 on a fine Saturday morning I have better things to do with my time.

  47. windriven says:

    @Billy Joe

    I must admit that my retreat was based on legal limitations.

    I provide health care insurance and paid sick days. Asking employees to participate in maintaining their health and the health of their coworkers seems perfectly reasonable to me. I can’t and won’t force anyone to have the vaccination, but I will make vaccinations and proactive health choices a more prominent feature of our corporate culture.

  48. mousethatroared says:

    @JWN – see rork’s comment up thread or I’ll quote an excerpt.

    “At my health center (U of Mich) you get the flu vax, or get shamed by filling out a form, having to wear a mask constantly, and not having a special mark on your ID that everyone else has. You’ll get people looking upon you with contempt too.”

  49. Janet Camp says:

    @Mouse

    No problem. I am trying to locate whatever it is I read that said hand sanitizer isn’t as good as washing. I certainly take Dr. Crislip’s point that you quoted, so perhaps that is the final word, although at my clinic they are not using foaming sanitizer, just some stuff you get at the supermarket–not that I know that to be less than effective.

    As to delicate hands, I just don’t have a good answer. I would think the sanitizers may also irritate some skin types–perhaps that leaves these few hyper-sensitive people with glove use?

    My main point is that if there is a procedure, then it needs to be followed and exceptions are really not allowed in the case of infection control. I feel the same about vaccinations for health workers. If you won’t get them, then find another job. As I understand it, there are waiting lists for most nursing programs. What is the point of me not being a dumb-ass if I end up in the hospital being tended to by a dumb-ass? At the very least, I want to be INFORMED if a dumb-ass is at my bedside so I like SkepticalHealth’s scarlet V idea.

  50. mousethatroared says:

    Personally, I have two kids in elementary school and in spite of the fact that I try to eat properly and take a basic calcium- vitamin D supplement (more for my bones than the thought that it prevents illness) and get the flu shot, it seems I am sick almost constantly during the school year. Of course, it does just SEEM like it. It’s just that someone is always sick in the family…so I’m either sick or facing impending sickness. Right now one of the neighbor kids is coughing all over the house.

    Before kids, when I worked in an office, I was hardly ever sick. Didn’t have asthma either. Hmmm, I think I have found the source of all disease. Now if we could just figure out how to reproduce without the germ infested childhood phase.

    My only complaint about the flu shot is why only defense against two or three viruses? :)

  51. Jan Willem Nienhuys says:

    MTR: I missed Rorks comment. But as ‘wearing a face mask’ is sometimes required for other peopel as well, one can mandate a special color face mask (striped yellow-black for instance) that is reserved for the nonvaxers. The idea is that everyone can see from at least the other end of any room rather than close-up inspection of an ID what the vax status is.

  52. Th1Th2 says:

    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.

    And why would someone compare vaccines to seatbelts?

  53. Chris says:

    windriven:

    So this year it will be “strongly recommended” with any abstainers needing to submit a written exemption request to their file.

    And not let the abstainers have any of the treats. No pizza and donuts without submitting to the vaccine!

    Oh, and a reminder of a Thingy classic:

    Why should I let the child walk on the dirt when there is a dry concrete pavement next to it? A toddler would readily know which is the safe path to take even without the knowledge of C. tetani, but I am just fascinated how parents are offering very poor choices (or lack thereof).

    She can safely be ignored. Just treat as light comic relief.

  54. BillyJoe says:

    I suppose a stick might be useful, but I think we should concentrate on education and encouragement.

  55. lilady says:

    About Thingy…she was banned from mothering.com, where she claimed that she was a Registered Nurse:

    http://scienceblogs.com/insolence/2011/01/21/mothering-a-bastion-of-quackery/

    A classic Thingy post at Respectful Insolence is when I asked her how to prevent transmission of measles in a hospital Emergency Room where a suspect case of measles was examined. Her reply was, “I would terminally disinfect the area where the patient was seen”.

    http://www.aab.org/aab/Measles_-_CDC.asp

    “Preventing transmission in healthcare settings

    To prevent transmission of measles in healthcare settings, airborne infection control precautions should be followed stringently. Suspected measles patients (i.e., persons with febrile rash illness) should be removed from emergency department and clinic waiting areas as soon as they are identified, placed in a private room with the door closed, and asked to wear a surgical mask, if tolerated. In hospital settings, patients with suspected available and, if possible, should not be sent to other parts of the hospital for examination or testing purposes.”

    Here, for mousethatroared…yet another example of Thingy “barking up the wrong squirrel”. Woof Woof Grrrrrr..

    http://www.youtube.com/watch?v=lvw-9XEyPKk

  56. David Gorski says:

    Oh, lovely. Thingy’s back. All I can say is that Thingy will be on a short leash.

  57. windriven says:

    Could Th1Th2 be a nom de moron for Tom Jefferson?

  58. lilady says:

    “Could Th1Th2 be a nom de moron for Tom Jefferson?”

    Not likely, windriven. Thingy is a female “health care professional wannabe” and Tom Jefferson is a YouTube publicity hound…

    http://www.youtube.com/watch?v=7HdJ4n0Ewu4&feature=related

  59. SneakyBooger says:

    By far the best immunity against the flu is natural immunity through exposure. Despite mass vaccinations for the flu the mortality during flu season has increased. Therefore, one could argue that we are faring worse for some reason due to the vaccine.

    Did I read correctly that you state the mortality for H5N1 is 60? In what population?

    Mr. Crislip, where can one find your financial disclosures?

  60. lilady says:

    To clarify Dr. Crislip’s statement,

    ” Some strains, such as H5N1 (the bird flu) or H3N2, are more likely to kill (60% for H5N1) than strains like H1N1 which was of moderate virulence.

    http://www.cdc.gov/flu/avianflu/h5n1-people.htm

    “Sporadic Cases of H5N1 Have Occurred in People

    Although highly pathogenic avian influenza (HPAI) A (H5N1) virus infection of humans is rare, sporadic cases of human infection have been reported.

    More than 600 human HPAI H5N1 cases have been reported to WHO from 15 countries in Asia, Africa, the Pacific, Europe and the Near East since November 2003. Approximately 60% of the cases have died.

    Indonesia, Vietnam and Egypt have reported the highest number of human HPAI H5N1 cases to date…..”

    @ Sneaky Booger: “Mr. Crislip” is Dr. Crislip. His medical specialty is infectious diseases and this article is recommends the seasonal influenza shot and Dr. Crislip describes his experiences with caring for people who are hospitalized with influenza viruses.

    Do you ask every physician who treats you where his/her “financial disclosures” are? You really are a Dumb Ass.

  61. Mark Crislip says:

    thank you lilady

    I have nothing to report: I have never taken dime one from pharma, I havent talked to reps in 22 years and I have not even eaten drug company pizza at conference since I was a medical student.

    The only thing I have ever accepted from big pharma was a Fleets enema. Long story.

  62. windriven says:

    @SneakyBooger

    Had you not been such a lazy booger and dug just a little deeper you would already know that outside of his ‘growing multimedia empire’ (read 3 podcasts, a couple of blogs, a couple of very, very reasonably priced e-books and an iPhone app to assist physicians with infectious disease issues), Dr. Crislip has no COIs to disclose. He proudly admits that the only freebie he’s ever accepted was a Fleet’s enema kit given to him by a sales rep, one presumes with the unstated suggestion that its use might, ahem, soften the good doctor’s opinion of the role of sales people in disseminating medical information.

    And yes, you are technically correct that the best immunity seems to accrue through exposure – at least in cases where we aren’t talking about infants, the elderly, those with significant comorbidities and those who are immuno-compromised. These groups have to first survive the infection before they acquire the immunity part.

    And finally, the point of immunization isn’t just to protect your sorry ass from infection, it is to protect the aforementioned groups from your wheezing, hacking aerosolized biological attack on them. Herd immunity. It is unlikely to ever be fully realized vis-a-vis influenza. But that does not diminish it as a worthy goal.

  63. windriven says:

    You beat me to it. But my telling is better than your ;-)

  64. Chris says:

    SneakyBooger:

    By far the best immunity against the flu is natural immunity through exposure. Despite mass vaccinations for the flu the mortality during flu season has increased.

    Uh, huh. Before or after one of the three forms of influenza virus mutates, again. All we really after to say about your collection of letters that seem to form sentences is: citation needed.

  65. Harriet Hall says:

    @SneakyBooger,

    Not only does Dr. Crislip have no financial incentive to promote vaccination, he would have a financial incentive if he discouraged it so that more people would get sick and need his services. And I have no financial incentive either way: I’m retired, and I fully support Dr. Crislip’s position. Our incentives are non-financial: truth and the public welfare. Also self-interest: we’d rather not get the flu ourselves.

    You say “By far the best immunity against the flu is natural immunity through exposure.” Really? Citations, please! And explain why getting immunity plus getting sick is better than getting immunity without getting sick.

    You say “one could argue that we are faring worse for some reason due to the vaccine.” One could just as well argue that we are faring worse for some reason not due to the vaccine.

  66. Alia says:

    Frankly speaking, I do not understand people who do not take the chance to get flu vaccine free of charge, in their workplace (other than for medical reasons, my mother is one of those few people who get severe adverse reactions following the shot). I have to pay for the vaccine and arrange a visit to a doctor – and I’m going to do it as soon as I recover from the cold that’s bothering me right now. I hate flu, I hate feeling miserable for a week, shivering in my bed, and before the vaccine I used to get flu at least every two years. Since I started vaccinating – no flu at all for the last 12 years or so.

  67. lilady says:

    From the September, 2012 Obstetrics and Gynecology Journal:

    http://journals.lww.com/greenjournal/Abstract/2012/09000/Effect_of_Influenza_Vaccination_in_the_First.6.aspx

    Effect of Influenza Vaccination in the First Trimester of Pregnancy

    Sheffield, Jeanne S. MD; Greer, Laura G. MD; Rogers, Vanessa L. MD; Roberts, Scott W. MD; Lytle, Heather MD, MSPH; McIntire, Donald D. PhD; Wendel, George D. Jr MD
    Collapse Box
    Abstract

    OBJECTIVE: To estimate the effect of first-trimester influenza vaccination on fetal and neonatal outcomes.

    METHODS: This was a retrospective cohort study examining delivery and neonatal outcomes after antepartum exposure to the seasonal trivalent inactive influenza vaccine. Data were collected and entered into an established computerized database. Outcomes by trimester of vaccination were then compared with women who did not receive the vaccine.

    RESULTS: During the 5-year study period, 10,225 women received the seasonal influenza vaccine antepartum; 8,690 of these delivered at our institution, 439 in the first trimester and 8,251 in the second and third trimesters. Women vaccinated antepartum were significantly older with higher parity than women who declined vaccination. Neonates born to mothers receiving the vaccine in any trimester did not have an increase in major malformations regardless of trimester of vaccination (2% regardless of vaccination group, P=.9). Stillbirth (0.3% compared with 0.6%, P=.006), neonatal death (0.2% compared with 0.4%, P=.01), and premature delivery (5% compared with 6%, P=.004) were significantly decreased in the vaccinated group.

    CONCLUSION: Influenza vaccination in the first trimester was not associated with an increase in major malformation rates and was associated with a decrease in the overall stillbirth rate. This information will aid in counseling women regarding the safety of influenza vaccination in the first trimester.

    LEVEL OF EVIDENCE: II

    Get your flu shot expectant mothers.

  68. Th1Th2 says:

    A classic Thingy post at Respectful Insolence is when I asked her how to prevent transmission of measles in a hospital Emergency Room where a suspect case of measles was examined. Her reply was, “I would terminally disinfect the area where the patient was seen”.

    Ah so the demented public health nurse violently disagrees.

    CHAPTER 64D-3 CONTROL OF COMMUNICABLE DISEASES AND CONDITIONS WHICH
    MAY SIGNIFICANTLY AFFECT PUBLIC HEALTH

    64D-3.010 Quarantine Disinfection Procedures, Concurrent and Terminal.
    (1) Concurrent disinfection is required of infectious or potentially infectious secretions or excretions of any quarantined person or animal or of objects contaminated by such secretions and/or excretions. The collection of such contaminated matter and disinfection procedures shall be approved by the county health department director or administrator or his representative.

    (2) Terminal disinfection shall be carried out at the termination of the period of quarantine and shall be applied to the quarters vacated. The disinfection procedures shall be approved by the county health department director or administrator or his representative.

  69. windriven says:

    @SmarmyBooger

    In an earlier comment I said:

    “And yes, you are technically correct that the best immunity seems to accrue through exposure…”

    but I was wrong. Or at a minimum, I am unable to scrape together compelling evidence from the peer reviewed literature to support that assertion. Thanks to Chris and Dr. Hall for calling for citations. It has long been believed that influenza immunity persistence was rather short (< 1year, at least among the elderly) but some work calls even that into question*. And given the rapid mutation of this virus, why is robust persistence particularly important?

    *Rapid Decline of Influenza Vaccine-Induced Antibody in the Elderly: Is It Real or Is It Relevant?, J Infect Disease. 2008 197 (4) 490-502

  70. PerplexedPatient says:

    I’ve started a Facebook page called Perplexed Patients of Unvaccinated Nurses. It’s not really about nurses, but any and all healthcare professionals who don’t get vaccinated for the flu. Dr. Crislip is responsible for its existence. In various posts and podcasts about the danger of unvaccinated healthcare workers, I thought it’d be a good idea to try to do something about it. If you’re on Facebook you can find it at https://www.facebook.com/PerplexedPatients.

    I know that there is a strong push make sure all health professionals get their jabs, it’s obvious that some won’t for whatever reason or rationalisation they come up with. The only valid exemption should be medical, but no matter what the reason unvaccinated workers are putting patients at risk. Dr. Crislip suggests asking that they be kept from your room, but how do you do that? Particularly when you’re unconscious or so sick that you’ve really got other things on your mind.

    In the pushback against the growing anti-vaccine movement I think this may be a key battle. All the same issues are at play as in the general population, but we’re talking to people who’s profession it is to treat vulnerable people. If we can’t make headway there we’re not going to be able to make headway in the population at large who, hopefully, have a level of trust in their doctors and nurses. I think this is a battle worth picking.

    So I’ve also got a “cause” going. It’s got a few parts – pledge to get a flu shot, a poll about mandatory vaccines and a petition about a national mandate. If you’d like to get involved that’s not a bad place to start either. More than 5,000 have done something on the cause. I’m pleased with the number because I didn’t know if I’d get anyone, but the Flu Shot Project (pledge to get your shot), which is at 1,711 right now, deserves to be in the hundreds of thousands or even a million or five. Anything you can do to help it go viral would be appreciated and may, with a whole lot of luck, make a difference.

    And, by the way, Mark, I love your work. I stumbled on your podcast days after you posted the first one. Sometimes I avoid reading you in SBM because I enjoy it more when I hear your voice. Keep it up.

  71. lilady says:

    “A classic Thingy post at Respectful Insolence is when I asked her how to prevent transmission of measles in a hospital Emergency Room where a suspect case of measles was examined. Her reply was, “I would terminally disinfect the area where the patient was seen”:

    http://www.infectioncontroltoday.com/articles/2009/11/patient-room-cleaning-protocol.aspx

    Terminal cleaning of patient rooms should include the following steps:

    • Using an EPA-approved, hospital-grade disinfectant, the following items should be cleaned:

    > Top, front and sides of the bed’s headboard, mattress, bedframe, foot board and side rails, and between side rails

    > TV remote

    > Nurse-call device and cord

    > All high-touch areas in the room including tabletops, bedside tabletop and inner drawer, phone and cradle, armchairs, door and cabinet handles, light switches, closet handles, etc.

    • In the bathroom, start with the highest surface and clean the toilet last; clean the sink and counter area, including sink fixtures, and if there is a shower, the support bars and shower fixtures and surfaces

    • Privacy curtains should be removed, placed in a plastic bag in the room and double bagged into a laundry bag with the assistance of another member of the ES staff standing at the door outside the room. The person outside the door should wear gloves. After completing the task this person should remove gloves, wash hands with an antimicrobial soap and water or apply an alcohol rub to their hands.

    • Cleaning of window curtains, ceiling or walls is not necessary unless visibly soiled.

    • Following patient discharge, clinical equipment must be cleaned and disinfected, moved to the door of the room for removal to central supply or to the sterile processing department.

    • Following the terminal cleaning of a patient room, gloves should be removed so as to avoid touching the outside of the gloves. Hands should be washed with an antimicrobial soap and water or an alcohol rub applied to the hands prior to donning a new set of gloves.

    Reference: “Practice Guidance for Healthcare Environmental Cleaning” from the American Society for Healthcare Environmental Services (ASHES).

    So…insane ignorant troll with an imaginary career as an infection control registered nurse post back at me Florida Department of Health Commissioner’s regulations about quarantining of humans or animals.

    DumbAss Troll still doesn’t know the difference between quarantine and the minimizing/prevention of measles transmission in a clinical area.

    http://www.medilexicon.com/medicaldictionary.php?t=74639

    quarantine
    Type: Term

    Pronunciation: kwar′an-tēn

    Definitions:
    1. A period (originally 40 days) of detention of vessels and their passengers coming from an area where an infectious disease prevails.
    2. To detain such vessels and their passengers until the incubation period of an infectious disease has passed.
    3. A place where such vessels and their passengers are detained.
    4. The isolation of a person with a known or possible contagious disease.

  72. lilady says:

    Again, Insane Thingy Troll…

    http://www.aab.org/aab/Measles_-_CDC.asp

    “Preventing transmission in healthcare settings

    To prevent transmission of measles in healthcare settings, airborne infection control precautions should be followed stringently. Suspected measles patients (i.e., persons with febrile rash illness) should be removed from emergency department and clinic waiting areas as soon as they are identified, placed in a private room with the door closed, and asked to wear a surgical mask, if tolerated. In hospital settings, patients with suspected available and, if possible, should not be sent to other parts of the hospital for examination or testing purposes.”

  73. Narad says:

    Again, Insane Thingy Troll…

    I am as certain as Ivory soap is pure* that the best way to irritate it is to ignore it completely.

    * “The impurities consist[] of uncombined alkali, 0.11%; carbonates, 0.28%; and mineral matter, 0.17%.”

  74. lilady says:

    @ Narad:

    I have (another) comment stuck in moderation (too many links, perhaps?), that I posted just before that particular post.

    Sometimes, I can’t resist posting back at Thingy, when she posts an especially crazy and delusional remark.

  75. TsuDhoNimh says:

    # Janet Camp and Mouse:
    The problem with gloves is that they don’t “breathe”, and the constant damp environment is hell on your hands. It doesn’t matter if they are made from latex, nitrile, polybutelene or unicorn poop. The lack of air circulation will give many people eczema, rashes, blisters and lead to opportunistic fungal infections.

    The problem with frequent hand washing is that it’s hell on your hands.

    The problem with frequent use of hand sanitizers is that it’s hell on your hands.

    Glove liners (half-fingered, washable knit) help with the gloves, there used to be a silicone-based cream that was excellent for frequent soap exposure, and lots of lotion helps with the dry skin the sanitizers cause … but it can’t make your skin as if it were not being abused.

  76. DrRobC says:

    A lot of HCW need a lesson in Pediatrics style hand washing. One should not just wash their hands but do so in view of the parents. Or use the alcohol gel in front of them and pause to allow it to dry before touching their child.

    BTW Mark, what took the vaccine so long this year? I couldn’t get mine until the 3rd week of August!

  77. WilliamLawrenceUtridge says:

    And why would someone compare vaccines to seatbelts?

    Are you illiterate? As he says in the post – vaccines sometimes cause minor harm, particularly in comparison to the major harms of actual infection. All your lies, deceptions, coy deflections, half-truths, outright falsehoods and pathetic hand-waving doesn’t change the fact that you have the luxury of pretending vaccines don’t work or are harmful because vaccines work. All your crass, inaccurate, inflammatory comparisons to rape and failures to substantiate your claims that constitute your one-line posts don’t change the fact that for a tiny amount of risk, vaccines effectively prevent dangerous infections.

  78. The Dave says:

    Since I started pharmacy school this year, I guess I became a Dumb A$$ because of #2, with a little #9 (the cheapskate one, right?) But since I found out today that my copay was only $3, I am proud to say I am no longer a Dumb A$$.

    (plus, having a 4 week old baby helped me see the light)

  79. Jan Willem Nienhuys says:

    In the Netherlands only 17% of health care workers and about half of family physicians get a flu shot. That was reason for me to plagiarise Dr. Crislip’s dumb reasons in http://www.skepsis.nl/blog/2012/09/de-griepprik-veertien-domme-redenen-om-hem-niet-te-halen/ (with reference of course). One commenter observed that in the Netherlands by far the most common reason for HCWs to not vaccinate is that it is

    15. vaccination is unnatural

    The people who say so often suffer from nicotine addiction. This reason is not listed by Dr. Crislip. I think it is pretty dumb. If such people want a natural life, I can mention quite a few amenities that they should forsake (such as money that they receive for their services or universal health insurance). It falls under religion (self made) so under 11, but it deserves a category of its own. But maybe HCWs in the USA are not that moronic. Please enlighten me.

  80. Calli Arcale says:

    I always thought the main problem with handwashing in hospitals wasn’t the abuse to the nurse’s hands (most nurses I know are working such hellacious schedules that they’re already used to the idea of personal physical sacrifice for their job) but the time it took. But I can accept there possibly being a lot of different problems which unwittingly conspire to keep handwashing rates lower than anyone wants. I doubt there will ever be a solution; germs are too similar to human cells for there to be an easy, universal sanitizing method that isn’t hard on the hands, I suspect.

  81. mousethatroared says:

    Yes, Calli Arcale, you are probably right. I think the skin effects probably loom larger in my mind because of my family member’s issues. But that doesn’t mean they are the main reason or even a common one. From my reading (linked, I hope above) it does seem that sanitizers are more well tolerated than soap and water. But that doesn’t mean they aren’t sometimes a problem too.

  82. Th1Th2 says:

    WLU,

    Are you illiterate?

    No I’m not, are you?

    All your crass, inaccurate, inflammatory comparisons to rape and failures to substantiate your claims that constitute your one-line posts don’t change the fact that for a tiny amount of risk, vaccines effectively prevent dangerous infections.

    I did not compare vaccines to rape but to minor sexual harrassment, you know, vaccines (or minor sexual harrassment) causes minor harm, particularly in comparison to the major harms of actual infection (or rape).

    So why would someone compare vaccines to seatbelts? Anyone?

  83. Th1Th2 says:

    WLU,

    All your lies, deceptions, coy deflections, half-truths, outright falsehoods and pathetic hand-waving doesn’t change the fact that you have the luxury of pretending vaccines don’t work or are harmful because vaccines work.

    Vaccines work by promoting infection, by priming (primary infection) or boosting (reinfection). And I don’t deny this fact.

  84. Chris says:

    I see the comedy relief has returned.

  85. lilady says:

    Just for mousethatroared.

    Thingy…Still barking up the wrong squirrel? Woof woof, grrrrrrr… http://www.youtube.com/watch?v=rJ9Gr7axZcI

  86. Mark Crislip says:

    The metaphor is clear: the seat belt buckle, when sharpened, can be used for for an emergency appendectomy; similarly vaccine bottles and syringes can be used to frighten off feral rats in the wilderness. Seems obvious to me.

  87. WilliamLawrenceUtridge says:

    Vaccines work by promoting infection, by priming (primary infection) or boosting (reinfection). And I don’t deny this fact.

    Sure, you just pretend, in the complete absence of evidence, that this is a bad thing. Perhaps you’d prefer the good old days of death by smallpox, iron lungs and the (not so old days) of pertussis killing infants while their parents get to watch.

    Incidentally, that’s exactly the kind of coy, half-truth I’m talking about. Your superficial pretense of acknowledging limited facts of vaccination hides a profound, sneaky and dishonest opposition that you never wo/man up and state openly. Just dodge, pretend you’re being reasonable and conceal your true purpose for posting. It’s all “hey, I’m just asking questions”, the same tactic used by Holocaust deniers – because you can’t rely on actual evidence.

    Douchebag.

  88. Jan Willem Nienhuys says:

    Vaccines work by promoting infection,

    At issue here are influenza vaccine.

    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.

    Infection = invasion of a host organism’s bodily tissues by disease-causing organisms. ( http://en.wikipedia.org/wiki/Infection )

    A killed virus, actually only pieces of viruses is not a disease-causing organism. Hence vaccines do not promote infection. The immune system fights infection by multiplying as quick as possible components that can seek the invader so it can be destroyed. As the invader also multiplies,and initially quicker too, the host becomes sick. The immune system has to meet the invader in order to set up a defense, so when the invader multiplies the immune system revs up and in the end the micro-organisms will lose, possibly with the help of Dr. Crislip. Micro-organisms that lose this race already in the beginning don’t make us sick, so one doesn’t vaccinate for these. Vaccination gives the immune system a headstart in the seek-business, in the same way that the immune system will have a head start when close relatives of the invader come again. Such vaccine-induced headstart is not an infection at all. If I make a mistake here, please correct me.

    Thingy is wrong to think or imply that vaccination equals infection. And the hopefully only metaphorical connection with sexiual harassment escapes me. Don’t explain. Stick to the science of vaccination.

  89. Any comments on this?
    http://www.cbc.ca/news/health/story/2012/09/10/flu-shot-pandemic.html

    Apparently, in 2009, in Canada (but not other years or places) people who got the seasonal vaccine were more likely to get sicker with H1N1. Quebec is therefore not paying for seasonal flu shot this year.

  90. Harriet Hall says:

    @Alison,

    Any explanation of those findings will have to account for why the phenomenon was seen in ferrets and in Canada but not in other countries.

  91. Jan Willem Nienhuys says:

    Re the Canadian ferrets
    1. In the publicity I don’t see anything about the effect size.
    2. It is quite important that the populations one compares (vaccinated vs. unvaccinated) are exactly equal in susceptibility to flu in general. This ‘exactly equal’ in RCTs is achieved by randomizing and blinding. In the publicity I see nothing to argue equality. And given the fact that people who don’t take vaccination, probably aren’t bothered too much by flu, I can’t right away think of a way to ensure equality without randomizing.
    3. The test with the 16+16 ferrets was apparently done by someone who was already convinced there might be an effect. In the publicity I see nothing about proper blinding and randomizing. A bias by an unblinded researcher might have a ‘statistically significant’ effect on the outcome. Which outcome actually? Was the outcome ‘sicker’ instead of ‘more deaths’ chosen beforehand, or is it just one of maybe 10 possible outcomes chosen after the fact?

    Maybe it actually is all OK, but if I were to do any properly blinded and randomized test, I would make a point of explaining how carefully I had been in preventing any of my own prejudices influencing the results.

  92. Th1Th2 says:

    Infection = invasion of a host organism’s bodily tissues by disease-causing organisms. ( http://en.wikipedia.org/wiki/Infection )

    Vaccination = invasion of host organism’s bodily tissues by disease -causing organisms. Please don’t ask how.

    A killed virus, actually only pieces of viruses is not a disease-causing organism. Hence vaccines do not promote infection.

    A disease-causing organism can be the whole pathogen or its virulence factors.

    Vaccination gives the immune system a headstart in the seek-business, in the same way that the immune system will have a head start when close relatives of the invader come again. Such vaccine-induced headstart is not an infection at all. If I make a mistake here, please correct me.

    That headstart is called primary infection or what is known to vaccinators as priming.

    Thingy is wrong to think or imply that vaccination equals infection.

    The more similar a vaccine is to the disease-causing form of the organism, the better the immune response to the vaccine.

  93. Th1Th2 says:

    The metaphor is clear: the seat belt buckle, when sharpened, can be used for for an emergency appendectomy; similarly vaccine bottles and syringes can be used to frighten off feral rats in the wilderness. Seems obvious to me.

    Why would someone use a seat belt buckle for an emergency appendectomy?

  94. Mark Crislip says:

    Because you can’t put a cutting edge on an air bag.

    Duh. My 15 year old got it right away.

  95. Th1Th2 says:

    Sure, you just pretend, in the complete absence of evidence, that this is a bad thing. Perhaps you’d prefer the good old days of death by smallpox, iron lungs and the (not so old days) of pertussis killing infants while their parents get to watch.

    As a wise man once said, the lesser of two evils is still evil.

    BTW, you need to study the principle of natural infection –there is no such thing as preference (well, of course, there are these insane pox party moms)

    Naturally acquired immunity occurs through contact with a disease causing agent, when the contact was not deliberate, whereas artificially acquired immunity develops only through deliberate actions such as vaccination[...]Naturally acquired active immunity occurs when a person is exposed to a live pathogen, and develops a primary immune response, which leads to immunological memory.[7] This type of immunity is “natural” because it is not induced by deliberate exposure.

    Does it make sense infection promoter?

  96. Th1Th2 says:

    Because you can’t put a cutting edge on an air bag.

    This is fun. So why would you prefer a seat belt buckle over a car key? Well?

  97. weing says:

    I see Th is back. Still doesn’t know his ass from his elbow.

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