It's the start of flu season again. Technically flu season starts in October and goes through May, but peaks between December and March. It's always a time of a lot of hype, with signs at every pharmacy urging you to get your flu shot. But does it work? Is it safe? There's a lot of conflicting information out there, it's hard to know for sure what the best choice is for you. Let's try to sum it up to help you decide.

First, the flu shot is really a combination of three strains of influenza. Influenza A, B and since 2010 it now includes the H1N1, or ‘swine flu’ strain. Canadian data from the 2009 H1N1 pandemic indicates that if you had the regular flu shot that year, you were more likely to contract the H1N1, which was really problematic that year. So, there’s some evidence that getting vaccinated with some strains of the flu vaccine may create greater susceptibility to other strains.

Every year, the WHO (World Health Organization) does its best to predict which strains of the flu will be circulated. Unfortunately, the flu mutates or changes slightly every year. Water fowl like ducks, geese, etc. that are the natural host for the virus, though it can live in mammals, too. Approximately every decade or more, a larger change in the virus occurs, which sometimes creates a more serious strain of influenza. Sometimes the WHO chooses the right strains of flu, and other times it misses and the vaccine offers little protection. Earlier this year, the CDC estimates that there has only been about an 18% effective against Influenza A, the more common and more severe strain of the flu, and 45% effective against Influenza B, which is generally very mild for most people. The FluMist vaccine had an even more dismal record for children, and may not have been effective at all.

According to the CDC, when the flu strains are correctly matched, the vaccine is up to 90% effective for preventing the flu in those under 65 years of age. However, for those 65 and older, the vaccine is only 30-40% effective even when the strains are well matched. Also, most flu vaccines are only approved for older children. That leaves those most vulnerable ages susceptible, the very young and the very old, while those who are young and healthy are the most protected from the vaccine.

In an effort to protect the seniors, there has been a high dose flu vaccine in the works for those over 65, but so far it has not been successful. There is little evidence that the flu vaccine reduces mortality for those above the age of 70. As for children, there is evidence that yearly vaccination reduces their immunity to other viruses according to a November 2011 Virology journal article. However, exposure to the virus seems to grant greater immunity for longer periods of time that may actually be effective even if there is a mutational shift in the virus.

The Flu Vaccine
First, you should know that there are many different flu vaccines available, and they are not all created equally. If you are a candidate or are considering getting the vaccine, it's worth a discussion with your provider to find the best fit for you. Some use a live attenuated (weakened) strain of the virus, and it’s possible to shed the virus and even get sick from the virus, although this virus has been weakened to limit that risk. Because this vaccine has a live virus, it may be most effective at activating your immune system thereby giving you the best immunity to the flu.

All the viruses for the flu vaccine are grown in an egg-based medium, so those who are allergic to egg should not get the vaccine. Though you can get the flu vaccine without mercury, most forms of the vaccine readily available contain high levels of thimerosal, a mercury containing compound. Because mercury is so toxic to the nervous system, this is a concern for a lot of people considering whether or not to get a particular vaccine. Many also contain formaldehyde, antibiotics, polysorbate 80, nonylphenol ethoxylate, and detergents with unknown ingredients because they are proprietary.

Because the flu virus strains change from year to year, and it requires quick manufacturing between the time that the most likely strains have been identified and the time that it needs to be made available to prevent flu, none of the flu vaccines are put through the scrutiny that we put most pharmaceuticals through. We only know well into the flu season if the vaccine is effective, and not all the components are as rigorously studied as most people would like.

The Risk of Getting Sick with the Flu
For most people, getting sick with the flu is largely an inconvenience. You may have fever, chills, cough, fatigue, and muscle aches. This usually lasts roughly a week, sometimes up to two weeks. Other viruses cause similar symptoms, such as coronavirus, and there is no vaccine for these. For those people who do not have a serious risk, are not immune compromised or don’t have serious illnesses, getting the flu has very little risk and may create the best immunity for varying strains of the flu into old age.

The most common complications are an ear infection in children. For adults, common complications include sinusitis. Very rarely, bacterial pneumonia can occur, usually in the elderly or those with pre-existing cardiac or respiratory disease. Often this is seen late in the course of the illness, and comes on after the person seemed to be recovering. Even more rarely, a viral pneumonia from the flu can occur, and this can be severe and life threatening. However, in the US in 2010 it’s estimated that only 494 people died as a direct result of the flu. These were largely people over the age of 65, who otherwise had compromised health due to heart disease, COPD, et. al. (The numbers of deaths from flu and pneumonia are lumped together statistically, and 494 is the number of deaths directly related to flu. The total number of deaths due to respiratory compromise combined as flu and pneumonia in 2010 was 50,003, so less than 1% of those deaths were directly from the flu).

The Risk of the Vaccine
The most common side effects of the vaccine are soreness and redness at the injection site, low grade fever, joint and muscle aches. Sometimes there can be a reaction to egg or other ingredients, which can include hoarseness, wheezing, shortness of breath, hives, dizziness, and palpitations. In severe cases, anaphylaxis may occur. Guillian Barre Syndrome, an autoimmune attack of the nervous system, may rarely occur. It may cause permanent nerve damage, and 5-6% of those who get Guillian Barre may die. However, this is rare, and can also happen as a result of the immune system being triggered by being sick with the flu, as well. Guillian Barre Syndrome was a problem with the 1970s swine flu vaccine, and is cited as a concern by some regarding the current trivalent combination vaccine. Many people also cite concerns about the ingredients, especially thimerosal, a mercury containing compound, but also the other chemical ingredients in the vaccine. In general, autoimmune diseases are on the rise, and it’s not unreasonable to think that immunizations with their myriad of ingredients may contribute to that in susceptible people. Of course, perhaps the biggest, most immediate side effect is that the vaccine doesn’t work. At best, it offers protection for a year, but often immunity fades before flu season even ends and it doesn’t protect the most vulnerable age groups.

Where does that leave me?
First, all vaccines are not created equally. Some are more effective than others. I personally don’t see the scientific evidence for the flu vaccine offering enough protection to warrant getting it for myself or my family, especially when there is only an 18% chance of protection that lasts for only a few months against a disease that is not particularly deadly. The vaccine works best for those that don’t really need it, and isn’t so great at protecting those that really do. The risk of this particular vaccine and its ingredients don't outweigh the risk of getting the flu for us, an otherwise healthy group. I see a lot of autoimmune disease in my practice, as well as in my family, and I have concerns about the ingredients and the way they trigger the immune system. I choose not to vaccinate myself or my family against the flu because the evidence suggests that occasionally getting sick with the flu is the best way for my body to develop effective and longer lasting immunity I’ll need into old age. Breast feeding is one of the best ways to protect an infant under two, who is not within the recommended age for the vaccine, but doesn’t have a fully functioning immune system yet. I understand that I am not in a high risk group. But for most people, most of the time, I don’t recommend this particular vaccine. I do, however, encourage you to make your own choice, and hope I’ve given you the information you need to make an informed decision.

From 1952, when the flu vaccine began being readily available, until the swine flu pandemic in 2009, it was only recommended that children under 19, pregnant women, people with chronic medical conditions, nursing home residents and health care workers be immunized. Largely, healthy adults between 20 and 64 were not immunized. I think this is still a pretty good general place to start, but that ultimately you should decide for yourself, with proper medical guidance if you have questions or concerns. Unfortunately, the vaccine is not that effective for the elderly and so some may decide to pass on the vaccine, but for people with heart disease, especially congestive heart failure, and with respiratory diseases like COPD, the vaccine may give some benefit that even if partially effective, may save someone’s life. If you have a chronic medical condition, or have close contact with or care for someone who does, it is worth a discussion with your doctor. Because of the mercury content (even bound mercury in thimerosal), I don’t recommend a flu shot containing thimerosal for pregnant women.

What should I do to prevent flu (whether or not I get the vaccine)?
First, wash your hands. The flu spreads easily from person to person before symptoms appear, and can live on surfaces for up to 48 hours. It’s possible to pick it up the virus through handshakes, breathing air droplets or touching surfaces that may droplets from coughing or sneezing. People may spread the disease before they even know they are infected. Also, clean surfaces and avoid touching your mouth, nose or eyes.

Get good sleep! It’s difficult for your immune system to do its job if you are always run down. Sleep is critical to staying healthy. You may find you need more sleep as the light fades. We are light-sensitive creatures, and it’s normal to need a little more sleep when the days are shorter.

Eat well. Eating seasonal whole foods is important to staying healthy. Include some good immune boosting spices like thyme, garlic, etc. Avoid excess sugar, as refined sugar depresses the immune system.

Get your vitamin D level checked. It may be no coincidence that the flu season is during the fall and winter, when we are not out soaking up the sun and making vitamin D. Particularly in the Pacific Northwest, vitamin D deficiency is a problem. Keeping your vitamin D at optimum levels has been strongly linked to immunity.

NAC, also known as n-acetyl cysteine, can be used as a preventive and lessens the impact of the flu if you are infected. An Italian study found it to be very helpful, with only 25% of those injected with the flu virus becoming ill after taking it for 6 months prior, (vs. 79% who became ill in the placebo group). For prevention, the adult dose is 1000mg, children 6-12 can take 500mg.

Over-the-counter homeopathics like Oscillococcinum, Influenzinum, or Mucococcinum have some research showing they can be effective as preventives.

What should I do if I get the flu?
Antivirals like Tamiflu are already becoming ineffective because of viral resistance, so prescriptions like these are likely not going to offer much relief. Because the flu is a virus, antibiotics will not help, unless you develop a secondary pneumonia (rare). Your doctor will likely prescribe rest and fluids. Echinacea in tea or capsules may be helpful. It has actions similar to Tamiflu, but there is no resistance to the herb as yet.

Elderberry syrup extract, also known as sambucus, at 15ml four times per day can reduce the severity and duration of colds, flu, and sinusitis if taken within the early stages of illness. (Dosage for adults.)

NAC as listed above can be helpful in fighting the flu. At the first sign of flu, adults can take 4000mg and children can take 1500mg.

Increasing the dose of vitamin D may be helpful. Some research shows that taking a megadose for three days at the first sign of the flu may prevent or lessen the symptoms. However, vitamin D can be toxic at high levels for prolonged periods of time, and you should consult your physician before taking large doses.

References:
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000258
http://phys.org/news/2010-04-seasonal-flu-vaccination-infection-pandemic.html
http://www.cdc.gov/vaccines/pubs/pinkbook/flu.html
http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm
http://www.influenzareport.com/ir/vaccines.htm
http://www.cdc.gov/flu/news/updated-vaccine-effectiveness-2014-15.htm
http://www.ncbi.nlm.nih.gov/pubmed/15080016