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].

Antiviral treatment may have some value for hospitalized patients when started even 5 days after symptom onset. Treatment may be extended beyond the usual recommendations (5 days for oseltamivir or zanamivir) in immunosuppressed patients or the critically ill. Additionally, recent guidelines include consideration of antiviral treatment in outpatients who are at normal risk if treatment can be started within 48 hours of symptom onset.¹⁴

The CDC currently recommends use of oseltamivir rather than other antivirals for most hospitalized patients, based on the availability of data on its use in this setting.¹⁴ Intravenous peramivir is recommended for patients who cannot tolerate or absorb oral medication; inhaled zanamivir or IV peramivir are preferred for patients with end-stage renal disease who are not undergoing dialysis (see Table 3).¹⁴

Strategy 2: Exercise caution when it comes to supportive care

There are other medications that may offer symptom relief or prevent complications, especially when antivirals are contraindicated or unavailable.

Corticosteroids are recommended as part of the treatment of community-acquired pneumonia,²⁰but their role in influenza is controversial. A 2016 Cochrane review²¹ found no randomized controlled trials on the topic. Although the balance of available data from observational studies indicated that use of corticosteroids was associated with increased mortality, the authors also noted that all the studies included in their meta-analysis were of “very low quality.” They concluded that “the use of steroids in influenza remains a clinical judgement call.”

Offering vaccination by the end of October, if possible, is recommended in order for immunity to develop by mid-November.

Statins may be associated with improved outcomes in influenza and pneumonia. Studies thus far have given contradictory results,^22,23 and a planned Cochrane review of the question has been withdrawn.²⁴

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