News and analysis · Nouvelles et analyses

CMAJ 1999;160:1814-7

• Campaign reduces antibiotic resistance among Icelandic children
• Echocheck: detection of hearing deficiencies in newborns
• First Lyme disease vaccine available
• Canadian soldiers used as "guinea pigs"?
• Peer counselling working well for Memorial's med students
• Cool sites
• PMAC changes name
• Pulse: Out of hospital, out of pocket
• Not all pains in the neck created equal

Alarmed by escalating resistance to antibiotic drugs, the Icelandic government and physicians of the tiny island nation launched an education and media campaign that has had a dramatic impact. The use of antibiotic drugs by children dropped by 36% between 1992 and 1997, and overall use dropped from 20% of the population in 1993 to 13% in 1997.

Iceland, with a population of 260 000 people, had the highest rate of antibiotic use among Nordic countries, Dr. Karl Kristinsson of the University of Iceland said during a "superbugs" symposium held in Vancouver this spring. Antibiotic resistance among Icelanders increased by about 20% annually between 1988 and 1993, and the increase was even higher among children. Day-care use is common in Iceland, and because of the climate children remain inside a lot. These factors tend to lead to a high rate of infections and, hence, use of antibiotic drugs, Kristinsson said. In 1992, 9% of children in Reykjavik's day-care facilities were taking antibiotic medications.

Kristinsson studied the incidence of pneumococcus resistance among 919 children in 5 health districts. Almost 70% of 2-year-old children in the group carried pneumococci bacteria, compared with an overall rate of 54%. The study also revealed that living in an area where use of antibiotic drugs is high, as well as the amount of drugs an individual used, were risk factors in the development of resistance. "People were worried about coming to Iceland because of the high antibiotic resistance rate," said Kristinsson. A telephone survey of about 500 patients near the end of the communications campaign found that 99% agreed that overuse of antibiotic drugs decreased their effectiveness.

Although the number of children in day-care centres has continued to increase, Kristinsson thinks the advent of a new, more powerful drug — azithromycin — may have contributed to decreased antibiotic resistance.

Kristinsson said continued intervention is important if the downward trend is to be maintained, and he hopes the government will continue to support the education campaign. "We don't know all of the pieces of the puzzle yet," he said. — © Heather Kent, Vancouver

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Echocheck, a new pocket-size hearing detector, is designed to allow detection of hearing deficiencies in newborns. The screening device, which won a 1998 Queen's Award for Technology in the UK, allows a nurse to check a baby's hearing in 30 seconds. Here, audiologist Mark Fenton uses Echocheck on a premature baby at the Royal Free Hospital, London.

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The world's first vaccine to prevent Lyme disease, a 3-injection treatment known as LYMErix (Lyme Disease Vaccine [Recombinant OspA]), is now available in Canada. LYMErix, manufactured by SmithKline Beecham Biologicals, has an overall efficacy rate of 82%, but without the third injection this drops to 60%. Side effects may include injection-site reactions, flu-like symptoms and a rash. Although Lyme disease is considered endemic in parts of BC and in southwestern Ontario near Long Point and Point Pelee, half of reported Canadian cases result from travel in certain areas of the US. For more information, call 800 268-4372 or visit www.lymevaccine.com. A report on Lyme disease appears in this issue (see page 1851).

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Canada's auditor general is "concerned" about the way an unapproved antimalarial drug was given to 900 soldiers bound for Somalia. Mefloquine was undergoing clinical trials during the fall and winter of 1992-3, but an auditor's report reveals that defence officials didn't follow the prescribed safety-monitoring protocol. In fact, soldiers were ordered to take the drug — no attempt was made to obtain consent — and they were not systematically monitored for adverse reactions.

Common adverse effects include nausea, vomiting, dizziness or vertigo, sleep disorders, diarrhea and abdominal pain. Mefloquine can also increase the risk of convulsions among patients with epilepsy. Health Canada had approved the terms of the clinical trial, but made no attempt to ensure that the protocol was followed. The drug has since been approved.

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No one understands the stress of being a medical student better than another student, and that's why medical students at Memorial University of Newfoundland have created a peer-counselling program.

The idea originated with the students. Valerie Taylor was in second year and Lawrence Hookey was in third year when they volunteered to set things up. "We wanted something substantial and professional," explains Taylor, who graduated this spring. "So we contacted the Counselling Centre at Memorial and they sent over people to train us."

Drs. Michael Doyle and Peter Cornish of the centre worked with the students to identify the reasons for their program, their intentions and goals, ethical considerations and related issues. Training focused on confidentiality, informal contact, conflict regarding role confusion, suicidal ideation and responding to crises. The counsellors developed training seminars on communication skills and taught students how to handle various difficult situations. As peer helpers, student volunteers are taught how and where to refer students who require additional help, and also to identify suicide risk factors. The students who started the program have since moved on, and 2 groups of new volunteers have been trained.

Cornish says it's difficult to assess how much the service is used due to the informal nature of peer relationships. "Peers are sometimes unable to determine whether other students are approaching them in their role as peers or as formal peer helpers."

Taylor has counselled about 5 students and feels the effort is worth while. "It's better to talk to someone who understands," says Taylor, who hopes to pursue a career in psychiatry. "Some stresses are unique to medicine, particularly the amount of work and the time commitment. It can help to talk to someone who has been there."

Other Canadian medical schools have expressed interest in the program, and Doyle and Cornish presented a poster session on it when the American College Personnel Association met in St. Louis last year. A package is being developed to provide other interested medical schools with the information needed to start their own programs. — Sharon Gray, Memorial University, St. John's

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History of medicine buffs would do well to acquaint themselves with the site from the National Library of Medicine www.nlm.nih.gov/hmd/hmd.html. Three features are particularly useful. HISTLINE is a database containing more than 150 000 citations about the history of health-related professions, individuals, institutions, drugs and diseases worldwide from all periods of history. You can read about Jenner and smallpox until the cows come home, and there is also a collection of 60 000 historical images, searchable by several methods. Entering the key word "Osler" resulted in 42 matches — Sir William at all stages of his career. Be warned that copyrighted images have an oblique line across them, but high-resolution images may be ordered separately. Finally, there is a collection of online exhibits, including Islamic culture and the medical arts, the life of Paracelsus and the history of cesarean sections. I particularly enjoyed the Frankenstein exhibition, which looks at the life of author Mary Shelley, discusses the original Boris Karloff movie and analyses the "modern Prometheus" in terms of DNA engineering and cloning. Whether you're a hard-core history nut or just want to find information on a particular topic, this site is well worth a visit. — Dr. Robert Patterson, robpatterson@attcanada.net

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In an effort to boost its members' image as research-based drug companies, the Pharmaceutical Manufacturers Association of Canada has adopted a new name: Canada's Research-Based Pharmaceutical Companies. President Murray Elston, Ontario's former minister of health, says the organization "wants Canadians to gain a better understanding of how every citizen benefits from research and development, and how the brand-name companies are contributing to extraordinary progress in medicine."

About 8000 medical researchers are employed as a result of the 60 or so member companies' investment in research and development in Canada. "The research-based industry has made invaluable contributions in Canada in the past decade," says Dr. Henry Friesen, president of the Medical Research Council of Canada.

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Canada lags far behind many other members of the Organization for Economic Cooperation and Development when it comes to public coverage of the cost of prescription drugs (see Fig. 1). According to 1995 data, only 45% of these drug costs are covered by Canadian governments. In comparison, public coverage of drug costs in the United Kingdom and The Netherlands stands at 90%, even after copayments and deductibles are considered.

In 1996, Canadians spent approximately $10 billion on prescription and nonprescription drugs. Prescription drugs accounted for 74% of drug expenditures and 10% of all health care spending. As hospital stays shorten and more conditions are treated on an ambulatory basis, patients requiring medication must either pay for prescriptions directly or rely on private insurance to help defray costs — hospitals are no longer picking up as much of the tab.

Based on the 1996/97 National Population Health Survey, 61% of Canadians over age 15 have insurance coverage for prescription medications. Coverage rates were lowest among those with less than a high school education (52%) and highest for those with a college diploma or university degree (65%).

Not unexpectedly, those working full time had better drug coverage (65%) than those who worked part time (57%) or were unemployed (52%). Employed professionals were most likely to have coverage (78%), while farmers (28%) were least likely. Less than half (49%) of self-employed professionals reported having drug insurance.

Rates of coverage for prescription medication also increased with income. Almost three-quarters (74%) of those in the highest income group were insured, compared with just over half that rate (38%) for the lowest income earners.

This column was written by Lynda Buske, Chief, Physician Resources Information Planning, CMA. Readers may send potential research topics to Patrick Sullivan (sullip@cma.ca; 613 731-8610 or 800 663-7336, x2126; fax 613 565-2382).

For years it was assumed that whiplash led to chronic neck pain, chronic headaches, anxiety and depression. But in the absence of population-based studies, researchers have begun to question the connection between automobile accident injury and these other complaints.

At the Whiplash-Associated Disorders World Congress held in Vancouver earlier this year, Pierre Côté of the Institute for Work and Health in Toronto outlined a cross-sectional study of trends in the general population, conducted in collaboration with the University of Saskatchewan.

The Saskatchewan Health and Back Pain Survey was mailed to 2184 randomly selected Saskatchewan residents aged 20 to 69, and had a response rate of 55%. Participants were asked whether they had ever injured their neck in a car accident. They were also asked whether they had any neck pain in the previous 6 months, how severe it was, whether they had experienced headaches in the same period and how the headaches affected their health and functioning. A third parameter was symptoms of depression in the past week.

Responses indicated that subjects with a history of neck injury (15.1%) were most likely to be young, male, divorced and living in an urban community. Neck pain was more prevalent in those who had a history of neck injury. Fifty percent with this history complained of low-disability, low-intensity pain, while nearly 10% were "highly disabled" by neck pain and 4% had no pain.

Headache with a moderate or severe impact on health was twice as common in subjects with a history of neck injury, while depressive symptoms, as defined by the Centre for Epidemiologic Studies Depression Scale, were also more prevalent among those with a history of neck injury.

Côté said respondents with a history of neck injury were almost 3 times more likely to experience mild neck pain, 4.5 times more likely to have high-intensity, low-disability pain and more than 3 times more likely to report high-disability pain. They were also more likely to report severe headaches that interfered with health.

The researchers concluded that there is an apparent strong and independent association between a history of neck injury and neck pain and headaches. However, because the study was cross-sectional, it cannot be inferred that neck injury will lead to future neck pain, headache and disability. "The reason for this," said Côté, "is that we don't know which happened first, and we don't know if the subjects had neck pain before they had the car accident. It's also likely that our sample included subjects who experienced other more severe injuries in the accident."

Côté suggested the study provides useful information for future research. "It clearly shows that future research assessing whiplash and neck pain must include a classification system that differentiates between severities of pain. It's not enough to just say one has neck pain — it should be whether or not this is pain that disables." — © Eleanor LeBourdais, Port Moody, BC

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© 1999 Canadian Medical Association (unless otherwise indicated)