January is National Winter Sports TBI Awareness Month: Recognizing Head and Neck Injuries

Head and Neck InjuriesEvery year, throughout January, The Johnny OTM Foundation, along with the CDC, local urgent care centers, like eMedical Urgent Care, and surrounding sports clubs, work to raise awareness about common health risks related to participation in winter sports. Some of the common injuries related to winter sports include sprains, strains, dislocations and fractures. While all winter sports injuries should be taken seriously, head and neck injuries are especially serious as they have the potential to cause long-term health problems.

About National Winter Sports TBI Awareness Month

It doesn’t matter if you’re five or 50, safety in the snow is important for all ages. The more you know, the more you and your family can have a safe and healthy winter season.

TBI stands for Traumatic Brain Injury. It’s a common result of head and neck injuries associated with winter activities such as skating, skiing, snowboarding, ice hockey, sledding and tobogganing. The Johnny O Foundation along with National Winter Sports TBI Awareness Month is a public campaign to highlight the dangers and importance of taking precautionary measures when participating in those sports. Their main goal is to decrease TBIs in the country.

Statistics on Head and Neck Injuries

According to the American Physical Therapy Association, each year, there are approximately 1.7 million head injuries in the United States. Commonly caused by falling or colliding into another person or object while skiing or skating, many of these accidents lead to head injures such as a concussion or TBI.

The top causes of TBI include:

  • Cycling
  • Football
  • Baseball
  • Softball & Basketball
  • Water Sports
  • Soccer
  • Powered Recreational Vehicles
  • Skateboards
  • Scooters
  • Golf
  • Fitness & Exercise
  • Winter Sports
  • Horseback Riding
  • Gymnastics
  • Dance
  • Cheerleading

However, not all head and neck injuries are related to sports. In fact, The Centers for Disease Control and Prevention (CDC) reports that over 30% of TBI causes results from falls. So, whether you’re taking the dog out for a walk on an icy sidewalk or hitting the ice for a hockey game, you could be at risk. But just because there’s risk, that’s no reason to lock up and put life on hold. Go ahead and head out to enjoy the New Jersey snow, just exercise caution.

Preventing Head and Neck Injuries in the Winter

Since falls are one of the leading causes of TBIs, take caution on icy surfaces: walk slowly, wear boots with good tread and pay attention to the surface you’re walking on.

Preventive measures, such as wearing protective head equipment, choosing helmets that fit correctly and following safety rules, can help those who participate in winter sports prevent head and neck injuries. New to the sport? Don’t be afraid to take lessons.

Proceed with Caution

If you suspect a loved one has suffered a concussion or TBI, it is important to take the injured individual out of the activity until he or she has been thoroughly evaluated by an experienced medical professional. We offer convenient walk-in hours designed to fit your busy schedule; learn more about our services and how we can treat you and your family by calling our location in Berkeley Heights, New Jersey (908) 464-6700, or Middletown, New Jersey (732) 957-0707.

The physicians at eMedical Urgent Care want to remind you and your loved ones to enjoy the winter season, but stay safe by taking proper precautions during play.

Ready for the New Jersey Flu Season? Here’s What to Expect and Where to Get a Flu Shot

New Jersey Flu SeasonFall is officially here which means the days are getting shorter, Halloween decorations are in full effect and Santa’s reindeer have hit the shelves. At eMedical Urgent Care, this time of year means our experienced providers are already underway with preparations for the upcoming New Jersey flu season. And we’re already getting reports of seasonal influenza-like illness activity throughout the state.

The New Jersey flu season can vary in their timing, severity, and duration from one season to another. Most of the time, flu activity starts around October and peaks between December and March, lasting as late as May. Flu activity is unpredictable, for example, last year’s flu season peaked later (March 12, 2016) than the previous seasons.

2016-2017 New Jersey Flu Season: What To Expect

The U.S. Centers for Disease Control and Prevention recently announced that influenza vaccination coverage declined 1.5 percent across the entire U.S. population during the 2015-2016 flu season, with only 46 percent of Americans receiving the annual vaccine.

The decline in influenza vaccine coverage is causing concern among public health officials that more Americans might wave off a flu shot this year. Since vaccination not only reduces the chance of getting the flu but it also helps reduce the severity of infection and complications, this is particularly troubling for older adults because seniors are disproportionately affected by the flu.

Although Nasal spray flu vaccine has been pulled off the U.S. market because it has proven ineffective, according to the CDC, this season’s flu vaccine has been updated to protect against the four influenza viruses that research suggests will be most common during the 2016-2017 season.  This year’s vaccine offers protection against: A/California (H1N1), A/Hong Kong, B/Phuket and B/Brisbane.

Don’t Delay Protection for the New Jersey Flu Season

Each year, millions of Americans come down with the flu and hundreds of thousands of them are hospitalized. Flu vaccine effectiveness can vary from year to year, but the Center for Disease Control and Prevention (CDC) estimated that for the 2013-2014 flu season, the vaccine prevented approximately 7.2 million illnesses and 90,000 hospitalizations.

In an effort to continuously improve prevention of seasonal flu, the CDC recommends everyone 6 months of age and older get a flu shot every year. The CDC states: “Vaccination is especially important for people at higher risk of severe influenza and their close contacts, including healthcare personnel and close contacts of children younger than 6 months.”  It takes up to two weeks after vaccination for antibodies to develop and protection may last for up to one year.

Flu Shots Available at eMedical

Because of the unpredictability of flu activity, the earlier you can get your vaccine, the more protection you, your family and your community will have.

The influenza vaccine for the 2016-2017 flu season is now available at both eMedical locations. At eMedical Urgent Care, receiving the flu vaccination is as easy as stopping by when it’s convenient for you; no need for an appointment.

Learn more about our services and how we can treat you by calling our location in Berkeley Heights, New Jersey (908) 464-6700, or Middletown, New Jersey (732) 957-0707.

10 Questions – And Answers – About Sinus Infections

By Jane Sennett, DO flu

While winter is known for cold weather, ice skating and hot chocolate, it’s also known for the flu, colds and the dreaded sinus infection. Deciphering and diagnosing a sinus infection can be tricky, but fortunately there are frequently asked questions to help you.

What are sinuses?

A sinus is a hollow, air-filled cavity. There is a frontal sinus, located in the forehead; the maxillary sinus, which is behind the cheek; ethmoid sinuses between the eyes and the sphenoid sinus, located deep behind the eyes.

What is sinusitis?

Sinusitis, or a sinus infection, is an inflammation or swelling of your sinuses. Normally, your sinuses are filled with air. When the sinuses become blocked and filled with fluid, bacteria can grow there and cause an infection.

How common is sinusitis?

More than 37 million Americans suffer from at least one episode of acute sinusitis each year. It has increased throughout recent years, perhaps due to increased pollution and resistance to antibiotics.

What are the signs of a sinus infection?

Symptoms include facial pain or pressure, nasal obstruction, or a “stuffed up” nose, nasal discharge, and a diminished sense of smell.

How is sinusitis treated?

Most sinus infections are viral and will resolve. However true bacterial infections require an extended course if antibiotics. Patients needing antibiotics are generally treated with 10 to 14 days of antibiotics. We also may prescribe oral and topical decongestants to help alleviate the symptoms.

Can I use over-the-counter sinus medicine for a sinus infection?

It depends on the person. It’s best to come to our office to be examined by a doctor to determine the best treatment.

How long does a sinus infection last?

Severe cases can last 4 to 12 weeks, while less severe cases can last up to 4 weeks. Chronic sinusitis can last 3 months of longer and may require surgery.

Is rinsing your sinuses safe?

You may safely use normal saline spray to help irrigate your sinuses. Using something like a neti pot is safe as long as the water used is filtered or distilled. If you experience a fever, nosebleed or experience frequent headaches after using a neti pot, you should definitely seek medical attention.

Are sinus infections contagious?

Sinusitis is not contagious. However, keep in mind that clogged sinuses can provide an ideal environment for bacteria to breed.

What happens if a sinus infection is left undiagnosed?

If left untreated, a sinus infection can lead to severe medical problems including infections of the eye socket and blood clots in the sinus area around the front and top of the face.

If this winter weather has you yelling ”achoo” instead of outside chanting ”woohoo,” visit eMedical Urgent Care in Berkeley Heights and Middletown, N.J., and to start feeling better today!

Jane Sennett, DO, is the medical director for eMedical Urgent Care, formerly known as eMedical Offices (EMO). She joined eMedical Urgent Care in 2014. She is board-certified in emergency medicine. Dr. Sennett earned her medical degree from the University of Medicine and Dentistry of New Jersey’s School of Osteopathic Medicine and completed her emergency medicine residency at Union Hospital and Newark Beth Israel Medical Center. Dr. Sennett holds a bachelor’s degree in English from Rutgers University. She also is an attending physician at Overlook Medical Center- Union Campus and Robert Wood University Hospital at Rahway.

A Long Winter May Equal a Vitamin D Deficiency: Tips for Getting More of the Sunshine Vitamin

ImageLet’s face it, this winter was awful. When the Farmer’s Almanac predicted an unusually harsh winter, thoughts of snow days and hot chocolate rushed through the minds of New Jersey residents. Never did we think we’d be shoveling snow on what felt like every other week, battling below-zero temperatures and calling to find alternative childcare when schools were delayed or closed.

With an unusually long winter comes vitamin D deficiency. Vitamin D is an essential nutrient that plays an important role in bone health. Historically, vitamin D deficiency in children leads to rickets, a bone-deforming disease. In adults, vitamin D deficiency leads to osteomalacia, the softening of the bone, which produces bone pain and weakness and increased risk of fractures. More recently, vitamin D deficiency has been linked to depression, poor dental enamel health, increased risk for allergies or asthma and perhaps coronary artery disease and diabetes .

Who is at Risk?

Those at risk for vitamin D deficiency include those who may not get enough sun exposure, such as seniors, hospitalized or institutionalized patients, those who live in countries far from the equator and those with darker skin pigmentation (since melanin acts as natural sunblock). Poor dietary intake also may play a role, especially in seniors and infants exclusively breastfed. Those with malabsorption issues, such as celiac disease, post-gastric bypass and intestinal resection patients, can’t effectively absorb vitamin D. Those with chronic renal disease also have a vitamin D deficiency.

How to Get More Vitamin D

Say goodbye to electronics and hello to the sunshine. Go outside! Enjoy a picnic in the park, take a walk or ride a bike. Vitamin D is obtained in two major ways: dietary and via the skin. Eating foods like salmon, egg yolk and yogurt help, but enjoying the sun outside is far more entertaining!

The recommended daily allowance (RDA) for children and adults under age 70 is 600 IU. Those aged 80 and older require 800 IU. It’s often difficult to get the recommended daily allowance of vitamin D through diet alone, since common fortified foods contain less than the recommended amount. Examples include:

  • 8oz of milk – 100IU
  • 8oz of orange juice – 100IU
  • One serving of fortified cereal – 40-80IU
  • 100g of Swiss cheese – 44IU

Is Sun Exposure Safe?

I recommend supplementing your diet with a daily multivitamin and sunlight exposure. When weighed against the risk for skin cancer, sun exposure becomes more important in trying to reach the recommended amount. During winter months when UV-B rays are not strong and snow and freezing temperatures restrict access to outdoor time, vitamin D deficiency rises and additional supplementation becomes very important.

However, when the sun and warmer weather returns during the spring, summer and fall, 10 to 15 minutes of sun exposure, without the use of sunblock during the mid-day, is enough to provide the RDA of vitamin D in the lightly pigmented population. Darker skinned individuals require more time in the sun to absorb the RDA of vitamin D.

Put aside the chores, turn off the TV and computer and go outside to enjoy the fresh air and sunshine. It’ll do your bones some good!

By Kristine Samson, MD

About Kristine Samson, MD
Kristine Samson, MD, joined eMedical Urgent Care in 2013. She is board-certified in emergency medicine. She completed her residency at Jacobi/Montefiore Medical Centers, Bronx, N.Y. She is an assistant professor of emergency medicine at Jacobi Medical Center.

5 Ways to Avoid Getting Sick When Traveling

3.19.13-Airplane-FlyingWhile illness can strike at any time of year, holiday travel makes most of us more susceptible to sickness. We’re stressed, we’re cold, and we’re spending time in cramped trains, planes and cars with lots of other people. It often may seem impossible to avoid getting sick when traveling.

“During the holidays, upper respiratory illnesses, such as the common cold and the flu, are very common,” says Susan Rehm, M.D., Medical Director of the National Foundation for Infectious Disease. “Gastrointestinal infections that cause nausea, vomiting and diarrhea also spread during the holiday season.”

So what can you do to prevent bringing home more than presents? Dr. Rehm suggests following these tips to avoid getting sick when traveling and ensure that your holidays are happy and healthy:

Stay up to date on routine immunizations

“Staying on top of routine immunizations is one of the best things you can do to prevent getting sick while traveling,” says Dr. Rehm. Visit the Centers for Disease Control and Prevention (CDC) website to see what you need.

Get the flu shot

Each year approximately 200,000 are hospitalized and 40,000 people die from influenza complications. Getting your annual flu shot will protect you and those around you from the flu. Even if you yourself do not have the symptoms of the flu, you can carry the virus around and expose others to it. Getting your flu shot before holiday travel is especially important, as holiday gatherings often bring the elderly and the very young together, two populations especially vulnerable to dangerous, potentially life-threatening complications from influenza. Many retail clinics like Health Clinics at select Walgreens provide affordable and convenient flu shots. You can book an appointment through iTriage online or on your smartphone.

Know flu symptoms

“Many people don’t realize that the flu is preventable (with a flu shot), or that may be treatable with prescription antiviral medication if caught within the first 48 hours of symptoms,” says Dr. Rehm. If you experience flu symptoms, visit your doctor, an urgent care or a retail clinic.

Flu symptoms include:

  • Fever
  • Headache
  • Fatigue
  • Chills
  • Dry cough
  • Sore throat
  • Stuffy nose
  • Muscle aches
  • Stiffness 

Avoid sick people if you can

Remember that most infections are spread through infectious droplets in the air (colds and flu) or when you touch a something that has been contaminated with viruses or bacteria by someone who is ill,” says Dr. Rehm. “When someone with a respiratory illness coughs, sneezes or even talks, viruses can spread in the air for six feet around them.  If you are aware that someone around you is ill, politely offer him or her a tissue and hand sanitizer. If it is possible to move away from the sick person, do so.” 


Your hands are the most convenient way for viruses and infections to travel. Wash your hands frequently with soap and water or use alcohol-based hand sanitizer to lower your risk of contracting an infection or virus while traveling, and avoid touching your nose, eyes and mouth.

Don’t travel when you’re sick

“If you’re sick, don’t travel, especially if you’re dehydrated or if you have a fever,” says Dr. Rehm. “You don’t want to be the person who gives the ‘gift that keeps on giving:’ a chain of infection that lasts long after the holidays are over.” If your doctor has prescribed you antiviral drugs, make sure to take them.

Treat yourself well

To maximize your ability to avoid getting sick when traveling and ensure that your immune system is ready for the holidays, keep hydrated, eat a healthy diet, make sure you get enough sleep, and keep alcoholic drinks to a minimum.

Though the basic principles can be applied broadly, recommendations for international travelers are country-specific and often more detailed. Please see your health care professional well in advance of your travel. You can also consult the CDC’s travel website for more information.

Courtesy of iTriage

New Year’s Resolutions: A Healthier Lifestyle

By eMedical Urgent Care

Habits are hard to break, but well worth the effort because we are the result of our habits, both good and bad.  Most of our behavior is not the product of well-considered decision making, but shaped by our habits, according to Charles Duhigg in The Power of Habit.  I will focus this post primarily on physical and health habits, but this also is true for mental habits we might want to kick: procrastination, pessimism, losing our temper, gossiping, etc.  Moving toward a healthier lifestyle is at the base of most New Year’s resolutions and I wholeheartedly agree that it is a most worthy goal.

In the beginning of the year, people make resolutions because they want another chance to improve something they feel they did not accomplish in the prior year.  Any change we make is only effective long term if it is maintained long term.  While the final goal is a healthier lifestyle, resolutions are important, as they constitute small steps in the right direction.  Resolutions are to lifestyle changes what a sprint is to a marathon, but ideally they should ease us into the marathon.

A common reason resolutions might not be successful is that they are too vague.  Things like losing weight or even losing one pound per week, fitting into a favorite dress, reducing salt intake or start exercising are goals, not resolutions.  We should always start by deciding on a goal, but the resolution should state the action we plan to take to achieve the goal.

Here are some examples of some specific resolutions to develop a healthier lifestyle:

Weight loss

  • Stop drinking your calories: drop the soda, juice, milk and sugar in your coffee or tea and stick to water.
  • Replace a sandwich with a salad.
  • Change your go-to lunch place to a healthier one; instead of pizza choose a salad bar or deli.
  • Avoid carbohydrates for dinner (lean protein and vegetables are a great substitute).
  • Eliminate fried foods.


    • Take the stairs instead of the elevator for a few flights.
    • Park at the far end of the parking lot.
    • Take a brisk walk every day.
    • Go to the gym once a week.

General Health

  • Introduce one healthy food each week: eat once a week the first week, twice a week the second week, etc.
  • If you are not used to cooking, cook from scratch one meal a week, then increase.
  • To start buying organic produce is not a specific enough resolution, but you might start with incorporating organic leafy greens the first week or month, vegetables the second, fruit the third, etc.
  • Start flossing if you were not doing that before, is specific enough

Reduce salt intake for people with high blood pressure

  • Eliminate pickles and deli meats.
  • Avoid eating processed foods for dinner.
  • Eating out less is not specific enough, but pack your own lunch is.

Better diabetic control

  • Pair all high glycemic index foods  with a high-fiber food: pasta with spinach, dried fruit with bran cereal (eliminating them will be the end goal).
  • No refined carbs on an empty stomach (their fast absorption leads to a spike in blood sugar). If you must have juice or something sweet, have it at the end of a meal, not in the morning.
  • Replace breakfast cereal with a high-protein food: eggs, protein shakes, yogurt.

Another reason a resolution fails is when it’s too drastic or hard to implement in one step.  For instance, a two-pack-a-day smoker should not resolve to quit “cold turkey,” but to decrease smoking to one pack a day for a few weeks.  Changing one’s mindset also is important.

Here are some ways to accomplish that:

  • Don’t restrict yourself, or the craving might actually increase.  Instead of saying “I can’t have cake, I am on a diet,” say “I’m trying to reduce carbs, so I am going to pass on this piece of cake now and have an apple instead, but in half an hour if I still want it, I will have a little piece.”

Focus on the things you like about the changes you made:  

  • Walking outside is enjoyable.
  • The flavor of a dish comes through better without the sugar.
  • It’s more fun to browse at the health store than the supermarket, etc.

Involve your loved ones. Sometimes we’ll go the extra mile for them when we wouldn’t do it for ourselves.

  •  Resolve to cook from scratch for the whole family once a week.
  • Stop buying processed foods for the family; don’t just stop eating them yourself.
  • We perform better when we feel better. Give yourself a little boost when you know the temptation to quit will be high.
  • Play your favorite music when you exercise.
  • Invite a friend to accompany you on that power walk.
  • Drink seltzer with a spritz of lemon in a champagne flute or wine glass.

If changing an eating habit seems too hard to do, here are some things that are easier to change and will bring you closer to your goal of having a healthier lifestyle:

  • Change what you buy: Replace canola oil with cold-pressed, extra-virgin olive oil; buy chicken or turkey and grill it instead of eating cold cuts; use aluminum-free deodorant; or dried fruit instead of fruit snacks.
  • Change where you go: hang out at the bookstore instead of the mall; go to the YMCA instead of the town fair; take the kids to a juice bar instead of the ice cream place.
  • Change who you socialize with: If choose one health-oriented acquaintance and become friends, his or her habits will brush off on you.

Change one thing: Make it small enough to feel easy, but big enough to count.

  • Serve dinner in smaller plates for portion control.
  • Avoid snacking after dinner.
  • Eat a salad at least once a day.

Remember, building a healthier lifestyle doesn’t happen overnight. They take time, perseverance and patience. Bad days happen – but the choice to keep going is yours.

Have a happy and healthy new year!

If you need medical attention for a non-life-threatening illness or injury, eMedical Urgent Care is open during the evening hours to treat walk-in patients. If you have questions about medical conditions, download iTriage from the iTunes or Android Marketplace, or check out iTriageHealth.com for your healthcare answers.

Breaking Down the Flu Vaccination

By eMedical Urgent Care Officesflu blog picture

The leaves have changed color and the air is much cooler; meteorologist would say we’ve entered autumn but for physicians, it is the start of flu season. Our urgent care office is full of sneezing, aching and coughing patients — many of whom did not receive the flu vaccination. When I bring up vaccination in conversation, patients seem confused or hesitant about receiving the vaccine. So that you can make an informed decision about receiving the vaccine, here are answers to some common questions about this issue.

Should I get the flu vaccine this year?

The short answer is yes. Vaccination is the main way to protect yourself from the flu. Since 2010, the recommendation from the CDC has been to vaccinate all individuals older than 6 months. If you are a young and healthy adult, the reason for this is not only to reduce your own chance of getting infected, but also to protect the people in your life who might be more prone to flu complications, such as children, elderly and people with chronic diseases.

Will last year’s vaccine protect me this year too?

Probably not. Even if some of last year’s viral strains still are circulating this year, chances are your antibody levels have dropped to the point where you no longer benefit from them. The current recommendations support getting vaccinating every year.

Are we expecting new strains of the flu virus this year?

No, not more than in any given year. Which strains of the virus will circulate in a season can be predicted by scientists to a certain extent, and vaccine manufacturers include those strains in the vaccine they produce. However, new strains do appear, more likely toward the end of the flu season.

How effective is the flu vaccine?

It is too early to tell for this year, but historically its effectiveness has ranged between 50 percent and 75 percent. Last year the vaccine’s effectiveness was a disappointing 56 percent. The effectiveness varies depending on the recipient’s age and health status, and by how good of a match there is between the expected and actual strains of the virus.

Who should get the flu vaccine?

Everyone 6 months and older should visit their doctor or urgent care office to be vaccinated, but especially people at risk for serious complications (pregnant women, children under 5 years of age and people with asthma, diabetes and chronic lung disease) or those who live with or care for them.

Why do some people feel sick a few days after being vaccinated against the flu?

The flu shot may cause mild side effects that are sometimes mistaken for the flu, such as low-grade fever, muscle pain and fatigue. These are signs of immune system activation and antibody production, and do not mean you got the flu from the vaccine.

What flu viruses does this season’s vaccine protect again?

The trivalent influenza vaccine that has been available in the past years offers protection against two influenza A viruses (H1N1 California and H3N2 Victoria) and one influenza B virus (Massachusetts). This year, the new quadrivalent vaccine includes a fourth strain, the B Brisbane virus.

Why was this fourth virus added to the mix?

Type A flu causes more serious disease and more deaths, especially the H3N2, but there are 2 type B families of viruses that circulate the globe. This year, to eliminate the guesswork regarding which one we’d see in the United States, they were both included in the quadrivalent varieties (Fluzone, Fluarix and FluLaval).

Should I get the quadrivalent or trivalent vaccine?

The quadrivalent vaccines are a better choice for children, as they tend to catch the newly added strain more often. The new vaccine only accounts for 30 million doses out of the more than 135 million available this season, so if you do not find the quadrivalent vaccine available in your area, the trivalent one is an excellent choice too. The CDC does not recommend one over the other.

What other kinds of flu vaccines are available for the 2013-2014 season?*

Clinicians are moving from a one-size-fits-all to individualized vaccination, a good thing once you understand how they are alike and how they are different.

  1. The Flumist quadrivalent is a nasal spray for healthy people ages 2 to 49 who are not pregnant. If you are not in this category, you still can get the regular quadrivalent shot.
  2. The Flublok is a new formulation specifically designed for people who are allergic to eggs. It can be used only in healthy adults between 18 and 49 years of age.
  3. The Fluzone High Dose is recommended for people age 65 and older. Four-times stronger, this vaccine offers a 24 percent higher immunity, as demonstrated in a clinical study of 30,000 people.
  4. The Fluzone Intradermal is a formulation of the trivalent vaccine for ages 18-64 that is delivered through the skin instead of intramuscularly via a much smaller needle.

So which vaccine should I get?

Depending on which category you fit in, you might have more than one option, but which vaccine you receive is not as important as getting vaccinated in the first place.
You prepare for Thanksgiving and the holidays too, but give some thought about preparing for the flu. eMedical Offices urgent care center is offering flu shots on Black Friday, Nov. 29, for only $25. Visit social media pages and website for health-related news and special offers.

If you need medical attention for a non-life-threatening illness or injury, eMedical Urgent Care Offices is open during the evening hours to treat walk-in patients. If you have questions about medical conditions, download iTriage from the iTunes or Android Marketplace, or check out iTriageHealth.com for your healthcare answers.

*eMedical Urgent Care Offices offers the quadrivalent and trivalent vaccine