Category Archives: Colds & Flu

Thick, Greenish Runny Nose = Antibiotics? No, It Doesn't…

runnynose2It’s a popular misconception among not just the population but also many doctors, that a greenish runny nose = bacterial infection = the need to take prescription antibiotics. Well,  it’s not true! As this fun New York Times article reviews, the color is more a sign of clumps of  your body’s infection-fighting white cells as well as colorful shades of your normal nose bacteria. They discuss the studies that show no difference in symptoms with or without antibiotics. Here’s a quote:

According to the Centers for Disease Control and Prevention, when cold viruses infect the respiratory tract, the body makes clear mucus that helps wash away germs from the nose and sinuses. After about three days, the body’s immune cells fight back, changing the discharge to a white or yellow color. ”As the bacteria that live in the nose grow back, they may also be found in the mucus, which changes to a greenish color,” the agency says. ”This is normal.”

So, No Antibiotics. What Helps?

Since this is almost always just a viral infection and not a severe bacterial sinusitis, the best treatments are decongestants. Pseudoephedrine (sudafed) products in the Tylenol Cold/Bufferin Cold pills work well for 4-6 hours, as do the Robitussin combo syrups. There’s also the oxymetazolone (“Afrin”) nasal sprays. Also important are natural treatments including salt water nose rinses, steam, menthol rubs, and keeping well hydrated. I’m a big fan of salt water nasal rinsing — easy, effective, non-toxic and free!

By the way, even if it is “sinusitis”, there is poor evidence that antibiotics do anything more than lessen the symptoms by a day or two. Yes, in some cases it helps, especially if symptoms are severe, but in general people are overprescribed antibiotics for an infection that would go away on its own with a little TLC and time.
(Most of this article was originally printed in an earlier post; I am reposting some archives as I am on vacation now.)

Great News: Something Actually Helps Fight The Common Cold — Zinc!

zinc common coldI’ve often complained, along with the rest of the world, that there is no magic pill yet designed to cure the world’s most common illness — the common cold. But now, there is some hope! There’s an excellent meta-analysis by the well-respected Cochrane Library which now says what some docs had been touting for years — that zinc supplements, when taken within 24 hours of cold symptoms, can truly improve symptom severity and length, as well as lower risk of needing antibiotics. This is great news! I already used zinc off and on for years in my cold supplements, which are usually Airborne or Dr Thompson Coldwar pills; and I will now definitely be more aggressive with zinc during my colds. I’m convinced.

The New York Times has a nice review of this Cochrane meta-analysis, and you can download the Cochrane PDF file here and also read their original conclusions here:

The common cold is often caused by the rhinovirus. It is one of the most widespread illnesses and is a leading cause of visits to the doctor and absenteeism fromschool and work. Complications of the common cold include otitis media (middle ear infection), sinusitis and exacerbations of reactive airway diseases. There is no proven treatment for the common cold. However, a medication that is even partially effective in the treatment and prevention of the common cold could markedly reduce morbidity and economic losses due to this illness.

Zinc inhibits rhinoviral replication and has been tested in trials for treatment of the common cold. This review identified 15 randomized controlled trials, enrolling 1360 participants of all age groups, comparing zinc with placebo (no zinc). We found that zinc (lozenges or syrup) is beneficial in reducing the duration and severity of the common cold in healthy people, when taken within 24 hours of onset of symptoms. People taking zinc are also less likely to have persistence of their cold symptoms beyond seven days of treatment. Zinc supplementation for at least five months reduces incidence, school absenteeism and prescription of antibiotics for children with the common cold. People taking zinc lozenges (not syrup or tablet form) are more likely to experience adverse events, including bad taste and nausea. As there are no studies in participants in whom common cold symptoms might be troublesome (for example, those with underlying chronic illness, immunodeficiency, asthma, etc.), the use of zinc currently cannot be recommended for them. Given the variability in the populations studied (no studies from low- or middle-income countries), dose, formulation and duration of zinc used in the included studies, more research is needed to address these variabilities and determine the optimal duration of treatment as well as the dosage and formulations of zinc that will produce clinical benefits without increasing adverse effects, before making a general recommendation for zinc in treatment of the common cold.

The usual dosing is 3-4 times a day during your illness; the most common lozenges are 23-30mg, so one of these 3-4 times a day would help best. Don’t forget, it’s important to start zinc quickly and not wait a few days. As it says above, side effects are common but not severe, including bad taste and a bit of nausea.

“Not All Bugs Need Drugs” — AKA Antibiotic Overuse…

Here’s another pop quiz: Which scenario below requires antibiotics?

  • A fever for 3 days
  • Cough that turns wet
  • A cough that “gets deeper into my chest”
  • Runny nose that turns yellow

The oversimplified answer is “none of the above“, at least not without having a doctor check you out first, to decide whether it’s a virus or a bacteria. The above scenarios, while a legitimate problem for patients, are usually caused by viruses and not bacteria — which means the antibiotics are totally unhelpful. In terms of the above scenarios:

  • A fever is normal in any virus infection, even over 40 degrees, and can last a few days
  • a “wet cough” implying bronchitis still doesn’t mean it’s a bacteria — viruses are the most common cause
  • Yellowish/greenish runny nose does not always mean bacteria — it’s simply white cells fighting off your infection, again usually just a virus

This brings up one of my daily jobs in clinic: convincing patients with simple viral infections that they do not need antibiotics.

I discussed this topic yesterday on China Radio International’s Beyond Beijing program, along with three experts from Chinese hospitals and the World Health Organization. Called “The Abuse of Antibiotics”, you can listen to the one hour program by clicking here. The main concern was recent news from China health agencies that the rate of antibiotic use in China (as well as adverse reactions) is very high compared to many countries. Antibiotics are also overused in America, especially for common cold symptoms.

And this well-known international overuse of antibiotics is causing dangerously high resistance rates. In other words, every time your doctor gives you antibiotics for a simple cold or bronchitis, you not only are not treating your likely-viral infection, but you are increasing your risk that next time, when you actually need to fight off a serious bacterial infection, your antibiotic will no longer work on you. Antibiotic abuse is a very real situation which is especially serious in hospitals and ICU wards. For example, many healthy young people are now getting more serious skin infections from the MRSA bacteria (=”Methicillin Resistant Staphylococcus Aureus”), which are much harder to treat now due to increasing resistance.

So What Can We Do?

One of our panel conclusions was that antibiotic abuse is an international issue that transcends borders. The radio panel’s WHO representative mentioned a successful program in Europe which plastered buses and other public spots with a “Not All Bugs Need Drugs” campaign. This started a healthy community discussion which actually did lead to a drop in antibiotic prescriptions.

Every country needs to tackle antibiotic abuse from many angles:

  • Doctors have to stop prescribing antibiotics for virus infections
  • Docs need to educate their patients much better about the virus/bacteria difference
  • Patients need to stop self-treating themselves with antibiotics
  • Pharmacies need to stop giving patients antibiotics without prescriptions
  • Hospitals need to stop selling antibiotics for a profit
  • Animal farms need to stop giving their animals antibiotics simply for growth yields

More Information

The World Health Organization has a program dedicated to decreasing antimicrobial resistance worldwide; you can see their documents and information here. There is also a good website with info geared more for kids and parents; it also has patient handouts in Chinese and other languages. Below is a poster from the Not All Bugs Need Drugs campaign:

Not All Bugs Need Drugs
Not All Bugs Need Drugs

Fight Off Your Cold — With Gargling?

It’s definitely the middle of winter season already, and my clinic’s waiting room is filled with sniffly, sneezing patients. Since there’s no magic bullet to cure the common cold, what natural methods help? I’ve mentioned a lot of preventive medicines on my blog, especially my new favorite, vitamin D. But there may be an even simpler way to cut down on getting the common cold — gargling! Yes, it seems that those of you who gargle regularly do indeed get colds less often. Thanks go to the always excellent “Really?” health blog at the New York Times, which just discussed the best literature on this. They quote from the randomized study published in The American Journal of Preventive Medicine in 2005, where researchers studied 400 healthy volunteers and followed them for 60 days during cold and flu season:

Some of the subjects were told to gargle three times a day. At the end of the study period, the group that regularly gargled had a nearly 40 percent decrease in upper respiratory tract infections compared with the control group, and when they did get sick, “gargling tended to attenuate bronchial symptoms,” the researchers wrote.

Interesting, no? One strange finding of the study is that the pure water gargling group actually did the best, even better than the povodine-iodine gargling group. But I still think it makes more sense to gargle with salt water, or one of the Listerine-type mouth washes. Why salt water and not just pure water? Here’s a bit from the article:

…gargling with salt water seems to help for several reasons. A saline solution can draw excess fluid from inflamed tissues in the throat, making them hurt less, said Dr. Philip T. Hagen, editor in chief of the “Mayo Clinic Book of Home Remedies,” which is due out in October. Dr. Hagen pointed out that gargling also loosens thick mucus, which can remove irritants like allergens, bacteria and fungi from the throat…

So let’s all try an experiment this winter; try to gargle at least once a day, or even three times (waking up, after lunch and bedtime) and let’s all check in during next spring and see how your winter went!

Healthy Tips to Prevent Colds & Flu

We are now deep into winter, and most likely you and your family have already been through a couple rounds of the common colds and flu. What simple tasks can we do to cut down on these inevitable illnesses? There are a lot of home remedies and folklore about preventing the common cold, but let’s review the best, evidence-based preventive tips.

One interesting idea is daily gargling, with simple salt water, during the entire winter season. In a 2005 published study in the American Journal of Preventive Medicine, people who gargled up to three times a day had a 40% decrease in respiratory illness and symptoms during the winter. Gargling also is a simple way to help improve sore throat pain and swelling, and it also loosens up mucus.

Another method with good evidence is a daily supplement of vitamin D, for all ages, during the entire winter season. Daily year-round doses of vitamin D (400 IU for children) are already recommended by the American Academy of Pediatrics. A recent study published in the American Journal of Clinical Nutrition showed that schoolkids who took a higher dose of vitamin D during flu season had a 42% decrease in influenza infections. Your local clinics should have vitamin D in stock; I recommend 1,000 IU daily for adults.

Don’t forget the simple things as well; simply getting a good night’s sleep can decrease your risk of infections. This has also been studied recently, in a fascinating experiment published in 2009 in The Archives of Internal Medicine. In this experiment, researchers literally injected the common cold rhinovirus into people’s nostrils and measured who got infected, then compared this to their previous sleep habit. Those who slept only 6-7 hours a night were three times more likely to get cold symptoms than those who had 8 or more hours of sleep. This study literally proves what we all assume — that proper sleep is crucial for our immune system. Perhaps those of you who feel you “always get colds in Beijing” should check into your sleep patterns!

Another very common sense preventive measure is hand washing. Last year’s H1N1 scare has really improved awareness all over China, and it’s much more common now to see alcohol gel hand-wash dispensers in schools, malls and restaurants. I think this is a great and simple idea that really does cut down on passing along the infection via handshaking or touching. People should not waste their money on the anti-microbial soaps as they don’t have much evidence of effectiveness, and they likely will lead to a worsening of the already serious worldwide problem of antibiotic resistance. Simple soap and water also does the trick — but I actually prefer the alcohol gels as they work quicker and wipe out a much larger percentage of viruses and bacteria than soap.

What about natural medicines for colds and flu, including the commonly used vitamin C, echinacea, and zinc? The best evidence so far is still fairly conflicting, and the online Natural Medicines Database lists all three as “likely safe” but “possibly ineffective”.

Another major key to prevent the winter flu (but not the common cold) is the annual flu vaccine. This vaccine can lower your chances of infection, as well as prevent you from infecting loved ones and colleagues. It’s not 100% effective, but I feel the benefits far outweigh the risks. Those of you with any contact with newborns and infants under 6 months of age should seriously consider getting the vaccine for yourselves as those infants are most vulnerable to the flu, and they are not eligible for the vaccine. It’s not too late to get the flu vaccine, as flu season can run into late spring.

Do You Need The Flu Vaccine? Maybe Not…

It’s definitely the middle of flu season already, and so far it isn’t so bad where I practice. I’m still having daily conversations with my patients about the flu vaccine — but who really needs the annual flu shot? There’s actually a very comprehensive new study which should help shed some light on this issue.

First, let’s just review the flu vaccine; available each fall, it’s a worldwide standardized collection of 3 influenza viruses that are presumed to be the upcoming season’s likely virus. The current 2010 vaccine also includes the H1N1 strain as one of the three strains. As I mentioned a couple months ago, the H1N1 pandemic was officially declared over but it is still around. More importantly, it never became the deadly pandemic we had feared it might. However, parents should know that H1N1 was more selectively deadly to toddlers and pregnant women, with the death rate for children over four times higher than is usual for the flu season, as you see in this graph from the American Academy of Pediatrics 2010 Policy Statement on Influenza:

Flu Deaths in Children 2006-2010
Flu Deaths in Children 2006-2010

“Universal Flu Recommendation”

As for who should get this year’s flu shot, the official recommendation from the US Centers for Disease Control is actually expanded from last year; they recommend that anyone over 6 months of age, whether healthy or sick, should consider getting the vaccine (as long as they don’t have the usual contraindications). Previously, many people in the 19-49 year old range weren’t considered, but this new recommendation includes everyone. This position by the CDC was endorsed by my American Academy of Family Practice as well as the American Academy of Pediatrics:

The AAP recommends annual trivalent seasonal influenza immunization for all children and adolescents 6 months of age and older. Special efforts should be made to immunize all family members, household contacts, and out-of-home care providers of children who are younger than 5 years; children with high-risk conditions (e.g., asthma, diabetes, or neurologic disorders); health care personnel; and pregnant women. These groups are most vulnerable to influenza-related complications.

How Effective Is The Vaccine?

There’s a brand-new meta-analysis from what I think is the world’s most esteemed and unbiased medical review team, the Cochrane Library. In their analysis of the best studies about the flu vaccine for healthy adults, they found a less-than overwhelming effectiveness for the flu vaccine in real-world situations in adults like missed work days:

Over 200 viruses cause influenza and influenza-like illness which produce the same symptoms (fever, headache, aches and pains, cough and runny noses). Without laboratory tests, doctors cannot tell the two illnesses apart. Both last for days and rarely lead to death or serious illness. At best, vaccines might be effective against only influenza A and B, which represent about 10% of all circulating viruses. Each year, the World Health Organization recommends which viral strains should be included in vaccinations for the forthcoming season.

Authors of this review assessed all trials that compared vaccinated people with unvaccinated people. The combined results of these trials showed that under ideal conditions (vaccine completely matching circulating viral configuration) 33 healthy adults need to be vaccinated to avoid one set of influenza symptoms. In average conditions (partially matching vaccine) 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalised or working days lost but caused one case of Guillian-Barré syndrome (a major neurological condition leading to paralysis) for every one million vaccinations. Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccines trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited.

It is indeed disturbing that the Cochrane group found that “there is evidence of widespread manipulation of conclusions and spurious notoriety of the studies“, that “reliable evidence on influenza vaccines is thin“, and that “our results may be an optimistic estimate.”

Please note that this study only covered healthy adults and not children. The Cochrane group in 2007 reviewed the flu vaccines for children and found fair effectiveness in children over, but not under, 2 years:

The review authors found that in children aged from two years, nasal spray vaccines made from weakened influenza viruses were better at preventing illness caused by the influenza virus (82% of illnesses were prevented) than injected vaccines made from the killed virus (59%). Neither type was particularly good at preventing ‘flu-like illness’ caused by other types of viruses (33% and 36% respectively). In children under the age of two, the efficacy of inactivated vaccine was similar to placebo. It was not possible to analyse the safety of vaccines from the studies due to the lack of standardisation in the information given but very little information was found on the safety of inactivated vaccines, the most commonly used vaccine, in young children.

My Bottom Line

I do find the latest Cochrane meta-analyses very disturbing, and I am not as gung-ho as I was in previous years. However, I still recommend the flu vaccine for all my patients, and certainly for myself, my co-workers and my family. Perhaps it’s not as effective as we thought, but it still offers at least partial protection, and I am comfortable with the risk/benefit balance. But families and readers need to make up their own minds.

I still mostly recommend the vaccine especially for anyone in contact with infants, especially under 6 months, as well as frail elderly people. Those groups, especially the infants, are most vulnerable to any complications of the flu, and many die each year from complications. And since infants under 6 months aren’t eligible for the vaccine, their best protection is prevention of exposure — to have their loved ones and caretakers be as immune to the flu as possible. So while the vaccine may offer only partial protection, it’s still the best we have.
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