It’s Not Too Late To Get Your Flu Shot

David J. Fletcher, MD

It’s never too late to get vaccinated for influenza, better known as the “flu”.

While we ache for the start of Spring (seems like the ground hog was wrong about an early spring this year), we can’t forget that the flu and other seasonal communicable diseases are still lurking around. The flu season can extend all the way through May and for those individuals who have not gotten the 2018-2019 version of the flu vaccine, it is still not too late to get vaccinated.

There are many benefits to the vaccination, including reducing the risk of flu illness, fewer doctor’s visits, decrease risk of hospitalization, and even preventing death. The Flu vaccination has also been shown to reduce severity of illness among people who get vaccinated, but still continue to get sick.

This season’s flu offers an option of either trivalent (three-component) or quadrivalent (four-component) vaccines, which protect against the different virus strains, or a nasal spray flu vaccine option (live attenuated influenza vaccine or “LAIV”).

It takes 10-14 days or two weeks before you develop enough protective antibodies to protect against contracting the flu.

CDC expects flu activity to remain elevated for a number of weeks. According to a recent Centers For Disease Control FluView report (February 22, 2019) flu activity reached a new high for this year’s season.

The Illinois Department of Public Health (IDPH), which also closely tracks flu activity, now reports widespread ILI all over Illinois.

“Influenza like Illness” (ILI), defined as fever ≥ 100°F with a cough and/or sore throat, makes up 2.7% of out-patient visits in Illinois in late February 2019.

CDC notes hospitalizations and deaths related to the flu this year are well below what was observed last season. Experts attribute the calmer flu season to the effectiveness of this year’s vaccine.

Besides getting vaccinated, even late in the flu season, one needs to follow the basics to stay healthy: wash your hands frequently (consider carrying a pocket bottle of hand sanitizer), avoid being around those who are sick, and try to get plenty of rest.

There is a new antiviral medication for treatment of influenza A and B Xofluza (baloxavir marboxil), which was FDA approved in October 2018 and should be given as a single dose by mouth to those who have been symptomatic for no more than 48 hours. However, it only reduces the duration of flu symptoms by approximately a day. In addition, Tamiflu, which is another Oseltamivir is used to treat symptoms caused by the flu virus (influenza). It helps make the symptoms (such as stuffy nose, cough, sore throat, fever/chills, aches and tiredness) less severe and shortens the recovery time by 1-2 days. This medication may also be used to prevent the flu, if you have been exposed to someone who already has the flu (such as a sick household member), or if there is a flu outbreak in the community.

This

medication works by stopping the flu virus from growing. It is not a substitute for the flu vaccine.

You are better to get vaccinated and it’s not too late!

Our 217 Immediate Care will take walk-ins for flu vaccines Monday-Friday 7AM-5PM and 8AM-12PM on Saturday!

Table 1. Requirements of the Diabetes Exemption Program vs. the New Rule

The new 4-page Insulin-Treated Diabetes Mellitus Assessment Form (ITDM Assessment Form), MCSA-5870 is now available on-line at the FMCSA website,[1]and must be submitted to the ME with 45 days of completion.

According to the new rules, the Treating Clinician (TC) is defined as the  health care provider who manages and prescribes insulin for the individual. The TC is to review 3 months of glucose logs and attests that the individual maintains a stable insulin regimen and proper control of his or her diabetes on the form which the examiner reviews and then performs an exam.

It is then up to the certified ME then determines that the individual meets the FMCSA’s physical qualification standards and can operate CMVs in interstate commerce.

Revised Diabetes Standard

September 19, 2018

  • Sec. 391.41 Physical qualifications for driver (b) (3) Has no established medical history or clinical diagnosis of diabetes mellitus currently treated with insulin for control, unless the person meets the requirements in Sec. 391.46;

Sec. 391.46 Physical qualification standards for an individual with diabetes mellitus treated with insulin for control.

(a) Diabetes mellitus treated with insulin. An individual with diabetes mellitus treated with insulin for control is physically qualified to operate a commercial motor vehicle provided:

(1) The individual otherwise meets the physical qualification standards in

Sec. 391.41 or has an exemption or skill performance evaluation certificate, if required; and

(2) The individual has the evaluation required by paragraph (b) and the medical examination required by paragraph (c) of this section.

(b) Evaluation by the treating clinician. Prior to the examination required by § 391.45 or the expiration of a medical examiner’s certificate, the individual must be evaluated by his or her “treating clinician.” For purposes of this section, “treating clinician” means a healthcare professional who manages, and prescribes insulin for, the treatment of the individual’s diabetes mellitus as authorized by the healthcare professional’s State licensing authority.

(1) During the evaluation of the individual, the treating clinician must complete the Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870.

(2) Upon completion of the Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, the treating clinician must sign and date the Form and provide his or her full name, office address, and telephone number on the Form.

Sec. 391.46 Physical qualification standards for an individual with diabetes mellitus treated with insulin for control

(c) Medical examiner’s examination.

  • At least annually
  • Within 45 days of completion of Form MCSA-5870 by TC
  • Determine if medically qualified and free of complications from DM that might impair ability to operate a commercial motor vehicle safely.
  • ME must receive properly completed Form, MCSA-5870, from TC
  • Form maintained as part of Medical Examination Report Form, MCSA-5875.

Sec. 391.46 Physical qualification standards for an individual with diabetes mellitus treated with insulin for control

(d) Blood glucose self-monitoring records.

  • Individuals with ITDM must self-monitor blood glucose in accordance with treatment plan of TC.
  • Must maintain blood glucose records measured with an electronic glucometer that stores all readings
  • Records date and time of readings
  • Data must be able to be electronically downloaded.
  • Printout of electronic blood glucose records or the glucometer must be provided to TC at time of evaluations required by this section

Sec. 391.46 Physical qualification standards for an individual with diabetes mellitus treated with insulin for control

(e) Severe hypoglycemic episodes.

(1) Individual with ITDM who experiences a severe hypoglycemic episode is prohibited from operating a CMV and must report to and be evaluated by TC as soon as “reasonably practicable”

The management of severe hypoglycemic episode requires the TC to determine that the cause has been addressed and that the individual is maintaining a stable insulin regimen and proper control of his or her diabetes mellitus. The TC completes a new Form, MCSA-5870 which the driver retains the new form and provides to ME at next medical examination.

While there is no requirement under 391.46(e) for ME to see a driver following a hypoglycemic episode under CFR 391.45c the motor carrier still has the obligation to determine if this illness renders the driver medically unqualified. Hence, this ITDM drive would need to undergo a medical examination, even if his current medical certificate has not expired.

The burden and negligent issuance malpractice exposure is now on the DOT medical examiners, and it is important for MEs to rely on more information that just provided by the treating clinician on the  Insulin-Treated Diabetes Mellitus Assessment Form (ITDM Assessment Form), MCSA-5870.

Since the change in November 2018, I have had several drivers apply for CDME exam that previously were unable to drive due to insulin and had not yet applied for the cumbersome diabetes exemption (several said they could not find an endocrinologist to treat them and completed the old diabetes examination forms four times a year. Also, many health insurance plans would not pay for the extra services required to comply the old DOT exemption program.

Now the new rule is a lower cost option and is much quicker process.

BEST PRACTICES

  1. Charge more for the exam that requires you to review MCSA 5870 Form. We tell drivers and employers up front that there will be a $150 extra charge on top of our regular DOT medical exam charge for this expanded service.

 

  1. The standard of care demands that MEs not just rely on the MCSA 5870 form completed by the TC. Verify the decision by the TC to sign off on the control of a driver’s diabetes with insulin. Review the TC’s records and ensure that the driver is on a stable dose of insulin. It is essential that the ME confirm that the driver does NOT have hypoglycemic episodes documented and he is monitoring his glucose electronically. It is best practice to confirm the logs actually exist.

 

  1. While no longer required any driver that uses insulin to control his diabetes will have still be required to have an annual eye exam at my office. I have found proper eye care for ITDM drivers is really lacking. I give drivers the two-page Vision Evaluation Checklist from the Federal Diabetes Exemption Program to get completed along with the MCSA 5870 before I certify an IDDM driver (page 13/14 of expired Exemption Program application form[2]). Drivers with severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy should be disqualified.

 

  1. If the urine dipstick shows glucosuria, I get very concerned and do a glucose fingerstick. I send them back to their TC for an updated evaluation before I medically clear them to drive.

 

 

Bottom-line with the advent of ME-certification of ITDM drivers negligent issuance risk expands and it imperative medical examiners MUST stay current with “established

best medical practices” and appropriately charge for their time.

 

[1] https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/regulations/medical/422521/itdm-assessment-form-final.pdf

 

[2] https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/regulations/medical/driver-medical-requirements/10436/diabetesexemptionpackage0706508cln_0.pdf

 

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