Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Contributions of physicians to government-subsidised
disease prevention programmes: an appeal for active participation
Junjie Huang, MD, MSc1; Harry HX Wang, PhD1; Edmond SK Ma, MD, MMedSc2; Martin CS Wong, MD, MPH3,4
1 Editor, Hong Kong Medical Journal
2 Epidemiology Adviser, Hong Kong Medical Journal
3 Editor-in-Chief, Hong Kong Medical Journal
4 Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
Pneumococcal infection, particularly invasive
pneumococcal disease (IPD), has placed a substantial
global burden of disease.1 In Hong Kong, from 2007
to 2015, the incidence rate of IPD increased from
1.7 to 2.9 per 100 000 population.2 It is one of the
leading causes of disability and mortality, affecting
individuals aged ≥65 years who are at higher risk
of complications and premature death.3 The total
number of local residents aged ≥65 years has already
exceeded one million, accounting for approximately
16% of the whole population in Hong Kong.4 Due
to the ageing population, the incidence of IPD is
expected to rise continuously in the coming years.5
Evidence has shown that pneumococcal
immunisation can effectively decrease the incidence
and mortality of pneumococcal infection and
IPD among older adults.6 7 An earlier large-scale
cohort study demonstrated that immunisation was
associated with a significant decrease in the risk
of pneumococcal infection (hazard ratio=0.56)
among patients aged >65 years.8 The pneumococcal
immunisation can also lower the risks of both
myocardial infarction9 and ischaemic stroke.10
Although pneumococcal immunisation is beneficial
for IPD and cardiovascular disease control, the
programme participation remained suboptimal
worldwide.
The uptake rate of pneumococcal immunisation
among older adults was only around 61% in the
United States during 2013 to 2014.11 In England,
the pneumococcal immunisation coverage among
older adults was <70% during 2014 to 2015.12 In
Hong Kong, only one-third of people aged ≥65 years
received pneumococcal immunisation.13
The Hong Kong SAR Government has launched
two pneumococcal immunisation programmes to
eligible residents in October 2019: the Vaccination
Subsidy Scheme and the Government Vaccination
Programme.14 The Vaccination Subsidy Scheme
provided a subsidy of HK$210 (~US$27) and
HK$250 (~US$32) for influenza and pneumococcal
immunisation, respectively, to eligible older
individuals at enrolled private clinics as a measure to strengthen the preventive strategy for these
diseases. It offers subsidies for both the 13-valent
pneumococcal conjugate vaccine and the 23-valent
polysaccharide pneumococcal vaccine. The
Government Vaccination Programme provides
eligible individuals with free pneumococcal
immunisation at residential care homes for the
elderly, designated centres of the Department of
Health, and public clinics or hospitals managed by
the Hospital Authority.14
In addition to pneumococcal vaccine, human
papillomavirus (HPV) vaccination is currently
available under the Hong Kong Childhood
Immunisation Programme, wherein eligible
female students may receive two doses of 9-valent
HPV vaccine in their primary five and six school
years.15 Other examples of Government-subsidised
programmes for disease prevention include cervical
cancer screening,16 colorectal cancer screening,17
and the Smoking Cessation Programme.18
In this issue of the Hong Kong Medical Journal,
Man et al19 report an 8-year large-scale retrospective
cohort study that included 792 adult patients in a
major hospital. The authors found that the 30-day
mortality rates were 11.5% overall and 24.5% in
those patients with IPD. Among 170 patients
admitted to the intensive care unit, the in-hospital
mortality was 31.2%. The study results indicate that
older age, the presence of chronic kidney disease,
and disease severity are significantly associated
with 30-day mortality. The study is limited by the
absence of controls for potential confounders
and its retrospective single-centre design; thus
the generalisability to other settings may require
cautious interpretation. This necessitates future
evaluations to explore drug resistance patterns and
capsular serotypes of pneumococcus. As claimed
by the authors, this was the first and largest-scale
investigation on pneumococcal disease in Hong
Kong showing the significant burden posed
by pneumococcal infection. The study exerts a
significant impact on clinical care and resource
planning for hospitals, given that up to 33% of IPD patients require intensive care unit care. In view of
the public health impact, the role of pneumococcal
vaccination in prevention should be enhanced.
Substantial evidence supports the effectiveness
of preventive care and disease screening. A meta-analysis
of 26 randomised controlled trials consisting
of >73 000 individuals found that HPV immunisation
can effectively protect adolescent girls and young
females from cervical cancer.20 An international
study conducted in eight countries by the World
Health Organization found that the cumulative
incidence of cervical cancer decreased by 94%, 93%,
91%, 84%, and 64% for a screening interval of 1 year,
2 years, 3 years, 5 years, and 10 years, respectively,
among women who were screened before age
35 years.21 Screening is also beneficial for women aged
61 to 65 years, and is associated with a decreased risk
of cervical cancer (hazard ratio=0.42), contributing
to a reduction of approximately 3.3 cancer cases
per 1000 women.22 Screening by faecal occult blood
test and colonoscopy can effectively reduce the risk
of colorectal cancer–related death by 33%23 and
68%24, respectively. Among patients who smoke
≥15 cigarettes daily, smoking reduction by 50% can
significantly reduce the risk of lung cancer.25
The effect of physician intervention on disease
prevention and screening is well documented in
the literature. Participation rates of pneumococcal
vaccination are associated with physician-delivered
routine vaccine and promotion programmes.26 A study among Japanese primary care physicians
found that patients who had pneumococcal
vaccination were more likely to have received advice
from physicians than those who did not receive
such advice (80% vs 21%), and a strong association
was shown between physician recommendation and
patient participation in vaccination with an adjusted
odds ratio of 8.50.27 A study in France demonstrated
that patients who received recommendations
from trusted family physicians were more likely
to participate in HPV vaccination programme.28
In Hungary, physicians effectively motivated
approximately 27% of women who initially refused
to join cervical cancer screening programmes.29
Moreover, higher non-compliance rates were related
to family physicians being foreign, at a younger
age, and with a longer distance to the clinic from
the patient’s home.30 A population-based telephone
survey in Hong Kong found that people who were
recommended by physicians were 23.5-fold more
likely to have colorectal cancer screening uptake
than those who did not.31 A recent study conducted
in Canada using large administrative databases
highlighted that the uptake of colorectal cancer tests
by family physicians was significantly associated with
greater uptake by their patients.32 Another study
found that clinicians who specialised in respiratory
diseases, thoracic surgery, and cardiology were more committed to encouraging patients to cease tobacco
use.33
We believe that the study by Man et al19 acts
as a call for more active participation by physicians
in disease prevention and screening programmes,
and appeal for your support. Physicians play an
important role in both primary and secondary
disease prevention for asymptomatic individuals,
including promotion of lifestyle modifications,
vaccination for infectious diseases, and screening
for early-stage cancer lesions such as cervical cancer
and colorectal cancer.
Author contributions
All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy
and integrity.
Conflicts of interest
The authors have disclosed no conflicts of interest.
References
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