Canadian National Advisory Committee Research Articles

Proportional of wheezing events in asthmatic children post-vaccination of annual flu vaccine

Background: The common childhood chronic disease asthma causes hospitalisation and exacerbations due to respiratory tract viral infections like influenza. Due to uncertainty about the benefits and role of influenza vaccines in preventing asthma exacerbations, many children with asthma do not receive them, despite recommendations from organisations like the Canadian National Advisory Committee on Immunisation. There are two main types of influenza vaccines: intramuscular trivalent inactivated and intranasal cold-adapted, live attenuated. Both vaccines are highly immunogenic and induce an adequate immune response, but their clinical efficacy varies by season and age. Aim: The aim of this study was to investigate the occurrence of increased wheeze rates in stable asthmatic children who received the annual flu vaccine, compared to a control group of asthmatic children who did not receive the vaccine. Methods: A retrospective study at the Queen Rania Abdullah for Children Hospital in Amman, Jordan, examined the vaccination status of 200 asthmatic children aged 3-14. The study focused on recurrent wheezing episodes and the minimum 12-month period between the last annual flu vaccination and asthmatic exacerbation. The study excluded uncontrolled or partially controlled patients for the past 12 months. Data was collected from demographic information, vaccination history, and past wheezing episodes. The children were divided into two groups, one without the flu vaccine and the other with the flu vaccine. A comprehensive questionnaire was used to assess sociodemographic and disease-related factors. If children received the vaccination as per the National Vaccination Schedule, their vaccination status was considered complete. Results: A study of 200 asthmatic children in Jordan found that 35% did not receive a flu vaccine, placing them in Group I. 65% had received a flu vaccine in the previous year. Males had higher distribution rates in both flu-based groups, with a statistically insignificant positive correlation. Age categories showed similar distribution rates, with 21.0% for 3-6 years, 34.0% for 6-9 years, 37.5% for 9-12 years, and 7.5% for 12-15 years. No significant correlation was found between receiving the flu vaccine and wheezing rates in the last seasonal year. Frequent wheezing episodes were higher in experienced groups than in naïve groups.

Pregnancy, breastfeeding and the SARS-CoV-2 vaccine: an ethics-based framework for shared decision-making

KEY POINTS In December 2020, the Canadian National Advisory Committee on Immunization recommended that the vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) should not be routinely offered to individuals who are pregnant or breastfeeding until further evidence is available

Pertussis vaccination in pregnancy in Canada: a cost-utility analysis.

The Canadian National Advisory Committee on Immunization recommends universal vaccination against pertussis in pregnancy. We assessed the cost-effectiveness of vaccination with tetanus-diphtheria-acellular pertussis (Tdap) vaccine in pregnancy in Canada. We conducted a cost-utility analysis comparing a vaccination program to no program corresponding with the 2017 Canadian guideline for economic evaluation from the Canadian Agency for Drugs and Technologies in Health. We developed 2 models - part decision tree, part Markov model - to estimate the long-term cost and quality-adjusted life-years (QALYs) for pregnant women and their infants. We obtained epidemiologic data from 2006 to 2015, and derived costs and utility values from relevant sources. Results were reported in 2019 Canadian dollars. We obtained expected values through probabilistic analysis, with methodologic and structural uncertainty assessed through scenario analyses. The analysis adopted an acquisition price of Tdap vaccine of $12.50, with scenario analysis conducted to identify the threshold price for vaccination to be cost-effective. In the base-case scenario, for every 1000 pregnant women vaccinated, the program would lead to a gain of 0.3 QALYs, occurring solely in infants, at an increased total cost of $12 987, or $44 301 per QALY gained. Based on a threshold of $50 000 per QALY gained, vaccination would have been cost-effective in 6 of the 10 years included in the model (range of incremental costs $20 463-$100 348 per QALY gained). The threshold cost for Tdap vaccine to be cost-effective over the 10-year horizon was $14.03. Based on a threshold of $50 000 per QALY gained, vaccination against pertussis in pregnancy would be cost-effective if the acquisition cost per vaccine were $14.03 or less. Province- and territory-specific analyses should be done to inform local decision-making.

Perinatal health care providers' approaches to recommending and providing pertussis vaccination in pregnancy: a qualitative study.

In 2018, the Canadian National Advisory Committee on Immunization and the Society of Obstetricians and Gynaecologists of Canada recommended a single dose of tetanus toxoid, reduced diphtheria toxoid and reduced acellular pertussis (Tdap) vaccine in every pregnancy. To understand how perinatal health care providers in Canada are translating recent recommendations for universal antenatal Tdap vaccine into routine clinical practice, we examined health care providers' perceptions of what influences their ability to recommend and provide Tdap vaccine consistently to pregnant women. Between June 2018 and July 2019, we conducted semistructured telephone interviews with perinatal health care providers (nurses, midwives, family physicians and obstetricians) from 5 provinces (British Columbia, Manitoba, Ontario, Quebec and Nova Scotia) representing diverse educational experiences, practice settings and models of care. We analyzed the data using interpretive description. We interviewed 44 perinatal health care providers (13 family physicians, 12 midwives, 10 obstetricians and 9 nurses) practising in a variety of settings. Health care providers' ability to recommend and provide antenatal Tdap vaccine was strongly influenced by structural constraints in the Canadian perinatal health care system. The participants' clinical training varied, which resulted in different knowledge and practices. Participants felt hindered by a lack of lay information resources. Consistent and convenient vaccine access was perceived to be key to promoting confidence and encouraging uptake, yet antenatal Tdap vaccine was not easily accessible for all women. Our findings suggest that Canada's fragmented health care model has a detrimental effect on health care providers' ability to recommend and ensure access to antenatal Tdap vaccine. Lessons from this study are pertinent to the implementation of successful pertussis vaccine programs and future pregnancy vaccination initiatives.

Cost-effectiveness of alternative strategies for use of 13-valent pneumococcal conjugate vaccine (PCV13) in Canadian adults

ObjectivesThe Canadian National Advisory Committee on Immunization (NACI) recommends use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine in a sequential schedule (PCV13 → PPV23) among adults aged ≥ 65 years and those aged ≥ 18 years who are immunocompromised. In light of recent PCV13 efficacy data from the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA), and new sero-epidemiology data on community-acquired pneumonia (CAP), we examined the economic implications of funding an expanded adult pneumococcal immunization program in Canada.MethodsA microsimulation model depicting expected lifetime risks, consequences, and costs of invasive pneumococcal disease (IPD) and CAP was developed. PPV23 effectiveness was based on published literature, and PCV13 effectiveness was based on CAPiTA; all other model parameters were based on published data or secondary sources. Herd effects from the PCV13 pediatric program were considered. Outcomes and costs were evaluated assuming use of PPV23 alone, and alternatively, use of PCV13 → PPV23 among (1) all adults aged ≥ 65 years (n = 5.4 M) and (2) immunocompromised and high-risk adults aged ≥ 65 years (n = 3.0 M).ResultsFor population no. 1, PCV13 → PPV23 reduced IPD cases by 1100, CAP cases by 7000, and disease costs by $135.8M; vaccination costs increased by $254.3M, and cost per QALY gained was $35,484. For population no. 2, PCV13 → PPV23 reduced IPD cases by 900, CAP cases by 6000, and disease costs by $120.3M; vaccination costs increased by $149.8M, and cost per QALY gained was $10,728.ConclusionExpanding use of PCV13 → PPV23 by funding PCV13 among Canadian adults aged ≥ 65 would be a cost-effective use of healthcare resources.

Intradermal pre-exposure rabies vaccination in a Canadian travel clinic: 6-year retrospective observational study.

The intradermal route of vaccine administration for pre-exposure rabies prophylaxis, endorsed by the Canadian National Advisory Committee on Immunization, was implemented at a large travel clinic in Montréal in 2008. We evaluated the effect of intradermal vaccination availability on uptake of pre-exposure rabies prophylaxis and rates of seroconversion with intradermal vaccination. We conducted a retrospective cross-sectional study using data from December 2008 to December 2014. The number of travellers who received pre-exposure rabies prophylaxis before and after the introduction of intradermal vaccination was compared. Postvaccination antibody titres were measured in intradermal vaccination recipients. We compared demographic and travel characteristics between vaccinated and unvaccinated travellers and between travellers in the intradermal and intramuscular groups using univariate and multivariate analyses. The proportion of travellers who received pre-exposure prophylaxis increased after the introduction of intradermal vaccination (annual average of 300 travellers from December 2009 to December 2014 v. 183 travellers from December 2006 to December 2007). Seroconversion occurred in 99.9% of those in the intradermal group. Travellers who received pre-exposure prophylaxis were older (mean age 35.8 yr v. 32.1 yr) and had longer travel duration than those who did not receive pre-exposure prophylaxis. Travellers to Asia were more likely to receive pre-exposure prophylaxis, and travellers visiting friends and relatives were less likely to receive it. Travellers in the intradermal group were younger than those in the intramuscular group and were more likely to be travelling for tourism. The introduction of intradermal vaccination for pre-exposure rabies prophylaxis was associated with an increase in vaccination uptake. Reduced cost may be responsible for the increased coverage among younger travellers and those travelling for tourism. The high seroconversion rate after intradermal vaccination supports the effectiveness of this route of administration for pre-exposure rabies prophylaxis in immunocompetent people.

Intranasal influenza vaccine: Why does Canada have different recommendations from the USA on its use?

Canada and the USA differ in their recommendations for the use of live attenuated influenza vaccine (LAIV). The Canadian National Advisory Committee on Immunization (NACI) continues to recommend LAIV as one of the influenza vaccines available for use in children 2 to 17 years of age. The US Advisory Committee on Immunization Practices (ACIP) made an interim recommendation against the use of LAIV for the 2016 to 2017 influenza season in response to low LAIV effectiveness observed in the USA during the 2013 to 2014 to 2015 to 2016 seasons. The recommendation has been continued for the 2017 to 2018 season. In response, NACI undertook a review of available LAIV effectiveness data in children and adolescents from Canada, the USA and a number of European countries. This commentary by Canada's Chief Public Health Officer summarizes the findings of that review and provides the rationale for Canada's current continued recommendation for LAIV use.

A Survey of Uptake and Barriers to the Seasonal Influenza Vaccination in Respirology Patients at an Ontario Academic Hospital

SESSION TITLE: Quality Improvement 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Seasonal influenza vaccination is recommended for patients with chronic respiratory conditions to reduce hospitalizations and mortality. Despite the Canadian National Advisory Committee on Immunization setting a vaccination target of 80% in high-risk individuals, vaccination rates still fall significantly below target. We sought to identify self-reported uptake and barriers to influenza vaccination in patients attending a Respirology clinic during the 2016-2017 flu season at Hotel Dieu Hospital (HDH), an academic hospital in Ontario, Canada. METHODS: A 10-question paper survey was distributed to patients from January-March 2017. Nursing staff performing the initial patient assessment asked patients to fill out the survey while waiting for the physician. Survey completion was optional and anonymous. Nursing staff collected surveys after patient visits. A single researcher entered survey data into a spreadsheet for analysis. Descriptive data are presented as n (%) and Chi-Square analysis was used to compare categorical variables. RESULTS: A total of 243 surveys were completed; response rate was about 13.5% (600 patients/month seen in clinic). Most common self-reported respiratory conditions included COPD (50, 22.2%), asthma (42, 18.7%), and interstitial lung disease (24, 10.7%). “Other” was selected frequently (122, 54.2%), though the underlying condition was often not specified. Of respondents, 127 (57.5%) were female and 119 (53.6%) were >65 years old. 161 patients (67%) reported receiving the vaccine, most commonly by a family doctor (97, 60.6%) or pharmacy (50, 31.3%). The 79 patients (32.9%) who reported not receiving the vaccine identified a range of barriers with 14 (18.7%) identifying >1 barrier: 22 (29.3%) selected “I do not think I need the flu shot”, 17 (22.7%) selected “I do not believe the flu shot works”, and the majority selected “Other” (29, 38.7%) identifying beliefs around vaccine effectiveness, potential harm, and associated illness. Comparing flu shot receivers and non-receivers, there was no significant difference in gender, respiratory condition, or education level. Patients reported being more likely to accept next year’s vaccine if administered in clinic than to accept it from the pharmacy in the hospital’s main lobby (43.1% “very likely” or “somewhat likely” in clinic vs. 19.1% in pharmacy, p = 0.0002). This finding was observed for both flu shot receivers (48.6% vs. 23%, p =0.001) and flu shot non-receivers (30.0% vs. 9.7%, p = 0.046). CONCLUSIONS: Self-reported influenza vaccine uptake in the HDH respirology clinic setting is above average, but below national target of 80%. Vaccine non-recipients identified multiple barriers to vaccination, many requiring multi-faceted educational interventions to increase uptake. Convenience of flu shot administration may influence future vaccine uptake. CLINICAL IMPLICATIONS: Our data serves both as a baseline for quality improvement (QI) initiatives aimed at increasing vaccination rates and identifies root causes of sub-target vaccination rates. We plan to develop QI initiatives focusing on increasing patient education and improving ease of vaccine access to ultimately reduce hospitalizations and mortality in patients with respiratory diseases. DISCLOSURE: The following authors have nothing to disclose: Kallie Stapleton, Genevieve Digby, Julie Gilmour No Product/Research Disclosure Information

The Perils of Pain: Applying Primary Prevention to Combat Canada's Opioid Crisis

The development and promotion of the pain reliever OxyContin marks a dark chapter in modern healthcare, leaving lasting impact. Following the introduction of the drug in 1996 by Purdue Pharma, it became popularized among prescribers due to the company’s unsupported assurance of its safety and efficacy. OxyContin has been highly profitable for Purdue but has resulted in dangerous health side effects, most notably chronic addiction. In addition, the increasing prevalence of opioid addiction exacerbates health and societal problems like illicit drug use, especially the abuse of other opioids like heroine and fentanyl. The ramifications of the opioid crisis extend beyond individual health problems, causing social issues, economic burden and political tensions as well. In response to this, the Canadian National Advisory Committee on Prescription Drug Misuse created the “First Do No Harm” strategy, focusing on prevention, education, treatment, monitoring and surveillance. Although these strategies have been applied with some success, opioid-related deaths and costs continue to grow in Canada. A primary preventative approach that focuses on using epidemiological data to reduce opioid access is thought to be an important part of ongoing strategies. Primary prevention will assist in improving the health of Canadians, mitigate future opioid-related healthcare costs and ultimately contribute toward stopping their ongoing distribution. In doing so, the future Canadian healthcare landscape, families and patients alike may be spared the collateral damage opioids cause.

Including males in Canadian human papillomavirus vaccination programs: a policy analysis.

The Canadian National Advisory Committee on Immunization (NACI) recommends human papillomavirus (HPV) vaccination for females aged 9–26 years (bivalent or quadrivalent vaccine) and males aged 9–26 years (quadrivalent vaccine) ([Figure 1][1]).[1][2] All Canadian provinces and territories

Efficacy and safety of Prothrombin Complex Concentrates Weight-Based Dosing for Reversal of Warfarin Anticoagulation

▪Background: Prothrombin complex concentrates (PCCs) are widely used for correcting elevated international normalized ratio (INR) levels in patients anticoagulated with warfarin requiring an urgent reversal. However, the optimal dosing regimen has yet to be defined. In 2008, the Canadian National Advisory Committee (NAC) on blood product utilization recommended a single dose of 1000 IU for all adults over 18 years of age, irrespective of INR levels, and suggested further consultation with a Hematologist if extremes in weight or INR were observed. A revision in 2011, suggested dosing based on the INR elevation as an option and in 2014 the recommendation was updated to include a possible algorithm including both INR and weight. Currently there is insufficient evidence to suggest that one approach is more efficacious than another. Our institution has been using a novel weight-based dosing protocol for PCCs since 2009, which dispenses to a maximum of 3000 IU for adults weighing over 100kg. Herein, we sought to determine the efficacy of our weight-based dosing nomogram.Methods: We conducted a retrospective cohort study of all consecutive adult patients (age > 18 years) who received PCCs using our weight based dosing regimen between April 30, 2009 and December 31, 2010. All patients were anticoagulated with warfarin. Clinical and laboratory information was obtained through chart review. The weight based regimen consisted of 1000 IU for weight less than 40kg, 1500IU for 41 to 60kg, 2000 IU for 61 to 80kg, 2500 IU for 81 to 100kg, and 3000 IU for > 100kg. Doses of PCCs were based on the concentration of factor IX. PCCs utilized at this centre were Octaplex and Beriplex. The primary outcome was reversal of warfarin anticoagulation, as defined by an INR of 1.5 or less to achieve a clinical response within 6 hours. Statistical analysis was done using descriptive statistics and chi squared analysis.Results: A total of 227 charts were included in the study from April 30, 2009 to December 31, 2010. The median age was 74 years old (range 40-95), the median weight was 76kg (range 44-200), and 56% of patients were male. Medical indications for warfarin anticoagulation included atrial fibrillation (68%), DVT (32%) and stroke (21%). The most common indication for PCCs was active bleeding (44%: 13% intracranial, 12% gastrointestinal, 4% trauma, 15% other), reversal for a procedure (22%) and reversal for surgery (30%). Prior to receiving PCCs, 29% of patients were taking Aspirin and 4% were taking Clopidogrel. The percentages of patients treated with each dose were: 1000IU (1.3%), 1500IU (17.6%), 2000IU (41.0%), 2500IU (24.2%), 3000IU (15.9%). A second dose of PCC was given to 0.4% of patients. FFP was given to 7% of patients prior to PCCs administration and 14% of patients post PCCs administration. 63% of patients received vitamin K. Seventy-nine percent of patients achieved an INR of 1.5 or less within 6 hours of PCC administration. There was a statistically significant difference in response based on pre-PCC INRs (see table 1). The median baseline INR was 2.9 (range 1.5- >10) and decreased to a median of 1.3 (range 1.0-3.7) post-PCCs administration. Planned procedures were completed in 93% of 60 patients, and planned surgeries were completed in 94% of 70 patients within 24 hours of receiving PCCs. Four patients (2%) developed a deep vein thrombosis within 30 days of receiving PCCs.Conclusion: Our study demonstrates that weight based dosing is effective in reversal of anticoagulation in patients on warfarin. Laboratory response rates are similar to other studies (Wozniak et al). Although the majority of patients in our study (99%) received doses over 1000IU; rates of thrombosis are low. Future studies comparing different strategies are needed.Table 1INR rangePre-PCCProportion with Post-PCC INR of 1.5 or less (%)P-value1.5-3110/122 (90%)3.1-4.533/43 (77%)0.037*>4.535/62 (56%)<0.001***1.5-3 vs 3.1-4.5**1.5-3 vs >4.5 DisclosuresLazo-Langner:Pfizer Bayer LEO Pharma: Honoraria. Chin-Yee:Alexion Pharmaceuticals: Research Funding.

Burden of seasonal influenza in children with neurodevelopmental conditions.

Studies have identified certain neurologic and neurodevelopmental conditions (NNC) as risk factors for severe influenza infection. The Canadian National Advisory Committee on Immunization does not currently recognize children with NNC as having a high risk of complicated influenza infection unless their condition compromises handling of respiratory secretions. We describe the burden of influenza in hospitalized children with NNC, focusing on those without potential airway compromise. Using multi-year surveillance data obtained by the Canadian Immunization Monitoring Program, Active (IMPACT), we examined presenting signs and symptoms, risk factors and outcomes of children hospitalized with seasonal influenza at 12 Canadian pediatric referral centers. Comparisons were made between children with various NNC and other medical conditions, with and without influenza vaccine indications. The analysis is descriptive with selected comparisons made among groups for important indicators of disease severity. We identified 1991 children hospitalized with influenza over 5 seasons: 293 had NNC, 115 of whom did not have airway compromise or another vaccine indication. The latter group presented with seizures more frequently than those with NNC and a vaccine indication (41.7% vs. 26.4%; P = 0.006) and required intensive care unit admission (20.9% vs. 11.8%; P = 0.02) and mechanical ventilation (14.8% vs. 4.5%; P < 0.001) more often than children without NNC but with a vaccine indication. The burden of influenza infection in children with NNC, even those whose conditions do not obviously compromise respiratory function, is significant. All children with NNC should be recognized as having a high risk of complicated influenza infection and be targeted to receive influenza immunization.

Massive haemorrhage: findings from the consensus conference for the Canadian National Advisory Committee on blood and blood products

The Canadian National Advisory Committee on Blood and Blood Products convened a consensus conference on transfusion and trauma in June 2011. Key findings included a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, and the expected value of an organized response plan in trauma. Practical massive haemorrhage plans must be developed locally and reiterate the importance of communication, education, and the role of audit and monitoring of cases. Generalising findings from trauma to other settings of major bleeding is limited by lack of relevant clinical studies.

The evidence for the use of recombinant factor VIIa in massive bleeding: revision of the transfusion policy framework

In 2006, the Canadian National Advisory Committee on Blood and Blood Products (NAC) developed a transfusion policy framework for the use of off-label recombinant factor VIIa (rFVIIa) in massive bleeding. Because the number of randomised controlled trials has doubled, the NAC undertook a review of the policy framework in 2011. On the basis of the review of 29 randomised controlled trials, there remains little evidence to support the routine use of rFVIIa in massive bleeding. Mortality benefits have not been demonstrated. Contrarily, an increase in arterial thromboembolic events has been observed with the use of off-label rFVIIa. Given the absence of evidence of benefit and with evidence of the risk of harm, the NAC recommends that recombinant VIIa no longer be used for the off-label indications of prevention and treatment of bleeding in patients without haemophilia.

Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

The evidence for the use of recombinant factor VIIa in massive bleeding: development of a transfusion policy framework

A review of the recent randomized control trial evidence of the use of recombinant factor VIIa (rFVIIa) in massive bleeding. rFVIIa is a recombinant genetically engineered clotting factor that has been used for the management of haemophilia patients with inhibitors. There has been increasing use in patients with massive bleeding, even when there is no underlying coagulation disorder present. In November 2006, the Canadian National Advisory Committee on Blood and Blood Products engaged in a consultation and review process with several leading Canadian experts to review and discuss the current evidence up to November 2006. There is little evidence to support the routine use of rFVIIa in massive bleeding on review of 13 randomized controlled trials. rFVIIa should only be considered as part of a transfusion policy framework for massive bleeding after all other transfusion and supportive measures are considered. An example of a policy framework is presented.

The new graduates’ professional inheritance

Across North America, health care systems are experiencing an escalating shortage of qualified and committed registered nurses (RNs). 1 Canadian National Advisory Committee [CNAC]Our health, our future. Advisory Committee on Health Human Resources, Health Canada, Ottawa, ON2002 Google Scholar , 2 Health Resources and Services Administration [HRSA]Projected supply, demand, and shortages of Registered Nurses. US Department of Health and Human Services, Washington, DC2002 Google Scholar There is mounting evidence that the perception of nursing as a challenging, satisfying, and fulfilling vocation by society’s youth is waning. The effect on health care workplaces is an increasingly limited pool of RNs available to fill nursing vacancies that crosses cultural, geographical, and economic boundaries. 3 American Nurses AssociationNursing’s agenda for the future. Nursing World, Inc, Washington, DC2002 Google Scholar Judy Boychuk Duchscher is an Executive Director for Nursing the Future and a Faculty Member at SIAST, Nursing Division, Saskatoon, Saskatchewan. Leanne S. Cowin is a Lecturer at the School of Nursing, College of Health and Science, Unversity of Western Sydney, Australia.

Previous creatinine levels safely predict amantadine dose for influenza A outbreak control.

Amantadine, an antiviral agent, is the only drug currently approved in Canada for prophylaxis of influenza A virus infection. To minimize side effects, the amantadine dose is adjusted for age and estimated creatinine clearance (CrCl) based on plasma creatinine (Cr) levels. As amantadine is used more frequently for influenza A outbreak control in care facilities for elderly people, physicians are increasingly called on to prescribe it for residents and to consider the necessity of requesting plasma Cr levels. To determine whether previous Cr levels are predictive in estimating current CrCl and safe amantadine dose determination. Residents' charts were reviewed in two facilities in Vancouver, British Columbia. CrCl estimated using previous or current Cr results, current weight and age, as well as recommended amantadine doses based on Canadian National Advisory Committee on Immunization guidelines, were studied. 165 charts with Cr results in March 1998 were included; 122 had results before March 1998, and 103 had Cr results after March 1998. Pearson's correlation coefficient for CrCl estimated from current and previous Cr values was 0.929 for results less than six months previously, 0.974 for six to 12 months previously and 0.952 for 12 to 18 months previously. The same or a more conservative dose of amantadine was predicted in 92% of cases when using a Cr result taken within the previous year and in 76% of cases when using a Cr result taken 12 to 18 months previously. In long term care facilities, Cr levels measured up to 12 months previously can usually safely be used to estimate CrCl. Using previous Cr results permits advance preparation of doctor's orders for amantadine prophylaxis and avoids repeating Cr testing on every resident when an outbreak occurs, reducing related staff time and cost.

Should We Revaccinate Seasoned Globe-Trotters for Influenza?

Global travel may increase the risk for contracting influenza. The Canadian National Advisory Committee on Immunization has recommended influenza vaccination for people at high risk for influenza complications who are traveling to destinations with circulating influenza. The known protective antibody effect of influenza vaccination peaks at 4 to …

Pneumococcal immunization and public health: the Canadian experience

Pneumococcal vaccine has been poorly used in Canada, despite strong recommendations for its use by the Canadian National Advisory Committee on Immunization. In a recent survey of health officials, however, seven of the 12 Canadian provinces and territories were found to either have a programme for all persons >65 years of age or were planning to implement one within the next year. Factors that have contributed to this increased interest include: better data on disease incidence and preventable illness from population-based surveillance; data on emerging resistance of Streptococcus pneumoniae in Canada to penicillin and other antimicrobials; implementation of vaccine programmes for the elderly by public health officials in Ontario, Nova Scotia and British Columbia; completion of a cost-benefit study of pneumococcal vaccine for Canada; and increased attention to pneumococcal vaccination at national immunization meetings and in the medical literature. Increased availability of vaccine and competitive pricing are also making programmes for the elderly more feasible and affordable. A national meeting entitled ‘Preventing Pneumococcal Disease: A Canadian Consensus Conference’ was held in February 1998 to further build on this growing interest.