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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Authors underestimate hospitalizations from influenza
Importance of CBA for Influenza A Treatment
Clinical Probability of Influenzae
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Michael B Rothberg, Springfield, MA, USA Internist, Baystate Medical Center
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I disagree with Hueston and Benich's statement that "the risk of complications from influenza are very low" and their estimate that serious complications occur in only 0.5% of elderly patients.(1) This estimate from the CDC uses the entire population as its denominator.(2) Because only approximately 10% of adults are infected each year, the probability of complications among infected patients is closer to 5%. Among high-risk elderly—those with heart or lung disease—the risk of hospitalization may be as high as 23%.(3) The authors also did not include the possibility of death, which may occur among 10% of hospitalized high-risk patients. In sensitivity analysis, the authors found that increasing the complication rate favored empiric therapy. It is not clear why this should be so, unless they assumed that therapy would decrease complications. The authors state only that treatment would shorten symptoms by 24 hours. Because complications are a key determinant in the cost-effectiveness of testing and treatment in high-risk patients, and pooled analysis suggests that neuraminidase inhibitors prevent hospitalization in such patients,(4) the authors' conclusions are more appropriate to healthy adults under 65 years of age. 1. Hueston WJ, Benich JJ, III. A Cost-Benefit Analysis of Testing for Influenza A in High-Risk Adults. Ann Fam Med. 2004;2:33-40. 2. Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2002;51:1-31. 3. Nichol KL, Wuorenma J, von Sternberg T. Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens. Arch Intern Med. 1998;158:1769-76. 4. Kaiser L, Wat C, Mills T, Mahoney P, Ward P, Hayden F. Impact of Oseltamivir Treatment on Influenza-Related Lower Respiratory Tract Complications and Hospitalizations. Arch Intern Med. 2003;163:1667-1672. Competing interests: I have done consulting for Quidel corporation which manufactures a rapid test for influenza. |
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Richard L. Dressler, Baltimore, MD Physician, Johns Hopkins Bloomberg School of Public Health
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Dr.’s Hueston and Benich have written a very informative piece with this article. In a very practical way, it has changed how I approach the management of patients that present to me with flu-like symptoms. I now realize the greater cost-benefit ratio of treating with ion channel blockers (rimantidine) in patients at high risk for complications as compared to viral neuaminidase inhibitors(zanamivir and oseltamivir). A greater percentage of patients that I see should really forgo influenza testing, if they have an appropriate history and physical findings. I would be eager to see more tools to help determine, by information from the history and physical exam, what a patient’s pre-test probability of having influenza (particularly influenza A) is to help with my stratification. On a personal note, I have found it very difficult to obtain accurate and up-to-date information on the incidence of influenza in my local area. I hope that local public health officials will be able to more conveniently present this information to local clinical practitioners. Competing interests: None declared |
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Paul M. McCormick D.O., Saint Paul,MN Physician, Clinical Associate Faculty Department of Family MedicineUniversity of Minnesota
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Do the authors have a reference on studies deriving and validating a clinical probabality score of an individual patient having influenzae. The results of this study would require such a derived probability to have siginificant clinical applicability. If no research do the authors have standard criteria that they use to assign low,moderate and high probability of inluenzae. Competing interests: None declared |
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