Saturday, November 20, 2010

Flu Fighting: Just Wash Your Hands - Often? We all appreciate quick fixes. Bag's got a hole in it and no time for a proper repair? Duct tape can help. On the run and no time for a full meal? A protein bar can help. These aren't meant as long term real fixes but emergency quickies when we just have to get from A to B. On the road and not sure of the nutrient quality in the food? A multivitamin can be a good idea for back up. Fine. Great. But sometimes, it seems, we look for quick fixes for more than emergency gap fillers. I'm talking about the flu vaccine.

We are told that getting a flu vaccine - or buying one for someone we love - is one of the best things we can do for health in the flu season. Indeed, in one province in Canada, this is the conclusion of a research study as a best way to promote vacine uptake in younger adults.

I have a couple issues with this message. 1 - a vaccine gives the impression that it's a shield against all flu ills. 2 - having said shield tends to afford a license to get sloppy with other more time intensive approaches to our care of self and those around us. Neither is a Good Thing.

This post offers a quick overview about flu vaccine  - and a quick reminder of other approaches that seem to be even more effective in reducing flu catching likelihood. Indeed the post ends with two challenges: frequent soap and water hand washing, and even harder perhaps: developing a strategy to ensure we stick with the practice.

Quite a years ago, moving to a new job/city, i got the flu three times in one year. I swore never again, and became an ardent fan of the flu vaccine. In canada, these are free. In the UK, once the prime population has 'em, GP's can also dispense the left overs freely. Great. Flu be gone! I put my success down to the vaccine. A couple years ago, on getting more into the research on the vaccine, i stopped getting it, and adjusted some health habits. Still haven't had the flu since. Some mighty colds (that hasn't changed though the frequency and intensity has gone down), but no flu. Maybe i'm a statistical anomoly. Maybe not.  So here's a bit of what seems to be known about the vaccine.

Flu Vaccine:
Drug Companies. Let's state the obvious: drug companies make their living on product sales. When the H1N1 virus broke out, sales of the rapidly developed and not so rapidly tested vacine sold an awful lot. The drug was rushed into production. Sales to governments like those in the UK were huge. Someone's problem is always someone else's silver lining.

Governments. Govn'ts also seem to like quick fixes and a fast way to show that they're Doing Something for the population. Buying in Lots of Drugs for the People does seem to look like the govn't is Being Responsible. Acting Fast. Grr. Way to Go, Government. This of course is the same motivation that has an ex-government homeland security head now lobbyist getting lots of back scatter, full body x-ray machines into airports. The Quick Fix Solution thanks to Technology. But i digress.

The Science. Last year, Canadian scientists found that folks who had had seasonal flu shots in the past, and then had the H1N1 shot were more likely to get H1N1. Apparently the reports of this study had a hard time making it into the US media where the vaccine was being promoted on a grand scale. Now that's a drug interaction effect. And indeed, a very recent report out of UofToronto suggests that in ontario, the mass shoot up of flu vaccine in Ontario was good value for money. That seems so odd: scientists saying it could make things worse; statisticians saying good value?

What do we know? That's a toughie. Let's take it by population.

For Elders. The flu shot is often prioritised for "people over 50." This past year, however, researchers lead by Thomas Jefferson in Rome, showed that the research doesn't support current vacines to be as beneficial as claims that have been made for them:
Overall, the authors write, "Our findings show that according to reliable evidence, the effectiveness of trivalent inactivated influenza vaccines in elderly individuals is modest, irrespective of setting, outcome, population, and study design. Our estimates are consistently below those usually quoted for economic modeling or decision making."
Does this mean don't get the shot?  In certain conditions, it's still viewed to be better than a kick in the head.
"We do need better studies to determine the effectiveness of influenza vaccine in the elderly, and CDC is working on such studies," Skinner commented. "However, it's a fact that influenza causes a heavy burden of illness and death among people 65 and older. This burden, combined with limited data from randomized trials as well as studies in nursing homes and other settings, support the current vaccination recommendations of the United States and many other countries."
In an interview with Jefferson in Der Spiegel, Jefferson was more critical:
Jefferson...In the best of cases, the few decent studies that exist show that the vaccine mainly works with healthy young adults. With children and the elderly, it only helps a little, if at all.
SPIEGEL: But aren't those the exact groups that influenza immunization is recommended for?
Jefferson: Indeed. That's one of the contradictions between scientific findings and practice, between evidence and policy.
For the General Population. One of the most compelling statements from the Jefferson interview is with regard to the well hyped drug Tamiflu. Jefferson states:
If taken at the right time, on average, Tamiflu reduces the duration of a real influenza by one day. One study found it reduced the risk of pneumonia [maybe this one? - mc].
The entire interview is well worth reading. Jefferson, whose group the Cochrane Collaboration whose mission is to review the scientific literature around disease,  points out that deaths attributed to flu are based on some pretty weird estimates (not facts) that may not be influenza virus based at all. Likewise that the huge focus on influenza as opposed to other viruses "is not only misguided, but dangerous." And what's the thing that's mis-guiding? What, good b2d readers, do you think? Even science is not immune.

Needless to say, Jefferson took a lot of heat for saying the Emperor may have some thin clothes. There's a nice discussion of the critique of the critique's critics over at the Atlatntic.

So what's a gal or guy to do? Wash Up
Turns out that the recommendations posted last year on b2d for fighting a wretched cold are pretty good when it comes to any respiratory illness: wash your hands.

At the risk of being single source repetetive, Jefferson suggests that airports get fitted with 100's of wash basins, and that folks who do not wash after exiting a plane be held by security.
Whoever gets off a plane and doesn't wash their hands should be stopped by the border police. You could tell for example by putting an invisible, neutral dye in the water. And wearing masks can be sensible, as well.
Soap and Water. And note: what is being promoted is hand washing rather than alcohol gels, but if there's no soap and water? Gels are better than nothing - a duct tape fix - but washing's best.

Cultural Awareness: Soap and water. Rinse and Repeat.
How make soaping up exciting? I wonder what dyson might do with this if they added some amazing Jetson's like technology to go with their awesome hand dryers? These things make a trip to the otherwise super crowded Waterloo Station toilets not just a necessity, but an adventure. It's like NASA for the masses. And assuming we don't have to touch the bathroom door handles on the way out? Really cool. Until these devices become more common, well, education campaigns?

communication? There are the occaisional totally disgusting ads in the UK that just gross one out to say there are bugs in the atmosphere - but they don't actually show one how to wash one's hands or how long to do so or how frequently.  And do they actually show cool easy ways to carry a hankerchief and use it if you are in the Snuffle Space?

Support? One of my students the other day was horking all over the place at a meeting. He just laughed the first time i said go get some kleenex. He didn't after i told him to leave and not come back till he had some. He missed my following mini-lecture on why that's what happened was a social catastrophe waiting to happen. Especially in light of upcoming deadlines for everyone in that room. Where's my educational back up pack, though? where's the illustrated posters? the iPhone Aps for the handwashing frequency competitions? The how-to videos? Maybe we need more than just a single-factor approach to support real behaviour change?
Research. How so certain that handwashing is the big help? Contact someone's germs from their spewing (germs: invisible; live on surfaces for hours); put contacted fingers on nose; we are toast. It's that simple a transmission. Wash hands with soap; this lifts germs from hands; rinse hands - germs get flushed, quite literally, down the drain. No hand to nose transmission. Wash hands frequently after surface contacts; reduce incidence of exposure.

Despite this simple and pretty fool-proof chain of actions, there's some pretty big work underway to see if handwashing can do more than cut back occurrences, but can cut back on days of sick time taken at work. And since sick days are a big cost to work, there's a big incentive to get this effect quantified. That study's just beginning.

But there's other work extant from the world of the 2003 SARS outbreak:
A korean study showed that ads to promote hand washing during various flu seasons definitely increased hand washing behaviour - especially among women. Guys, it seems, need other methods to encourage practice. let's get on it, Science! Likewise, a review of studies around the SARS outbreak in 2003 showed that handwashing went up, and that the habit stayed up after the outbreak, declining only slowly. Again, gals get with the program in greater numbers. What's with this, boys? Seems that a single approach like *just* education is not enough to get action.

Lessons from Hospitals. Other research around the SARS outbreak showed that the biggest protection for hospital workers against the disease spreading was actually - i love this - multifactorial. In other words, not JUST an education program to staff to wash hands, but all around better processes for identifying problems before they get to congested emergency rooms, better processing of these infectious cases to be detected, isolated, processed, and then better inter-patient/carer hand hygiene. The whole package.

From Hospital to Workforce. What would a whole package for an office or university environment be? I'm not alone in suggesting, at the first sign of sniffles or just "that feeling" of a Thing coming on, have support from work to work from home, to rest and beat back the symptoms.  In the work/school space, where are those extra wash basins everywhere?  Why have to go to the loo to use a basin? in hospitals, they're in the hallways, no? What about investment in actually having kleenex and secure kleenex disposals everywhere? Bring back the role of the handkerchief in fashion?

Overview of Research: just frickin' wash up. In lieu of wholesale improvement, we can all wash our hands more frequently, eh? Some of us may even have some influence in on-site work practices. We can use that too, no?  Indeed, another Cochraine review has shown that. "Many simple and probably low-cost interventions would be useful for reducing the transmission of epidemic respiratory viruses" Talk about cost-effective.

Some Back Ups: Vitamin D as a help?
I'm almost hesitant to suggest vitamin d as a flu busting helper because it seems so quick fix-y. But where we KNOW that hand washing helps reduce the opportunities for a respiratory virus to spread, there seems some evidence that vitamin d seems to help reduce incidence of these viruses taking hold - some.

The idea seems to be not so much that super dosing with vit D is the big antibiotic win; rather, most of us who are not exposed sufficiently to the sun to get it through our skin, are simply too deficient in this steroidal hormone vitamin to have enough of it in our systems to do what we evolved out in the desert to do. Have a lot more vit D in our systems. Get that up to "normal" levels (what those are is still under debate, but 4000IU's a day seems to be in the zone. That's ten times the current RDA) and it seems we're in for better disease prevention all 'round. There's a nice discussion of these points by J. J. Cannell here.  Cannell seems to be one of the biggest proponents of vitamin D as a break on the flu, though there are some growing results to suggest he's not alone (some papers listed below).

Now, i've been taking 4000IU's a day for over a year. I'm about to have blood work done to see if the vit D i'm taking is actually being absorbed or if i'm deficient. I'm curious. If we're not testing, we're guessing, right? I'll report back. 

Ok what about the Vaccine?
Readers, like last year, i'm not getting one this year. That's my choice and it's not a recommendation. I haven't experienced any harm from taking a vaccine; i haven't expereinced any harm of late from not taking it.

So why not get one? We know that by the time a vaccine is ready for one virus, that virus may have already mutated and the vacine be pretty worthless. It also seems that wholesale vacination can assist mutation and helps, some contend, to weaken the immune system. Again, i am not making a recommendation.

So if not about the Vacine, What? Better Broader Habits - including soap and water.
THis post really isn't at bottom to get folks either to take or not take the flu vaccine; it's to encourage us to practice safer, broader health habits. And these habits are simple: wash hands frequently. Find an excuse to get to sink and get into the technique of soap and water use.

Handwashing is part of course of an overall health regimen: good food, rest, happiness, stress management, vit D levels, reducing exposure to infected folks, etc. But all that said, it seems it's a pretty good practice to ensure is up to speed.

Skills. The only way i've been able to not become entirely bored about hand washing is to note what seems a good correlation between decreased personal incidence of hand washing and cold getting for instance, zero flu; and pretty quick return of cold getting if my hand washing habits get a little sloppy.

And so, as a geek, i've gotten into hand washing technique. Getting each diget - back front inbetween - seeing if i can actually make the exercise last 20 secs. Using a paper towel to open the door to the loo after washing my hands. That sort of thing. Without which, oh come on, it's so tedious, eh?

SO here's the challenges for most of us:
  • every time we go to the loo (that's you too, guys), wash our hands.
  • every time we come out of an office or classroom or gym or dining space where we've been touching surfaces others of dubious provenance have hit before us, wash our hands with soap and water (i shudder thinking about all of the objects in the gym alone)
  • every time we get off public transportation, find somewhere to soap and water it. 

Perhaps a bigger challenge:
  • spending some cycles to find a way to keep us motivated to develop and keep up this practice.

How are you motivating yourself to wash your hands - frequently? Please post a comment.

For bonus points? All the vids on hand washing that i've seen on YouTube actually kinda suck. Too much talking head stuff. Or really depressing visuals. The CDC one above seems about the best. Surely there are better ways to do this, to blend technique with a bit of the why's? - Like the fact that soap just lifts the germs off the hands, and it's the running water that moves 'em off the hands? or that having paper towels may actually be good for openning the bathroom door on the way out so as not to re-germ up the hands? If you make a vid, please post a link in the comments below.

Thanks, and best to you and your health this flu season.

Cannell, J., Zasloff, M., Garland, C., Scragg, R., & Giovannucci, E. (2008). On the epidemiology of influenza Virology Journal, 5 (1) DOI: 10.1186/1743-422X-5-29
Ginde, A., Mansbach, J., & Camargo, C. (2009). Association Between Serum 25-Hydroxyvitamin D Level and Upper Respiratory Tract Infection in the Third National Health and Nutrition Examination Survey Archives of Internal Medicine, 169 (4), 384-390 DOI: 10.1001/archinternmed.2008.560
Kaboli, F., Astrakianakis, G., Li, G., Guzman, J., Naus, M., & Donovan, T. (2010). Influenza Vaccination and Intention to Receive the Pandemic H1N1 Influenza Vaccine among Healthcare Workers of British Columbia, Canada: A Cross‐Sectional Study Infection Control and Hospital Epidemiology, 31 (10), 1017-1024 DOI: 10.1086/655465

Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Nair S, Foxlee R, & Rivetti A (2010). Physical interventions to interrupt or reduce the spread of respiratory viruses: a Cochrane review. Health technology assessment (Winchester, England), 14 (34), 347-476 PMID: 20648717
Park, J., Cheong, H., Son, D., Kim, S., & Ha, C. (2010). Perceptions and behaviors related to hand hygiene for the prevention of H1N1 influenza transmission among Korean university students during the peak pandemic period BMC Infectious Diseases, 10 (1) DOI: 10.1186/1471-2334-10-222
Savolainen-Kopra, C., Haapakoski, J., Peltola, P., Ziegler, T., Korpela, T., Anttila, P., Amiryousefi, A., Huovinen, P., Huvinen, M., Noronen, H., Riikkala, P., Roivainen, M., Ruutu, P., Teirila, J., Vartiainen, E., & Hovi, T. (2010). STOPFLU: is it possible to reduce the number of days off in office work by improved hand-hygiene? Trials, 11 (1) DOI: 10.1186/1745-6215-11-69

Sander, B., Bauch, C., Fisman, D., Fowler, R., Kwong, J., Maetzel, A., McGeer, A., Raboud, J., Scales, D., & Gojovic, M. (2010). Is a mass immunization program for pandemic (H1N1) 2009 good value for money? Evidence from the Canadian Experience☆ Vaccine, 28 (38), 6210-6220 DOI: 10.1016/j.vaccine.2010.07.010
White, J. (2008). Vitamin D Signaling, Infectious Diseases, and Regulation of Innate Immunity Infection and Immunity, 76 (9), 3837-3843 DOI: 10.1128/IAI.00353-08


Steven Rice Fitness said...

I think the vaccine approach is from the public health(government) mindset: It is better to have a large number of people do something marginally effective than to recommend something a smaller number of people will comply with even though it works much better for the individual. It _sounds_ better too, something politicians prefer.

Steve Freides said...

mc, good reading, as always, so thank you.

Two issues you don't raise:

1) There are some of us who don't react well to most flu vaccines. I used to get the vaccine every year, but started realizing that I felt like crap for not just days, but weeks afterwards every time. The shot basically gave me the symptoms of the flu. I understand that I'm in the minority on this, but I am also not alone. After this happened two or three years in a row, my doctor and I agreed that I ought not to get the vaccine any longer. He did recommend that my wife and children get it, and they did. I've never come down with the flu since.

2) The fact that I haven't come down with the flu in a number of years brings me to my next point - if you're healthy, you eat well, get enough sleep and all that, isn't it reasonable to assume you won't get the flu, even if you're exposed to it? My understanding is that both the common cold and the flu only get you down if your resistance is low. I will grant you that exposure still means you could be a carrier, and that's a good reason to wash often, etc., as you suggest, but my question remains - if all those hospital nurses and doctors can treat flu patients without getting sick themselves, isn't it reasonable to assume that I'm capable of the same thing.

dr. m.c. said...

Steven, yup no doubt.
Steve, i'm not sure what you mean by nurses and medical staff not getting ill: they're down with illness all the time - besides the research that shows this in terms of struggles to get staff to scrub up all the time a colleague of mine does staffing audits at canadian hospitals in one of the provinces. Nurses and related staff off for flus/colds is certainly no less than in the general pop.

likewise as i think i said, washing up is just one part of a whole picture of stress, rest, nutrition etc, but with that said, it seems to be a pretty important one.

Consider this: the likelihood during flu season of having the immune resources to fight off EVERY attack is asking an awful lot without a little help like rest, destress, good food, and clean hands?

glad you've been keeping well. thanks for dropping by,


dr. m.c. said...

Steve - sorry - i may have mis-heard you - do you have reports that show that hospital workers have less incidence of flu etc? the only studies i've seen have been impact from washing up more between patients - so keen to here what you've found.

thanks a bunch.


Unknown said...

Food for thought, I got the flu vaccine for the first time a couple years ago because it got me off the factory floor for about 15 minutes. That year? I got the flu. Since then I haven't bothered with it and have been just fine.

Also, Dr. Mercola (of is pretty adamant about the flu vaccine being a negative overall for your health. Mainly due to mercury and other things (probable cause of your symptoms-you are probably sensitive to something in the shot) you don't want in your body still in it. Also, it is healthy for the immune system to be exposed to common diseases. Something about how it updates it's library of anti-biotics through direct contact with various viruses and bacteria. Something that really resonated with me was that Shingles is actually the same virus that causes chicken pox. Only it is shingles because the individual with it is older and more susceptible to a more severe version of the virus. How do you keep yourself from getting shingles? Stay exposed to chicken pox. Your body will have a healthy immune response ready and waiting whenever you are exposed to the virus.

Also, one of the best philosophies of sickness and health...

Disease isn't the presence of disease, it is the absence of health. If you are healthy, you won't have disease.

now, among the more conservative minds out there, Dr. Mercola will seem like a bit of a conspiracy nut; however everything he's led me too (including the kettlebell community) has been spot on for me.


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