A standardized methodology for the surveillance of antimicrobial prescribing linked to clinical indications in primary care.

Background: A key component of strategies to reduce antimicrobial resistance is better antimicrobial prescribing. The majority of antibiotics are prescribed in primary care. While many existing surveillance systems can monitor trends in the quantities of antibiotics prescribed in this setting, it can be difficult to monitor the quality of prescribing as data on the condition for which prescriptions are issued are often not available. We devised a standardized methodology to facilitate the monitoring of condition-specific antibiotic prescribing in primary care. Methods: We used a large computerized general practitioner database to develop a standardized methodology for routine monitoring of antimicrobial prescribing linked to clinical indications in primary care in the UK. Outputs included prescribing rate by syndrome and percentages of consultations with antibiotic prescription, for recommended antibiotic, and of recommended treatment length. Results: The standardized methodology can monitor trends in proportions of common infections for which antibiotics were prescribed, the specific drugs prescribed and duration of treatment. These data can be used to help assess the appropriateness of antibiotic prescribing and to assess the impact of prescribing guidelines. Conclusions: We present a standardized methodology that could be applied to any suitable national or local database and adapted for use in other countries.

Modelling estimates of age-specific influenza-related hospitalisation and mortality in the United Kingdom.

BACKGROUND: Influenza is rarely confirmed with laboratory testing and accurate assessment of the overall burden of influenza is difficult. We used statistical modelling methods to generate updated, granular estimates of the number/rate of influenza-attributable hospitalisations and deaths in the United Kingdom. Such data are needed on a continuing basis to inform on cost-benefit analyses of treatment interventions, including vaccination. METHODS: Weekly age specific data on hospital admissions (1997-2009) and on deaths (1997-2009) were obtained from national databases. Virology reports (1996-2009) of influenza and respiratory syncytial virus detections were provided by Public Health England. We used an expanded set of ICD-codes to estimate the burden of illness attributable to influenza which we refer to as 'respiratory disease broadly defined'. These codes were chosen to optimise the balance between sensitivity and specificity. A multiple linear regression model controlled for respiratory syncytial virus circulation, with stratification by age and the presence of comorbid risk status (conditions associated with severe influenza outcomes). RESULTS: In the United Kingdom there were 28,516 hospitalisations and 7163 deaths estimated to be attributable to influenza respiratory disease in a mean season, with marked variability between seasons. The highest incidence rates of influenza-attributable hospitalisations and deaths were observed in adults aged 75+ years (252/100,000 and 131/100,000 population, respectively). Influenza B hospitalisations were highest among 5-17 year olds (12/100,000 population). Of all estimated influenza respiratory deaths in 75+ year olds, 50 % occurred out of hospital, and 25 % in 50-64 year olds. Rates of hospitalisations and death due to influenza-attributable respiratory disease were increased in adults identified as at-risk. CONCLUSIONS: Our study points to a substantial but highly variable seasonal influenza burden in all age groups, particularly affecting 75+ year olds. Effective influenza prevention or early intervention with anti-viral treatment in this age group may substantially impact the disease burden and associated healthcare costs. The high burden of influenza B hospitalisation among 5-17 year olds supports current United Kingdom vaccine policy to extend quadrivalent seasonal influenza vaccination to this age group. TRIAL REGISTRATION: ClinicalTrial.gov, NCT01520935.

Modelling estimates of the burden of Respiratory Syncytial virus infection in adults and the elderly in the United Kingdom.

BACKGROUND: Growing evidence suggests respiratory syncytial virus (RSV) is an important cause of respiratory disease in adults. However, the adult burden remains largely uncharacterized as most RSV studies focus on children, and population-based studies with laboratory-confirmation of infection are difficult to implement. Indirect modelling methods, long used for influenza, can further our understanding of RSV burden by circumventing some limitations of traditional surveillance studies that rely on direct linkage of individual-level exposure and outcome data. METHODS: Multiple linear time-series regression was used to estimate RSV burden in the United Kingdom (UK) between 1995 and 2009 among the total population and adults in terms of general practice (GP) episodes (counted as first consultation ≥28 days following any previous consultation for same diagnosis/diagnostic group), hospitalisations, and deaths for respiratory disease, using data from Public Health England weekly influenza/RSV surveillance, Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics. The main outcome considered all ICD-listed respiratory diseases and, for GP episodes, related symptoms. Estimates were adjusted for non-specific seasonal drivers of disease using secular cyclical terms and stratified by age and risk group (according to chronic conditions indicating severe influenza risk as per UK recommendations for influenza vaccination). Trial registration NCT01706302 . Registered 11 October 2012. RESULTS: Among adults aged 18+ years an estimated 487,247 GP episodes, 17,799 hospitalisations, and 8,482 deaths were attributable to RSV per average season. Of these, 175,070 GP episodes (36 %), 14,039 hospitalisations (79 %) and 7,915 deaths (93 %) were in persons aged 65+ years. High- versus low-risk elderly were two-fold more likely to have a RSV-related GP episode or death and four-fold more likely be hospitalised for RSV. In most seasons since 2001, more GP episodes, hospitalisations and deaths were attributable to RSV in adults than to influenza. CONCLUSION: RSV is associated with a substantial disease burden in adults comparable to influenza, with most of the hospitalisation and mortality burden in the elderly. Treatment options and measures to prevent RSV could have a major impact on the burden of RSV respiratory disease in adults, especially the elderly.

Trends in antibiotic prescribing in primary care for clinical syndromes subject to national recommendations to reduce antibiotic resistance, UK 1995-2011: analysis of a large database of primary care consultations.

OBJECTIVES: To measure trends in antibiotic prescribing in UK primary care in relation to nationally recommended best practice. PATIENTS AND METHODS: A descriptive study linking individual patient data on diagnosis and prescription in a large primary care database, covering 537 UK general practices during 1995-2011. RESULTS: The proportion of cough/cold episodes for which antibiotics were prescribed decreased from 47% in 1995 to 36% in 1999, before increasing to 51% in 2011. There was marked variation by primary care practice in 2011 [10th-90th percentile range (TNPR) 32%-65%]. Antibiotic prescribing for sore throats fell from 77% in 1995 to 62% in 1999 and then stayed broadly stable (TNPR 45%-78%). Where antibiotics were prescribed for sore throat, recommended antibiotics were used in 69% of cases in 2011 (64% in 1995). The use of recommended short-course trimethoprim for urinary tract infection (UTI) in women aged 16-74 years increased from 8% in 1995 to 50% in 2011; however, a quarter of practices prescribed short courses in ≤16% of episodes in 2011. For otitis media, 85% of prescriptions were for recommended antibiotics in 2011, increasing from 77% in 1995. All these changes in annual prescribing were highly statistically significant (P < 0.001). CONCLUSIONS: The implementation of national guidelines in UK primary care has had mixed success, with prescribing for coughs/colds, both in total and as a proportion of consultations, now being greater than before recommendations were made to reduce it. Extensive variation by practice suggests that there is significant scope to improve prescribing, particularly for coughs/colds and for UTIs.

Global mortality estimates for the 2009 Influenza Pandemic from the GLaMOR project: a modeling study.

BACKGROUND: Assessing the mortality impact of the 2009 influenza A H1N1 virus (H1N1pdm09) is essential for optimizing public health responses to future pandemics. The World Health Organization reported 18,631 laboratory-confirmed pandemic deaths, but the total pandemic mortality burden was substantially higher. We estimated the 2009 pandemic mortality burden through statistical modeling of mortality data from multiple countries. METHODS AND FINDINGS: We obtained weekly virology and underlying cause-of-death mortality time series for 2005-2009 for 20 countries covering ∼35% of the world population. We applied a multivariate linear regression model to estimate pandemic respiratory mortality in each collaborating country. We then used these results plus ten country indicators in a multiple imputation model to project the mortality burden in all world countries. Between 123,000 and 203,000 pandemic respiratory deaths were estimated globally for the last 9 mo of 2009. The majority (62%-85%) were attributed to persons under 65 y of age. We observed a striking regional heterogeneity, with almost 20-fold higher mortality in some countries in the Americas than in Europe. The model attributed 148,000-249,000 respiratory deaths to influenza in an average pre-pandemic season, with only 19% in persons <65 y. Limitations include lack of representation of low-income countries among single-country estimates and an inability to study subsequent pandemic waves (2010-2012). CONCLUSIONS: We estimate that 2009 global pandemic respiratory mortality was ∼10-fold higher than the World Health Organization's laboratory-confirmed mortality count. Although the pandemic mortality estimate was similar in magnitude to that of seasonal influenza, a marked shift toward mortality among persons <65 y of age occurred, so that many more life-years were lost. The burden varied greatly among countries, corroborating early reports of far greater pandemic severity in the Americas than in Australia, New Zealand, and Europe. A collaborative network to collect and analyze mortality and hospitalization surveillance data is needed to rapidly establish the severity of future pandemics. Please see later in the article for the Editors' Summary.

Health benefits, risks, and cost-effectiveness of influenza vaccination in children.

Annual vaccination of all children 6-59 months of age is recommended in the United States but not in most of Europe. This paper reviews issues surrounding the epidemiology of influenza and vaccine effectiveness relevant to the determination of vaccination policy. Most clinical trials of vaccines (and treatments) that provide the evidence for current policy took place in the 1990s when rates of influenza-like illness (ILI) were twice those reported in recent years. The impact of influenza in the community is concealed by the variety of diagnoses appropriate to describing acute respiratory infections. Even in influenza virus active periods diagnoses of coryza, acute bronchitis, and otitis media made by general practitioners greatly exceed those of ILI. Respiratory syncytial virus presents particular problems because it often circulates at the same time as influenza. Thus, the diagnostic uncertainty and variety of respiratory pathogens causing similar illnesses are major confounders when estimating influenza vaccine effectiveness. Although meta-analyses have cast doubt on the wisdom of the universal vaccination of children, high-quality clinical trials have demonstrated efficacy against laboratory-confirmed infection. The distinction between this positive benefit and the wider issue of effectiveness against ILI in the community poses difficulties for determining policy. Mathematical models examining this issue are populated with data that are mostly estimated: therefore, the sensitivity analysis is critical and the conclusions are invariably accompanied by reservations. National policies based on demonstrated cost effectiveness are desirable, but these should not become a barrier to parents wishing to secure a benefit for their child or family, provided there is clear evidence of clinical efficacy.

Acute respiratory infections and winter pressures on hospital admissions in England and Wales 1990-2005.

BACKGROUND: Hospitals experience winter surges in admissions due to respiratory infections. The roles of acute bronchitis and influenza-like illness (ILI) in the timing and severity of these surges are examined over the years 1990-91 to 2004-05. METHODS: Respiratory admissions of persons aged > or =65 years in England and Wales were analysed in relation to patients with ILI or acute bronchitis diagnosed by community-based general practitioners from a sentinel surveillance network. RESULTS: Acute bronchitis and ILI accounted for 46 and 7% of the variation in respiratory admissions, respectively: when admissions were lagged by 1 week, these estimates were 20 and 14%, respectively. Admissions peaked in weeks 52, 01 or 02 (late December to early January) in 14 of the 15 winters. Acute bronchitis peaked during weeks 01 or 02; ILI exhibited greater variability and peaks ranged from weeks 46 (mid-November) to 07 (mid-February). During winters where acute bronchitis and ILI peaked concurrently, surges on hospitals were most severe. CONCLUSIONS: During each winter acute bronchitis provides a consistent and major contribution to the winter admissions surge in the elderly. The variable incidence of ILI can increase the surge in admissions, especially when ILI and acute bronchitis peak together.

Skin infections and antibiotic prescribing: a comparison of surveillance and prescribing data.

BACKGROUND: Reductions in the number of dispensed antibiotics and the incidence of respiratory infections presented to GPs and have been reported. Whether this trend applies to skin infections requires further investigation. AIM: To examine trends in the incidence of skin infections in relation to trends in dispensed prescriptions for flucloxacillin, topical fusidic acid, mupirocin, and corticosteroids with fusidic acid. DESIGN OF STUDY: Population-based analysis of patients presenting to GPs (1999-2005) contrasted with national prescribing data. SETTING: A sentinel practice network covering a population of 700,000 in England and Wales. METHOD: Quarterly incidence rates of skin infections and of impetigo reported over the years 1999-2005 were compared with quarterly data on dispensed prescriptions reported by the Prescription Pricing Authority for England. RESULTS: In children (aged 0-14 years) the incidence of skin infections decreased slightly between 1999 and 2003 and more sharply from 2004 to 2005. In adults (aged > or =15 years) incidence was reasonably constant from year to year. In every year examined, and in both age groups, there were autumnal incidence peaks. There were annual increases in dispensed prescriptions for flucloxacillin capsules, but there was little change in the use of flucloxacillin syrups and topical antibiotic prescriptions. All prescribing data sets showed increases in the third quarter: topical corticosteroids with fusidic acid were prescribed more frequently in summer than winter. CONCLUSION: In spite of slight reductions in the incidence of skin infections, flucloxacillin capsule-dispensed prescriptions have increased, suggesting that doctors have not limited their antibiotic prescribing behaviour for skin conditions.

Comparison of the efficacy and safety of live attenuated cold-adapted influenza vaccine, trivalent, with trivalent inactivated influenza virus vaccine in children and adolescents with asthma.

BACKGROUND: Despite their potential for increased morbidity, 75% to 90% of asthmatic children do not receive influenza vaccination. Live attenuated influenza vaccine (LAIV), a cold-adapted, temperature-sensitive, trivalent influenza vaccine, is approved for prevention of influenza in healthy children 5 to 19 years of age. LAIV has been studied in only a small number of children with asthma. METHODS: Children 6 to 17 years of age, with a clinical diagnosis of asthma, received a single dose of either intranasal CAIV-T (an investigational refrigerator-stable formulation of LAIV; n = 1114) or injectable trivalent inactivated influenza vaccine (TIV; n = 1115) in this randomized, open-label study during the 2002-2003 influenza season. Participants were followed up for culture-confirmed influenza illness, respiratory outcome, and safety. RESULTS: The incidence of community-acquired culture-confirmed influenza illness was 4.1% (CAIV-T) versus 6.2% (TIV), demonstrating a significantly greater relative efficacy of CAIV-T versus TIV of 34.7% (90% confidence interval [CI] 9.4%-53.2%; 95% CI = 3.9%-56.0%). There were no significant differences between treatment groups in the incidence of asthma exacerbations, mean peak expiratory flow rate findings, asthma symptom scores, or nighttime awakening scores. The incidence of runny nose/nasal congestion was higher for CAIV-T (66.2%) than TIV (52.5%) recipients. Approximately 70% of TIV recipients reported injection site reactions. CONCLUSIONS: CAIV-T was well tolerated in children and adolescents with asthma. There was no evidence of a significant increase in adverse pulmonary outcomes for CAIV-T compared with TIV. CAIV-T had a significantly greater relative efficacy of 35% compared with TIV in this high-risk population.

WHO diagnostic criteria as a validation tool for the diagnosis of diabetes mellitus: a study in five European countries.

OBJECTIVE: In 1999, the World Health Organization (WHO) published new diagnostic criteria for diabetes mellitus (DM). The cut-off value of the fasting plasma glucose concentration was lowered from 7.8 to 7.0 mmol/l. The WHO criteria were used to validate the diagnosis made by the general practitioner, and to compare the diagnostic validity of diabetes mellitus in different countries. METHODS: We retrospectively analysed 2556 newly diagnosed diabetics. Incidence was calculated according to the 1999 WHO criteria. Data were collected in general practice networks in five European countries or regions (Belgium, England, the Netherlands, Portugal, Spain). RESULTS: According to the WHO criteria, 82% of the cases were valid diagnoses. Compared to the total group, in Spain, significantly more diagnoses were in agreement with the WHO criteria, whereas this number was significantly lower in England and Portugal. From the patients whose diagnosis was not in agreement with the WHO criteria, significantly more were women than men. CONCLUSION: By using the WHO diagnostic criteria, the international standard, as a validation tool, we show that the diagnoses of diabetes mellitus made in primary care are valid. Furthermore, we show that these diagnoses are comparable between countries. Therefore, information from general practice registration networks is a valuable and valid source for international comparisons.

Modelling estimates of the burden of respiratory syncytial virus infection in children in the UK.

OBJECTIVE: The burden of respiratory syncytial virus (RSV) illness is not well characterised in primary care. We estimated the burden of disease attributable to RSV in children in the UK between 1995 and 2009. DESIGN: Time-series regression modelling. SETTING: A multiple linear regression model based on weekly viral surveillance (RSV and influenza, Public Health England), and controlled for non-specific seasonal drivers of disease, estimated the proportion of general practitioner (GP) episodes of care (counted as first visit in a series within 28 days; Clinical Practice Research Datalink, CPRD), hospitalisations (Hospital Episode Statistics, HES) and deaths (Office of National Statistics, ONS) attributable to RSV each season. PARTICIPANTS: Children 0-17 years registered with a GP in CPRD, or with a respiratory disease outcome in the HES or ONS databases. PRIMARY OUTCOME MEASURES: RSV-attributable burden of GP episodes, hospitalisations and deaths due to respiratory disease by age. RSV-attributable burden associated with selected antibiotic prescriptions. RESULTS: RSV-attributable respiratory disease in the UK resulted in an estimated 450 158 GP episodes, 29 160 hospitalisations and 83 deaths per average season in children and adolescents, with the highest proportions in children <6 months of age (14 441/100 000 population, 4184/100 000 and 6/100 000, respectively). In an average season, there were an estimated 125 478 GP episodes for otitis media and 416 133 prescriptions for antibiotics attributable to RSV. More GP episodes, hospitalisations and deaths from respiratory disease were attributable to RSV than to influenza in children under 5 years. CONCLUSIONS: The burden of RSV in children in the UK exceeds that of influenza. RSV in children and adolescents contributes substantially to GP office visits for a diverse range of illnesses, and was associated with an average 416 133 prescribed antibiotic courses per season. Effective antiviral treatments and preventive vaccines are urgently needed for the management of RSV infection in children. TRIAL REGISTRATION NUMBER: NCT01706302.

Mortality in children from influenza and respiratory syncytial virus.

STUDY OBJECTIVE: To quantify mortality attributable to influenza and respiratory syncytial virus (RSV) infection in children. DESIGN AND METHODS: Comparison of death rates (all cause and certified respiratory) in England over winters 1989/90 to 1999/00 during and outside influenza and RSV circulation periods. Virus active weeks were defined from clinical and virological surveillance data. Excess deaths associated with weeks of either influenza or RSV activity over virus non-active weeks were estimated in each winter for age groups 1-12 months, 1-4, 5-9, and 10-14 years. The estimate obtained was allotted to influenza and RSV in the proportion derived from independent separate calculations for each virus. MAIN RESULTS: Average winter respiratory deaths attributed to influenza in children 1 month-14 years were 22 and to RSV 28; and all cause deaths to influenza 78 and to RSV 79. All cause RSV attributed deaths in infants 1-12 months exceeded those for influenza every year except 1989/90; the average RSV and influenza attributed death rates were 8.4 and 6.7 per 100 000 population respectively. Corresponding rates for children 1-4 years were 0.9 and 0.8 and for older children all rates were 0.2 or less, except for an influenza rate of 0.4 in children 10-14 years. CONCLUSIONS: Influenza and RSV account for similar numbers of deaths in children. The impact varies by winter and between age groups and is considerably underestimated if analysis is restricted to respiratory certified deaths. Summing the impact over the 11 winters studied, compared with influenza RSV is associated with more deaths in infants less than 12 months, almost equal numbers in children 1-4 years, and fewer in older children. Improved information systems are needed to investigate paediatric deaths.

Recent changes in the prevalence of diseases presenting for health care.

BACKGROUND: Practice-based morbidity surveys inform on the prevalence of diseases presenting for health care. The last major survey in England and Wales was conducted in 1991. AIM: To reveal changes in disease prevalence between 1991 and 2001. DESIGN OF STUDY: Population-based analysis of persons presenting to GPs. Annual prevalence of diseases reported in the Weekly Returns Service (WRS) of the Royal College of General Practitioners in 2001 was compared with prevalence reported in Morbidity Statistics from General Practice, Fourth National Study (MSGP4). SETTING: Thirty-eight general practices contributing to the WRS, monitoring a population of 326,000 in 2001. METHOD: Prevalence was determined from Read codes for morbidity entered in the respective survey years. Diseases and disease groups were defined from Read codes mapping to the chapters, major sub-groups and 3-digit codes of the International Classification of Disease version 9 (ICD9). Age-standardised prevalence rates per 10,000 registered persons and 99% confidence intervals (CIs) were calculated using the national census population for 2001 as the standard. Survey differences in prevalence were identified from non-overlapping CIs. RESULTS: There was a general reduction in the prevalence of disease caused by infection and an increase of degenerative disorders. The prevalence of mental disorders, skin disease and musculoskeletal disorders showed little change. Particular increases were noted for other malignant and benign neoplasms of the skin, hypothyroidism and diabetes. There were marked reductions for disorders of the conjunctiva, ear infections, acute myocardial infarction and heart failure, respiratory infections and injuries. CONCLUSIONS: The role of the GP continues to change. These results confirm the importance of the management of chronic diseases as the dominant (though not the sole) role of the GP. The results demonstrate the use of the WRS as a source of data on disease prevalence.

Striking Similarities in the Presentation and Duration of Illness of Influenza A and B in the Community: A Study Based on Sentinel Surveillance Networks in France and Turkey, 2010-2012.

Influenza B represents a high proportion of influenza cases in some seasons (even over 50%). The Influenza B study in General Practice (IBGP) is a multicenter study providing information about the clinical, demographic and socio-economic characteristics of patients affected by lab-confirmed influenza A or B. Influenza B patients and age-matched influenza A patients were recruited within the sentinel surveillance networks of France and Turkey in 2010-11 and 2011-12 seasons. Data were collected for each patient at the swab test day, after 9±2 days and, if not recovered, after 28±5 days. It was related to patient's characteristics, symptoms at presentation, vaccination status, prescriptions of antibiotics and antivirals, duration of illness, follow-up consultations in general practice or emergency room. We performed descriptive analyses and developed a multiple regression model to investigate the effect of patients and disease characteristics on the duration of illness. Overall, 774 influenza cases were included in the study: 419 influenza B cases (209 in France and 210 in Turkey) and 355 influenza A cases (205 in France and 150 in Turkey). There were no differences between influenza A and B patients in terms of clinical presentation and number of consultations with a practitioner; however, the use of antivirals was higher among influenza B patients in both countries. The average (median) reported duration of illness in the age groups 0-14 years, 15-64 years and 65+ years was 7.4 (6), 8.7 (8) and 10.5 (9) days in France, and 6.3 (6), 8.2 (7) and 9.2 (6) days in Turkey; it increased with age but did not differ by virus type; increased duration of illness was associated with antibiotics prescription. In conclusion, our findings show that influenza B infection appears not to be milder disease than influenza A infection.

Zanamivir in the treatment of influenza.

Influenza is a common illness, affecting many people every winter, with a considerable impact on mortality, hospital admissions, healthcare utilisation and sickness absence from work and school. Influenza management is currently focused on annual vaccinations for those in certain risk groups. Risk is determined by age and chronic illness, particularly diabetes, chronic respiratory and cardiac disease, and persons immunocompromised from disease or concomitant therapy. Amantadine (and in some countries, rimantadine is available but has not been widely used, because it is only effective against influenza A infections. The use of amantadines for treatment has been associated with the rapid emergence of resistant viruses capable of transmission, compromising its potential as a prophylactic, as well as a treatment. Side effects are well recognised and are a particular problem in the most vulnerable elderly populations, where dose restriction is necessary and prior knowledge of creatinine clearance desirable. The potential market for a new influenza treatment is large and the potential role of neuraminidase inhibitors in addressing this market has been covered in several review articles [1-4]. This review reports on the introduction of zanamivir (Relenza) to the market with particular reference to experience in the UK.

The reducing incidence of respiratory tract infection and its relation to antibiotic prescribing.

BACKGROUND: There is good evidence of reduced prescribing of antibiotics in recent years, but the reason for this has not been established. AIM: To study the incidence of respiratory tract infections presenting to general practitioners (GPs) in England and Wales in relation to the incidence of other infections and to the prescription of antibiotics. SETTING: Sentinel practices in England and Wales who contribute to the Weekly Returns Service (WRS) of the Royal College of General Practitioners. DESIGN: Time-series analysis of disease incidence data reported by the practices and of antibiotic prescription data from the Prescription Pricing Authority (PPA) during the years 1994-2000. METHOD: Incidence data reported weekly from 73 practices in England and Wales, serving a population of 600,000, for acute respiratory tract infections, otitis media, infectious mononucleosis, shingles, urinary tract infections, and skin infections, were consolidated into quarterly datasets and examined graphically for evidence of secular and seasonal trends. Trends in antibiotic prescription items (data for England only were supplied by the PPA) were examined for association after adjustment for seasonal variation. RESULTS: The incidence of respiratory tract infections and antibiotic prescribing showed virtually identical seasonal variation, with both declining from 1995: respiratory tract infections by 48% in winter and 38% in summer, and antibiotic prescriptions by 34% and 21%, respectively. Trends in both were very highly correlated. The incidence of shingles and skin infections was constant. The incidence of urinary tract infections declined by 10%. The incidence of otitis media in children and acute bronchitis in the elderly followed the all-age trend in the reduction of respiratory tract infections. CONCLUSION: The considerable reduction in the incidence of respiratory tract infections between 1995 and 2000 is the main reason for the decline in antibiotic prescribing rather than changing prescribing thresholds for antibiotics.

New Wisdom to Defy an Old Enemy: Summary from a scientific symposium at the 4th Influenza Vaccines for the World (IVW) 2012 Congress, 11 October, Valencia, Spain.

Both seasonal and pandemic influenza cause considerable morbidity and mortality globally. In addition, the ongoing threat of new, unpredictable influenza pandemics from emerging variant strains cannot be underestimated. Recently bioCSL (previously known as CSL Biotherapies) sponsored a symposium 'New Wisdom to Defy an Old Enemy' at the 4th Influenza Vaccines for the World Congress in Valencia, Spain. This symposium brought together a renowned faculty of experts to discuss lessons from past experience, novel influenza vaccine developments, and new methods to increase vaccine acceptance and coverage. Specific topics reviewed and discussed included new vaccine development efforts focused on improving efficacy via alternative administration routes, dose modifications, improved adjuvants, and the use of master donor viruses. Improved safety was also discussed, particularly the new finding of an excess of febrile reactions isolated to children who received the 2010 Southern Hemisphere (SH) trivalent inactivated influenza vaccine (TIV). Significant work has been done to both identify the cause and minimize the risk of febrile reactions in children. Other novel prophylactic and therapeutic advances were discussed including immunotherapy. Standard IVIg and hIVIg have been used in ferret studies and human case reports with promising results. New adjuvants, such as ISCOMATRIX™ adjuvant, were noted to provide single-dose, prolonged protection with seasonal vaccine after lethal H5N1 virus challenge in a ferret model of human influenza disease. The data suggest that adjuvanted seasonal influenza vaccines may provide broader protection than unadjuvanted vaccines. The use of an antigen-formulated vaccine to induce broad protection between pandemics that could bridge the gap between pandemic declaration and the production of a homologous vaccine was also discussed. Finally, despite the availability of effective vaccines, most current efforts to increase influenza vaccine coverage rates to higher levels (i.e., above 70-80%) have been ineffective in highly developed countries where the vaccine is used, hindered by the public's skepticism towards vaccines in general. New educational and social media methods to increase vaccine acceptance and coverage were discussed. While the first priority should be the development of improved influenza vaccines, a particular focus on the aging global population is critical. It is also important to draw lessons from other academic disciplines that can help to inform vaccine education programs, policy, and communication. By tailoring communications and patient education using an understanding of cognitive bias and the model of preferred cognitive styles, the likelihood of effecting desirable health decisions can be maximized, leading to improved vaccine coverage and control of influenza and other vaccine-preventable diseases.

Ten lessons for the next influenza pandemic-an English perspective: a personal reflection based on community surveillance data.

We review experience in England of the swine flu pandemic between May 2009 and April 2010. The surveillance data from the Royal College of General Practitioners Weekly Returns Service and the linked virological data collected in the integrated program with the Health Protection Agency are used as a reference frame to consider issues emerging during the pandemic. Ten lessons are summarized. (1) Delay between illness onset in the first worldwide cases and virological diagnosis restricted opportunities for containment by regional prophylaxis. (2) Pandemic vaccines are unlikely to be available for effective prevention during the first wave of a pandemic. (3) Open, realistic and continuing communication with the public is important. (4) Surveillance programs should be continued through summer as well as winter. (5) Severity of illness should be incorporated in pandemic definition. (6) The reliability of diagnostic tests as used in routine clinical practice calls for further investigation. (7) Evidence from serological studies is not consistent with evidence based on health care requests made by sick persons and is thus of limited value in cost effectiveness studies. (8) Pregnancy is an important risk factor. (9) New strategies for administering vaccines need to be explored. (10) Acceptance by the public and by health professionals of influenza vaccination as the major plank on which the impact of influenza is controlled has still not been achieved.