Researchers in Canada have hurled a stone at two relatively large birds: annual outbreaks of influenza and increasing proliferation of antibiotic-resistant bacteria.
Their question: Would providing an opportunity for universal flu immunization result in a decrease in antibiotic use, even though antibiotics don't work on influenza? The answer is a resounding yes.
Results of the 10-year study published in Clinical Infectious Diseases show that after universal flu vaccinations in Ontario, there was a 64 percent decline in antibiotic prescriptions. A larger study shows a 39 percent drop in flu-related mortality with universal immunization and a 52 percent decline in flu-related hospitalizations, emergency room visits and doctor visits.
The rate of antibiotic use, mortality and health care use remained similar to what it had been in Canadian provinces that did not implement the program.
The impetus for the study — concerns arising from overuse of antibiotics in recent years, which has produced antibiotic-resistant bacteria — has made treating infectious diseases more difficult and created a public health problem.
Lead author Jeffrey Kwong said physicians often prescribe antibiotics for people suffering from the flu. Although the flu is a virus and antibiotics are not effective against viruses, physicians may not be sure if a patient has the flu or a bacterial infection (most often treated with antibiotics); or a patient requests a prescription for antibiotics when suffering from flu symptoms.
"Sometimes it can be really hard to tell if it's a viral infection or a bacterial infection," said Kwong, a practicing family physician, a research fellow at the Institute for Clinical Evaluative Sciences in Toronto and an assistant professor of family and community medicine at the University of Toronto.
"It can be hard to tell with coughs and fever," he said. "And sometimes you can start with a viral infection and it becomes a bacteria infection, which could have been prevented if we prevented the viral infection."
The universal immunization program in Ontario began in 2000. Free vaccine was offered to everyone aged 6 months and older. About 40 percent of the population participated.
The study compared antibiotic use of this population to other provinces, which continued targeting high-risk groups. (Children aged 6 months to 23 months, pregnant women, those with chronic conditions and people over 65.)
Kwong said flu shots were offered through a variety of venues: physicians' offices, pharmacies, public health departments (which offered flu shots at shopping malls, schools and other sites) and employers who obtained the vaccine and hired nurses to provide shots to their employees.
Implementing universal flu immunization should be a snap in Canada, with its universal health care, right?
Not exactly. Even though the shot is free, people still need to seek it out and consent to the vaccination. Secondly, immunizing such a large number of people costs a lot.
Kwong described Canada's health care system as 13 "large HMOs" with 10 provinces and three territories operating their own systems — "so basically, we have 13 slightly different health care systems in Canada. Each province has to make their own decision if they want a program like this or not. They have to pay for the vaccine and figure out how to deliver it."
Alberta made the decision to implement a universal immunization program before the emergence of the H1N1 virus, Kwong said, so it, along with Ontario, will be providing a seasonal flu shot on a universal basis in October as well as an H1N1 shot later in the fall.
Kwong said the recent study of use of antibiotics is part of a larger research program that is evaluating the effects of universal flu immunization on rates of hospitalization, visits to emergency rooms, visits to physicians and mortalities.
"What's nice is that all five outcomes show the same pattern," he said.
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