Lack of Vaccination Coverage in the Medical Office

This week a patient, going on a foreign trip, was required to fill out a vaccination and immunization record to obtain a visa. To his dismay he discovered his records were not available. On further questioning he realized his vaccinations were done at retail clinics and pharmacies up and down the Eastern seaboard. Yes, he had requested a record of the vaccination be sent to the office but it never arrived.

I am a firm believer in the recommendation of the CDC, American College of Physicians and Advisory Council on Immunization Practices. Their literature is displayed in my office and available as a resource to my patients. I find it abhorrent that CMS, through its Medicare Part D program, will pay for the shingles shots (Zostavax and Shingrix) and the pneumonia series (Prevnar 13 and Pneumovax 23) at the pharmacy but not at a doctor’s office. The pharmacies use these vaccinations as loss leaders to get individuals into the store hoping that they will buy additional items while there.

As a general internist and practitioner of adult medicine, I too use these vaccinations as a “loss leader.” When patients call for a vaccination and have not been seen in a long while we encourage an appointment. We check on prevention items recommended by the ACP. the AAFP and the USPTF and make sure the patients are current on mammograms, HPV or Pap testing, colonoscopies, eye exams, hearing evaluations, skin and body checkups and other essential health items. We make little or no money on vaccinations or immunizations but like the idea that once a patient is here we can provide a gentle reminder about those health tasks we all need to follow up on with some regularity.

I like the idea of making vaccinations and immunizations more convenient for patients. I just believe the same payment should be made if the patient is in your office or in the pharmacy. In addition, the law should require the pharmacy to send a record of the vaccination to the patient’s physician so we can have immunization records readily available.

The ACP, AMA, American College of Physicians and American Academy of Family Practitioners should be using their influence to encourage the Center for Medicare Services (CMS) to pay for these vaccines in doctors’ offices as well as in pharmacies and retail clinics. If encouragement doesn’t work then legal action is appropriate.

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Does Tdap Protect You From Whooping Cough?

Within the past few years an epidemic of whooping cough swept through and injured youngsters in California and Arizona. There were tragic childhood mortalities in the frail not yet vaccinated pediatric population. The researchers from the Center for Disease Control and National Institute of Health swooped in and concluded that adults, primarily grandparents, were transmitting the disease to their newly arrived and not yet immunized grandchildren. They reasoned that the adults’ immunity from their childhood vaccinations with DPT had worn off and they were unknowingly transmitting it to the youngsters after a mild adult upper respiratory tract infection with bronchitis.  We were told that in adults, Bordetella pertussis produced bronchitis indistinguishable from a viral bronchitis. This was just the type of illness health care leaders were telling physicians not to prescribe an antibiotic for in their international campaign for the prevention of antibiotic resistance developing.  Little did they know at first that in adults, the bronchitis is a mild illness but in children it is aggressive and is often lethal.  They were not originally aware that long after our adult mild bronchitis resolved we could still transmit the bordetella pertussis to our grandchildren.

Their solution was to re-immunize adults with a pertussis booster in combination with your next tetanus shot. The combination was called Tdap.  A national information campaign was undertaken to get primary care physicians to spread the word to their adult patients.  The question is does it really work? In a recently published study led by Dr. Nicola P. Klein of the Kaiser Permanente Vaccine Study Center in Northern California which appeared in the Journal Pediatrics, it seems that the vaccine is only effective for a short time in the very healthy and robust 11 and 12 year children.  Their study showed that Tdap protected young adolescents 69% of the time in the first year, 57% in the second year, 25% in the third year and only 9% in the fourth year.  The vaccine was given during an epidemic in California in whooping cough in the hopes of averting a greater infection rate.

 

The failure of the vaccine to provide long term benefits in adolescents and teenagers will lead to different immunization strategies. Tdap is already a milder form of a former vaccine, scaled down to prevent some of the rare side effects seen when it was administered.  A possible return to that previous vaccine or whole cell preparation may be needed. Another proposal calls for vaccinating pregnant women hoping that their maternal antibodies will pass to the fetus and provide long term protection.

The real question with no answer is what about the millions of adults who received Tdap with immune systems far less robust and protective than adolescents?  Are they immune and for how long?  No one knows because the research has not been done or published yet.  Still the CDC and the NIH and the American College of Physicians call for adult immunization with Tdap.  The Kaiser Permanente Study will surely establish the need for an adult efficacy investigation. Until then we will give the Tdap while we wait for answers. It does raise the question of whether our approach to adult bronchitis should include an antibiotic that treats Bordetella pertussis until a quick test is developed to distinguish it from run of the mill viral pneumonias.

Zika Fever and Virus

The Brazilian Government has asked young women to avoid becoming pregnant until they can determine how to stop the spread of Zika fever.  Pregnant women, especially those who are infected in the early stages of pregnancy are at high risk for their offspring developing microcephaly. This small brain in an even smaller skull leads to death or severe permanent neurological deficits. There are now over 3,800 children born with microcephaly in Brazil due to their mother’s infection with Zika Virus.

Zika Virus is in the family of Dengue Fever. It is transmitted by the bite of the Aedes mosquito which also transmits Chikengunya Fever. The incubation period is only 2 – 14 days producing symptoms in only one of five people who have been infected. Symptoms are generally very mild with a very low grade fever, a rash, joint and muscle pains, headache, conjunctivitis and vomiting in some. Treatment is supportive with the disease resolving in about one week.

In adults infected in Brazil there has been an upsurge of post infection Guillan – Barre syndrome which is believed to be due to the disease.  While the mode of transmission has been by mosquito in most instances there are two cases in the United States believed to be due to blood to blood transmission and or sexual fluid transmission. Both of these individuals became infected in Brazil.

The Center for Disease Control and Prevention (CDC) has noted the presence of Zika fever in South America, Central America, the Caribbean   and now Mexico.  Avoiding mosquito bites is the best way to avoid the disease. For women who are infected there is no commercial test to confirm the diagnosis.  A polymerase chain reaction RNA test available through the Florida Department of Health and research centers can be obtained one week after the onset of symptoms.

 

In the United States a protocol has been developed with obstetricians to screen pregnant women who have been infected with frequent ultrasound evaluations of the developing child to determine if the virus has affected the development of the fetus.

 

The emergence of this virus, which is devastating to developing fetuses, is leading to calls for the development of a vaccine which is “at best” years off. For now the best we can do is avoid endemic areas and be diligent in mosquito control.

CDC and ACP: Stop Prescribing Antibiotics for Common Respiratory Infections

The Affordable Health Care Act has created patient satisfaction surveys which can affect a physician’s reimbursement for services rendered plus their actual employment by large insurers and health care systems. This has created a fear of not giving patients something or something they want at visits for colds, sore throats and other viral illnesses. Aaron M Harris, MD, MPH, an internist and epidemiologist with the CDC noted that antibiotics are prescribed at 100 million ambulatory visits annually and 41% of these prescriptions are for respiratory conditions. The unnecessary use of antibiotics has resulted in an increasing number of bacteria developing resistance to common antibiotics and to a surge in Emergency Department visits for adverse effects of these medications plus the development of antibiotic related colitis. To address the issue of overuse of antibiotics, Dr Harris and associates conducted a literature review of evidence based data on the use of antibiotics and its effects and presented guidelines for antibiotic use endorsed by the American College of Physicians and the Center for Disease Control.

  1. Physicians should not prescribe antibiotics for patients with uncomplicated bronchitis unless they suspect pneumonia are present”. Acute bronchitis is among the e most common adult outpatient diagnoses, with about 100 million ambulatory care visits in the US per year, more than 70% of which result in a prescription for antibiotics.” The authors suggested using cough suppressants, expectorants, first generation antihistamines, and decongestants for symptom relief.
  2. Patients who have a sore throat (pharyngitis) should only receive an antibiotic if they have confirmed group A streptococcal pharyngitis. Harris group estimates that antibiotics for adult sore throats are needed less than 2% of the time but are prescribed at most outpatient visits for pharyngitis. Physicians say it is quicker and easier to write a prescription than it is to explain to the patient why they do not need an antibiotic.
  3. Sinusitis and the common cold result in overprescribing and unnecessary use of antibiotics often. Over four million adults are diagnosed with sinusitis annually and more than 80% of their ambulatory visits result in the prescribing of an antibiotic unnecessarily. “ Treatment with antibiotics should be reserved for patients with acute rhinosinusitis who have persistent symptoms for more than ten days, nasal discharge or facial pain that lasts more than 3 consecutive days and signs of high fever with onset of severe symptoms. They also suggest patients who had a simple sinusitis or cold that lasted five days and suddenly gets worse (double sickening) qualified for an antibiotic

Last year two patients in the practice who were treated with antibiotics prescribed elsewhere for situations outside the current guidelines developed severe antibiotic related colitis. They presented with fever, severe abdominal pain and persistent watery bloody diarrhea. Usual treatment with oral vancomycin and cholestyramine did not cure the illness. One patient lost thirty pounds, the other sixty pounds. Fecal transplants were required to quell the disease. At the same time community based urine infections now require a change in antibiotic selection because so many of the organisms are now resistant to the less toxic, less expensive , less complicated antibiotics that traditionally worked.

“My doctor always gives me an antibiotic and I know my body and what it needs,” can no longer be the criteria for antibiotic use.

Influenza Vaccine 2015- 2016 Season

The Center for Disease Control and Prevention (CDC) has recommended that all adult s receive the flu shot vaccination this coming fall. Our supply of flu vaccine is expected to arrive by September 1, 2015 and we will begin administering the vaccine shortly thereafter. This season there will be three types of intramuscular injectable flu vaccines available. All will contain a non-live attenuated version of the flu viruses. The Senior High Dose vaccine is recommended for all adults 65 years of age or older. The Trivalent or Quadrivalent vaccine is suggested for younger adults. The vaccine will contain 3 antigens including: an A/California/7/2009 H1N1 pdm09- like virus, an A/Switzerland/9715293/2013 H3N2 like virus and a B/Phuket/3073/2013 like virus. It is called a trivalent vaccine because it contains three virus types. The Quadrivalent Vaccine will contain a fourth antigen B/Brisbane/60/2008 like virus.

Please call the office to set up an appointment for your vaccination. Once you have received the vaccine it takes about ten to fourteen days for your body to develop antibodies against the flu. Influenza begins to appear in the northern United States in late October. The season can run through February into March. In South Florida we see little flu prior to Thanksgiving with the disease peaking in late January early February. Immunity in younger healthier patients will last throughout the flu season. Older and sicker individuals see their immunity decrease over time lasting as short a period as 3-4 months in some. The shortened immunity in seniors is the reason we usually suggest they receive the vaccine between Halloween and Thanksgiving. If you have any questions please call the office.

Flu Vaccine will be available at most commercial pharmacies as well as our office and at many workplaces. Please let us know if and when you obtain the vaccine elsewhere and tell us which of the vaccines you received.

I am often asked about adverse reactions and side effects of the vaccine. It is a dead virus. It cannot give you influenza. A successful vaccine will produce some redness, warmth and swelling at the injection site. That means that your immune system is working and reacting appropriately to the injected material. If this occurs put some ice on it and take two acetaminophen. Feel free to call us or set up an appointment to be seen that day so we can evaluate the injection site.

Malaria Cases on the Rise in the U.S.

MalariaThe Center for Disease Control and Prevention (CDC) has reported the number of malaria cases in the U.S. hit a new high in the last reportable year – 2011. There were 1925 cases, including five deaths, which is an increase of 14%.  Not only were there more cases but there were more cases reported as “severe” than in previous years.  Most of the imported cases came from Africa although India had the largest number of cases at 223. Nigeria was next at 213.

The CDC reviewed the use of medications in 929 civilian cases and found that only 57 of the 929 had followed the CDC medication recommendation regimen.  Malaria is a serious disease and causes significant illness and mortality. As our population becomes more mobile, patients need to seek the advice of physicians knowledgeable in travel medicine and follow their recommendations.  

My web site has a link to the CDC website which provides travel information and I maintain a professional relationship with local travel services which keep in stock some of the more uncommon vaccines you need when traveling to exotic locations. Feel free to discuss travel plans in advance by calling the office for an appointment.

Flu Shot Campaign Begins

As school bells ring out announcing a new school year and pigskins fly through the air announcing the arrival of a new football season, the Center for Disease Control and Prevention (“CDC”) begins its annual influenza vaccine campaign.  “Flu” or influenza is a viral illness associated with fever, severe muscle aches, general malaise and respiratory symptoms.  Most healthy children and adults can run a fever for 5 – 7 days and fight off the infection over a 10 day to three week period.  There is clearly a long period of malaise and debilitation in many that lasts for weeks after the acute febrile illness resolves.

The illness is especially severe and often lethal in the elderly, in infants, in patients with asthma and chronic lung disease and in those patients who have a weakened immune system due to disease or cancer treatments. Diabetics and heart patients are particularly vulnerable to the lethal effects of unchecked influenza.

The CDC recommends vaccinating all Americans over six years old against influenza.  Adults can receive an injection, or a nasal application.  The 2012 – 2013 vaccine has been updated from the 2011 – 2012 version based on samplings of current influenza viruses spreading around the world.   It takes about two weeks to develop antibodies and immunity to influenza after you receive the vaccination.  If you received the vaccine last season or had the flu last season you are still advised to receive the 2012 – 2013 vaccine this year because immunity fades with time.  Flu vaccine should have arrived in most physician offices and community health centers and pharmacies by mid- August.  The CDC advises taking the shot as soon as it is available.

The vaccines used are not live viruses so one cannot catch the flu from the vaccine. Side effects usually include warmth and tenderness at the injection site and rarely general malaise and low grade fever a day or so later.  The benefits of receiving the vaccine far outweigh these minor and rare ill effects which can be treated with an ice pack to the injection site and some acetaminophen.  Please call your doctor to set up an appointment for a flu vaccine.

For those individuals who catch the flu we still have several antiviral agents available to treat the illness. These agents should decrease the intensity or severity and duration of the flu. We try to use these medicines as infrequently as possible because the flu can develop resistance to them over time.

Prevention of disease is an ever increasing component of our everyday language. Vaccination against an infectious disease such as flu or influenza is clearly one of the more effective preventive strategies physicians have available to offer patients.  While you are making arrangements to receive your flu shot inquire about several other effective adult vaccines including Pneumovax to prevent bacterial pneumonia, Zostavax to prevent shingles and post herpetic neuralgia and Tdap to prevent whooping cough or pertussis and tetanus.