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The effect of universal influenza immunization on mortality and health care use

In 2000, Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free influenza vaccines for the entire population aged 6 mo or older. Influenza immunization increased more rapidly in younger age groups in Ontario compared to other Canadian provinces, which all mainta...

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Published in:PLoS medicine 2008-10, Vol.5 (10), p.e211-e211
Main Authors: Kwong, Jeffrey C, Stukel, Thérèse A, Lim, Jenny, McGeer, Allison J, Upshur, Ross E G, Johansen, Helen, Sambell, Christie, Thompson, William W, Thiruchelvam, Deva, Marra, Fawziah, Svenson, Lawrence W, Manuel, Douglas G
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description In 2000, Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free influenza vaccines for the entire population aged 6 mo or older. Influenza immunization increased more rapidly in younger age groups in Ontario compared to other Canadian provinces, which all maintained targeted immunization programs. We evaluated the effect of Ontario's UIIP on influenza-associated mortality, hospitalizations, emergency department (ED) use, and visits to doctors' offices. Mortality and hospitalization data from 1997 to 2004 for all ten Canadian provinces were obtained from national datasets. Physician billing claims for visits to EDs and doctors' offices were obtained from provincial administrative datasets for four provinces with comprehensive data. Since outcomes coded as influenza are known to underestimate the true burden of influenza, we studied more broadly defined conditions. Hospitalizations, ED use, doctors' office visits for pneumonia and influenza, and all-cause mortality from 1997 to 2004 were modelled using Poisson regression, controlling for age, sex, province, influenza surveillance data, and temporal trends, and used to estimate the expected baseline outcome rates in the absence of influenza activity. The primary outcome was then defined as influenza-associated events, or the difference between the observed events and the expected baseline events. Changes in influenza-associated outcome rates before and after UIIP introduction in Ontario were compared to the corresponding changes in other provinces. After UIIP introduction, influenza-associated mortality decreased more in Ontario (relative rate [RR] = 0.26) than in other provinces (RR = 0.43) (ratio of RRs = 0.61, p = 0.002). Similar differences between Ontario and other provinces were observed for influenza-associated hospitalizations (RR = 0.25 versus 0.44, ratio of RRs = 0.58, p < 0.001), ED use (RR = 0.31 versus 0.69, ratio of RRs = 0.45, p < 0.001), and doctors' office visits (RR = 0.21 versus 0.52, ratio of RRs = 0.41, p < 0.001). Sensitivity analyses were carried out to assess consistency, specificity, and the presence of a dose-response relationship. Limitations of this study include the ecological study design, the nonspecific outcomes, difficulty in modeling baseline events, data quality and availability, and the inability to control for potentially important confounders. Compared to targeted programs in other provinces, introduction of universal vaccination in O
doi_str_mv 10.1371/journal.pmed.0050211
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Hospitalizations, ED use, doctors' office visits for pneumonia and influenza, and all-cause mortality from 1997 to 2004 were modelled using Poisson regression, controlling for age, sex, province, influenza surveillance data, and temporal trends, and used to estimate the expected baseline outcome rates in the absence of influenza activity. The primary outcome was then defined as influenza-associated events, or the difference between the observed events and the expected baseline events. Changes in influenza-associated outcome rates before and after UIIP introduction in Ontario were compared to the corresponding changes in other provinces. After UIIP introduction, influenza-associated mortality decreased more in Ontario (relative rate [RR] = 0.26) than in other provinces (RR = 0.43) (ratio of RRs = 0.61, p = 0.002). Similar differences between Ontario and other provinces were observed for influenza-associated hospitalizations (RR = 0.25 versus 0.44, ratio of RRs = 0.58, p &lt; 0.001), ED use (RR = 0.31 versus 0.69, ratio of RRs = 0.45, p &lt; 0.001), and doctors' office visits (RR = 0.21 versus 0.52, ratio of RRs = 0.41, p &lt; 0.001). Sensitivity analyses were carried out to assess consistency, specificity, and the presence of a dose-response relationship. Limitations of this study include the ecological study design, the nonspecific outcomes, difficulty in modeling baseline events, data quality and availability, and the inability to control for potentially important confounders. Compared to targeted programs in other provinces, introduction of universal vaccination in Ontario in 2000 was associated with relative reductions in influenza-associated mortality and health care use. The results of this large-scale natural experiment suggest that universal vaccination may be an effective public health measure for reducing the annual burden of influenza.</description><identifier>ISSN: 1549-1676</identifier><identifier>ISSN: 1549-1277</identifier><identifier>EISSN: 1549-1676</identifier><identifier>DOI: 10.1371/journal.pmed.0050211</identifier><identifier>PMID: 18959473</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adolescent ; Adult ; Aged ; Aged, 80 and over ; Cause of Death ; Child ; Emergency medical care ; Epidemics ; Female ; Health Policy ; Health services research ; Hospitalization ; Hospitalization - statistics &amp; numerical data ; Humans ; Immune system ; Immunization - statistics &amp; numerical data ; Immunization Programs - statistics &amp; numerical data ; Infectious Diseases ; Influenza ; Influenza A virus ; Influenza Vaccines - administration &amp; dosage ; Influenza Vaccines - immunology ; Influenza virus ; Influenza, Human - immunology ; Influenza, Human - mortality ; Influenza, Human - prevention &amp; control ; Long term health care ; Male ; Middle Aged ; Models, Theoretical ; Mortality ; Ontario ; Pneumonia ; Provinces ; Public domain ; Public Health ; Public Health and Epidemiology ; Respiratory Medicine ; Vaccines ; Viruses ; Young Adult</subject><ispartof>PLoS medicine, 2008-10, Vol.5 (10), p.e211-e211</ispartof><rights>COPYRIGHT 2008 Public Library of Science</rights><rights>2008 Public Library of Science. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited: Citation: Kwong JC, Stukel TA, Lim J, McGeer AJ, Upshur REG, et al. (2008) The Effect of Universal Influenza Immunization on Mortality and Health Care Use. PLoS Med 5(10): e211. doi:10.1371/journal.pmed.0050211</rights><rights>This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration, which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. 2008</rights><rights>2008 Public Library of Science. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited: Citation: Kwong JC, Stukel TA, Lim J, McGeer AJ, Upshur REG, et al. (2008) The Effect of Universal Influenza Immunization on Mortality and Health Care Use. 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Similar differences between Ontario and other provinces were observed for influenza-associated hospitalizations (RR = 0.25 versus 0.44, ratio of RRs = 0.58, p &lt; 0.001), ED use (RR = 0.31 versus 0.69, ratio of RRs = 0.45, p &lt; 0.001), and doctors' office visits (RR = 0.21 versus 0.52, ratio of RRs = 0.41, p &lt; 0.001). Sensitivity analyses were carried out to assess consistency, specificity, and the presence of a dose-response relationship. Limitations of this study include the ecological study design, the nonspecific outcomes, difficulty in modeling baseline events, data quality and availability, and the inability to control for potentially important confounders. Compared to targeted programs in other provinces, introduction of universal vaccination in Ontario in 2000 was associated with relative reductions in influenza-associated mortality and health care use. 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Influenza immunization increased more rapidly in younger age groups in Ontario compared to other Canadian provinces, which all maintained targeted immunization programs. We evaluated the effect of Ontario's UIIP on influenza-associated mortality, hospitalizations, emergency department (ED) use, and visits to doctors' offices. Mortality and hospitalization data from 1997 to 2004 for all ten Canadian provinces were obtained from national datasets. Physician billing claims for visits to EDs and doctors' offices were obtained from provincial administrative datasets for four provinces with comprehensive data. Since outcomes coded as influenza are known to underestimate the true burden of influenza, we studied more broadly defined conditions. Hospitalizations, ED use, doctors' office visits for pneumonia and influenza, and all-cause mortality from 1997 to 2004 were modelled using Poisson regression, controlling for age, sex, province, influenza surveillance data, and temporal trends, and used to estimate the expected baseline outcome rates in the absence of influenza activity. The primary outcome was then defined as influenza-associated events, or the difference between the observed events and the expected baseline events. Changes in influenza-associated outcome rates before and after UIIP introduction in Ontario were compared to the corresponding changes in other provinces. After UIIP introduction, influenza-associated mortality decreased more in Ontario (relative rate [RR] = 0.26) than in other provinces (RR = 0.43) (ratio of RRs = 0.61, p = 0.002). Similar differences between Ontario and other provinces were observed for influenza-associated hospitalizations (RR = 0.25 versus 0.44, ratio of RRs = 0.58, p &lt; 0.001), ED use (RR = 0.31 versus 0.69, ratio of RRs = 0.45, p &lt; 0.001), and doctors' office visits (RR = 0.21 versus 0.52, ratio of RRs = 0.41, p &lt; 0.001). Sensitivity analyses were carried out to assess consistency, specificity, and the presence of a dose-response relationship. Limitations of this study include the ecological study design, the nonspecific outcomes, difficulty in modeling baseline events, data quality and availability, and the inability to control for potentially important confounders. Compared to targeted programs in other provinces, introduction of universal vaccination in Ontario in 2000 was associated with relative reductions in influenza-associated mortality and health care use. 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language eng
recordid cdi_plos_journals_1288087131
source Publicly Available Content Database (Proquest) (PQ_SDU_P3); PubMed Central (Training)
subjects Adolescent
Adult
Aged
Aged, 80 and over
Cause of Death
Child
Emergency medical care
Epidemics
Female
Health Policy
Health services research
Hospitalization
Hospitalization - statistics & numerical data
Humans
Immune system
Immunization - statistics & numerical data
Immunization Programs - statistics & numerical data
Infectious Diseases
Influenza
Influenza A virus
Influenza Vaccines - administration & dosage
Influenza Vaccines - immunology
Influenza virus
Influenza, Human - immunology
Influenza, Human - mortality
Influenza, Human - prevention & control
Long term health care
Male
Middle Aged
Models, Theoretical
Mortality
Ontario
Pneumonia
Provinces
Public domain
Public Health
Public Health and Epidemiology
Respiratory Medicine
Vaccines
Viruses
Young Adult
title The effect of universal influenza immunization on mortality and health care use
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