Plans-Rubió Antiviral therapy can be used also in unvaccinated persons who can transmit inﬂuenza to high-risk patients, including healthcare workers, residents of nursing homes or chronic care facilities, close contacts of high-risk patients, and household member of high-risk persons. Antiviral therapy can be used as an adjunct to vaccination in controlling outbreaks of inﬂuenza among patients with COPD and other high-risk conditions in long-term facilities and hospitals. The majority of published reports showing the efﬁcacy and effectiveness of antiviral agents to control inﬂuenza outbreaks are based, however, on studies carried out in nursing homes where amantadine and rimantadine were used to prevent influenza A infections (Patriarca et al 1987; Guay 1994; Wintermeyer and Nahata 1995). The prophylactic use of zanamivir and oseltamivir in nursing homes and among patients with chronic medical conditions is more limited, but their efﬁcacy and effectiveness could be similar to that for amantadates (Bowles et al 2002; Schilling et al 1998; Lee et al 2000; Parker et al 2001). Persons at high risk for complications of inﬂuenza still can be vaccinated after an outbreak of inﬂuenza has begun in a community. Medication should be taken, in this situation, for two weeks in order to provide early protection until vaccine-induced antibodies appear. When inﬂuenza vaccine is administered while influenza viruses are circulating, chemoprophylaxis should be considered for persons at high risk during the time from vaccination until immunity has developed. Children aged <9 years who receive inﬂuenza vaccine for the ﬁrst time can require six weeks of prophylaxis (ie, prophylaxis for four weeks after the ﬁrst dose of vaccine and an additional two weeks of prophylaxis after the second dose). When determining the timing and duration for administer- ing inﬂuenza antiviral medications for prophylaxis, factors related to cost, compliance, and potential side effects should be considered. To be maximally effective as prophylaxis, the drug must be taken each day for the duration of inﬂuenza activity in the community. However, to be most cost-effective, one study of amantadine or rimantadine prophylaxis reported that the drugs should be taken only during the period of peak inﬂuenza activity in a community (Patriarca et al 1987). When outbreaks occur in institutions, chemoprophylaxis should be administered to all residents, regardless of whether they received inﬂuenza vaccinations during the previous fall and should continue for a minimum of two weeks. If surveil- lance indicates that new cases continue to occur, chemopro- phylaxis should be continued until approximately one week after the end of the outbreak. The dosage for each resident should be determined individually. Chemoprophylaxis can 50 be offered to the unvaccinated staff providing healthcare to persons at high risk. Prophylaxis should be considered for all employees, regardless of their vaccination status, if the outbreak is caused by a variant strain of inﬂuenza that is not well-matched by the vaccine. To limit the potential transmission of drug-resistant virus during outbreaks in institutions, whether in chronic or acute-care settings or other closed settings, measures should be taken to reduce contact as much as possible between per- sons taking antiviral drugs for treatment and other persons, including those taking chemoprophylaxis, and therapy with amantadine and rimantadine for persons with inﬂuenza A ill- ness should be discontinued as soon as clinically warranted, typically after 3–5 days of treatment or within 24–48 hours after the disappearance of signs and symptoms. Vaccination strategies in patients with COPD Successful vaccination programs in persons with COPD should combine a plan for identifying persons with COPD, use of reminder/recall systems, assessment of practice-level vaccination rates with feedback to staff, and efforts to remove administrative and ﬁnancial barriers that prevent persons from receiving the vaccine (Lawson et al 2000). All patients with COPD should be vaccinated each year with the best available inﬂuenza vaccine, and monitoring inﬂuenza disease and inﬂuenza vaccine efﬁcacy. The following strategies could be developed to achieve higher vaccination levels: 1) Vaccinating patients with COPD in different healthcare facilities during the immunization period (October to December in the Northern hemisphere and April to June in the Southern hemisphere). 2) Developing specific influenza vaccination programs in primary healthcare centers and outpatient facilities attending patients with COPD. The immunization period begins in October (Northern hemisphere). October and November is the best time to get vaccinated, but receiving vaccination in December or later can still be beneﬁcial. The ﬂu season can begin as early as October and last as late as May. The ﬁrst vaccination strategy can be developed in different healthcare settings, including 1) outpatient facilities providing ongoing care, 2) outpatient facilities providing episodic or acute care, 3) nursing homes and other residential long-term care facilities, 4) acute-care hospitals, 5) visiting nurses and other providing home care to patients with COPD, and 6) workplace healthcare facilities. Hospitals are important sites for immunization because persons at increased risk for subsequent hospitalization can International Journal of COPD 2007:2(1)