It’s That Time of the Year

We have declared December Cold & Flu Month. Look around. Adults are coughing and sneezing and assuring you, “Don’t worry. I’m not contagious anymore.” And the children, ah, the little darlings, obviously are confused: They think their clothing and the backs of their hands are interchangeable with Kleenex.

Throughout the month, Health will equip you with everything you need to know in this seasonal battle. Today, we give you fever, antibiotics, vaccines and products--and lots of other stuff:

Fever

Perhaps no aspect of cold and flu season is more universally misunderstood than fever.

And it’s not just consumers who are confused about the good, bad and ugly characteristics of fever. Even the top scientific brains around the world are, admits one researcher, “beginning to realize everything we don’t know about fever.”

One reason for the confusion dates back about 100 years when people suddenly began to view fever very differently. At that time, drugs to reduce fever were invented, and people began to fight fever instead of embracing it as a good thing, says Matthew J. Kluger, a scientist at the Lovelace Respiratory Research Institute in Albuquerque, N.M.

“For thousands of years, fever was considered a protective response, and fevers were induced by physicians to combat certain infections. But with the advent of antipyretic drugs [medications that block fever], physicians started reducing fevers, and fever therapy was virtually abandoned,” he says.

Historically, humans found ways to warm themselves when they had a fever and, even today, our human tendency is to crawl under a blanket when we’re feverish. His studies show that the urge to warm oneself during a fever is common throughout the animal kingdom; even a feverish lizard will crawl onto a warm rock when infected with germs.

And, in recent years, Kluger says, “the view of fever as a defense mechanism has reemerged.”

Eventually, this may lead to another shift in the way doctors treat fever and to new treatments, says Kluger, who recently co-chaired an international meeting on fever sponsored by the New York Academy of Sciences.

Even the most basic question--should a fever be lowered by drugs or other means?--needs to be addressed, Kluger says.

“We don’t know if taking fever-reducing medication is a good thing to do,” he says. “In humans, there is very little data on this. People like to take drugs, such as aspirin or ibuprofen, to block fever. But if you can allow the fever to run its course, you might reduce the duration of the illness. It’s time to do careful, clinical studies on whether allowing a moderate fever to run its course decreases the duration of an infection.”

In the future, you may be able to leave a fever alone without suffering. Researchers have identified numerous substances, called cytokines, that induce fever. Cytokines are proteins that regulate response to infection and inflammation. There are also many substances in the body that regulate fever to keep it from getting too high. “The fever is a balancing act between these two,” Kluger says.

Identifying these cytokines and what each does may help scientists target the specific causes of the sleepiness, body aches, chills and loss of appetite that typically accompany fever.

“If we better understood the causes of fever and how to modulate these cytokines, we may be able to find ways to let a fever run its course while the discomforting effects of the fever are prevented,” Kluger says.

Moreover, identifying the cytokines that cause sleepiness and loss of appetite during fever may even help researchers come up with new agents to treat insomnia and obesity.

Some doctors who are attuned to evolutionary biology agree with the idea that a fever should be allowed to run its course, Kluger says. “But there is a large group of people who don’t know this.”

And, in general, Americans have an unreasonable fear of fever, says Dr. Mark Stegelman, a pediatrician with the Eagleston Children’s Healthcare System in Atlanta.

This fear causes many unnecessary visits to doctors’ offices and emergency rooms each year--particularly when the patient is a child, according to the Assn. for the Care of Children’s Health. One study found that fever was the principal complaint among as many as 30% of all patients seen by pediatricians.

But fever is rarely harmful, says Stegelman, a spokesman for a new ACCH campaign to help parents understand fever in their children.

“The major misconception is that fever, in itself, is a disease. But it’s a symptom of another illness,” he says. “Fever does have some beneficial effects. We talk about lowering the temperature for one simple reason: to make the child more comfortable.”

But according to one survey, 62% of parents believe that high fever could cause permanent harm. (Half of the parents surveyed were even fearful of moderate fever.)

“Only extremely high fevers, of 108 degrees Fahrenheit or higher, have been known to cause brain damage. And those fevers are usually linked to specific illnesses,” Stegelman says.

Only fevers of 105 degrees and higher need immediate attention, he says, mainly because they are a clue that a serious infection could be present. In addition, infants younger than 3 months with any fever should be checked out. A child with a high fever who may have a potentially serious illness may also have one or more of these symptoms: stiff neck, difficult to awaken, skin rash or seizure.

To offset the fear-of-fever mania in the United States, the ACCH is promoting a new informational tool to help parents address fever in a rational way. The method is called C.A.L.M.:

* Check your child’s temperature.

* Assess other signs and symptoms your child may have.

* Lower the temperature of the environment to make your child more comfortable.

* Monitor your child’s behavior and temperature.

The approach instructs parents to try lowering fever first by reducing the room temperature to between 65 degrees and 70 degrees, removing heavy clothing, applying cool compresses to the forehead and arms, giving fluids and keeping the child in bed. If the child is still uncomfortable, medication to lower fever can be given.

According to a Kaiser Permanente study, 88% of parents who were given fever education felt they were better able to respond to their children’s fevers. They also made about one-third fewer trips to the doctor’s office because of concerns about fever.

For a free C.A.L.M. brochure, call: (800) 997-2256.

The ABCs of Antibiotics

Over the next few months, millions upon millions of prescriptions for antibiotics will be written for wintertime infectious illnesses. Most are silently accepted by the patient and faithfully filled at the pharmacy.

But how often do you, as a consumer, question whether the antibiotic you’re getting is the right one for you?

If you’ve never thought about that, you’d better start. Increasingly some of the most popular--and least expensive--antibiotics are losing their punch against an array of bacteria. And yet these very antibiotics may be the ones that your HMO demands be prescribed first, says Dr. Gideon Bosker, an expert on medications at the Oregon Health Sciences University.

Meanwhile, several newer, but expensive, antibiotics, remain on the shelf.

According to Bosker, author of a new book, “Pills That Work, Pills That Don’t,” (Harmony Books), Americans have done a great job questioning their doctors about many aspects of health care and participating in decisions. But when it comes to prescription medications, most consumers are hands-off.

His book, which addresses all kinds of medications, not just antibiotics, is designed to arm consumers with the knowledge they need to look out for themselves.

“The book is not designed to tell patients to become the architects of their own drug regimen. It’s designed so the physician and patient are steered toward medication based on unbiased, neutral information,” Bosker says.

And, when it comes to the antibiotics typically prescribed for wintertime infectious illnesses--such as bronchitis, sinusitis, ear infections, strep throat and pneumonia--consumers should realize that they may not be getting a “neutral” opinion on what medication will work best. This is because, under many managed-care plans, drug formularies exist to guide doctors on what to prescribe.

The goal of drug formularies is to keep costs down, Bosker adds.

“These decisions go on behind what I call ‘the drug secrecy barrier,’ ” he says. “The physician is incentivized into trying the least expensive medication. But selecting cheaper medications is just like selecting cheaper technological products. You are downgrading consumers to medications that may not work as well.”

(In response, several managed-care officials point out that drug formularies vary widely among companies and that individual physicians have various opinions on which antibiotics work best. It may be best for consumers to question their own insurer about the choice of antibiotics on its drug formulary.)

Drug-formulary restrictions on antibiotics are a particular problem, Bosker says, because so many of the medications are beginning to fail against certain bugs. The sweet-tasting, pink antibiotic amoxicillin is a good example of the cheaper-but-less-effective dilemma.

“I call it Big Pink because it has been such a warhorse for so many years. And it’s still recommended very often as the initial choice,” says Bosker. “Yet we know that the window of bacterial vulnerability is so large that when you give this drug, you are playing a little Russian roulette in that it may not work. Wouldn’t you think your health plan should step up to the plate and get [the patient] well on the first try?”

He puts amoxicillin in the avoid-if-possible category of his book. Ceclor and Suprax are two other common antibiotics for ear and sinus infections that are “rapidly losing their punch,” he adds, while erythromycin for pneumonia is not as effective as it used to be.

Besides the problem of drug resistance, Bosker says, doctors and patients often fail to consider if the antibiotic is the right “fit” for the patient:

* Could it interfere with other medications the patient is taking? For example, some antibiotics render oral contraceptives useless.

* Does it taste good? This is very important if the patient is a child. For example, avoid Ceftin, Defzil and Biaxin if palatability is an issue.

* How many doses a day are administered, and for how many days? This is another important consideration when the patient is a child in school or day care, or among adult patients who are poor at complying with a medication regimen. For children with ear infections, for example, Lorabid tastes good and needs to be given only twice a day while Pediazole tastes bad and must be given four times a day.

* What does it cost? A suitable alternative to an expensive medication should be considered for patients paying out-of-pocket and who are concerned about cost.

In recent years, Bosker notes, several antibiotics have come on the market that require only one dose a day or require only five days of treatment. For example, Zithromax Oral Suspension covers all the bugs, needs to be taken only once for five days and is a great alternative for patients who forget to take pills, he says. One study showed that at the end of a 10-day course of antibiotics (the most common dosing regimen), only eight out of 100 people were still taking the medication.

“We know the failure to take a medication is one of the primary weak links between the prescription the doctor gives you and a cure,” he says.

Vaccines: Your Best Shots

If you are among the millions of Americans who are advised to get a flu shot each year, you may be missing out on an equally powerful tool to prevent serious infectious disease.

The pneumococcal vaccine is an intramuscular shot that protects for five or more years against some of the biggest killers of the winter.

Pneumonia, meningitis and bacteremia account for about 40,000 deaths each year in the United States, usually during fall and winter. But at least half of those deaths could be prevented if more Americans knew about the pneumococcal vaccine, according to federal health officials.

The vaccine, which protects against the common, and increasingly deadly, bug called Streptococcus pneumoniae, is among the best-kept secrets in public health. It’s a secret, experts say, that badly needs to be shared.

Approximately 31 million Americans 65 and older and roughly 23 million Americans younger than 65 are considered at high risk for pneumonia, meningitis or bacteremia (also called sepsis). Yet, well under 25% of these individuals are getting the pneumococcal vaccine.

“This is a good vaccine that is under-utilized,” says Dr. Raymond Strikas of the federal Centers for Disease Control and Prevention. “It’s not expensive. It’s readily available. Anyone who should get a flu shot [under CDC recommendations] should get the pneumococcal vaccine at least once. Ask your doctor: ‘Should I receive this vaccine?’ ”

According to CDC guidelines, the vaccine should be given to people 65 or older, unless they have had the shot within the past five years. It is also recommended for people 2 to 65 who have chronic illnesses, such as heart, lung or kidney disease; people with diabetes mellitus; and people who have weakened immune systems, such as those undergoing cancer treatments, those infected with HIV or organ transplant recipients.

The CDC recommends the vaccine for Native Americans and Alaskan natives, regardless of an individual’s age or health status, because of their high prevalence of infection. Healthy people younger than 65 who have had pneumonia previously may also want to discuss the vaccine with their personal physician.

The vaccine is marketed by both Merck & Co. (Pneumovax 23) and Lederle Laboratories (Pnu-Immune 23) and is covered by most health plans. The safety of the shot has long been established, with the only typical side effect being a sore arm for a day or two, Strikas says.

Pneumococcus is a bacterium that colonizes in the upper respiratory tract. From there, it can wreak havoc in susceptible people. It causes about 3,000 cases of meningitis (when the bacteria infect the central nervous system) each year in the United States as well as 50,000 cases of bacteremia (bacteria infect the bloodstream); 500,000 cases of pneumonia; and 7 million cases of otitis media, or middle ear infection. It can also cause sinusitis.

Moreover, the vaccine--which protects against 23 strains of S. pneumoniae--is taking on increased importance as the bug becomes resistant to an increasing variety of antibiotics. Treatment for resistant bugs often requires the use of expensive alternative drugs and may result in prolonged hospitalizations and higher costs, the CDC notes.

So, if this bug is causing this much illness, why aren’t people rolling up their sleeves?

According to Strikas, the public is strangely unaware of the vaccine, even though it has been around for about 20 years. Not enough health care professionals think about it, either.

Many opportunities to vaccinate people are missed, says Strikas. One study revealed that two-thirds of people with serious pneumococcal disease had been hospitalized within the previous four years but had not received the vaccine.

There is some debate over how effective the vaccine is in preventing pneumonia. While it is clearly effective in curbing bacteremia and meningitis, studies looking at pneumonia have been mixed, with some showing that the vaccine reduces cases and others showing it has no impact.

However, a recent study in the Journal of the American Medical Assn. found that use of the vaccine just in elderly people to prevent bacteremia alone would be overwhelmingly cost-effective. For the 23 million elderly people who were unvaccinated in 1993, the study found that vaccination would have gained about 78,000 years of healthy life and saved $194 million in health care costs.

Low vaccination coverage in high-risk groups, the authors conclude, “is wasting both lives and money.”

The vaccine may become even more far-reaching. Studies are underway to examine whether a variation can reduce sinus and ear infections in young children.

The bacteria cause 30% to 50% of all cases of middle ear infection and sinusitis in children, according to the CDC. Ear infections account for 24 million visits to pediatricians each year.

The vaccine in use now, however, appears to be ineffective in children younger than 2, in general, as well as being ineffective in preventing middle ear infection and sinusitis. Several studies are underway to test variations of the vaccine that will better target those illnesses, Strikas says.

A potent pneumococcal vaccine for children could potentially prevent 86% of all cases of bacteremia, 83% of meningitis cases and 65% of otitis media infection in children younger than age 6.

The Products: What’s Hot

“Natural” is the buzzword for this cold and flu season.

Instead of shuffling down the “colds” aisle in the pharmacy to stock up on the cough syrup, antihistamines, decongestants and throat lozenges, consumers may shuffle down the “supplements” aisle to pluck some vitamins, minerals and herbs.

At least that is what pharmaceutical manufacturers are predicting.

While there is still no cure for the common cold, hopes are rising that some specific vitamins, minerals and herbs will alleviate cold symptoms and reduce the duration of colds more effectively than the traditional products.

“There are a lot of good uses for natural products. And, certainly, there is a big movement in America in taking supplements. But it’s always best to show your doctor the product that you want to take first,” advises Dr. Russell Zwolinski, a Chicago internist.

* Echinacea has emerged as the most popular choice to fight off winter respiratory illnesses. You’ll often find it sold in combination with goldenseal, another herb that is thought to help boost the immune system.

There is some evidence that echinacea works to bolster the immune system and cut the duration of the common cold. About 25 studies have been done on the herb. But most of those studies were done using injected echinacea, says Bosker.

“Whether the oral products do the same is not known,” he says.

A variety of echinacea supplements is available from natural-products manufacturers. And, in a sure sign that natural products are capturing Americans’ fancy, even major pharmaceutical companies like Warner-Lambert have entered this arena. Its new offering is Celestial Seasonings Herbal Comfort, a lozenge containing echinacea. It costs $3.99 for eight lozenges and comes in two flavors.

* Zinc is the other hot remedy this season, thanks to a study published last year by researchers at the Cleveland Clinic. The study showed that zinc could shorten the duration of a cold. But even the author of the study is reportedly embarrassed by the hype surrounding zinc.

It’s quite possible zinc does work to shorten a typical cold, but there are caveats. For example, you have to take the supplements at the first sign of a cold. And you have to take enough of the zinc without risking the nausea and vomiting that occurs with about 20% of people.

In the study, Bosker notes, the zinc was taken every two hours along with Tylenol. Several new zinc lozenge products have joined last year’s hero, Cold-Eeze, this year, including Weider Nutrition International’s Cold-Free, Nu-Wave Health Product’s Cold-Rid and Hall’s Zinc Defense. Cold-Rid bills itself as the first zinc gluconate lozenge with no sugar, honey or fructose. Most zinc lozenge products cost under $5.

* Vitamin C is the old standby of the winter season, but experts disagree on its effectiveness. According to Zwolinski, who is serving as a Florida Department of Citrus spokesman, vitamin C has been shown to reduce the duration of colds. Moreover, vitamin C in orange juice helps replace fluids and boost energy.

Bosker, however, disagrees.

“Despite the initial hype, study after study suggest that vitamin C, at high or low doses, neither prevents a cold nor decreases the severity of symptoms,” he says.

By the way, if you can’t decide among zinc, echinacea or vitamin C, one manufacturer (Action Labs of Farmingdale, N.Y.) is marketing ZINChinacea lozenges, which contain all three plus a couple of other herbs to boot.

There are some other new products designed to comfort you as you shiver, sneeze and doze.

Parents might want to consider a new fever reducer and pain reliever called Tempra Quicklets. Manufacturer Bristol-Myers Squibb says this product represents the first children’s pain reliever to feature “quick-dissolving” technology. Basically, the child places the chewable grape tablets--which contain acetaminophen--on the tongue and they dissolve before the kid can decide whether to chew or spit them out.

Tempra Quicklets comes in two formulations, one for kids ages 2 to 6 and one for ages 6 to 12.

* Also under the category of easier-to-administer, a La Jolla doctor has developed a new method to administer liquid medication to children. The Safe-T-Dose is a small tube attached to a patented adapter that fits into the mouth of a bottle of liquid medicine. To measure the medicine, a plastic oral syringe is inserted into the adapter and medication is suctioned into the syringe. You can then squirt the liquid into the child’s mouth. If you’ve ever knocked over a bottle of liquid medicine, you may find this appealing. It’s also helpful to ensure the correct dosage.

Eventually, the product will be available in most pharmacies, according to the manufacturer. For now, you can find it at Brent-Air Pharmacy in Brentwood and at Long’s drug store in Orange on Chapman Avenue. It can also be ordered by calling (888) 723-3836. It costs about $2.

* Children’s Cepacol Sore Throat Formula is another new product (about $5) aimed at comforting kids. It’s a grape-tasting liquid that, according to the manufacturer, will soothe sore throat pain for up to six hours. Since sore throats can be extremely painful, this might be worth trying in order to maximize both the child’s and the parents’ hours of sleep. It costs about $5.

* Anyone who hates a runny nose might wish to talk to their doctor about a new prescription product, Atrovent Nasal Spray, which is touted to stop runny noses. It is not an antihistamine and will not relieve congestion. But it may keep you from going through three boxes of tissue in three days and sporting a red, raw nose at the company Christmas party.

Atrovent can be used by people 12 and older. It won’t make you drowsy but can occasionally cause mild nose bleeds.

Resources

* National Coalition for Adult Immunization. For information, call (301) 656-0003, or go online at https://www.medscape.com/NCAI/.

* California Coalition for Childhood Immunizations sponsors a hotline for referral to local immunization clinics: (800) 232-2522. In Spanish: (800) 232-0233.

* Assn. for the Care of Children’s Health. For information on how to deal with fever: (800) 997-2256.

* American Lung Assn. cold and flu guidelines are available online at https://www.lungsusa.org.

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Cold & Flu Season

Head: Your hair looks a ‘70s shag carpet after a keg party, and your head is as cloudy as an El Nino sky. Blocked nasal passages, nasal discharge and post-nasal drip are best treated with a combination of a decongestant and an antihistamine.

Face: On the outside, you’re pale and in need of a shave. On the inside, you feel like you’ve gone 10 rounds with Evander Holyfield. Achiness can be relieved somewhat by taking acetaminophen, and it’s less likely to irritate the stomach.

Chest: You’re as clogged and congested as the 405 at rush hour, and you sound like Darth Vader’s grandfather during a smog alert. Though colds will go away within a few weeks--with or without treatment--drinking fluids aids in a speedier recovery.

Arms: Oh, your achy-breaky arms. The only workout they are going to get is hitting the TV remote. Bed rest is advised for the first four days of the flu, and a full active schedule should not be resumed until all the symptoms have gone.

Hankie: Mr. Nose, meet Mr. Hankie! Use your tissues, but do not reuse. Discard them immediately.

Source: American Lung Assn.