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.
