Pekka O. Honkanen

The impact of vaccination strategy and methods of information on influenza and pneumococcal vaccination coverage in the elderly population.

We compared the coverage achieved with either an age-based, free-of-charge vaccination program offering influenza vaccine alone or with pneumococcal vaccine with a restricted risk disease-based influenza vaccination program supplemented by self-funded immunization. We also compared two means of informing the public, either using mailed personal reminders or through the mass media only. Forty-one administrative districts with a total of 41,500 persons aged 65 years or older participated in the study during three consecutive seasons from 1992 to 1994. The average vaccination coverage achieved by the risk disease-based program was 20%, by the age-based program with mass media information, 52%, and by the age-based program with mailed personal reminders 82%. The availability of free-of-charge vaccines is thus not sufficient to ensure a high vaccination rate. The effect of the personal reminders was restricted to the year they were sent. The addition of pneumococcal vaccine to the age-based influenza vaccination program had little influence on the acceptance rate.

Persistence of Antibodies to Pneumococcal Capsular Polysaccharide Vaccine in the Elderly

Persistence of antibodies to 23-valent pneumococcal vaccine was assessed among 62 subjects aged 65-88 years. IgG antibodies were measured by standardized EIA to serotypes 4, 6B, 9V, 14, 19F, and 23F before and 1 month, 1 year, and 3 years after vaccination. After satisfactory antibody responses (fold increases from 2.6 to 5.3), 3-year geometric mean concentrations (GMCs) had waned to close (for types 4, 9V, and 23F) or similar (for types 6B and 19F) to their prevaccination values. Type 14 was exceptional: 1-month GMC was 7.7-fold and 3-year GMC was 3.0-fold in comparison to the prevaccination GMC. Antibody concentrations decreased at an equal rate irrespective of serotype and age or sex of the vaccinee. The major factor predicting the persistence of antibodies above the prevaccination level was the magnitude of the original antibody response. Present results suggest that pneumococcal revaccination of the elderly may be needed as early as 3-4 years after the initial vaccination.

The Antimicrobial Treatment Strategies (MIKSTRA) Program: A 5-Year Follow-Up of Infection-Specific Antibiotic Use in Primary Health Care and the Effect of Implementation of Treatment Guidelines

BACKGROUND A national 5-year follow-up study of infection-specific antibiotic use in primary care was conducted to see if prescribing practices change after implementing new treatment guidelines. METHODS The data were collected during 1 week of November each year from 1998 to 2002 from 30 health care centers that covered a total population of 819,777 persons and in 2002 from 20 control health care centers that covered a population of 545,098 persons. National guidelines for 6 major infections (otitis media, sinusitis, throat infection, acute bronchitis, urinary tract infection, and bacterial skin infection) were published in 1999-2000. Multifaceted interventions were performed by local trainers teaching his or her coworkers, supported by feedback and patient and public information. RESULTS The 6 infections targeted for intervention, together with unspecified upper respiratory tract infection constituted 80%-85% of all infections. The proportion of patients who received prescriptions for antibiotics did not change significantly. However, use of first-line antibiotics increased for all infections, and the change was significant for sinusitis (P<.001), acute bronchitis (P=.015), and urinary tract infections (P=.009). Also, the percentage of antibiotic treatments prescribed for the recommended duration increased significantly. Correct prescribing for respiratory tract infections improved by 6.4 percentage units (P<.001). However, there was no statistically significant difference in performance between study and control health care centers at follow-up. CONCLUSIONS Moderate qualitative improvements in antibiotic use were observed after multifaceted intervention, but prescribing for unjustified indications, mainly acute bronchitis, did not decrease. Obtained infection-specific information on management of patients with infections in primary health care is an important basis for planning targeted interventions in the future.

Antibiotic Use by Indication: A Basis for Active Antibiotic Policy in the Community

The aim of this study was to survey current treatment practices for common infections in primary care as a basis for implementation of recently released evidence-based guidelines for community-acquired infections. A point-prevalence survey was conducted in 30 health centres in the Finnish primary care system with a population base of 819,777. All patients consulting the health centres for an infection during a 1-week period were included in the study. The main outcome measures were the prevalence of antibiotic prescription and the selection of drugs by infection diagnosis. Of the 7777 recorded consultations, 85% were with a physician and the rest with a nurse. The most common cause for a visit was respiratory tract infections (74%), followed by skin/wound infections and urinary tract infections (both 6%). The infection panorama varied markedly according to age: in the youngest children (< 5 y) 84% of the infections were respiratory tract infections whereas the corresponding figure for patients > 65 y was 50%; the proportions of visits for urinary tract infections in these age groups were 7% and 26%, respectively. Of the patients with acute bronchitis, 70% were treated with antimicrobial agents, mostly macrolides (39%) and doxycycline (36%). Of the otitis media patients, 53% were treated with amoxicillin, 16% with macrolides and 16% with sulphatrimethoprim. Macrolides were mostly used to treat otitis media (31%), acute bronchitis (26%) and sinusitis (20%). In conclusion, antimicrobial agents are still used excessively in Finland, particularly for the treatment of acute bronchitis. Moreover, the selection of drugs for treating sinusitis and otitis media is non-optimal; macrolides and cephalosporins are frequently chosen unnecessarily. Knowledge of the indication-based prescription practices for antimicrobial agents is essential in order to improve the treatment habits of primary care physicians. The data obtained in this study provide a unique tool for the active and targeted implementation of evidence-based guidelines for primary care physicians.The aim of this study was to survey current treatment practices for common infections in primary care as a basis for implementation of recently released evidence-based guidelines for community-acquired infections. A point-prevalence survey was conducted in 30 health centres in the Finnish primary care system with a population base of 819,777. All patients consulting the health centres for an infection during a 1-week period were included in the study. The main outcome measures were the prevalence of antibiotic prescription and the selection of drugs by infection diagnosis. Of the 7777 recorded consultations, 85% were with a physician and the rest with a nurse. The most common cause for a visit was respiratory tract infections (74%), followed by skin/wound infections and urinary tract infections (both 6%). The infection panorama varied markedly according to age: in the youngest children ( < 5 y) 84% of the infections were respiratory tract infections whereas the corresponding figure for patients > 65 y was 50%; the proportions of visits for urinary tract infections in these age groups were 7% and 26%, respectively. Of the patients with acute bronchitis, 70% were treated with antimicrobial agents, mostly macrolides (39%) and doxycycline (36%). Of the otitis media patients, 53% were treated with amoxicillin, 16% with macrolides and 16% with sulphatrimethoprim. Macrolides were mostly used to treat otitis media (31%), acute bronchitis (26%) and sinusitis (20%). In conclusion, antimicrobial agents are still used excessively in Finland, particularly for the treatment of acute bronchitis. Moreover, the selection of drugs for treating sinusitis and otitis media is non-optimal; macrolides and cephalosporins are frequently chosen unnecessarily. Knowledge of the indication-based prescription practices for antimicrobial agents is essential in order to improve the treatment habits of primary care physicians. The data obtained in this study provide a unique tool for the active and targeted implementation of evidence-based guidelines for primary care physicians.

Associations of prevaccination antibody levels with adverse reactions to pneumococcal and influenza vaccines administered simultaneously in the elderly

The association of prevaccination antibodies with the adverse reactions seen after vaccination was studied in 85 elderly subjects (65-90 years) vaccinated simultaneously with pneumococcal and influenza vaccines. The subjects with a temperature rise (9% of vaccinees) had significantly higher prevaccination antibody levels to pneumococcal capsular polysaccharides (PPSs) than those without a temperature rise; no difference was seen in their haemagglutination inhibiting (HI) influenza virus antibody levels. Pain in the left arm (the pneumococcal vaccine injection site) occurred in 45% of the subjects and was likewise associated with elevated PPS antibody levels. Pain at the site of influenza vaccine injection (the right arm) seen in 33% of the vaccinees was significantly more common among those who had previously received influenza vaccine, but was not associated with elevated HI antibody levels. In conclusion, prevaccination pneumococcal but not influenza antibodies were associated with both systemic and local reactions following vaccination.

Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study.

Objectives – To study the management of acute maxillary sinusitis (AMS) in Finnish primary care and to compare it both to recommendations in national guidelines and to the management of other upper respiratory tract infections (URTI). Design – A cross-sectional multi-centre epidemiological survey. Setting – Thirty primary care health centres in Finland. Subjects – 7284 patients with symptoms of possible acute rhinosinusitis during one week in both November 1998 and November 1999. Main outcome measure – Symptoms and their duration, use of diagnostic tools, choice of antibiotics, patient outcomes. Results – A total of 1601 patients were diagnosed as having AMS (12% of all patients with infectious disease). In 45% of cases the differentiation between AMS and URTI was based on clinical examination alone. Sinus ultrasound was the most common diagnostic tool used (38%). Sinus radiography or blood tests (CRP or leukocytes) were both studied in 8% of cases. AMS was diagnosed and treated with antibiotics also in the early stages of URTI when viruses are the most likely explanation. In total, 83% of patients with AMS received a prescription for antibiotics; the most common choice was amoxycillin (37%), doxycycline was used in 29% of cases, and macrolides in 15%. Conclusions – Antibiotics are prescribed for AMS 2 to 5 times more often than true disease incidence would suggest in Finland. The choice of antibiotics follows the guideline recommendations; however, use of macrolides is higher than recommended. Physicians feel strong pressure from patients to prescribe antibiotics for AMS. Primary care physicians need better support in the accurate diagnosis of AMS.

Management of pain in acute otitis media in Finnish primary care

Most treatment recommendations for acute otitis media favour active use of pain relief medication. These data comprised 3059 Finnish primary care acute otitis media patients. We found that 10.4% of the patients were prescribed or recommended analgesics, which is in contrast to treatment recommendations.

Diagnostic Tools in Respiratory Tract Infections: Use and Comparison with Finnish Guidelines

The objectives of this prospective epidemiological study were to describe the diagnosis and treatment of respiratory tract infections by Finnish general practitioners and to compare current practice with national evidence-based guidelines. All patients (n = 4386) seeking primary care for a respiratory tract infection for the first time in 30 health centres during 1 week in November 1998 participated in the study. The main outcome measures were the amounts and types of diagnostic tests used and antimicrobials prescribed. Tympanometry was used in 1% of patients with acute otitis media. Ultrasonography, sinus radiography or both were used in 80% of cases of sinusitis and antigen detection or culture for Streptococci in 57% of throat infections. In acute bronchitis, a chest radiograph was taken in 5% of cases and the CRP level determined in 8%. The corresponding figures for pneumonia were 49% and 39%. In pneumonia and throat infection, diagnostic testing was statistically significantly associated with the use of antimicrobials, but not in otitis, sinusitis or acute bronchitis. Diagnostic tests were underused in respiratory tract infections compared to evidence-based recommendations.

Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children.

OBJECTIVES Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland. METHODS A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients. RESULTS The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy. CONCLUSIONS Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.

Prescription rates and diagnostic patterns are stable: a comparison of high-, medium- and low-prescribing primary care physicians treating community-acquired respiratory tract infections.

The objective was to study prescription practices of primary care physicians in prescribing antibiotics for community-acquired respiratory tract infections. Design was time series analysis and cross-sectional survey. The setting was 30 community primary health care centres. A case report form was completed for 3478 patient consultations treated by 198 office-based primary care physicians. Main outcome measures were: classification of diagnoses of respiratory tract infections made by each physician; number of antibiotic prescriptions related to these diagnoses; each physicians mean weekly number of antibiotic prescriptions during 6 months before and after the survey. Patients’ risk (odds ratio: OR) to receive an antibiotic prescription from the high and medium prescribers was 5.81 (95% confidence interval [CI] 4.85–6.96) and 2.41 (95% CI 2.04–2.86), compared to low prescribers. High and medium prescribers made more diagnoses of otitis media (OR 2.07, 95% CI 1.70–2.53 and 1.85, 95% CI 1.51–2.26, respectively) and fewer diagnoses of unspecified upper respiratory tract infection (OR 0.32, 95% CI 0.26–0.38 and 0.57, 95% CI 0.48–0.68, respectively) than low prescribers. The rank of the prescription rate of high, medium and low prescriber groups remained the same for all diagnoses except pneumonia. In addition, the annual rank between high, medium and low prescriber groups remained stable; high group prescribed more antibiotics during the year than medium group, which prescribed more than low prescriber group.