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Friday, January 4, 2013

Flu me once

The Centers for Disease Control and Prevention has noted an early and nasty start to the flu season. Perhaps its own website has caught it, because as I'm writing this, the whole thing is down. Assuming it recovers, I will insert relevant links per routine. Otherwise, I wish it well, and leave you to find your way there on your own.

It's a bit soon to say, but the virus and the outbreak pattern at this point seem to resemble those of the 2003-2004 flu season, in which nearly 50,000 Americans died. At least two children have already died of flu complications this fall.

This is not the sort of stuff a public health physician can ignore. So, I recently noted on LinkedIn and Twitter that I've been vaccinated, as I am every year, and recommend this year's vaccine, which appears to match the prevailing viral strain quite well, to everyone else. I promptly got comments back from naysayers, including at least one self-identified microbiologist, who noted he never got vaccinated, and had "never gotten the flu."

I believe him. But this is like that proverbial "Uncle Joe" everyone knows, who smoked three packs a day and lived to be 119. It could happen, but I wouldn't bet the farm on it. Uncle Joe is that rare character who somehow comes away from a train crash with a minor flesh wound. The rest of us are mortal.

But there is something more fundamentally wrong with the "I've never gotten the flu, and therefore don't need to be vaccinated" stance than the Uncle Joe fallacy. Let's face it, those who were ultimately beneficiaries of smallpox or polio immunization never had smallpox or polio, either. If they ever had, it would have been too late for those vaccines to do them any good.

Not all that long ago in the grand scheme, when our parents were children, polio was the dreaded scourge of summer. Our grandparents knew that the advent of summer meant a reasonable chance that one of their children would be infected with the polio virus, and possibly come away crippled for life as a result. Immunization put an end to this, of course. But all of the beneficiaries of it, all those children who never were crippled by the virus, could say just what the nihilistic microbiologist said. They never got polio.

The same is true of smallpox, one of the most dreaded killers in human history, and still the only infectious disease willfully eradicated. We can no longer say how many millions of lives have been saved by the smallpox vaccine. (Which was, by the way, the original "vaccine," and the reason for the name. The word "vaccine" comes from the Latin word for cow, and refers to the fact that the smallpox vaccine was derived from cowpox.) But we can say that no one saved by the vaccine ever had smallpox before they got it.

The trouble with serious illness is that one time can be one time too many.

Familiarity breeds contempt, or at least complacency, and perhaps the annual return of influenza has induced that response. Perhaps that's why we seem to be dismissive of this germ, and overlook what a serious illness it can be.

But that tendency is at our peril. The single greatest infectious disease calamity in all of human history was not plague, or typhus, or smallpox, it was the 1918 flu pandemic, which killed as many as 50 million. Those who don't respect the flu just aren't paying attention.

That said, I do understand the reasons for reticence about immunization in general, and flu immunization in particular.

For any vaccine to do us any good, we need to get it while feeling fine. This is quite different from, say, an operation that is much more dangerous, but easily justified by the obviously hemorrhaging bullet hole, plugged-up gallbladder or occluded arteries. Convinced as I am of the benefits of immunization, I feel a momentary hesitation each year myself.

It can be hard to talk ourselves into rolling up our sleeves and getting jabbed with a needle when healthy, even if we are not particularly worried about a government conspiracy. With a little nudge from conspiracy theories, up to and including allegations of flu vaccine used for purposes of willful genocide, however unreliable the source, doubt can become insurmountable.

There are several reasons why the potential harms of flu vaccine may loom much larger in the imagination than they actually are. First, any adverse event, an allergic reaction, the now exceedingly rare case of Guillain-Barré syndrome, or anything else, is amplified many orders of magnitude by repetition in the blogosphere. One case, appearing on 500,000 websites, exerts the influence of 500,000 cases.

There is also our prevailing tendency for risk distortion. Consider if flu infects one person in five, and kills one person per 10,000 infected. There is certainly a good chance you, if healthy, would not be among those who get the flu. There is a very good chance the majority of people you know would not get the flu, either. And you are very unlikely to know anyone who is killed by the flu.

But one infection per five means 60 million or so infections nationally. One death per 10,000 of these infections might be invisible in your circle of friends and family, but it would mean 6,000 deaths nationwide. This is consistent with a quite mild flu season in the U.S. A bad season is 10 times worse, to say nothing of a truly dreadful season.

In contrast, the most dangerous flu vaccine in history, the notorious swine flu debacle in 1976, was associated with 25 deaths. That's bad, of course, but it is more than two orders of magnitude less bad than even the mildest flu season.

Perhaps a more legitimate roadblock is doubt about the effectiveness of the flu vaccine. It is certainly far from perfect, and the elderly, who most need protection, may need two inoculations to get it. But leaving aside some of the subtleties that complicate measuring vaccine effectiveness in real-world settings, and applying even a low-level estimate of overall vaccine effectiveness, routine flu vaccination produces a decisive overall benefit compared to just taking our chances with the flu.

We should also recognize that when it comes to contagion, not one of us is an island. While true that the elderly most need protection and benefit least from vaccination, there is another way to protect our older loved ones: Vaccinate ourselves and our children. People who can't get the flu can't transmit the flu to those most vulnerable to it and its complications.

I have recently read The Wild Life of Our Bodies, and am currently reading An Epidemic of Absence, and these books raise an issue that warrants brief mention here. We can overshoot in our zeal to banish potential infectious agents, and the result may be other ills, from allergies, to asthma, to serious autoimmune diseases. We clearly don't want these, any more than we want river blindness. The right balance is a work in progress, a fascinating area of inquiry and research, and a topic I will certainly revisit in future columns. For now, we may simply note that there is nothing in the work thus far to suggest that bouts of influenza do us any good.

Unlike that microbiologist, I have had influenza, several times over my 50 years. All but one bout were in the years before I got the vaccine annually. One case, the most recent, was despite the vaccine, and obviously a strain from which I was unprotected. I'm quite healthy, and recovered each time, but it was a truly miserable experience. There were moments when I really wanted to die!

Whatever your doubts about the influenza vaccine, it is an established fact that immunization is many times, many times, safer than the flu itself. That does not mean flu is a plague, nor that the vaccine is perfectly safe. Nothing in medicine and little in life is perfectly safe. Harm from the flu vaccine is possible, but a highly remote risk. For what it may be worth to make this personal, I readily accept that risk every year not only for myself, but for my beloved wife and children as well. I put the arms of the people I love most on the planet where my mouth is on this topic.

So, I am unimpressed and not persuaded by those who argue against flu vaccination because they have avoided the flu without it.

You presumably know the expression, unless, that is, you are George W. Bush, "Fool me once, shame on you, fool me twice, shame on me." If you are George W. Bush: Thank you, Mr. President, for reading my column, no offense, hope those English lessons are coming along, and please get a flu shot.

For everyone else, the relevant point is this: Influenza unashamedly kills tens of thousands of us ever year. Being fooled by it even once could be one time too many.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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