CDC Flu Webinar: Protecting People with Chronic Conditions from Influenza/Flu

By: Centers for Disease Control and Prevention (CDC)

Julie Yegen: Hi, everybody. Thank you for joining today's briefing on the importance of flu vaccination for individuals with chronic conditions. My name is Julie Yegen and I work with CDC on its National Influenza Vaccination Campaign.

Before we begin, I just wanted to go over a few housekeeping items for today's call. Today's briefing will be one hour long, and please note that it is being recorded for archiving purposes. We will be distributing a PDF of these slides as well as our speakers' bios following the briefing, and please feel free to contact me directly if you don't receive them. My email address is on the screen and will be posted again at the end of the session. And finally, after the moderator panel discussion, we'll open the floor up to questions from attendees.

So, please feel free to type and send your questions to "host" in the dropdown menu next to the Q&A at any time throughout the session, and during the final portion of the briefing we'll get to as many questions as possible. Okay. So, now to introduce today's panelists. First, Dr. Seema Jain. She is a Medical Epidemiologist for the Epidemiology and Prevention Branch in the Influenza Division of the National Center for Immunization and Respiratory Diseases at the CDC.

Her current research focuses on influenza and pneumonia, pediatric influenza, influenza complications, and includes work on understanding factors associated with being at high risk for influenza and its complications. Dr. Otis Brawley is Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society.

CDC Flu Webinar: Protecting People with Chronic Conditions from Influenza/Flu

He's responsible for promoting the goals of cancer prevention, early detection, and quality treatment through cancer research and education. A special thanks to Dr. Brawley for joining us today. Dr.

Len Lichtenfeld with American Cancer Society was originally slated to speak on today's briefing but actually had an emergency eye surgery earlier this week and couldn't make it. But thanks again to Dr. Brawley.

We're really looking forward to hearing from you. Dr. Vincent Bufalino, he's the Senior Director of Cardiology for the Advocate Medical Group, a physician led medical group practicing throughout Chicago and Bloomington Normal. He's responsible for overseeing the work of 100 cardiologists practicing in a network of 10 hospitals in the Chicago area. He currently co-chairs American Heart Association's International Committee and serves on the Heart Association's Consumer Health and Quality Science Advisory and Corporate Relations Committee. Next up is Dr. John Anderson.

He's immediate past President of Medicine and Science of the American Diabetes Association. He's also a board certified internist and just completed a term as president of the Frist Clinic, a 31-member internal medicine multispecialty group in Nashville, Tennessee. He has more than 20 years of experience in the practice of internal medicine with a focus on the care of people with diabetes. Next is Dr. Mitchell Grayson. He's currently an Associate Professor of Pediatrics, Medicine, Microbiology, and Molecular Genetics at the Medical College of Wisconsin. Dr.

Grayson has been the recipient of several NIH research grants and oversees an active laboratory studying the role that viral infections play in the development of allergic disease. He's an active fellow of the American Academy of Allergy, Asthma, and Immunology as well as the American College of Allergy, Asthma, and Immunology. And finally Pamela Coleman. She's a member of Women Heart, the National Coalition for Women with Heart Disease whose mission is to improve the health and quality of life of women living with or at risk of heart disease.

She has always lived with heart disease and continues to battle it daily. Pam is the mother of an 18-year-old and makes sure she teaches him about healthy living and eating. She also continuously educates women about heart disease in her various community service events.

So, thank you to all of our panelists for joining today. We're really looking forward to hearing from you. And before we start the panel portion of today's discussion, I'd like to turn it over to Dr. Seema Jain with CDC to kick us off with an overview of current flu activity and CDC's recommendations for flu vaccination. So, with that I will pass it over to you, Dr.

Jain. Dr. Seema Jain: Great. Thank you so much. Well, I think let's just start off by talking about what's going on right now. So, I think everybody hopefully knows this, but flu activity remains high and widespread nationally. Right now the predominant virus so far this season is 2009 H1N1, which is the same strain of influenza that was predominant during the 2009 pandemic but has also been circulating every season.

However, this season it's the most predominant strain that we're seeing. All of the vaccines that are available for the 2013 to 2014 season are designed to protect against this particular strain of influenza virus. If this flu season continues on this track with 2009 H1N1 being the predominant strain, then flu elements will continue to greatly affect young and middle-aged adults, especially those with chronic conditions. Everyone six months or older needs an annual flu vaccine. There is a special emphasis on people at high risk of flu-related complications, which includes people with chronic conditions such as asthma, diabetes, and those also with neurologic disorders. In addition, pregnant women, children younger than five but especially those who are younger than two years old, and then older adults who are 65 years and older should get vaccinated. In addition, those patients or people who live with and care for those who are at high risk, including health care workers need to get vaccinated. There are a lot of variety of vaccine options this year.

We have our website that's listed here. At this point we have no specific recommendations that we give at CDC. I think the most important message here is to get a flu vaccine. It's certainly not too late to get a vaccine. People with underlying medical conditions such as asthma, diabetes, heart, and lung disease or neurologic conditions are at risk for flu complications. There's a complete list at the website that's listed here. Flu can make chronic health problems like asthma or heart failure or COPD worse.

And people with chronic conditions are more likely to suffer from flu-related complications that result in either hospitalization or in death. People with chronic disease should get a flu shot and not the nasal mist. Flu vaccination is your first line of defense. So, again, as I said before, this is the time, get vaccinated if you haven't already done so. An important adjunct and second line of defense is antiviral medication that can help treat flu illness and also can help prevent complications.

So, if you're feeling sick or think you have influenza, please get in touch with your doctor and see if you need flu antivirals. These are CDC's take three actions to fight the flu. Number one, take the time to get a flu vaccine. It's our first line of defense. Number two, take everyday preventive actions to stop the spread of germs. And number three, take flu antiviral drugs if indicated.

Please follow what's going on with flu activity this season. This is our website where you can access Flu View, which gives local data on what flu strains are circulating and how activity is going. Lastly, this is our website and our flu inbox for any kinds of questions. Julie: Thanks, Dr. Jain. And just to reiterate to folks on the phone and who are joining via webinar, we will be sending these slides around. So you will be able to access the links shared here.

So, now before we again move on to the panel discussion, I did just want to see if Pamela Coleman, who is joining the call today, if she could give – share a bit about her personal experience living with a chronic condition and the importance of flu vaccination for her personally. So, Pam, thanks for joining us and please take it away. Pamela Coleman: Yes. Thanks, Julie. I appreciate it. Good afternoon, everyone. I was born with a congenital heart valve defect which was detected at birth.

I had three open heart surgeries by the time I was 30. My first surgery was at age seven to repair my valve, and unfortunately that was not successful and at age 13 my valve was replaced. And at that time I was put on blood-thinning medication for life. At age 30 I was 33 weeks pregnant and I went into heart failure.

A clot had formed on my aortic valve and prevented it from opening and closing. Doctors feared the clot would break off, travel to my brain, I would have a stroke, and we both would die instantly. I delivered my son, thankfully, weighing 3 pounds 8 ounces via C-section. And 24 hours later I was back in the operating room having my valve replaced for the second time, thus my third surgery.

Heart disease has always been a part of my life. And a few years ago I wanted to give back to the community and help others become aware of heart disease and how to prevent it. So, I became a Women Heart Champion. And just a little bit about Women Heart, it's a nonprofit patient advocacy organization. And their members include women heart patients and their families, health care providers, advocates, and consumers who are committed to helping women live longer, healthier lives. Women Heart supports, educates, and advocates millions of American women living with or at risk of heart disease.

Being high-risk it was always recommended, and as long as I can remember, I always got the flu vaccine to prevent endocarditis or any other valve problems that I may encounter. So, every October my son and I get our vaccine. My son gets his for two reasons.

One, he has respiratory problems; however, even if he was not high-risk, I would still have him vaccinated as a caregiver. So, I want to protect myself as well. It's very important that if he gets sick, that I don't get sick.

I do recall a few years ago he did get the flu, a sinus infection, and bronchitis all at once. And when I took him to the doctors, they checked me out immediately and put me on antibiotics as a preventative measure. So, it is important that family members also consider getting vaccinated as well. Women Heart supports flu vaccination for women living with heart disease because they know how important it is for women with heart disease to stay healthy. Women Heart educates women about the importance of flu vaccinations through webinars such as this and information on their website, which is womenheart.org. In closing, I want to thank Women Heart for the opportunity to partner with CDC to spread the word about the importance of the flu vaccine for women living with heart disease.

And lastly, I want to encourage women living with heart disease to talk to their health care provider about whether they should or should not get the flu vaccine. In my experience every situation is different and it's always best to seek medical advice rather than to do something on your own or something that you don't normally do. So, Julie, I want to thank you again for the opportunity to share my story and my experience with Women Heart and living with heart disease. Julie: Thanks so much, Pam. I think that it's always helpful when we're having a discussion like this to hear from someone who's experiencing it firsthand. So, we appreciate your being here and sticking around for the Q&A at the end of the session. So, now on to our panel discussion. So, so far this flu season the vast majority of adults and over half of children hospitalized with flu have had a medical condition that puts them at high risk for flu-related complications.

So, I'd like to ask each of the panelists to start by explaining the potential impact of flu for people who suffer from the particular condition that you specialize in. So, Dr. Bufalino, I'll ask you to kick off and then I'll go ahead and prompt the other folks on the call to jump in with their information. Dr. Bufalino: Thank you. Good afternoon. And I'm a cardiologist.

And heart disease and stroke are very important to me and the group we represent. And we know that people with heart disease and stroke are clearly at higher risk for developing serious complications from the flu. And if you look at the adults hospitalized last season, the 2012, 2013 flu season, heart disease was the most commonly incurring chronic condition. Forty five percent of the adults that were hospitalized had some form of heart disease. So, we know that influenza is also associated with increased risk of heart attacks and strokes. And the flu vaccine obviously gives us an opportunity to prevent that.

We know that patients in the vulnerable age group, that 18 to 64 group with heart disease, only 48 percent were vaccinated in the 2011, 2012 cycle, which was better than it had been over the 2007 to 2011 seasons. But as you see, clearly we're missing half the folks. So, from our perspective we believe that all patients with heart disease should receive the flu vaccine along with the pneumococcal vaccine to protect them against pneumonia. Pneumonia's a serious complication related to the flu that can actually lead to premature death. So, we think both the flu vaccine and the pneumococcal vaccine are very important for patients with underlying heart disease.

Julie: Great. Thanks, Dr. Bufalino. Dr. Anderson, I'll pass it to you.

Dr. Anderson: I'm an internist in Nashville, Tennessee. So, I do a lot of primary care in addition to having a special interest in diabetes. And one of the most common fallacies that I see around some of my patients with diabetes is that if their diabetes is really well managed, they really are not at increased risk of influenza and they have sort of a lackadaisical approach to getting the flu shot every year. And the actual facts are is if you have diabetes, you are almost three times more likely to be hospitalized for your influenza and you're going to get more complications than other people. In addition, if you do get the flu, even if you're well-controlled, influenza, just like any infectious disease can really wreak havoc with your blood glucose levels.

It can cause huge fluctuations that are out of your predictable day-to-day pattern and makes it a lot harder to manage diabetes, particularly if we're on insulin and on a complicated regimen. It can cause glucose levels to rise because of the infection, the fever, the inflammation. And the body releases stress hormones such as cortisol that can cause blood glucoses to go way up. In addition, you can also have low blood glucose levels. If you're on insulin or any agents that have the potential for lowering blood sugar below normal levels and causing what we call hypoglycemia, you may experience this because you have a decreased appetite. You may not be eating. You may have nausea. Then you can see your glucose levels go down.

But one of the things we tell our patients is you have to measure, and I'll talk about this a little later today, because even if you're not eating, the inflammation can cause glucose levels to surge. And it's a common fallacy well, if I'm nauseated and not eating, then I'm okay. So, if you have diabetes, you just got to monitor carefully. In addition, you have a greater risk of developing the pneumonia that Dr. Bufalino just alluded to.

You've got a greater risk of developing pneumonia by itself or after the flu. So, that's why everyone who takes care of people with diabetes recommends an annual – a pneumococcal vaccination even if you're below 65. Julie: Dr. Grayson, we'll pass it to you now. Dr. Grayson: Okay. Great. Thanks.

I'm going to sound a little bit like a broken record here, but we're going to talk a bit about asthma, which obviously is a lung illness and obviously flu is a lung infection. So, it's not surprising that people with asthma, if they have uncontrolled asthma, that a flu infection will actually make their asthma worse, but what people sometimes forget, and this is similar to what Dr. Anderson just said about diabetics, is that even if your asthma's well-controlled, a flu infection can actually make your asthma exacerbate just like any other respiratory viral kind of thing. And so people with asthma really are much more likely to have breathing problems if they get the flu regardless of whether they're well-managed or not. Obviously if their asthma's not well-managed, they're at much more risk, but either way.

And these asthma attacks with the flu can even lead to pneumonia. So, just like you've just heard with Dr. Anderson and Dr. Bufalino, we recommend getting the pneumococcal vaccine even though that's not really what we're talking about today as well as the flu vaccine in anyone who has asthma. And one thing to remember about asthmatics, that while they are more likely to have a worse outcome from flu, they're not more likely to get flu than anybody else. But if they do get the flu and they do have these exacerbations they're found to have pneumonia more often.

And one last little piece about asthma and the flu is that if you look at children that have been hospitalized with the flu, the most common chronic medical condition they have is asthma. So, it's one of the big risk factors for them getting hospitalized. And a last thing, although Dr.

Jain mentioned this, remember with asthmatics you always because we're talking lung disease, we never want to give flu mist. We always want to give the inactivated virus shot. So, I'll stop there for right now. Julie: Okay. Thanks so much. Dr.

Brawley, I wanted to pass this question to you about the potential impact of flu for people who are struggling with cancer. Dr. Brawley: Hello. We don't know if cancer patients and survivors are at greater risk for infection with the flu.

However, we do know that cancer patients and survivors are at higher risk for complications from the flu, including hospitalization and death if they get the flu. And a recent study found a significant decrease in deaths in cancer patients vaccinated against the flu compared to those who did not have the vaccination. Chemotherapy and cancer both can reduce the number of infection-fighting white blood cells and make it harder for patients to fight infections, especially when they're being treated with chemotherapy. And patients with cancer should get a flu shot and not the nasal spray. Julie: Okay. Thanks so much for that information. Dr. Jain, I was wondering if you could tell us a little bit about the high risk of complications associated with obesity.

Dr. Jain: Sure. And I guess I just wanted to add one thing, which is, you know, in addition to my role at CDC I am also a practicing clinician and internist and infectious disease specialist in the community. And a lot of my patients are at the VA here in Atlanta. And one of the things that we really probably kind of uncovered really more during the 2009 H1 pandemic were risk factors of obesity and morbid obesity. So, you know, let's just stop for a moment and say, you know, what is that? Obesity and morbid obesity are defined on body mass index or most of us will refer to it as the BMI, which is a measure of body fat based on a person's height and weight. And the cutoffs for obesity are a BMI of 30 or greater and then morbid obesity is a BMI of 40 or greater. And what we found during the pandemic was that people who were morbidly obese were at higher risk for flu related complications than those who were not morbidly obese.

And because of this finding and because we found it also during the pandemic, which is, again, as I stated before, the current strain that is circulating is the same strain that we had in 2009. So, during this time we found out that morbid obesity put people at higher risk for flu-related complications. And during that time it became part of the ACIP recommendation for flu vaccinations. So, essentially the bottom line is, you know, if you are morbidly obese but don't actually know that you have any of the other medical problems that all the other panelists have been talking about, whether that's heart disease or diabetes, et cetera, the recommendation is for getting a flu vaccine. And I think it's important to talk a little bit about sort of what we're seeing this season.

So, in addition to the fact that 2009 H1N1 is the most predominant strain that's circulating, our data when you look at flu-related hospitalizations here at CDC, show that out of all the flu-related hospitalizations that we've seen so far, 43 percent of these hospitalizations have occurred in adults who are obese. So, bottom line is if you're either obese or morbidly obese, number one, get the flu shot. If you do develop illness, you really should seek medical care right away. Julie: Thanks for that, Dr.

Jain. I think that, you know, from this first question here it's clear that it's important to get the flu vaccination but it's especially important for people who suffer from any of these chronic conditions to get an annual flu vaccination because of that high risk for complications. So, let me move on to the second question here. It's about why it's important for people who live with or care for someone with a chronic disease to get vaccinated. So, Dr. Brawley, I thought you could talk to us a little bit about why this is a necessity for caregivers of people with cancer.

Dr. Brawley: Sure. By getting a flu vaccination you protect yourself and those around you. This means that your flu vaccine helps reduce the chance that you'll spread the flu and, therefore, reduces the chance that the persons who live with you will actually get the flu. Indeed, most experts believe the flu virus is spread mainly by droplets made when people with the flu cough, sneeze, or talk, and these droplets land in the mouths or noses of people who are nearby.

Less often a person might also get the flu by touching a surface or object that has the flu virus on it and then touching their own mouth, nose, or eyes. Most with the flu can spread it to others about six feet away, by the way, when sneezing and coughing and things. And most healthy adults may be able to infect others from one day before they actually have symptoms to about five to seven days after they get sick.

This means that there's a whole bunch of people who can pass the flu to someone and not even realize that they're sick or that they're actually passing the flu along. Children and people with weakened immune systems can shed the virus for longer and still might be contagious past five to seven days, by the way, especially if they still have symptoms. Julie: Thanks, Dr.

Brawley. I think that that question helps put in context why this is an important topic even for those who don't suffer from a chronic condition. It's about the importance of getting yourself vaccinated to stay healthy yourself and to not spread the germs to others. So, our next question is about pediatric health. And we have folks joining us today who focus on children's issues and children's health. So, Dr. Jain, I was wondering if you could talk about the importance of flu vaccination for young children specifically? Dr Jain: Sure. I guess I'll add my other hat here, which is a mom of three, all six and under.

So, I think, you know, the number one point here is that we know that influenza is – that children both under five and, as I mentioned earlier, children who are under two are at greater risk for flu complications. That includes both hospitalization and death. And that is true in most seasons. And then this particular again with H1N1 being the circulating strain, it's some of these older children and younger adults who are at risk. So, I think a few things that one needs to understand about kids is that kids are a little bit different than big people, as we all know. Some kids that are six months through eight years of age actually need two doses of the flu vaccine. And children in this age group who are getting vaccinated for the first time as well as some who have been vaccinated previously might need two doses.

So, it's really important when you're talking about the flu vaccine with your doctor, to understand what your previous vaccination records have been and how many doses you actually need. So, that's one of the sort of more specific points about kids and the flu vaccine. I think the other thing to think about is that every year we see that children who get infected with influenza die. This season so far we've had 28 influenza-related pediatric deaths as of January 18th. Last season, 2012, 2013, we had a total of 171 flu related pediatric deaths. And during the pandemic – so, during the 2009, 2010 season, we had three hundred and fifty eight influenza-associated pediatric deaths. So, you can see that during the time when we had H1N1 circulating during the pandemic, we had many more, almost twice as many deaths than we saw last season. Again, this is the same strain that is currently circulating.

And from the data that we've seen through our surveillance systems here at CDC, what we found is among children who are six months or older, about 80 to 90 percent of flu-related pediatric deaths occur in those children who did not get a flu vaccine. So far, many of these children, about half when we've looked at it, have chronic conditions that we've already talked about, but half of them actually don't have any chronic conditions as well. So, I think the bottom line is kids are really an important group to think about when we think about flu vaccine and also antivirals during this season and any season. Julie: Thank you.

We focused largely on the importance of preventing flu, especially for people that are at high risk for severe complication. So, let's talk for a minute about what people with some of these chronic conditions should do if they get the flu. So, Dr.

Bufalino, if you'll kick us off, then I'll ask Dr. Anderson and Grayson to talk about what to do if someone with diabetes or asthma gets the flu. So, Dr. Bufalino. Dr. Bufalino: Thank you.

I guess I'm most worried about Dr. Jain with three kids under six. If they get the flu at their house, they've got a real handful. So, good luck with that. So, I'm glad you're all getting vaccinated.

Dr Jain: Well, we get vaccinated. Dr. Bufalion: Thank God for that.

So, you know, for us obviously we're concerned about people who are high risk for the flu, that they need to get in and see their doctor promptly. You know, if you listened to Pam Coleman's story here, three valve replacements, she's clearly somewhat at high risk. Particularly in our heart failure patients, those are our most sensitive group of folks who are many times tenuous.

And so even if they've been vaccinated, if they get sick, we want them to get in and see their doctor quickly because many of these folks will need to be treated with antiviral drugs. And, you know, it's sort of based on what their syndrome is, but the opportunity to treat them shows that, you know, we can maybe make that episode of the flu milder or that the time that they're ill a shorter period of time. So, that's important for us to help lead to preventing these complications because if you have an underlying condition like heart disease, you know, it may mean the difference between a quick brief illness and something serious that could end up with a hospitalization or a very prolonged hospitalization with a stay in intensive care. So, we think that the antivirals work best within the first two days of the flu symptoms once they first appear, although the data suggests that they're beneficial out to about five days after getting sick.

So, it's very important for that high-risk group, as I said earlier, because that's the folks who are likely to get the sickest and probably need to be treated early on in their illness. Thank you. Julie: Thanks, Dr. Bufalino. Dr. Anderson? Dr. Anderson: Yes. As I said before, people with diabetes can have real fluctuations in their blood sugars because of being ill.

In addition, if anybody's – all of us have been ill before. You know it keeps you from eating properly. You're nauseated. That can further affect blood glucose levels. But I think one of the most important things to tell your patients is continue to take your oral medicines or your insulin. Don't just assume because you're ill and you're not eating as much that you are to stop your medication. And this is a time to be on the phone with your health care provider or in communication with their office so you can be guided through this illness.

I mean you may even need more insulin with the inflammation and the fever and the illness than you had before even if you're not eating much. And then the other part of this is you need to be checking your glucoses rigorously. We recommend every four hours, before breakfast, lunch, and dinner, and at bedtime. And then not just check them but keep track of the results because if you're not following the trends, then you're not going to be able to make the right decisions. The other part of this for people with diabetes, and this is probably true for all people who get influenza, drink extra fluids. Stay hydrated. And for people with diabetes, that means non calorie containing liquids, not Mountain Dew.

Okay. But you also try to eat as normally as you can. And if you don't feel like eating a lot, eat small meals. Eat soft foods.

Try to get enough carbohydrate in to match the regimen and the medications that you're on. And then we tell our patients to weigh every day. We know that when you're losing weight rapidly in an illness, especially if you have diabetes, it's a sign not only of possible dehydration but also that your glucoses may be soaring. And then we also advise our patients to check their temperature in the morning and in the evening.

Keep a sign, keep a log of the trend and report that back to your health care provider. I think the last thing I'd like to say about this is when you feel lousy and you're terribly ill with something like influenza, that's not the time to make up your mind to decide what to do. I think every patient needs to have that discussion with their health care provider if they have diabetes about what should my sick day protocol look like so that you have an action plan before you get sick. Thanks. Julie: Thanks, Dr. Anderson.

Dr. Grayson? Dr. Grayson: Well, so for someone with asthma, the first part about if they get the flu is the same as anyone else. If you get sick with flu symptoms, you want to call your doctor. And if your doctor recommends it, take the antiviral drugs. And it's important to call as soon as possible because the treatment with the antiviral drugs works best, as actually Dr. Bufalino has said, when started early, preferably within the first two days of the onset of symptoms.

And the drugs that we have for treating the flu are oseltamivir or Tamiflu, which is the pill form. You require a prescription to get that. So that's why you got to call your doctor.

And it fights by keeping the flu from replicating and making more copies of itself. Now, for people with asthma there's a couple of issues. There's another anti-flu drug, zanamivir or Relenza, which is actually an inhaled medicine.

And we don't recommend this for people with asthma or any lung disease because it's been shown to actually make lung disease worse. So, if you have asthma, you really want to make sure you get the pill, the oseltamivir or Tamiflu. The other issue with somebody with asthma is you should have an asthma action plan kind of like what Dr. Anderson just mentioned for diabetes, but we have an asthma action plan with the green, the yellow, and the red zones as far as how your breathing is going. And when you begin to have symptoms of flu, that's the time to start thinking about moving into the yellow zone.

Again, you'll be talking to your doctor and letting them know. So, I think that's an important thing to remember because that's going to try and keep your lungs, for a person with asthma, from getting any worse and hopefully preventing an asthma exacerbation down the road. Julie: Thanks so much. Okay.

So, our last question for this moderated portion of the discussion is about steps to take to prevent flu. So, Dr. Jain, you touched on this at the start of the briefing, but is there anything that you'd like to leave us with now or reiterate before we take a few questions from the audience? Dr Jain: Sure. I mean I think everybody here has really emphasized, and I think the most important thing is that getting an annual flu vaccine is always the best way to prevent either flu complications and also the spread of influenza. So, particularly people with high-risk conditions as we stated before should get the flu shot and not the nasal spray. So, that's always number one.

And as long as flu is circulating, which it is now, everybody can benefit from having a flu vaccine. I think, you know, number two which we've also talked about before is if folks do get sick, to get in touch with their doctor about whether or not antivirals are needed. Then there are a lot of other preventative ways to stop the spread of germs, particularly influenza. A few that I can talk about a little bit is, one, covering your nose and mouth with a tissue when you cough or sneeze and then obviously throwing the tissue away when you're done and then washing your hands. Avoiding close contact with sick people. Staying at home when you're sick and then while sick limiting contact with others as much as possible to keep from infecting them. And a few other things would be avoiding touching your eyes, nose, or mouth because that's another way that influenza and other germs can spread.

And then not last – not, you know, what is it? Last not before least is that washing your hands often with soap and water is very key to stopping the spread of influenza and other germs as well. And if soap and water are not available, then alcohol-based hand rubs are also effective. Julie: Great. Thank you.

So, now for the audience Q&A portion of the session. Feel free to type your question in the Q&A box, and I will – we'll scroll through those questions if they come in. And while you're kind of thinking about your questions, I did just want to post this slide with website and social media links to the organizations each of our panelists are representing today. As I said, these slides, along with our panelists' bios, will be sent to you following the briefing. So you'll be able to capture these links then.

If you don't receive them or if you have any further questions, you can feel free to contact me and I'll help you get connected to the right resource. My email is JulieYegen@westat.com. And for those of you who are on the phone only, I'll just real quickly spell that out.

It's J-U-L-I-E-Y-E-G-E-N at W-E-S-T-A-T.com. Let me go back to our Q&A section. If anybody has any questions, again feel free to type any in. I do see one coming in now. Are there any medical conditions that people should not get a vaccine for if they have them? I've heard people with a chicken allergy should not get vaccinated. Dr.

Jain, that might be a question for you to start off answering. Dr. Jain: Sure.

The biggest group is folks with egg allergies. So, even though now we actually have some vaccines that folks with egg allergies could get, but one does have to ask their doctor about that. But other than that there really are not any particular groups that I can think of. I think the key here is what we've been talking about is that there are differences between getting a flu shot and getting the flu mist. And so those with chronic conditions that we've been talking about shouldn't get the mist but can get the flu shot.

And then folks with egg allergies should talk to their doctor. Dr. Grayson: This is Mitch Grayson. I'm just going to jump in. Most of the people, most of the kids with egg allergy, it's not a problem. They'll tolerate it fine, but, yeah, they should talk to their doctor.

Sometimes they have to get divided doses just to make sure they're not going to react. Dr. Bufalino: Vince Bufalino on the heart side. I would just add in it's actually the opposite.

We want our sickest patients to be included, our heart transplant patients, our mechanical heart device folks. Those are the folks that we're most worried about. So, we wouldn't exclude anybody on our side. Dr. Jain: Yeah.

I think that's absolutely true. I think that goes for really every group. Julie: Thanks, all. Another question we got is what if someone got the flu already this season? Should they still get vaccinated? Dr.

Jain: Yeah. Well, I think I could probably deal with that. This is Dr.

Jain again. Yes, actually they should. And just a little bit of a more complicated answer to this question, but, you know, what we often see in influenza is that you have like right now what we're seeing is that we're seeing that influenza A, specifically H1N1 is the circulating strain. However, there are other strains of influenza. And often after we see influenza A, we actually see a little bit later influenza B outbreaks occurring. Currently the vaccines all have at least one B strain and then there's the quadrivalent vaccine, which has two B strains in it.

So, you know, we recommend vaccination even if you already got sick this season for multiple reasons, but one of the main ones is because we can never predict with influenza what's going to happen, but often after we see an A epidemic, we will often then see a B epidemic as well. Julie: Thanks, Dr. Jain. It looks like one of our attendees has a question, and I'm going to go ahead and unmute your line. Jackie Boche, did you have a question that you wanted to share with the group? Jackie: I think it's already been answered about summarizing each of the speakers to clarify and summarize which vaccination method, the shot versus the mist, is really recommended for each of the diseases, but I think we already covered it.

Julie: Great. Yeah, I think that what we covered was that the flu shot is recommended over the vaccine. I'm sorry, over the nasal mist. One other question that we've got in. If kids under six months can't be vaccinated, what's the best way to protect them? And, Dr. Jain, I'll go ahead and pass this one to you too if you don't mind. Dr.

Jain: Sure. No problem. So, the key for this group is their moms. So, we really want mom – pregnant women need to get vaccinated because that's their main way – the main way for children under six months to have – to be protected for influenza. But not just the moms but all the family members who are living with and around children under six months should get vaccinated. And then some of the other measures are the things that I had talked about earlier in trying to prevent germs in general using good hand hygiene and avoiding contact with an infant under six months if you're ill. And I'll put one more plug in is for, you know, the health care workers in hospitals and clinics and institutions that are taking care of infants. The greatest way you can help is by getting a vaccine.

Julie: Okay. Thanks. And in the similar vein there's a question about for people with chronic disease is there an age group that is more at risk than another or does chronic disease at any age put you more at risk in general? And if any of our other panelists want to jump in on that before if, Dr. Jain, you want to comment too, feel free. Dr Bufalino: This is Vince Bufalino on the heart side.

You know, unfortunately our oldest patients tend to be the sicker group in general although obviously we have younger people with significant underlying structural heart disease who would be at risk. But, you know, our elderly population is always the group that we're concerned about and frankly, you know, we have a growing elderly population. The number of folks that we have in their 80s and early 90s is a number that is climbing. And so obviously those are the folks we'd probably have the most concern about. Dr. Anderson: This is Dr. Anderson.

I agree. You know, both my patients with diabetes and without diabetes, our elderly population is particularly vulnerable. So, we not only talk to them about the musts of a flu shot but also good behavior during peak flu seasons when we have epidemics around. Dr.

Grayson: This is Dr. Mitch Grayson. I'm going to take the opposite side for asthma. We're really worried about the kids more so than adults. But again, elderly are also a problem, but in the case of asthma it's a lot more kids that are ending up in the hospital.

Dr. Jain: This is Dr. Jain again. Let me add in that I think it's complicated. I think that for all of these groups it's true that when you're looking at heart disease and diabetes, it's more likely that you have heart disease or diabetes because you're older.

Flu is really interesting because generally we have influenza that affects the very young, so children under five, and then also the very old. And we talk about elderly, but when we say that, we're talking about 65 years and older and sometimes even 50 years or older. But what's so interesting about this influenza season is that the H1N1 virus predominantly affects actually younger adults from age 18 to 49. And some of those patients and people will have some of these chronic conditions and some won't. So, really the key message is that there is a universal vaccine or a recommendation so that people are covered annually for whatever flu virus is circulating. Julie: Thanks. Another question is to all the panelists who are currently practicing medicine. They're wondering if you've seen patients personally who have been affected by flu and kind of talking about your experience dealing with it firsthand.

Dr. Anderson: Well, I guess I can jump in since I'm an internist and a primary care physician. We had a little bit of a bump in December with some of the influenza. And we've had a lot of positive nasal swabs in our emergency room. As a primary care physician, you know, we try desperately to keep these patients out of waiting rooms and our hallways. So, we're very careful about taking a history and sometimes even without nasal swabs, we will treat prophylactically if the patient's really sick and as we've all said, trying to get it within the first 48 hours.

The only other part I'd like to say as a primary care physician is it used to be that the flu shot was the purview of your health care provider. One of the things I emphasize to my patients now is I don't care where you get your influenza vaccine. I mean they are at pharmacies. They are at schools. They are at places of work. They are available in our office. So, I always tell my patients get the most convenient location and get it done.

Don't let the need to come to the physician's office be a barrier. Julie: Thanks, Dr. Anderson. Is there anybody else who wanted to comment on that one? Dr. Bufaliono: This is Vince Bufalino on the cardiology side again.

You know, we had a flurry of this in January. We had at several of our institutions a number of folks with congestive heart failure admitted with significant influenza illnesses. And, you know, as I said earlier, it really tips the balance in these folks who may be borderline compensated and it pushes them over the edge. Some of them get dehydrated and it affects their kidney function. You know, we have to adjust all of their drugs.

They develop low blood pressure and, you know, need to be hospitalized and replaced with fluids. A number of things happen in terms of disrupting their stable state. And so, you know, we're always very wary of this time of the year. Julie: Thanks. Okay. I'll leave the question section open as I close out here a few minutes early. I did want to give the panelists each a chance since we do have just a couple of minutes. Is there anything else that you'd like to add or kind of close out with, you know, knowing that this topic of flu vaccination for chronic conditions is so important? I just wanted to give everybody a chance to say a final few words.

So, maybe, Dr. Bufalino, if you don't mind, I'll kick off with you for closing remarks. Dr. Bufalino: Sure. Our biggest concern is that only half the folks are getting vaccinated.

It's a real problem from our perspective because people don't realize, you know, you're doing well and feel compensated so you don't think you need it, but the truth is all of our patients need it. So, we would implore particularly the group of folks with underlying heart disease to make sure they get vaccinated each and every year. Julie: Thanks. Dr. Brawley, and I apologize that Dr. Lichtenfeld's name is still on the slide. And thank you again so much for joining us today.

Dr. Brawley: Not a problem. Julie: Is there anything that you'd like to leave us with at the end of this session? Dr.

Brawley: Yeah. I would say that the major thing that all of us have said is there are very few, very few downsides to getting the flu vaccine; tremendous upsides. And I would encourage people to get the flu vaccine because it actually is one of the few things that we have in medicine that so clearly saves lives and clearly reduces suffering.

Julie: Thank you. That's a great message. Dr. Anderson? Dr. Anderson: I think the only thing I would close on is this is an ongoing conversation with your patient population.

I think the public awareness about the importance of a flu vaccine has really taken off in the last 5 to 10 years. I hear very few of those patients who still remain that say well, you know, the last time I had the flu vaccine I got ill from it. And I think that's a credit to our public awareness. But I agree. We still have a long way to go.

And this should be just a part of routine general conversation with your patients every time the fall and winter seasons start to come along. Julie: Great. Thanks. And Dr. Grayson? Dr Grayson: So, get vaccinated.

Get vaccinated. Get vaccinated. I mean I think that's the key point. And obviously people with asthma, if they do come down with a respiratory disease like the flu, that they should follow their asthma action plan. But really the key thing is like everybody's saying, get vaccinated. Julie: Thanks.

And, Pam, thanks for sticking with us. I'm curious to know, you know, as someone who is living with a chronic condition, you know, what does hearing this information from all of these experts, you know, how that makes you feel about the importance of vaccination. Pamela Coleman: Absolutely. I feel like each and every one has been speaking to me personally because I do have the chronic disease. I have an aortic prosthetic valve. So, as Dr. Bufalino had mentioned, you know, I am at higher risk for the bacteria and everything to develop around the heart muscle. So, that is a big concern of mine.

And having a son that has asthma, both of us having two chronic diseases in the household, he's been getting his flu shot since he was six months old, and he had the double dose because he has food allergies. So, he had the one dose and the second one. But he is highly recommended by his pediatrician to get the flu shot every year, as am I. And it's just wonderful to know that we're doing the right thing to stay healthy in our house and how I will continue to encourage other people who have their doubts about getting the flu shot how important it is, especially if there's someone with a chronic disease in their household or they, themselves, have a chronic disease, to get a flu vaccine. So, I want to thank everyone personally for this information because I definitely will take it away and share it with co-workers and family and friends.

Julie: Thanks so much, Pam. And, Dr. Jain, I just wanted to give you a moment to offer any closing remarks.

Dr. Jain: Sure. I mean I think I'm just going to reiterate what everybody said, which is vaccine, vaccine, vaccine. However, I think, you know, I think it was Dr. Bufalino who talked about how our population is not well-vaccinated, and I'd like to make a point that again because the H1N1 virus is the main circulating strain right now, we do know that amongst the people who are at highest risk, so that group from 18 to 49, they're also the least likely to get vaccinated.

And so right now from fall estimates only 30 percent of people who are age 18 to 49 were getting vaccinated. And that's at least 10 points lower than our national average is. So, you know, as providers the message needs to get out that this group is at risk, particularly this season. So, that's the number one take-home message. And the second is for both for people who are patients who are on the line but then also clinicians who are providing care, all of the groups here represent groups that are at high risk for getting flu-related complications. So, these groups when they come into outpatient clinics or in hospitals and if they're coming in with influenza or suspected influenza, really should get antivirals. So, that's the other message to get out there because we don't use influenza antivirals as much as we should be either.

Julie: All right. Thank you so much. And a big thank you to all six of our panelists for providing information about flu vaccination and these high-risk conditions. Thank you also to all who joined today's briefing. We hope that you heard some valuable information that you can then use, whether it's on a website or a blog, newsletter, social media, anywhere that can really help us spread the word about the importance of flu vaccination.

My contact information is up on the slide. And again, we'll send these out to you and please feel free to follow up with any questions that you might have. And with that, another thank you, and I will close the session. Thanks, everybody.

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