Applied Evidence

Take these steps to improve your flu season preparedness

J Fam Pract. 2018 October;67(10):602-607

References

1. CDC. Weekly US influenza surveillance report. https://www.cdc.gov/flu/weekly/index.htm. Published June 8, 2018. Accessed August 22, 2018.

2. CDC. Estimated influenza illnesses, medical visits, hospitalizations, and deaths averted by vaccination in the United States. Published April 19, 2017. https://www.cdc.gov/flu/about/disease/2015-16.htm. Accessed Setptember 18, 2018.

3. CDC. Seasonal influenza vaccine effectiveness, 2005-2018. https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm. Published February 15, 2018. Accessed August 22, 2018.

4. Sah P, Medlock J, Fitzpatrick MC, et al. Optimizing the impact of low-efficacy influenza vaccines. Proc Natl Acad Sci. 2018:201802479.

5. Flannery B, Reynolds SB, Blanton L, et al. Influenza vaccine effectiveness against pediatric deaths: 2010-2014. Pediatrics. 2017;139: e20164244.

6. Kim DK, Riley LE, Hunter P. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older—United States, 2018. MMWR Morb Mortal Wkly Rep. 2018;67:158–160.

7. Robinson CL, Romero JR, Kempe A, et al. Advisory Committee on Immunization Practices recommended immunization schedule for children and adolescents aged 18 years or younger—United States, 2018. MMWR Morb Mortal Wkly Rep. 2018;67:156–157.

8. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2017-18 influenza season. MMWR Recomm Rep. 2017;66:1-20.

9. CDC. Influenza vaccines—United States, 2017–18 influenza season. https://www.cdc.gov/flu/protect/vaccine/vaccines.htm. Published May 16, 2018. Accessed August 22, 2018.

10. Grohskopf LA, Sokolow LZ, Fry AM, et al. Update: ACIP recommendations for the use of quadrivalent live attenuated influenza vaccine (LAIV4)—United States, 2018-19 influenza season. MMWR Morb Mortal Wkly Rep. 2018;67:643–645.

11. Jenco M. AAP: Give children IIV flu shot; use LAIV as last resort. AAP News. May 21, 2018. http://www.aappublications.org/news/2018/05/21/fluvaccine051818. Accessed August 22, 2018.

12. Glinka ER, Smith DM, Johns ST. Timing matters—influenza vaccination to HIV-infected patients. HIV Med. 2016;17:601-604.

13. Castilla J, Martínez-Baz I, Martínez-Artola V, et al. Decline in influenza vaccine effectiveness with time after vaccination, Navarre, Spain, season 2011/12. Euro Surveill. 2013;18:20388.

14. CDC. Influenza antiviral medications: summary for clinicians. https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm. Published May 11, 2018. Accessed August 22, 2018.

15. CDC. Pneumococcal vaccination summary: who and when to vaccinate. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html. Published February 28, 2018. Accessed August 22, 2018.

16. Jefferson T, Del Mar CB, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev. 2011;(7):CD006207.

17. Loeb M, Dafoe N, Mahony J, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA. 2009;302:1865-1871.

18. Dobson J, Whitley RJ, Pocock S, Monto AS. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. Lancet. 2015;385:1729-1737.

19. Ghebrehewet S, MacPherson P, Ho A. Influenza. BMJ. 2016;355:i6258.

20. Kaysin A, Viera AJ. Community-acquired pneumonia in adults: diagnosis and management. Am Fam Physician. 2016;94:698-706.

21. Rodrigo C, Leonardi‐Bee J, Nguyen‐Van‐Tam J, et al. Corticosteroids as adjunctive therapy in the treatment of influenza. Cochrane Database Syst Rev. 2016;3:CD010406.

22. Brassard P, Wu JW, Ernst P, et al. The effect of statins on influenza-like illness morbidity and mortality. Pharmacoepidemiol Drug Saf. 2017;26:63-70.

23. Fedson DS. Treating influenza with statins and other immunomodulatory agents. Antiviral Res. 2013;99:417-435.

24. Khandaker G, Rashid H, Chow MY, et al. Statins for influenza and pneumonia. Cochrane Database Syst Rev. January 9, 2017 [withdrawn].

Strategy 2: Make use of chemoprophylaxis

Preventive use of antiviral medication (chemoprophylaxis) may be a useful adjunct or alternative to vaccination in certain circumstances: if the patient is at high risk for complications, has been exposed to someone with influenza, has contraindications to vaccination, or received the vaccine within the past 2 weeks. The CDC also suggests that chemoprophylaxis be considered for those with immune deficiencies or who are otherwise immunosuppressed after exposure.¹⁴ Antivirals can also be used to control outbreaks in long-term care facilities; in these cases, the recommendedregimen is daily administration for at least 2 weeks, continuing until at least 7 days after the identification of the last case.¹⁴ Oseltamivir (Tamiflu) and zanamivir (Relenza) are the recommended prophylactic agents; a related intravenous medication, peramivir (Rapivab), is recommend for treatment only (see Table 3¹⁴).

Strategy 3: Prevent comorbidities and opportunistic infections

Morbidity associated with influenza often comes from secondary infection. Pneumonia is among the most common complications, so influenza season is a good time to ensure that patients are appropriately vaccinated against pneumococcus, as well. Pneumococcal conjugate vaccine (Prevnar or PCV13) is recommended for children younger than 2 years of age, to be administered in a series of 4 doses: at 2, 4, 6, and 12-15 months. Vaccination with PCV13 is also recommended for those ages 65 or older, to be followed at least one year later with pneumococcal polysaccharide vaccine (Pneumovax or PPSV23).¹⁵ Additional doses of PCV13, PPSV23, or both may be indicated, depending on health status.

Strategy 4: Encourage good hygiene

The availability of immunizations and antivirals does not replace good hygiene. Frequent handwashing reduces the transmission of respiratory viruses, including influenza.¹⁶ Few studies have evaluated the use of alcohol-based hand sanitizers, but available evidence suggests they are effective in lowering viral transmission.¹⁶

Barriers, such as masks, gloves, and gowns, are helpful for health care workers.¹⁶ Surgical masks are often considered more comfortable to wear than N95 respirators. It may therefore be welcome news that when a 2009 randomized study assessed their use by hospital-based nurses, masks were non-inferior in protecting these health care workers against influenza.¹⁷

Presenteeism, the practice of going to work while sick, should be discouraged. People at risk for influenza may wish to avoid crowds during flu season; those with symptoms should be encouraged to stay home and limit contact with others.

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