With so many viruses circulating, from the common cold to influenza or – you guessed it — COVID-19, many people are wondering how to stay healthy.

Dr. Alison Culbert is a physician with Sunnybrook’s Academic Family Health Team, where she treats patients, including older adults with complex chronic care needs, through many of life’s ups and downs such as seasonal illnesses.

Dr. Culbert spoke to Your Health Matters about how to stay healthy this respiratory virus season.

Respiratory virus season is in full swing. What are you noticing among the patients you treat?

We are definitely seeing an increase in respiratory illnesses in all ages. We have had more calls to the office with our patients looking for advice about what they should do because they are feeling sick or their kids or loved ones are sick.

And we are also seeing an increase in the number of patients that we are bringing in to be seen in the clinic for acute respiratory illnesses.

What reminders can you offer to people about how to stay healthy during respiratory virus season?

The general things I usually recommend are to try to make sure you are getting enough sleep, that you are eating well, and that you make time for physical activity. And it is always a good idea to wash your hands frequently and try to avoid touching your face, especially at this time of year. I also encourage people to take advantage of the vaccines available to them for COVID-19 and influenza.

What should people do if they are experiencing common cold, flu or COVID symptoms such as cough or fever?

Number one is please stay home and try to use available over-the-counter medications like acetaminophen and ibuprofen to manage symptoms like fever, chills, or aches. Resting and staying well hydrated is also important. The vast majority of people will get better within a few days but if they don’t, they should call their healthcare provider for advice and help deciding if it’s time to make an appointment.

This year, health officials are spreading the word that it’s both safe and convenient to get a COVID vaccine and a flu vaccine at the same visit. What advice do you have about how folks should plan to get their vaccines?

Certainly from a convenience perspective, it makes sense to get the flu and COVID-19 vaccines together. We encourage people to get one in each arm. And many people have already had a flu shot or COVID vaccine before, so they can predict how they will feel based on their past experience. Some people might notice a sore arm, but the vast majority of people won’t experience too many side effects.

I often tell people to plan to get their vaccines on a day when they don’t have anything really important to do the next day, just in case they feel a little bit achy afterwards. But most people tolerate getting both vaccines at the same time without any issues.

What would you say to people who might be wondering if they need a COVID-19 vaccine now that the virus is no longer considered a global public health emergency?

It’s important to remember that although the vast majority of people with COVID will recover well, we continue to see those people who get sicker than other individuals and end up experiencing long COVID symptoms. So given that we have a safe and effective vaccine against this virus, I recommend taking advantage of it.

What about people who might think, ‘I hardly ever get the flu so I don’t need to get a flu shot’? What would you say to them?

True influenza usually makes you feel quite unwell with symptoms like fever and body aches, so anything you can do to avoid that is a good idea. If you do end up with the flu and you are vaccinated, chances are the illness will be far less severe.

But getting the flu shot isn’t just about protecting yourself. There is also a benefit to getting the flu vaccine to help protect those around you such as young children, vulnerable seniors, or immunocompromised friends or family, for instance, someone going through chemotherapy treatment for cancer.

I’d like to ask you about older adults in particular because this year there are more vaccinations available to them: COVID, influenza, pneumococcal, and — for the first time for people over 60 — respiratory syncytial virus (RSV) vaccines. What can you tell us about RSV and why this new vaccine is being offered to older adults?

Respiratory syncytial virus (RSV) is a common virus that affects both young children and older adults. It is highly contagious. While it causes symptoms similar to a common cold in most people, in more vulnerable populations it can cause severe illness such as bronchiolitis, which is inflammation of the small airwaves of the lungs. It can also cause pneumonia.

The new RSV vaccine has been shown to be effective in preventing lower respiratory tract infections the virus can cause in adults over the age of 60.

My understanding is that the recommendation is adults over age 60 with at least one underlying health condition — such as congestive heart failure, diabetes, or liver and kidney disease — should consider getting the RSV vaccine.

It is not available at primary care offices at this time, but is available in some pharmacies with a doctor’s prescription.

In addition, the new RSV vaccine is not publicly funded in Ontario at this time except for adults over age 60 living in long-term care homes. This means patients would have to pay for it out of pocket unless they have a private drug plan that will cover the cost.

But if people are able to get the vaccine, it is definitely worthwhile and hopefully will help cut down on the number of patients getting this infection and ending up in hospital.

Is there anything else you would like to add?

I would encourage people to take advantage of any of the vaccines they might be able to access in order to help prevent unnecessary illness.

We know that emergency departments are still operating at full capacity and patients seeking care are often experiencing long wait times. If there is anything people can do to lower their risk of having a severe respiratory illness this season, I hope they will consider it.

Vaccines are available through primary care providers, pharmacies, and public health clinics, so there are lots of ways to get your COVID and flu vaccine.

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Flu season is already here. Have you gotten your flu shot yet?

As a physician working in internal medicine and infectious diseases at Sunnybrook, I’m often asked about the flu and the flu shot. Here are answers to some of the most commonly asked questions I hear:

1. What’s the difference between a cold and the flu? What are the symptoms of flu?

A simple cold and the flu are actually quite different. A person with a cold may have a cough, sneezing, runny nose, and feel unwell. A person with the flu may have those symptoms and can be sicker with symptoms such as high fever and full body muscle aches. Most people can generally still function when they have a cold. Flu symptoms can cause a person to feel unable to even get out of bed.

Flu causes over 3000 deaths every year in Canada and is the tenth-leading cause of death overall. The very young and old are at highest risk of complications, but bad outcomes in otherwise healthy people can happen too.

2. Can I get the flu from the flu shot? I got sick after my shot last year.

No, you can’t, because the flu shot contains dead virus. If you did get sick after getting the flu shot, there are a number of possible explanations:

1. Maybe you had rhinovirus (common cold) and this was not flu;
2. You were in contact with the flu before vaccination (it takes 2 weeks to develop full immunity); or
3. Because the flu shot doesn’t provide 100 per cent immunity, you can still get the flu if you get the flu shot. But the shot doesn’t give you the flu.

3. Can I prevent the flu with holistic remedies (chicken soup, vitamins, infusers) instead of getting the flu shot? 

No. Hot liquids can soothe a sore throat and provide much needed fluids. But there is no evidence that chicken soup has any specific qualities that help prevent the flu. Your best protection against the flu is getting the flu shot, as there is lots of scientific evidence for this.

4. I heard there are a few different flu vaccines available this year. What are the differences? 

There are trivalent and quadrivalent vaccines available. The trivalent vaccine contains three strains of flu virus and higher levels of an antigen, which helps the body produce a stronger immune response. This vaccine is recommended for people over age 65.

The quadrivalent vaccine contains the same as the trivalent, plus an additional strain (four strains total), but with a lower dose of antigen. This vaccine is given to people over 6 months old to 64 years.

5. I heard there’s weird stuff like formaldehyde and thimerosal/ethylmercury in the flu shot. Are those things safe to put in my body?

Formaldehyde occurs naturally in your body, and is a product of healthy digestive function. While it can be toxic and potentially lethal in high doses, it’s present in such small amounts in a flu vaccination that it is harmless.

Thimerosal acts as a preservative, keeping the flu vaccine free from contamination by bacteria and fungi. Thimerosal is made of an organic form of mercury known as ethylmercury, a safe compound that usually only stays in the blood for a few days.

This is different from the standard mercury that can cause illness in large doses, and from the mercury found in seafood (called methylmercury), which can stay in the body for years.

6. Is it possible to receive a preservative-free vaccine?

Preservatives are only used with multi-dose vials. If you would like to receive a preservative-free flu shot, check with a pharmacy or doctor’s office for the type they have available.

7. If the flu shot doesn’t guarantee 100 per cent immunity from the flu, why should I even bother getting it?  

If you get the flu shot, your risk of getting the flu or flu-related complications is between 40-70 per cent lower. The flu shot doesn’t give 100 per cent immunity because the flu virus mutates and changes as the year goes along. But when it comes to becoming infected with a potentially fatal infection, or transmitting that infection to those you love, 40-70 per cent lower risk is not something to dismiss.

At a population level, the flu vaccine campaign each year prevents thousands of hospitalizations for flu in Ontario alone. The more people get vaccinated, the better our “herd immunity,” which keeps our community safe. We all need to do our part to reduce the burden of flu every year.

8. Can you receive the flu shot if you’re feeling under the weather (cough, runny nose)?

If you have a mild cold, you may still receive a flu vaccination. Vaccination won’t be given if you have a serious, acute illness, such as anything with a fever or requiring antibiotics. Some people choose to wait until they are feeling “100%”; however, as we get in to colder weather and longer days, this may not happen and receiving the vaccination will keep being postponed.

9. Is it safe to get the flu shot while pregnant?

Yes, pregnant women should absolutely be getting the flu shot. In fact, the flu shot is recommended for pregnant women at all stages of pregnancy, as well as those who are breastfeeding. The flu itself, not the flu shot, can harm pregnant women seriously enough to land them in hospital and cause death. The flu poses a major threat to fetuses, too.

Another reason for pregnant women to get the shot: flu vaccination causes the body to produce infection-fighting antibodies. When a pregnant woman receives a flu shot, her antibodies get passed on to the developing fetus, providing protection to the newborn in the first months of life. A baby can also acquire antibodies through a vaccinated mother’s breast milk. This is particularly important since infants can’t receive the flu shot, and are at higher risk of complications if they do get the flu.

10. The flu doesn’t seem that bad. Why can’t I just take my chances and not get the shot?

You’re not only getting the flu shot for yourself, it’s offering protection to those around you.

While the flu may not seem like a big deal, it can have deadly consequences for many people. The flu can be a serious illness and cause hospitalizations and deaths, especially in people over 65 and young children like Jude, who was a healthy two-year-old when he died from Influenza B.

This year’s vaccine is quadrivalent, meaning it provides some immunity to four strains of the flu virus.

11. When someone gets the flu, how could it actually cause them to die?

The flu can be fatal for different reasons, including (but not limited to):

• The flu can cause severe inflammation of vital organs, which is when the immune system attacks itself. This could leads to failure of vital organs and requires supportive treatment in the critical care unit
• The flu can progress into a secondary bacterial pneumonia or other respiratory conditions, which could then become fatal
• A person could have other medical conditions that can become unmanaged or more complicated when sick with the flu, such as exacerbation of lung disease, heart failure, kidney failure, or delirium. There is also evidence that flu can increase your risk of a heart attack, especially within the week after the infection 

12. Is my immunity lowered after the flu shot? Three years in a row, I got a cold right after the flu shot.

No, the flu shot does not lower your immune system – it boosts it.  You likely became ill with something else, but due to the timing it is common for people to think it was caused by the vaccine.

13. I live a healthy lifestyle (eat well, exercise, etc.) and consider myself to be a healthy person. I never get sick. Do I still need to get the flu shot?

Yes. You do. Public health agencies from around the world recommend everyone over the age of 6 months get the flu shot every year.

A flu shot not only protects you against the flu, it also helps protect your loved ones, colleagues, strangers on the street. By getting the shot, you are reducing your chance of spreading the illness. Even if you’re healthy, you should still get the flu shot.

14. I got the flu shot so that’s all I have to do to stop spreading the flu, right? Or can I spread the flu even if I feel well?

Your chance of spreading the flu is significantly reduced if you have been vaccinated. But whether you’re vaccinated or not, you can be a carrier of the flu even without symptoms. About 20 to 30% of people carrying the influenza virus have no symptoms at all. So, wash your hands after every contact you have with other people.

There are a number of steps you can take to protect yourself during flu season besides vaccination. Avoid contact with people who have the flu, wash your hands often, cover your mouth when you cough or sneeze, avoid touching your face, stay home when you are sick, clean and disinfect surfaces and shared items.

This article was posted November 21, 2018.

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“While flu season can happen anytime between October and April, it does seem to be starting earlier in Ontario this year,” says Dr. Andy Simor, head, department of microbiology and infectious diseases consultant at Sunnybrook.

With that in mind, here are five things you should know about the 2017-2018 flu season:

1. Australia was hit hard by the flu this year

Each year, experts look to Australia’s flu season (which occurs during their winter, between May and October) to get an idea of what our flu season might be like. While the influenza (flu) vaccine match was good this year in Australia, the country saw a much higher number of cases than usual, resulting in an increased number of hospitalizations and deaths.

“If the experience of southern hemisphere is predictive, we’re in for a more difficult flu season than usual,” says Dr. Simor.

2. There’s more than one flu strain circulating

There are usually several strains of the flu circulating each year. As a result, the flu vaccine is trivalent, which means the shot protects against three different strains. This year, those three strains are influenza A (H1N1), H3N2 (the prevalent strain that was seen in Australia) and B.

The World Health Organization (WHO) determines which strains to include in the flu vaccine every year. With input from experts around the world, the WHO tries to predict which virus will be the most dominant. As a result, the flu shot protects against different strains every year. So, even if you got a flu shot last year, it won’t be effective against the flu strains circulating this year.

3. Getting the flu shot is safe and effective

The flu vaccine is safe and effective, particularly in preventing serious complications that may occur from the flu (such as pneumonia, which can become deadly for some people).

“The flu can cause severe illness, especially in the very young and the elderly. The most effective thing we can do to protect ourselves and others against the flu is to get the vaccine,” says Dr. Simor.

4. You can’t get sick from the flu vaccine

“The flu vaccine is made entirely of killed virus and cannot cause you to get sick,” says Dr. Simor. Studies have found that symptoms occur just as often in people who get a placebo shot versus the real thing. However, you can definitely still get a sore arm!

It’s important to note, though, that it takes two weeks for the flu shot to work. “If you get sick in those first two weeks, it’s because you had already been infected or you weren’t yet fully protected,” says Dr. Simor.

5. Clean your hands to prevent the flu from spreading

While the flu vaccine is safe and effective, it’s not perfect, and it doesn’t provide a 100% guarantee that you’ll avoid getting sick.

This is why it’s so important to take steps to prevent the spread of the flu, like cleaning your hands often. If you do get sick, don’t go to work and try to stay away from crowded places so you don’t pass the flu virus on to someone else.

“If you get the flu, you’ll feel sick for 5-7 days, and you’re contagious for the first four days. It’s important to limit your contact with other people during that time,” says Dr. Simor.

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An e-monitored hand hygiene pump on D2, the first unit to install them at Sunnybrook.

Cleaning your hands is recognized as one of the best ways to keep patients safe and prevent the spread of infections. But what’s the best way to actually measure hand hygiene rates?

For years, hospitals have sent auditors from unit to unit to monitor how often staff members are cleaning their hands. Now, a new study is trying to show that using technology to measure hand hygiene rates can provide more accurate results.

“In-person audits can actually overestimate hand hygiene rates by three to five times. Electronic monitoring, on the other hand, provides more accurate, real-time measurement of hand hygiene in a specific clinical area, which helps staff improve their rates more quickly,” says Dr. Jerome Leis, medical director, Infection Prevention and Control at Sunnybrook Health Sciences Centre.

Sunnybrook is leading a five-hospital improvement study that aims to detect a reduction in healthcare-associated infections by improving hand hygiene compliance (a measure of how often staff use alcohol-based hand sanitizer to clean their hands when moving between rooms or delivering patient care).

To do this, electronically monitored, or e-monitored, hand hygiene pumps have been installed on 18 inpatient units in Greater Toronto Area hospitals. That number will soon expand to 25, and depending on what the results show, e-monitored pumps could become the new standard of practice in Ontario.

How e-monitoring works

E-monitored hand hygiene pumps are equipped with a sensor that counts hand hygiene events. That number is compared to a pre-determined number of hand hygiene opportunities, giving each unit a compliance rate measured by percent.

“To come up with that number, we collaborated with the manufacturer of the pumps and sent them information about each unit’s level of acuity, model of care, patient census and type of patients,” says Dr. Leis. The presence of visitors on the unit was also taken into account when determining the number of hand hygiene opportunities.

One of the biggest surprises was realizing just how many hand hygiene opportunities actually exist. “In a two month period alone, one of our units had 170,000 hand hygiene opportunities,” says Dr. Leis. He adds that the system is accurate and has been validated in different care settings worldwide.

The limitations of observational audits

Hand hygiene compliance rates have plateaued at around the 85-90% range across most hospitals in Ontario. While those numbers seem high, multiple covert studies have shown that actual compliance is less than 50%.

The reason for such a large discrepancy? “People change their behaviour when they know they’re being watched, which is something known as the Hawthorne Effect,” says Dr. Leis.

Under the current observational, in-person auditing system, units only receive feedback on their hand hygiene rates every three months. E-monitored systems allow participating units to get weekly feedback on their performance. Units will also be able to track their improvement using technology that provides accurate measurement of hand hygiene compliance.

According to Dr. Leis, while many healthcare providers think they have good hand hygiene compliance, you actually need to clean your hands between eight and 20 times per hour (assuming a four-patient assignment) to have perfect hand hygiene compliance. Over a single eight-hour shift, this is an average of 120 hand hygiene events.

“Many staff members tell me they are cleaning their hands, and I believe them. But the question is whether they are cleaning enough – if you’re not cleaning your hands more than 1-2 times per hour while caring for multiple patients, your compliance is likely suboptimal,” says Dr. Leis.

A higher number of hand hygiene opportunities, combined with a more accurate measurement system, means hand hygiene compliance rates recorded by e-monitored pumps will be much lower than the numbers we’re used to seeing, at least initially.

Preliminary results

The first e-monitored hand hygiene pumps were installed on an inpatient unit at Sunnybrook in July 2017. The improvement in hand hygiene rates was immediate.

“On that unit, we started with a baseline hand hygiene rate of 35%. By August, the compliance rate had already gone up to 58%, surpassing our original 3-month goal of 55%, so were very pleased to see that happen so quickly,” says Dr. Leis.

E-monitoring recently rolled out to two more units at Sunnybrook, and will be implemented in two more in January 2018. Dr. Leis is hopeful it will become the norm in the near future.

“Our study involves multiple hospitals and a large number of patients, which we expect will allow us to determine the benefit of this technology in preventing hospital-acquired infections. This data will help us determine whether to install these pumps in as many units as possible.”

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