Measles Memo: VACCINES WORK!

By now you have probably heard about the MEASLES outbreak that originated in Disneyland last month. At this point, over 100 cases (that span at least 14 states) have been documented since the first of this year...and we have only entered February. If you are my age or older (40-something), odds are good you remember HAVING the measles. In my case, I missed the coveted LAST DAY OF SCHOOL in 7th grade...miserably feverish, coughing, aching and covered in itchy red spots, so that particular event is etched in my middle school memories. I lay in bed sobbing in my self-pity for missing all the fun at school that day, as well as the first days of summer. But in truth, I was lucky. The worst part of measles for me was my pre-teenage angst.

Fast forward to medical school, during another measles outbreak in the late 1980's. Our pediatric hospital ward in Houston's medical center was literally filled with very sick kids dealing with complications of measles. Did you know that roughly three out of ten people infected with the measles develops complications? Most of the time, those complications are nonlethal medical "frustrations" like ear infections or diarrhea, but measles also can cause far more serious complications such as pneumonia or encephalitis (brain involvement). Watching a family grieve the loss of a young child from any cause is heartbreaking, but from a preventable disease...words escape me.

In 2000, measles was declared "eliminated" from the United States, meaning that this disease is no longer constantly present here. Measles was not, however, eliminated world-wide. In 2013, the World Health Organization recorded over 400 DEATHS from measles every DAY- primarily in young children under the age of 5. Before routine measles vaccination in the United States (which began in the 1960's), there were over 3 MILLION cases of measles per year, including over 500 annual deaths and nearly 50,000 hospitalizations (each year).  Today, thanks to widespread immunization, we are facing a measles outbreak that is only (so far) in the hundreds of cases.

The good news here is that vaccination WORKS- it saves lives. Worldwide immunization strategies with measles have decreased measles deaths by 75% in the last decade, saving an estimated 15.6 million lives. Who is at the most risk today? Anyone un-immunized, including our precious children too young to be immunized yet (less than one year old).

BOTTOM LINE: The major lesson learned from Measles immunization? VACCINES SAVE LIVES. Check with your doctor to be sure your family is up to date!

How Accurate are Flu Tests?

In primary care offices, we do many types of rapid testing to help us diagnose and treat patients- pregnancy tests, urine tests for infection, rapid strep tests, and of course, rapid flu tests. How accurate are these tests? If a rapid flu test is POSITIVE, it is extremely accurate- 98%. This means they are very SPECIFIC tests- if it says you have it, you have a 98% chance that you really do have the flu, so the likelihood of a false positive is very low. If your rapid flu test result is NEGATIVE, however, you might still have the flu...and your doctor should rely on her clinical judgement. The SENSITIVITY of these tests varies, but averages about 62%, meaning about 1/3 of the time when you DO have the flu, the test could miss it.  (The most recently published meta-analysis of rapid flu tests analyzed 26 different rapid test brands, but all had similar data on accuracy-http://www.ncbi.nlm.nih.gov/pubmed/22371850.)

Why do doctors even use these tests if they are not super sensitive? Because it affects our treatment plan. If we have confirmation that someone has the flu (with a positive test), then we can feel more confident in NOT prescribing an antibiotic, and limit our conversation to pros/cons of taking an antiviral medication as well as medications for symptomatic relief. This step greatly reduces unnecessary antibiotics, which is critical in an era of increasing antibiotic resistance.
Additionally, knowing a patient definitely has the flu helps us advise them about returning to work/school/activities, since we know flu stays infectious for up to a WEEK. (So STAY HOME at least several days, and until you are fever-free for at least 24 hours!)

If you had the flu vaccine, will that affect your rapid flu test?  If you had a shot- no. If your flu vaccine was the intranasal spray, there is a chance that you could have a false positive test. Studies have shown that in the first several days after receiving the nose spray vaccine, people may test positive for the flu (even though they are not infected.)

During epidemic years of the flu (including 2015) the CDC encourages doctors to treat all high risk individuals with suspected flu with antiviral medications, and in fact, last week the CDC put out a special Health Update.

Who should be treated with SUSPECTED illness? Some are obvious- anyone hospitalized, patients in nursing homes, and people with immune problems, significant chronic problems (lung or heart disease, for example) or with severe illness such as pneumonia. However, HIGH RISK also includes all otherwise healthy children under the age of two years,  adults over the age of 65, and women who are pregnant or have just delivered their baby within the past two weeks. There are also other less common subgroups that are high risk such as people who are very obese (BMI >40), American Indians or Alaska natives, and youth under 19 who are on chronic aspirin therapy.

Who should be treated with CONFIRMED illness? Anyone in the high risk categories above should be treated with antiviral medications if they have a positive test, because treatment definitely decreases severe complications, hospitalization and even death. Otherwise healthy, active adults who test positive for the flu should have a discussion with their physician about taking the antiviral medications. When taken within 48 hours of the onset of flu symptoms, these drugs have been shown to decrease the duration of the flu by one or two days...which can make a big difference to a student, parent or employee. However, these medications are not without side effects, and for some people, they may aggravate flu symptoms- particularly nausea. In controlled studies, the antiviral medications only cause about 10% more nausea/headaches/fatigue than placebo, but there is no doubt that in a minority of patients, the medicine causes more side effects than they are worth. However, since you have the FLU when you are taking the medications- you already likely HAVE nausea, headache, fatigue, etc- so it is often difficult to sort out. In my family, half of us can tolerate the antiviral medications with zero problems, and half...barely keep the pills down long enough to know.

BOTTOM LINE: If you have flu symptoms, get to the doctor as soon as possible (especially if you would consider taking antiviral medications), and understand that a positive test is REALLY positive, but a negative test does not definitely rule out the possibility of the flu. 

Flu Without Fever?

Can it be? Should you even wonder if you have the flu if you don't have a fever? Unfortunately, YES. While it is true that the classic presentation of seasonal flu includes an often HIGH fever, body aches, fatigue, sore throat, cough and abdominal symptoms like nausea, pain or diarrhea, no single symptom is absolutely necessary for a diagnosis.  Children under the age of 6 years frequently do not have fever and cough with their flu symptoms. This year in particular, I have seen more cases of flu with purely fatigue and stomach symptoms...including one in our family this week.

The incubation period for influenza averages about two days, so that means that you are exposed to flu 1-4 days before you have symptoms. Unfortunately, you are contagious (spreading germs yourself) the day BEFORE you have intense symptoms, and then continue to be contagious for roughly 5 - 7 days. Whether or not you have FEVER.

What's my point? We all have to be responsible about not spreading the flu. It's hard for anyone to miss work/school/sports, but when we go back too soon, we are just increasing the chance of passing on this illness to our peers. When SHOULD we return to work/school? If you HAVE fever, it's a clear recommendation to wait to go back until you have been completely fever-FREE for 24 hours, without the benefit of tylenol or ibuprofen (which obviously can lower temperatures, and therefore, mask a fever). If you do NOT have fever, but have a positive flu test, then it is less obvious when you should go back, but on average most otherwise healthy people will need to be at home for at least three days. If you are vomiting and having diarrhea, a good rule of thumb is to wait for 24 hours after these symptoms subside to return to work/school. As a parent, I cringe every time I here someone talking about sending their kid to school after that same kid was up "all evening last night vomiting" or they comment nonchalantly, "I know she's wiped out, but she hasn't thrown up since lunch yesterday... and they have a huge test this week."

The flu is spread via respiratory secretions, and this can be transmitted directly by coughing or sneezing (or simply by talking) or indirectly by transfer as the infected person touches their mouth or nose, then touches surface (leaving the virus there) and then the next person touches that surface before touching their own mouth/nose. Remember all of this is microscopic, not visible.

When we DO go back, perhaps we should at least take some antibacterial hand sanitizer with us. And tell your friends and family to get the flu vaccine. True, this year's vaccine is not a great match, but at least it lessens the severity of the flu if you still get it.

BOTTOM LINE: Please, if you get the flu, do your part to stop spreading this disease and STAY HOME from work, school, sports, (and restaurants, grocery stores, Starbucks, whatever!) until you feel significantly better AND are FEVER-FREE (and puke-free) for at least 24 hours without taking medicines to stop/blunt those symptoms.

Will You "Cervive" in 2015?

Is 2015 the year you finally truly prioritize YOUR health? The majority of Americans include weight loss and possibly exercise in their New Year's Resolutions each year...and do really well on their strict diets for a few days or maybe even a few weeks. While I absolutely applaud attention to weight and activity levels, I want to encourage you to think beyond diet and exercise for your 2015 health resolutions. (And I will spend time in future blogs this month talking more about what diets work best, but today I want to shift the focus...)

January happens to be Cervical Cancer Awareness month, so women- how about starting your 2015 Resolution list with scheduling your "annual" exam, especially if your last "annual" was way more than a year ago? The GOOD news is that screening recommendations have changed quite a bit, so women no longer need to have Pap tests every year. Current guidelines tell us for young women to have their FIRST Pap test at age 21, then (assuming tests do not show a problem) every 3 years between 21-29, and then after age 30, testing can actually occur simply every 5 years (by using both the Pap test and a specific HPV test combined).

In the United States, cervical cancer is still diagnosed in over  12,000 women per year, and tragically, still causes over 4000 deaths per year. We can do better! The vast majority of women with cervical cancer have little to NO symptoms- this is a silent killer. While prevention (with the HPV vaccine) is optimal, early detection absolutely saves lives- so do NOT put off getting your Pap test.

While most of us have run 5K's or worn PINK for breast cancer awareness, few people know or talk about their diagnosis of cervical cancer. Tamika Felder, a now 13 year survivor of cervical cancer, is leading the charge to increase personal and community support for cervical cancer. For my fellow AUSTINITES- if you or someone you love has been diagnosed with cervical cancer (whether that diagnosis was recent or many years ago), please let them know about CERVIVOR SCHOOL- a four day learning, connecting and revitalizing retreat NEXT WEEK, starting Thursday evening, 1/15/15 through Sunday afternoon.

BOTTOM LINE: Women, if you are due for a Pap test, please move that to the top of your 2015 Resolution list! 

'Tis the FLU SEASON

It's that special time of year again...so please give yourself (and your family) the GIFT of a flu vaccine NOW so you are not struck down with this illness at the busiest time of year! Flu shots have been available for a few weeks and seem to be available everywhere.  Clinics, schools, grocery stores, pharmacies and many employers are all offering flu shots these days. Add a flu shot to your grocery list- I'll bet the pharmacy there is stocked and you won't even have to add an extra stop on your weekly errands.

Who should get the flu vaccine?
The Center for Disease Control and Prevention (the CDC) recommends annual flu vaccines for everyone over the age of six months.

What is different this year?
As with last year, we have quadrivalent vaccines (that include protection against four strains- 2 influenza type  A strains, and 2 influenza type B strains) in addition to the usual trivalent vaccines. Pick one or the other, you don't need both. If you have egg allergies, make sure to ask for the trivalent vaccine that is egg-free.

Didn't I hear that the flu vaccine this year doesn't match the strain that is going around? 
Well...unfortunately, yes. We are early in the season, and the CDC is seeing that most of the diagnosed cases are a result of the H3N2 strain (as opposed to the H1N1 that was so devastating several years ago), and although that strain is included in the vaccine this year, there has been a mutation in roughly half of the circulating virus that makes it resistant to the vaccine. The take-home message, however, is that even if the vaccine is LESS effective, it is still the best protection that we have AND it should still reduce the severity of the infection if you happen to contract one of those mutated strains.

But I hate needles...no problem, just ask for the vaccine that is delivered via a nasal spray! The only caveat here is that this is a live vaccine, so there are some restrictions: you must be age 2-49 years, not pregnant, have no major problems with immunity (such as having AIDS or cancer), not take aspirin daily, and not have asthma.

Hate needles and have asthma? There is also a trivalent shot that has a tiny needle which is injected just below your skin, rather than into the muscle.


What is FLU? Influenza is not a simple cold, nor is it a twenty four hour stomach virus. The flu causes fever, chills, cough, runny/stuffy nose, muscle aches, headaches, fatigue, and sometimes involves vomiting and diarrhea (more often in kids). Colds and allergies tend to bother you from the neck up- stuffy, sore throat, headache- but don't knock you down for the count, and coughs are generally less bothersome.

How is the FLU spread? This virus is spread from infected people when the cough, sneeze or talk, via tiny respiratory droplets, and the scary part is that you are contagious a full day BEFORE you develop symptoms (as well as for about a week after you feel sick.)

How can you prevent the FLU? Get vaccinated. Get vaccinated. Get vaccinated! 

Who should NOT get vaccinated? Those with bad reactions to vaccine in the past; infants younger than 6 months; and those people with a history of an uncommon disease called Guillain-Barre. If you are sick with a fever, wait till this illness is over before getting the vaccine.

BOTTOM LINE:  Your best gift for good health this season is the FLU VACCINE!

More Dancer Problems...

Dancers pretty much abuse their feet, with repetitive forces in unnatural poses, so it is no surprise that they end up with stress fractures in their feet. When we think about broken bones in the foot, most of us picture a broken toe or a large bone in the middle of the foot (the metatarsals). However, there are two tiny pea-like bones that can also be broken- the sesamoid bones. These little bones are embedded side by side within the tendon that is in the ball of your foot, just beneath the base of your big toe. They act like pulleys, allowing the tendon to slide more easily as you bend your foot, pushing off with running, jumping or walking. Stress fractures of the sesamoid bones show up as gradually increasing pain every time you put pressure on them, especially with the act of bending and pushing off. The pain tends to stay very localized, is relieved with rest, and the maximal tenderness to touch is underneath the base of your big toe.

How are these fractures diagnosed?
Sesamoid fractures, like all stress fractures, may not show up on x-rays till they have been present for a couple of weeks. A dark line is seen within the white "ball" that is the sesamoid bone. Occasionally the sesamoid bone will be completely broken into two parts, and these fractures may require surgical correction.

What is the treatment?
There is no quick fix for this problem, much to the dismay of dancers (and runners). The treatment is to stop bending the ball of your foot, most easily accomplished with a firm walking boot. How long? Typically a minimum of 3 weeks, but more often roughly 6 weeks. Upon return to activity, the key is to "start low and go slow"- do NOT jump back in to full workouts!

BOTTOM LINE: For deep, persistent, worsening pain under the ball of your foot, consider the possibility of a stress fracture of your sesamoids- head to your family doctor for an exam and possible X-ray.

Dancer Problems...

Have you ever had a plantar wart? These are the warts that show up as a painful bump underneath your foot. These unwelcome growths often show up at the site of "trauma", so dancers obviously most frequently develop them on their feet or toes. Warts are incredibly common, with a prevalence of up to 10% of Americans. In fact, the vast majority of us will develop at least one wart somewhere on our body during our lifetime.

Are warts dangerous? Not really. Warts do not turn in to cancer, and in fact, untreated, will eventually go away on their own. The problem is that "eventually" could be years. Since warts are rather unsightly, and obviously plantar warts can be painful (picture having a pebble under your foot as you walk), most people do not choose to do nothing and simply wait out the wart.

How can you get rid of a plantar wart?
There are many different remedies out there, most of which have some success- including the perennial favorite, duct tape. Over-the-counter fixes may work as well as treatments in your doctor's office. None are perfect. One relatively recent study from 2011 again demonstrated that home daily self-application of salicylic acid yielded the same results as a physician treating in the office once with cryotherapy (liquid nitrogen). EVerT: cryotherapy versus salicylic acid for the treatment of verrucae--a randomized controlled trial.

My personal favorite treatment for plantar warts is a non-prescription product called Curad Mediplast. This stick on product is a combination of higher dose salicylic acid (the active ingredient in most OTC liquid wart removers) and, well, tape. You simply cut a tiny piece large enough to just cover your wart, and stick it on your freshly washed, but thoroughly dry wart. Leave it on for 24 hours. Take it off, scrub your wart a bit with soapy water and a pumice stone or washcloth, then let dry for 10 minutes and place a new one on. Repeat this for ONE week. Then, do nothing for two weeks (you can continue to use the pumice stone if you want, but don't be tempted to start digging around with sharp objects. Repeat the week-long cycle again. Smaller plantar warts like the one pictured above may resolve after only one cycle, while larger ones may take three or more. Just remember- one week of treatment, then two weeks off. Is this 100% evidence-based practice? No, but it has been successful for my patients, and correlates with clinical studies using similar protocols.

BOTTOM LINE: Think you have a plantar wart? Head in to your family doctor to confirm the diagnosis and start on a treatment that will get you back to action as quickly as possible.