From the Editor

Influenza: It’s right to bare arms

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Snow season is nearly upon us, which means, first, that I must emotionally prepare to put up the top on my convertible, and second, that it is time for the Journal’s influenza update by Dr. Sherif Mossad.

We were relatively spared in the last flu season, considering what might have been. The 2007–2008 vaccine, specifically formulated to stave off the strains predicted to predominate in North America last year, had lower-than-usual efficacy. Resistance to the oral antiviral oseltamivir (Tamiflu) became widespread, and the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) increased. MRSA is relevant to any discussion of influenza, since staphylococcal pneumonia was a lethal complication of influenza even before virulent MRSA emerged in the community. Nonetheless, the vaccination rate increased last year, fears of widespread bird-to-human spread of avian flu were not realized, and influenza-related death rates did not increase. And there are additional reasons for optimism in the upcoming years.

Vaccine for the coming flu season is readily available, and the targeted strains seem to be appropriate. Strategies to assure greater compliance with vaccination guidelines in the workplace, particularly in health care settings, continue to be implemented. If we should need it, there is a vaccine that is active against the H5N1 avian flu. Several studies have documented the safety and immunologic efficacy of the vaccine in therapeutically immunocompromised patients. Akin to using adjunctive corticosteroids when treating severe Pneumocystis jiroveci (formerly P carinii) pneumonia or bacterial meningitis, provocative preclinical studies found that down-modulating the inflammatory response to experimental influenza infection with cyclooxygenase-2-selective nonsteroidal anti-inflammatory drugs lessened lung injury and improved survival (Zheng BJ et al, Proc Natl Acad Sci U S A 2008; 105:8091–8096).

But the immediate realities are that the roof of my convertible will be up for the next 6 months, and that some of my patients will decline the flu shot, saying “I never get the flu,” or the “flu shot made me sick,” or “the flu shot gave my mother the flu.” As busy as we are in the office and hospital, it is worth spending extra time continuing to aggressively promote appropriate immunization to our patients, our staff, and ourselves.

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