November 1, 2008

November 1, 2008
Should People With HIV and AIDS Get a Flu Shot?

Welcome to the start of another month in my life. I hope you had a safe and very Happy Halloween! Did you get any good treats or just tricks? Daddy wants to know.

With the election and my Teddy Bear Touchdown for children with HIV and AIDS, it is going to be a very busy month for me.

I have been getting the question about whether to get a flu shot a lot through the website and I understand why. I know many years ago I was told by doctors not to get a flu shot because they thought the potential harm outweighed the possible benefits.

But now, we know a lot more about HIV and AIDS and we have many new medications to help fight the war. Because of these changes, the recommendations have changed.

The flu season for this year is on the horizon, and the U.S. Centers for Disease Control and Prevention (CDC) is recommending that everyone living with HIV get vaccinated during the next several weeks. That is because the vaccine will not just help protect you from a week or two of a fever, stuffy nose, sore throat and a cough. It can also prevent you from developing serious influenza related complications, such as a trip to the hospital with pneumonia. Studies show that people with HIV including those with high CD4 counts are more likely than their HIV negative counterparts to end up seriously ill with flu complications.

Given the misery the flu can cause, and how easy many doctors and pharmacies make it to get a flu shot, you'd think that everybody would get one. Unfortunately, a third of people over 65, and more than two thirds of everyone else at high risk for serious complications from the flu, do not. The reasons vaccine dodgers give are usually based either on a fear of needles or misinformation.

I hopes that people will overcome their hang ups and learn how safe and effective the flu vaccine can actually be, even for people with HIV. Urban legends suggesting that the vaccine can cause the flu or that it can cause a dangerous spike in HIV viral loads have been disproved. The vaccine is not foolproof, of course. Sometimes the strains of flu virus that end up circulating during the winter are different from the strains that researchers used to make the vaccine. This year, however, the virus that just finished causing the flu in the Southern hemisphere matches up very well with the vaccine.

There is a flu vaccine available as a nasal spray made especially for kids and those scared of needles, but it is not recommended for people with HIV, because it contains live strains of influenza viruses. Ultimately, getting a flu shot means enduring a millisecond of pain to prevent days, or possibly weeks, of suffering.

How Effective Is the Vaccine?

Currently, the CDC recommends the flu vaccine for adults over 50, children from six months to 19 years old, anyone with respiratory problems such as asthma or chronic obstructive pulmonary disease (COPD) and people with compromised immune systems, including all people with HIV.

The usual tests to measure the safety of a vaccine and effectiveness placebo controlled clinical trials are not appropriate for flu immunizations. This is because different strains of the three major influenza viruses (A, B and C) emerge on an annual basis and spread quickly around the world, most readily during the winter seasons, likely because people are more prone to be inside and in closer proximity to others and, as a result, more likely to come in direct contact with someone with the virus. Thus, each year, a new vaccine is needed to combat the top three major strains of the virus, leaving little time to conduct clinical trials. Instead, public health experts study medical records of large cohorts of people enrolled in various insurance plans over a number of years to determine the efficacy of vaccination efforts.

Some critics claim that scientists have not done a great job choosing which strains of the virus to use when developing a vaccine for the coming flu season, and therefore that claims of its effectiveness are overstated. But according to the CDC, years when the vaccine strains and the virus strains are well matched, the vaccine can reduce the chances of getting the flu by 70 to 90 percent in healthy adults. And while the efficacy rate drops to 30 to 40 percent in those older than 65 years of age and is also lowered for everyone when public health officials do not correctly predict which flu strains will be most prevalent for that year the vaccine is thought to be 50 to 60 percent effective in preventing hospitalization and pneumonia and 80 percent effective in preventing death from the flu in those older than 65.

Studies in people with HIV have produced similar results. One small study of 102 people with HIV back in 1999 found that illness and hospitalization from all respiratory infections was significantly lower in people who got the vaccine compared with people who did not. In the people who did get some form of respiratory illness, influenza was found to be a possible cause in only one person who was vaccination, compared with 21 of those who were not vaccinated.

People with CD4 cells under 100 are in a unique situation. On the one hand, experts say, they need the vaccine more than people with higher CD4 counts. On the other hand, their weakened immune systems may be less likely to produce sufficient influenza fighting antibodies in response to the vaccine. Even people with particularly low CD4 cell counts can still realize the possible benefits of vaccination.

What makes the flu shot so important to people living with HIV is not so much the flu itself, though the severity of the flu is often worse for people with HIV. Rather, it is the likelihood of the flu developing into a serious lung infection such as bronchitis or pneumonia. If it is bad enough, pneumonia can be deadly, especially for people with low CD4 counts.

Timing also matters. The flu season really starts picking up in December, peaks in February and remains fairly high until late March. This means that people should be vaccinated every year, no later than the end of November.

Will the Vaccine Make Me Sick?

The CDC hears a lot of reasons why people do not get vaccinated. The most common is that people believe a vaccine gave them the flu. The perception that the vaccine can cause the flu has been hard to overcome.

Some people with HIV, and some physicians, remain concerned about the flu vaccine because of a small study in early 1990s that said the vaccine could temporary cause a your viral load to increase. Subsequent, larger studies have demonstrated little to no effect of the vaccine on viral load, especially among those who are currently on antiretroviral therapy.

Needles, specifically the fear of them, are another prominent reason some people give for not getting the vaccine. Their fear of needles was one of the primary reasons the CDC helped develop the nasal spray version of the vaccine, which is made from a weakened, but live flu virus. It is particularly effective in small children, not only because it involves no needles, but also because the live virus produces a stronger immune response than the inactive virus used in the injected vaccine. The fact that the virus is live, however, means that it can cause the flu in people with compromised immune systems. Thus, until the necessary safety clinical trials are completed, the CDC recommends that no one with HIV should use the nasal spray vaccine.

Forecasting the Flu Season

Just as it is difficult to predict which specific flu strains will circulate this coming winter, it is also difficult to predict when the various strains will hit and how long they’ll last. The severity of this season depends on a number of factors. Sometimes we have very short seasons where there is a rapid spike, followed by a rapid drop, in the number of flu causes. There can also be long lasting seasons, where the number of flu cases in any given week is not particularly bad, but goes on and on. All of those things are sort of beyond our understanding at this point.

When it comes to the vaccine, why put off what may be easier to take care of now? In some seasons the vaccine has been in short supply later in the season, when there are many more cases being diagnosed. The CDC and other health care organizations strive to make getting vaccinated relatively convenient. Most people should be able to schedule a flu shot with their doctors, at their local pharmacies or supermarkets or even at their places of work. Despite the convenience, however, a recent study found that nearly 60 percent of people with HIV still don’t get a flu shot.

Stop by to see your health care provider for your flu shot. If you can not conveniently stop in to see your health care provider for your annual flu shot and are not aware of other places you can go, simply log on to the website of the American Lung Association.

Wishing you health, hope and happiness.

big bear hug,

Daddy Dab