Sinusitis

Description

Alternative Names

Prevention

The best way to prevent sinusitis is to avoid and, if unavoidable, effectively treat colds and influenza.

Good Hygiene and Preventing Transmission

Colds and flus are spread primarily when an infected person coughs or sneezes near someone else. A very common method for transmitting a cold is by shaking hands. Everyone should always wash his or her hands before eating and after going outside. Ordinary soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for every day use and may even kill cold viruses. (They are less effective, however, if extreme hygiene is required. In such cases, alcohol-based rinses are needed.) Antibacterial soaps add little protection, particularly against viruses. In fact, one study suggests that common liquid dish washing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory syncytial virus (RSV), which is known to cause pneumonia. Wiping surfaces with a solution that contains one part bleach to 10 parts water is very effective in killing viruses.

Note: Colds are not caused by insufficiently warm clothes or by going outside with wet hair. A 2002 study reported, however, that in older adults cold temperatures can thicken the blood and may increase the risk for respiratory infections and even circulatory and heart problems. (This danger does not appear to affect people under 55 years of age.)

Dietary Factors

Foods Containing Lactobacilli (Good Bacteria). Researchers are also studying the possible protective value of certain strains of lactobacilli bacteria found in the intestines. Some of these strains, particularly acidophilus, are used to make yogurt. According to one Finnish study, children attending day care who ate milk containing the strain lactobacilli GG could reduce respiratory infections in these children by 10% to 20%. More research is warranted. (The strain used was not the kind found in most commercial yogurt products.)

Vitamins. Studies are mixed whether vitamin supplements protect against upper respiratory infections. Large doses of vitamin C, for example, may help reduce the duration of a cold, but they do not appear to protect against one in the first place, even after exposure to a cold virus. Two studies in 2002 on multivitamins reported opposite results, with one finding fewer infections and one finding no difference. It is possible that vitamin C or multivitamin supplements may be helpful in specific people, such those who are vitamin deficient or have medical problems that impair their immune systems.

Studies on vitamin E specifically have been largely negative. A 2002 study, in fact, reported a higher incidence and greater severity of respiratory infections in older adults who took 200 mg of vitamin E daily.

Other Factors Associated with a Lower Risk for Respiratory Infections

Breastfeeding. Some evidence suggests that women who breastfeed reduce the risk of respiratory infections in their children.

Low Stress and Active Social Life. More than one study has reported that people with low stress who also have an active social life have fewer colds than people who have high stress levels or those who have low stress and few social connections.

Zinc

Zinc appears to have certain important effects on the immune system and it may have a direct effect on viruses. How it works is not entirely clear, however. Zinc preparations in lozenge or nasal gel form are now available as cold treatments. Studies are very mixed on the effects of zinc on colds. The variance may be due to different zinc preparations. Studies are underway to determine advantages, if any. Some examples include the following:

• A nasal gel (Zicam), which contains zinc gluconate, has shown some success, possibly because the gel sticks to the nasal passages long enough for the zinc to interact with the virus. In a 2003 study, for example, the nasal gel shortened the duration and severity of the cold compared to placebo when it was started within 14 to 48 hours of the onset of symptoms. The supports earlier studies reporting that it shortened the duration of a cold by about two days.
• Zinc lozenges are showing mixed results. One 2000 study suggested that the use of zinc acetate lozenges (e.g., Fast-Dry, Galzin) may be more effective and have a better taste than other formulations, such as zinc gluconate (Cold-Eeze, Orazinc). On the other hand, a 2002 study reported that zinc gluconate reduced cold duration significantly. To further confuse matters, the two zinc lozenge preparations were directly compared in a 2000 study, and neither was effective. The reasons for these conflicting results are not clear.
• A small 2001 study on a nasal spray preparation found no benefits. The spray preparation had less zinc than the nasal gel.

In any case, no one with an adequate diet and a healthy immune system should take zinc for prolonged periods for preventing colds.Long-term use of zinc (100mg or higher daily) has been associated with heart problems, anemia, and other conditions.

Side Effects. Side effects include the following:

• Dry mouth.
• Constipation.
• Nausea.
• Bad taste (possibly only with zinc gluconate lozenges).
• Overdose may cause severe vomiting, dehydration, and restlessness. Call a physician if any of these symptoms occur.
• In rare cases, an allergic response may occur.

Food and Drug Interactions. Zinc may also interact with drugs or other elements.

• It may reduce absorption of certain antibiotics.
• Foods high in calcium or phosphorus may reduce zinc absorption.
• In high doses and for long periods of time zinc can cause copper deficiencies.

Viral Influenza Vaccines

Description of Vaccines. Vaccines against influenza employ inactivated (not live) viruses. They are designed to provoke the immune system to attack antigens contained on the surface of the virus. (Antigens are foreign molecules that the immune system specifically recognizes as alien and so targets for attack.)

Unfortunately, the antigens in these influenza viruses undergo genetic alterations (called antigenic drift) over time, so they are likely to become resistant to a vaccine that worked in the previous year. Vaccines are then redesigned annually to match the current strain.

• Influenza A. The influenza A virus is further categorized by primary molecular antigens (hemagglutinin and neuraminidase), which serve as the targets for the vaccines. Influenza A is a particular problem because it can infect other species, such as pigs or chickens, and undergo major genetic reassortments.
• Influenza B viruses tend to be more stable than influenza A viruses, but they too vary. Although influenza B has been far less common than A, a vaccine for type B is important because experts are concerned that small children will not have developed any immunity to the virus and will experience severe flu if they are exposed to type B.

A live but weakened intranasal vaccine called FluMist (FDA approved in June 2003) is the first nasally administered vaccine to be marketed in the United States. Each dose is formulated to contain each of the influenza virus strains recommended by the U.S. Public Health Service for the specific influenza season. The vaccine is engineered to grow only in the cooler temperatures of the nasal passages, not in the warmer lungs or lower airways. It boosts the specific immune factors in the mucous membranes of the nose that fight off the actual viral infections. In one study, it provided protection against the flu in up to 93% of children. FluMist is approved to prevent the flu due to influenza A and B viruses in healthy individuals between the ages of 5 and 50.

Timing and Effectiveness of the Vaccine. Ideally, appropriate candidates should be vaccinated every October or November. However, it may take longer for a full supply of the vaccine to reach certain locations. In such cases, the high-risk groups should be served first.

Antibodies to the influenza virus usually develop within two weeks of vaccination, and immunity peaks within four to six weeks, then gradually wanes.

In healthy adults, immunization typically reduces the chance of illness by about 70% to 90%. The current flu vaccines may be slightly less effective in certain patients, such as the elderly and those with certain chronic diseases. Even in people with a weaker response, however, the vaccine is usually protective against serious flu complications, particularly pneumonia. In fact, among the elderly, interesting studies are now suggesting that influenza vaccination may help protect against stroke, adverse heart events, and death from all causes.

Children Who Should Be Vaccinated. The following children over six months should be vaccinated against influenza:

• Any child with a condition that requires regular medical care or who has been hospitalized for a serious illness (particularly lung or kidney disease, diabetes, sickle-cell, or immune deficiencies). Vaccinations even in infants under six months old with certain conditions are warranted. In fact, for 2003 the American Academy of Pediatrics (AAP) and the CDC recommend the vaccination in all healthy children between six months and two years of age. This recommendation may vary from year to year depending on the supply of the vaccine.
• Children who are receiving long-term aspirin therapy should also be immunized against the flu because they are at higher risk for Reyes syndrome, a life-threatening disease, if they get the flu.

Of note: There has been some question concerning influenza vaccinations because of some reports that vaccines may worsen asthma. Recent and major studies have been reporting, however, that the vaccination is safe for children with asthma. It is also very important for these patients to reduce their risk for respiratory diseases. Still, 90% of asthma patients remain unvaccinated.

Older Children and Adults Who Should Be Vaccinated. The following, in order of priority, are the population groups who should be vaccinated each year. The first two groups have the highest need for influenza vaccinations and are given top priority:

• All adults 65 years and older. Vaccinated older adults have lower hospitalization rates than unvaccinated peers. Evidence now suggests that vaccination may help protect against adverse heart events (including after heart surgeries), stroke, and death from all causes in the elderly. Still, studies suggest that only two thirds of this group are vaccinated, mostly because of unwarranted fears of ineffectiveness or adverse effects.
• People of any age at high risk for serious complications from influenza. Such people include those with heart disease, lung problems, immune deficiencies, diabetes, kidney disease, or chronic blood disease. (There have been concerns about the safety of the vaccinations in certain high-risk patients such as those with HIV or asthma. Studies now suggest that the vaccine is generally safe in these patient groups. Furthermore, their risk for serious complications from influenza outweighs any potential adverse effects from the vaccines.)
• Adults between the ages of 50 and 64 who have chronic medical conditions. (The US Advisory Committee on Immunization Practices (ACIP) suggests that all adults over age 50 should be vaccinated, although this is not recommendation of the CDC.) People (such as household members or healthcare workers) in contact with individuals who are at high-risk for complications from influenza.

Other adults who should consider influenza vaccinations include the following:

• People at risk for complications for influenza and who are traveling to the tropics at any time or to the Southern Hemisphere between April and September.
• Pregnant women who are at risk for complications of influenza and who will be in their second or third trimester during flu season. (Vaccinations should usually be given after the first trimester. Exceptions may be women who are in their first trimester during flu season and their risk from complications of the flu is higher than any theoretical risk to the baby from the vaccine.)
• People such as firemen or policemen who are critical for public safety.

Negative Effects. Possible negative responses include the following:

• Allergic Reaction. Newer vaccines contain very little egg protein, but an allergic reaction still may occur in people with strong allergies to eggs.
• Soreness at the Injection Site. Up to two thirds of people who receive the influenza vaccine develop redness or soreness at the injection site for one or two days afterward.
• Flu-like Symptoms. Some people actually experience flu-like symptoms, called oculo-respiratory syndrome, which include cough, wheeze, tightness in the chest, sore throat, or a combination. Such symptoms tend to occur between 2 and 24 hours after the vaccination and generally last up to two days. These symptoms are not influenza itself but an immune response to the virus proteins in the vaccine. (Anyone with a fever at the time the vaccination is scheduled, however, should wait to be immunized until the ailment has subsided.)
• Guillain-Barre Syndrome. Isolated cases of a paralytic illness known as Guillain-Barre syndrome occurred in about one of every 100,000 people vaccinated with the swine-flu vaccine in 1976, but it has not been a problem with subsequent vaccines.

Pneumococcal Vaccines

The pneumococcal vaccine protects against S. pneumoniae (also called pneumococcal) bacteria, the most common cause of respiratory infections. There are two effective vaccines available, one called a 23-valent polysaccharide vaccine (Pneumovax, Pnu-Immune) for adults and a 7-valent conjugate vaccine (Prevnar or PCV7) for infants and young children. Experts are now recommending that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria. This has created a great sense of urgency in the medical community to find effective measures for preventing infection.

Pneumococcal Vaccine in Young Children. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Evidence suggests that this vaccination, plus the vaccination against Haemophilus influenzae (an important cause of meningitis), has led to 25,000 fewer cases of serious bacterial infections each year.

The pneumococcal vaccine is now recommended by many experts for the following groups:

• All children up to age two. The pneumococcal vaccine (Prevnar or PCV7) has now been added to the Recommended Childhood Immunization Schedule. The pneumococcal vaccine (Prevnar or PCV7) is very effective in children. Studies are suggesting that it prevents common ear infections as well as serious infections, such as pneumonia. In one study, a similar vaccine under investigation protected not only children in day care from serious respiratory infections, but their younger unvaccinated siblings had fewer infections as well.
• Children up to age five who are at risk for pneumonia or complications of influenza, such as children with sickle disease, those with immune deficiencies, or children with chronic medical conditions.
• Other children ages two to five that are higher risk for serious pneumococcal infections should be considered for vaccinations. They include African or Native Americans, children in group child care, socially or economically disadvantaged children, or those who have had frequent or complicated acute middle ear infections within the past year. (In one study, the vaccine reduced the number of ear infections episodes by 6%.)

The recommended schedule of immunization for Prevnar (PCV7) is four doses, given at 2, 4, 6, and 12 to 15 months of age. Infants starting immunization between 7 and 11 months should have three doses. Children starting their vaccinations between 12 and 23 months only need two doses. And those who are over two years old need only one dose.

Pneumococcal Vaccine in Older Children and Adults. The vaccine is proving to be effective in reducing the rate of pneumonia in young adults, although not to the degree that it protects young children. Its benefits for the elderly--other than protection against bloodstream infection--is unclear. Still, pneumonia is declining among adults, which may be due to fewer infections being transmitted from vaccinated young children. Many experts now recommend the vaccine for the following older children or adults:

• All people over 65 years old. (Anyone vaccinated more than five years previously should be revaccinated.) Of note, the vaccination is protective against pneumococcal bacteremia (invasive infection) in this group, but it does not appear to protect against community-acquired pneumonia itself.
• Adults with any chronic condition that increases the risk for pneumonia. This includes patients with heart disease (e.g., congestive heart failure, cardiomyopathies), chronic lung disease (COPD or emphysema, but not asthma), or diabetes.
• Individuals with immune deficiencies (e.g., HIV) or those undergoing treatments to suppress the immune system.
• Patients with autoimmune diseases, such as rheumatoid arthritis and lupus. Unfortunately, studies suggest the vaccine may not be as effective in these patients as those with healthy immune systems. Nevertheless they are at high risk for serious respiratory infections and should be vaccinated.
• Patients with kidney disease or kidney transplants. Older people who have had transplant operations or those with kidney disease may require a revaccination after six years.
• Patients with problems in the spleen.
• Alcoholics (especially those with cirrhosis).
• People living in long-term care facilities.
• Alaska Natives or American Indians, who may be at increased risk for pneumonia.

Because the vaccine is inactive, it is safe for pregnant women and people with immune deficiencies. In fact, when the vaccine is administered to pregnant women, it may actually protect their infants against certain respiratory infections.

Protection lasts for over six years in most people, although the protective value may be lost at a faster rate in elderly people than in younger adults. Anyone at risk for serious pneumonia should be revaccinated six years after the first dose, including those who were vaccinated before age 65. Subsequent booster doses, however, are not recommended.

Side Effects of the Pneumococcal Pneumonia Vaccine. Side effects include pain and redness at the injection site, fever, and joint aches. Children are more likely to have fever within 48 hours if they receive other vaccines at the same time and also after the second dose. Rarely, such local reactions can be severe. Even if a person is mistakenly re-vaccinated before the effects of the first vaccination have worn off, the risk for severe side effects is very low. Allergic reactions are very rare.