The Q&A: Pedro Piedra

With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject:

Pedro Piedra is a virology and microbiology professor at the Baylor College of Medicine. He studies respiratory virus illnesses in children and ways to reduce their frequencies through vaccination programs. Specifically, his research focuses on influenza virus, respiratory syncytial virus, adenoviruses and human metapneumovirus.

Editor's note: This interview has been edited for length and clarity.

Trib+Heath: First of all, is it too late to get the flu vaccine? 

Pedro Piedra: The answer is absolutely not. Flu season has not really hit us and even if it did, there is no better way to prevent the flu than to be vaccinated because the flu season is long. 

Trib+Heath: Can you talk to me about the characteristics of flu season? When does it typically fall and how can you predict when it will start? What is kind of your landmark for, ‘OK, flu season is upon us’? 

Piedra: In order to know when it starts, there is active surveillance at the state level and at the U.S. level. That information is provided by the Centers for Disease Control. And right now, in the state of Texas as well as in many other states in the United States, the level of activity is what we would call sporadic for the most part. That is, that there are very few isolates that are being detected, very few cases of influenza that are being detected.

This is what we see early before the influenza season starts to begin. It is difficult to predict on any given year when it will begin. Sometimes it begins earlier, sometimes it begins a little later. What we can state is that right now there is a low level of influenza activity and, like you stated, if you have not received your influenza vaccine, this is the time to do so. You are much better protected if you get vaccinated before the influenza season arrives than after it arrives. 

Trib+Heath: How long does it typically last?  

Piedra: So the influenza season normally lasts about three months of intense activity. The caveat to that is that on any given year, you can have, let's say, an outbreak of the A viruses and then later in that season, have an outbreak of influenza B viruses. The B viruses, we tend to see more in the spring. It tends to lag longer. So it’s not unusual to be seeing influenza activity, in particular caused by influenza type B, let's say in April and in May – that’s not unusual. So it can be long. 

Trib+Heath: While the season hasn’t technically started, from what you can tell so far, how do the viruses you’re seeing crop up this year compare to previous years as far as severity goes?

Piedra: Well, you can’t say anything yet about severity. What we can say, and this is, I think, very important, of the viruses that they have identified to date, the vast majority are covered by the vaccine. And that’s important because last year, the major virus that was circulating – the influenza AH3N2 – was not well covered by the vaccine. And this year, the major virus that so far has been seen is, again, an influenza AH3N2, but this time it is well covered in the vaccine. 

Trib+Heath: Can you talk to me a little bit about what this year’s vaccine looks like? 

Piedra: So every year there might be a change or two to the components in the vaccine. Traditionally, the influenza vaccine has been made of two influenza As, an H1N1 and an H3N2 and one of the two potential influenza B components. About two to three years ago, there was a major push to make quadrivalent vaccines so that it contained both B components. The reason that was so is because the trivalent, on any given year, may miss the influenza B that was circulating. It was kind of like a hit or miss.

So in order to ensure that you have a more robust coverage for any of the influenza viruses that may circulate, quadrivalent formulations were made. Now there are still trivalent formulations out there, but it is preferable to be vaccinated with an influenza vaccine that has all four components – two As and two Bs. So far, we’re actually seeing all four viruses circulating. 

Trib+Heath: Would there be any conditions that would prompt you to encourage someone to get the trivalent as opposed to the quadrivalent? 

Piedra: No. The quadrivalent will provide the broader coverage. Now in a particular season, you may only have one of the Bs circulating, and that would be covered and it might be covered well in the trivalent. But that is hard to predict. It is really a hit or miss type of thing, almost like flipping a coin and hoping that it will fall heads but it falls tails. That’s why there has been a major push to make quadrivalent flu vaccines. 

Trib+Heath:  I’m looking at this interview you did in September about this and it says you can get the vaccine as a nasal spray or as the physical flu shot, can you tell me about the difference between those two options?

Piedra: For sure. So there are two major types of influenza vaccines that are available to the public. There’s what we call the live attenuated vaccine, which is flu mist. That is an actual live, but weakened, vaccine virus. It containts all four components: 2 As and 2 Bs and it is approved and recommended for healthy individuals 2 through 49 years of age.

Then there is the inactivated vaccine that is not live, it has been killed and has been semi-purified. There are a number of different manufacturers for the inactivated influenza vaccine and depending on the manufacturer, some are approved for infants six months of age through elderly. Others are approved for children, lets say, three years of age through elderly and others are approved for adults only.

One would have to know the vaccine manufacturer, but the inactivated influenza vaccines you could say, in general, are for children or infants six months of age or older and you would have to look at which particular one to determine if there is any limitation on age.

Then, to make it a little bit more complicated, there is an inactive influenza vaccine that is called a “high dose” and that is recommended for older adults only because they don’t respond as well to the regular influenza vaccine and thereby a special one, one that contains basically four times as much anlagen, was made and approved for the older folks.

Trib+Heath: Every year there seems to be some sort of new round of anti-vaccination rhetoric that comes up, does that ever impact the number of people that actually get flu shots, depending on how prevalent it is that year? How do you guys in the medical field who see the benefits of getting vaccinated, how do you combat that kind of dialogue? 

Piedra: I think it’s most important to be transparent. So to state what the vaccine can do and what it cannot do; to put out there myths and truths of the influenza vaccine. And (it is important) for the physician and the healthcare providers, and that means nurses and everybody else who is associated, to truly be advocates. What you want to do is reduce any potential barrier so that people are protected and vaccinated against flu.

What is very important, and often times people forget, is that influenza truly impacts the community. If you think that in any given year, during any given time period, it infects about 5 to 20 percent of the population, and this is worldwide. Although most of the individuals will do fine, a few individuals will not do well.

Older folks are more susceptible to dying from it. Every year, on average, you have about 30 to 40 thousand adults that die from it – that’s a huge number. You have over 200,000 people in the United States that are hospitalized from the flu and children, young kids as well as older children, can develop very bad flu and die. That’s unusual, it’s not common, but it is very heartbreaking when you have a healthy 13-year-old child who was not vaccinated and dies within a few days of getting infected.

And that happens. Last year, I think they reported close to 150 children that died in the U.S. and probably three to four times that number was unreported because we have a passive surveillance system. In other words, there are many children that may die from flu that we just don’t know because they were not tested. So we only know those that were tested for it.

Although the bad disease, the severe disease is uncommon, because flu is such a common disease, all of a sudden the numbers start to go up very quickly. On average, there is about $80 billion that one loses because of flu every year, and that’s tremendous. So again, although we do not have a perfect vaccine, we have a good vaccine. One can see why there is such a strong effort at the government level and at the local level for people to be vaccinated against flu, because of its major impact that it has on the community.

Trib+Heath: As far as the virus itself goes, what are some other common misconceptions that you see? 

Piedra: One of the common misconceptions is, “Oh, it’s just the flu.” And it may be just the flu for nine persons out of 10, but that No. 1 person can end up seriously ill. And because it’s so common, we see a lot, especially as doctors, you see a lot of bad flu cases. So that would be one misconception.

Another misconception is, “Well I’m healthy, I won’t get sick from it.” Well, flu really doesn’t care whether you’re healthy or you have morbidities, comorbidities. The truth is, you can get very sick. I’m a pediatrician and I can tell you that, of the children that die from flu, about 50 percent of them have no known risk. They are perfectly healthy. Of those that are perfectly healthy and die from flu, many of them die at home or en route to the emergency room because it’s that quick.

Trib+Heath: Is there any methodology or any way to predict how the flu will affect somebody?

Piedra: No, and that’s why we have the universal influenza vaccination program in the U.S. Because if you have a comorbid condition, let's say you have asthma, you have heart disease, you’re going to be at greater risk for a worse outcome, but most of the worst outcomes occur in healthy people. That’s because there are a greater number of people who are healthy than there are who have comorbid conditions and that’s what people forget. It’s a very common infection and it impacts all of us. 

Trib+Heath: Do you have any trade secrets of ways to combat the flu if you do contract it? In addition to standard medication and treatment? 

Piedra: What I would say is, let's say you’ve been vaccinated or if you have not been vaccinated and you get sick with a flu-like illness during the flu season, there are anti-viral medications that one could use and would be very beneficial. In particular, let's say you’re one of those individuals who have a risk condition, something else that puts you at greater risk. Anti-virals are available for treatment and they need to be initiated early.

Another is that, if you get sick with a flu-like illness – stay home, don’t go to work. We forget that and we go and we’re feeling miserable and all you’re going to do is spread the misery to others, you’re going to spread it to your colleagues. The best thing is to stay at home, make sure that you stay well hydrated and let it resolve.

Those would be the two major things that I would advocate, that if you have an at-risk condition or if you are pretty sick, don’t forget about anti-virals. And talk to your doctor, because anti-virals are very important in reducing the complications associated with flu. Also, if you have a flu-like illness, stay home, don’t spread it to others.

That’s the way that we have our outbreaks. Especially if you’re in the healthcare profession or you’re a teacher or something like that. Imagine you’re going to work and you’re sick, you’re going to be spreading it. We tell that to the students too. Also, if you have a child in daycare, don’t come in if you have a fever for the same reason. If you’re an adult and you’re sick, stay home, let it resolve, then go back to work.

Dehydration is something that happens in particular in pediatrics, so stay well hydrated. And lastly, again for pediatrics, don’t use aspirin or aspirin products to reduce the fever, that’s a major no-no. Aspirin, with flu, can really cause serious, serious morbidity and death in children, with Reye's syndrome. As a pediatrician you’ll hear the message, don’t use aspirin with respiratory illnesses.