Episode 33: The Flu. 

Saba and Dr Arreaza gave us a brief review on the flu shot. Influenza vaccination starts at 6 months of age. Vaccinate everyone including pregnant women. Pectoriloquy is basically being able to understand the voice of a patient with a stethoscope placed on their chest. We learned the Spanish word gripe (gree-pay) which means cold and flu in Spanish. 

The sun rises over the San Joaquin Valley, California, today in October 30, 2020.

Halloween is just around the corner! Today we will talk about vaccines because the new influenza season just started. If you have not realized it yet, this podcast is a strong defender of vaccines. So today we bring you what you need to know about the feared flu shot.

Some fun facts about cold and flu symptoms. 

A cough can travel as fast as 50 mph and expel almost 3,000 droplets in just one go. Sneezes can travel up to 100 mph and create about 100,000 droplets. Yikes![1] During a pandemic, coughing or sneezing in public may even be more embarrassing than farting. 

Did you know that the average adult produces about 1.5 quarts of mucus a day, that’s 48 ounces! and we swallow most of it. As a reference, a Big Gulp has about 30 ounces. The amount of mucus can double or triple during infections. That’s a lot to swallow!

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. 

“If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say that you are neutral, the mouse will not appreciate your neutrality.” — Desmond Tutu.

This is not a podcast about politics, but with elections coming soon, we remind everyone to vote for the candidate who represents their values and beliefs. The two big contenders, Donald Trump and Joe Biden, have their own opinions and two different visions of what they want to do in the following 4 years in America. So, go and vote! You can decide who is the oppressor and who is the oppressed, based on your own judgement.

Here we have Saba Ali, a fourth-year medical student who will talk about influenza vaccine.

Timing of vaccine

Saba: Remember to start influenza vaccination at 6 months of age. Any patient who has not received any influenza vaccine before age 8 should receive 2 doses 1 month apart. Vaccination is most effective if received by the end of October, although a vaccine administered in December or later is likely still beneficial.

 

Intranasal vaccine

Arreaza: And for those who are scared of needles, we have good news: The “intranasal vaccine” or live attenuated influenza vaccine (LAIV4) is approved for use in healthy non-pregnant individuals, 2 years through 49 years of age. 

Saba: Don’t use LAIV4 in younger than 2 years or older than 50 years, pregnant women, patients with severe allergies to previous flu vaccines, patients younger than 18 receiving aspirin or salicylate-containing medications, immunosuppressed patients, caregiver of immunosuppressed patients, children younger than 5-year-old with asthma, people on antiviral medications, patients with active communication between the CSF and oropharynx, nasal pharynx, nose, or ear, or any other cranial CSF leak, and patients with cochlear implants, asplenia or persistent complement component deficiencies.

Types of vaccines

Arreaza: CDC recommends using any age-appropriate influenza vaccine: 1. inactivated influenza vaccine [IIV], 2.  recombinant influenza vaccine [RIV], or 3. live attenuated influenza vaccine (LAIV). No preference is expressed for any influenza vaccine over another. 

Egg Allergy

Saba: A common question we have from patients is “I have egg allergy; can I still get the flu shot?”

Arreaza: The answer is: The influenza vaccine contains potential allergic components that may cause an anaphylactic reaction. One such allergen is egg proteins. Currently, all vaccines except for (Flublok (RIV4) quadrivalent for ≥18yo, and Flucelvax (IIV4) quadrivalent for ≥4yo) may contain trace amounts of egg proteins such as ovalbumin. Healthcare providers should be aware that allergic reactions, although rare, can occur at any time, even in the absence of a history of previous allergic reactions to vaccines. Therefore, providers giving the vaccination should have a plan for emergencies and be trained in cardiopulmonary resuscitation. 

Saba: The following are recommendations for patients with a history of egg allergies:

1. Patients with only urticaria after exposure to egg should receive an influenza vaccine appropriate for their age and health status. 
2. Patients that report having more severe reactions to egg and required epinephrine or other emergency intervention can also get any vaccine appropriate for age and health status. If a vaccine other than CCIIV4 or RIV4 is given, it should be given in an inpatient or outpatient setting supervision of a healthcare provider who can manage and identify severe allergic reactions. No post-vaccination observation is recommended; however, providers are advised to observe patients for 15 minutes after administering the vaccine for concern of injury secondary to syncope. 

Contraindications

Arreaza: When is the flu shot contraindicated? The only true contraindication to the influenza vaccine is a severe allergic reaction to a previous influenza vaccination regardless of the suspected allergen responsible for the reaction. 

Gillian-Barre Syndrome

Saba: Let’s talk briefly about Guillain-Barre Syndrome (GBS). GBS is a rare autoimmune disorder which causes muscle weakness and paralysis. GBS can last a few weeks or longer. Most people recover fully, but some people have long-term nerve damage. GBS can be deadly if the respiratory muscles are affected. In the United States, an estimated 3,000 to 6,000 people develop GBS each year, about 80 to 160 cases each week, regardless of vaccination. 

Arreaza: Since 1973, the data about increased risk associated with influenza vaccines is variable and inconsistent across flu seasons. When there has been an increased risk, it has consistently been in the range of 1-2 additional GBS cases per million flu vaccine doses administered.

Saba: Anyone can develop GBS; however, it is more common among older adults. The incidence of GBS increases with age, and people older than 50 years are at greatest risk for developing GBS. What if the patient has history of GBS? Should they get vaccinated? 

Arreaza: A history of GBS within 6 weeks of a previous dose of any type of influenza vaccine is considered a precaution to vaccination. Persons who are not at higher risk for severe influenza complications and who are known to have experienced GBS within 6 weeks of a previous influenza vaccination generally should not be vaccinated. As an alternative to vaccination, providers might consider using influenza antiviral chemoprophylaxis for these persons. 

Influenza and COVID-19

Saba: And what about COVID-19 patients? Visits for routine vaccination should be deferred for asymptomatic and pre-symptomatic persons who have tested positive for SARS-CoV-2, the virus that causes Influenza vaccine should be postpone in patient with asymptomatic COVID-19 for 10 days from their positive test result. 

Arreaza: For symptomatic persons with suspected or confirmed COVID-19, visits for routine vaccination should be deferred until criteria have been met for them to discontinue isolation: at least 10 days after symptom onset AND 24 hours with no fever without the use of fever-reducing medications AND COVID-19 symptoms are improving, AND the person is no longer moderately to severely ill. Moderate to severe illness with or without fever is a precaution to vaccination for all vaccines. 

Saba: If a patient has been exposed to a person with COVID-19, wait until their 14-day quarantine period has ended. For additional considerations regarding influenza vaccination of persons who are already in healthcare or congregate settings, we invite you to review the most current information from the CDC and ACIP websites.

____________________________

Speaking Medical: Pectoriloquy
by Levi Shen, MS3

The word for today is pectoriloquy.

Normally, you should not be able to understand the words “One-two-three” when you auscultate the lungs. 

Pectoriloquy refers to the increased resonance of the voice through lung structures so that it is intelligible during auscultation. It is a useful tool that clinicians may employ to identify areas of consolidation in a patient’s lung, which may indicate pneumonia, fibrosis or even cancer. 

Types of pectoriloquy include: 

1. Egophony: It is a result of enhanced transmission of high-frequency sound across fluid or solid, with lower frequencies filtered out. In practice, this would involve a patient making a long E sound which is then heard as an A sound by the physician; this is known as the E to A transition.
2. Bronchophony: Normally, the sound of a patient's voice is less clear in peripheral airways as compared to the larger airways. In bronchophony however, the patient's voice remains loud at the periphery, indicating possible consolidation. 
3. Whispered pectoriloquy: It is similar to bronchophony, except that in this test, the patient is told to whisper. If there is consolidation, the physician should be able to hear the patient clearly during auscultation. Bronchophony and whispered pectoriloquy take advantage of the fact that sound travels faster through fluid and solid, resulting in decreased loss of volume. 

Common words that physicians ask patients to repeat are “one-two-three”, "toy boat”, "Scooby Doo", and “blue balloons”. Another common word used is “ninety-nine.” There is historical significance to this. When the test was originally described by a German physician, he used the phrase "neunundneunzig”, which he found would cause maximum vibration of the chest. And what does that word mean in English? Ninety-nine.

When physicians find pectoriloquy during physical, they may confirm diagnosis with labs and imaging.

Remember the word of this week, pectoriloquy.

____________________________

Espanish Por Favor: Gripe
by Anabell Lorenzo, MD

“Doctora, tengo gripe”. 

The Spanish word of the week is gripe. When you see the spelling of the Spanish word gripe, in English you may think the patient has a colic. That’s why you can find “gripe water” which is a non-prescription medication for colicky in babies. But gripe (gree-pay) means having a cold or the flu. People may use the word gripe for any runny nose, cough, sneezing… or any upper respiratory symptoms. Your job is to determine what is causing the gripe based on your clinical judgment, and use additional studies as needed. Most gripes are viral colds, and most of them need only conservative management (rest, fluids, acetaminophen), but don’t forget to rule out other serious causes, including COVID-19 and influenza. During this flu season, remember the Spanish word gripe.

____________________________

For your Sanity: Skeletons
by Tana Parker, MD, and Steven Saito, MD

Where do you send a patient injured in a Peek-a-Boo accident? Straight to the I.C.U.

Why don’t skeletons ever go trick-or-treat? Because they have no body to go with.

Why didn’t the skeleton cross the road? Because it did not have the guts to do it.

Within minutes the detectives knew what the murder weapon was. It was a brief case.

 

Conclusion: Now we conclude our episode number 33: “Flu”. Saba and Dr Arreaza gave us a brief review on the flu shot. Remember to start influenza vaccination at 6 months of age, and vaccinate everyone including pregnant women. Then we learned the word pectoriloquy, which is basically being able to understand the voice of a patient with a stethoscope placed on the chest. And to finish up our episode, we learned the Spanish word gripe (gree-pay) which means cold and flu. 

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Saba Ali, Anabell Lorenzo, and Levi Shen. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

1. “How Fast Is a Sneeze Versus a Cough? Cover Your Mouth Either Way!”, May 12, 2016, American Lung Association, https://www.lung.org/blog/sneeze-versus-cough#:~:text=Sneezes%20win%20though%E2%80%94they%20can,create%20upwards%20of%20100%2C000%20droplets, accessed on October 29, 2020. 

 

1. “Mucus is gross. But here are 9 things you should know about it.”, VOX, https://www.vox.com/2015/2/11/8013065/mucus-snot-boogers, accessed on October 29, 2020. 

 

1. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season. MMWR Recom Rep 2020;69(No. RR-8):1–24. DOI: http://dx.doi.org/10.15585/mmwr.rr6908a1

 

1. Influenza Vaccination: Updated 2020–2021 Recommendations from ACIP, Am Fam Physician. 2020 Oct 15;102(8):505-507. https://www.aafp.org/afp/2020/1015/p505.html

 

Further episodes of Rio Bravo qWeek

Further podcasts by Rio Bravo Family Medicine Residency Program

Website of Rio Bravo Family Medicine Residency Program