Physicians' perspectives of HMOs and marketing: implications and recommendations

The authors compare physicians in HMOs and those not in HMOs in order to determine how HMOs have affected their practices. Physicians in HMOs see more patients per day, but receive less income per patient than physicians not in HMOs; however, both groups of physicians agree that HMOs have not changed marketing practices. In fact, both groups report uncertainty as to the best way to market their practice, and in their understanding of marketing. The physicians do agree that patient referrals are the most important means of patient acquisition; however, both groups report a surprisingly low use of patient questionnaires. Implications and recommendations for HMOs, physicians, and health care marketing researchers are discussed.     

Adoption of revised dosage recommendations for childhood tuberculosis in countries with different childhood tuberculosis burdens

Background and objective:

In 2010, the World Health Organization (WHO) published revised dosage recommendations for the treatment of tuberculosis (TB) in children. The aim of the survey was to assess whether countries adopt these new dosage recommendations, as well as to identify challenges in the management and treatment of childhood TB. In addition, countries were asked to provide 2010 surveillance data on childhood TB.

Design:

A survey questionnaire was developed and broadly disseminated to National Tuberculosis Programmes or people with close links to them.

Results:

Among the 34 countries that responded to the survey, the proportion of total national TB caseload reported in children in 2010 ranged from 0.67% to 23.6%. The data on new cases reported to this survey varied from data provided to the WHO global TB database. Most countries had childhood TB guidelines in place, and half had adopted the new dosage recommendations. Countries reported a number of challenges related to the implementation of the new recommendations and general management of childhood TB.

Conclusions:

Despite the adoption of the new dosage recommendations, their implementation is complicated by the lack of appropriate fixed-dose combinations. In addition, accurate and consistent estimates of the global burden of childhood TB remained a major challenge. Technical assistance and support to countries is needed to improve childhood TB activities.     

New perspectives for hexavalent vaccines

With the increase in the number of routine vaccinations the development of pentavalent and hexavalent combination vaccines fitting the routine vaccination schedules became a necessity. In this respect, Europe has taken the lead in comparison with other world regions, and routine vaccination with pentavalent and hexavalent combinations including DTPa, Hib, HepB and IPV has been on European vaccination programs for >15 years. Since the marketing authorization of Hexavac® and Infanrix Hexa® in 2000, immunization schedules in most European countries have included hexavalent vaccines. In the last years, two new hexavalent vaccines have been licensed and commercialized worldwide. This paper presents a review of the pharmaceutical profiles of the three hexavalent vaccines currently available. In addition, we aim to review safety, co-administration, tolerability and other practical concerns of their use.     

New ICRP recommendations

This paper provides a review of the 2007 recommendations of the International Commission on Radiological Protection (ICRP). These new recommendations take account of the latest biological and physical information and consolidate the additional guidance provided by ICRP since 1990. The changes to the scientific data are not substantial. ICRP has retained its fundamental hypothesis for the induction of stochastic effects of linearity of dose and effect without threshold and a dose and dose-rate effectiveness factor (DDREF) of 2 to derive nominal risk coefficients for low doses and low dose rates. While the overall detriment from low radiation doses has remained unchanged, ICRP has made adjustments to the values of the radiation and tissue weighting factors. In particular, the tissue weighting factor for breast has increased while that for gonads has decreased. There are some presentational changes to the system of protection. While ICRP has maintained the three fundamental principles--justification, optimisation of protection, and dose limitation-it has attempted to develop a more holistic approach to radiological protection covering all exposure situations--planned, existing and emergency--and all radiation sources, whether of natural or artificial origin. This approach should ensure that attention is focused on those exposures that can reasonably be controlled. It has also strengthened the principle of optimisation of protection with a particular emphasis on the use of constraints for planned exposure situations and reference levels for existing and emergency exposure situations. Dose constraints and reference levels are categorised into three bands which should assist in rationalising the many values of dose restrictions given in earlier ICRP publications. There are no changes to the dose limits. ICRP also indicates its intentions with respect to the development of further guidance on the protection of the environment. The fact that these new recommendations are more a matter of consolidation of previous ICRP recommendations and guidance should provide confidence that the system of protection established by and large in its present form several decades ago has reached a certain level of maturity. As such, no major changes to radiological protection regulations based on the 1990 recommendations should be necessary.     

Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

This study explores the perspectives of tuberculosis patients on which factors influenced their health seeking behaviour, with special reference to gender differentials in terms of delays in health seeking. In 1996, a multi-disciplinary research team carried out 16 focus group discussions. The study was done in four districts in Vietnam, both in the south and north of the country and in urban and rural areas. Qualitative analysis of data was performed following general principles of modified grounded theory technique. Participants in the focus groups described three main factors as contributing to delay in health seeking. These were fear of social isolation, economic constraints and inadequate staff attitudes and poor quality of health services. A model illustrating different factors influencing health seeking was elaborated and served as a basis for discussion of the findings. The main factor contributing to delay among women was described as fear of social isolation from the family or the community. Stigma was described as closely related to contextual factors such as gender-roles, socio-economic status and level of education and seemed to be mediated via denial and concealment of tuberculosis diagnosis and disease, thus causing delay. The main factor contributing to delay among men was described as fear of individual costs of diagnosis and treatment. Staff attitudes and quality of health service facilities were described as not always corresponding to people's expectations of appropriate health services. Women saw themselves and were seen by others as being more sensitive than men to poor service conditions and staff attitudes. A typical feature of the described health seeking behaviour of men was that they neglected symptoms until the disease reached a serious stage, by which time they tended to go directly to public health services without first visiting private health practitioners. Women, on the other hand, were described as having a tendency to seek out private services and practice self-medication before seeking care at public services. In conclusion, there is a need for better understanding of behavioural factors and for developing strategies, that take these into account. Health workers need to better understand gender and social aspects of tuberculosis control, particularly aspects that influence the likelihood for achieving equity in diagnosis and cure.     

Veterinary public health perspectives: trend assessment and recommendations.

In a world of increasing populations, new patterns of land use and new biotechnologies, the orientation towards population veterinary medicine within the health triad of environment, animals and people will be of growing importance. This orientation should be accompanied by a dramatic expansion of veterinary public health (VPH) practices and considerable modification of veterinary training, with emphasis on interdisciplinary approaches under multifocal leadership. A high level of specialisation and, at the same time, integration into the major goals of the health triad will be important factors. The management of integration will also influence the coherence of the veterinary profession in research and education. Major issues in VPH concern new biotechnologies, urbanisation (particularly in developing countries), the control of "hidden infections" entering the food chain, new agricultural practices and ethical questions associated with these developments.     

Effectiveness of interventions for the control and prevention of tuberculosis in health care facilities: a review of ATS,CDC, OSHA recommendations

BACKGROUND: Health care workers (HCWs) are occupationally exposed to a multitude of biological hazards, and among these to the risk of tuberculosis (TB) infection, especially involving individuals working in specific workplace (TB and Chest divisions, Infectious Diseases wards, Microbiology laboratories) and performing thoracic endoscopy and "cough-inducing" procedures. According to national legislation (title VIII D.lgs. 626/94, 1998 Health Minister guide lines document) concerning the control and prevention of TB transmission among HCWs, health care facilities are required to (i) perform an accurate risk assessment and (ii) implement an exposure control plan and worker health surveillance program, thus involving the occupational health professionals. OBJECTIVES: The aim of this paper is to provide a general view of the epidemiological and scientific evidence related to the effectiveness of health interventions in the prevention of occupational TB infection. METHODS: Comparative evaluation and critical review of U.S. CDC (1994) guidelines, OSHA (1997) rules, and the most recent ATS and CDC (2000) "statement" documents. RESULTS: In low risk groups TCT shows decreased positive predictive value, high variability, and can be confounded by other factors (age, BCG, MNT), thus reducing its diagnostic value for latent TB infection. CONCLUSIONS: Recent recommendations on the control of TB infection in health care settings underline the need of implementing accurate risk evaluation in all hospital units, compared to the epidemiological profile in the community, and "targeted tuberculin testing" programs among high risk HCWs.     

Barriers to reaching the targets for tuberculosis control: multidrug-resistant tuberculosis

The development and expansion of WHOs DOTS strategy was successful, with 83% of the worlds population living in countries or parts of countries covered by this strategy by the end of 2004. Treatment success in the 2003 DOTS cohort of 1.7 million patients was 82% on average, close to the 85% target. Treatment success was below average in the African Region (72%), which can be partly attributed to occurrence of HIV co-infection, and in the European Region (75%), partly due to drug resistance. Drug resistance, specifically multidrug resistance and extensive drug resistance, is a serious threat to public health in all countries, especially in the Russian Federation, where the highest rates of multidrug resistance are presently accompanied by a rapid increase in HIV infection. Based on the experience of the first projects approved by the Green Light Committee, the treatment success of patients with multidrug-resistant tuberculosis (MDR-TB) is lower than that of drug-susceptible cases, but nevertheless reaches 70%. The collaborative effort of different organizations, professionals and communities is needed to address the development and spread of multidrug resistance and extensive drug resistance, which combined with the epidemic of HIV infection is one of the barriers to dealing effectively with TB. This effort should be directed towards facilitating the diagnosis and treatment of TB patients, in particular by improving access to drug susceptibility testing and strengthening treatment delivery by rigorous adherence to DOTS as outlined by the Stop TB Partnership.     

Rabies in China: recommendations for control.

Reviewed are the results of 15 years' experience with rabies at You-An Infectious Disease Hospital, Beijing, China. The purpose of the study was to determine whether there are any epidemiological or clinical features of rabies that are unique to China and which might be important in developing a strategy to control it. During the period under study, 64 patients with rabies were admitted to You-An Hospital. Exposure to dogs was associated with 61 cases, two involving the handling of dog carcasses that were being prepared for meals. All of the exposures occurred in rural areas, and none of the patients received adequate prophylaxis. Patients with proximal sites of exposure and with severe injuries developed rabies after short incubation periods (P less than 0.05, and P less than 0.02, respectively). Failed vaccination was also associated with a short incubation period (P less than 0.05). Haematemesis occurred in 20 patients and was associated with shorter incubation periods (P less than 0.02), facial exposure sites (P = 0.021), and severe injuries (P = 0.047). A strategy to control rabies in China should include efforts to educate the public about handling the carcasses of stray dogs, in addition to the currently recommended strategy of controlling the dog population and of vaccinating domesticated animals.     

Paediatric pandemic planning: children’s perspectives and recommendations

Children, as major stakeholders in paediatric hospitals, have remained absent from discussions on important healthcare issues. One critical area where children’s voices have been minimised is in the planning for future pandemics. This paper presents a subset of data from a programme of research which examined various stakeholder experiences of the severe acute respiratory syndrome (SARS) outbreaks of 2003. These data also generated recommendations for future pandemic planning. Specifically, this paper will examine the perspectives and recommendations of children hospitalised during SARS in a large paediatric hospital in Canada. Twenty‐one (n = 21) child and adolescent participants were interviewed from a variety of medical areas including cardiac (n = 2), critical care (n = 2), organ transplant (n = 4), respiratory medicine (n = 8) and infectious diseases (patients diagnosed with suspected or probable SARS; n = 5). Data analyses exposed a range of children’s experiences associated with the outbreaks as well as recommendations for future pandemic planning. Key recommendations included specific policies and guidelines concerning psychosocial care, infection control, communication strategies and the management of various resources. This paper is guided by a conceptual framework comprised of theories from child development and literature on children’s rights. The authors call for greater youth participation in healthcare decision‐making and pandemic planning.     

The status of tuberculosis control in New York City.

Problems in tuberculosis control still exist in New York City. They range from an increase in the incidence of the disease to the discovery of new cases in children under 5 years of age. Ninety-three percent (1,395) of the cases reported in 1980 were verified by cultures positive for tuberculosis. The rest of the cases in the 1980 tuberculosis disease count were verified by histology or a physician''s recommendation for treatment with two or more antituberculosis drugs. Of the tuberculosis at extrapulmonary sites, pleural meningeal and miliary tuberculosis, as well as genitourinary tuberculosis, ranked high in incidence in 1980. New tuberculosis cases occurred in all age groups, but the 37 cases in the age group 0-4 years is alarming and indicates a high rate of transmission of tuberculosis from parents to children. Performance indicators of the Centers for Disease Control show that in terms of drug continuity, completion of treatment, and bacteriological conversions to negative, a great deal needs to be done in New York City. The tuberculosis mortality rate for the city has been showing a steady decline over the years; it was 1.8 per 100,000 population in 1980.