Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
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)
 Full paper in PDF
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.
1. Oishi K, Suga S. Pneumococcal infection: update [in Japanese]. Nihon Naika Gakkai Zasshi 2015;104:2301- 6. Crossref
2. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Updated recommendations on the use of pneumococcal vaccines for high-risk individuals. 2019. Available from: https://www.chp.gov.hk/files/pdf/updated_recommendations_on_the_use_of_pneumococcal_vaccines_amended_120116_clean_2.pdf. Accessed 3 Sep 2020.
3. Shapiro ED. Prevention of pneumococcal infection with vaccines: an evolving story. JAMA 2012;307:847-9. Crossref
4. Census and Statistics Department, Hong Kong SAR Government. Population by age group and sex. 2019. Available from: https://www.censtatd.gov.hk/hkstat/sub/sp150.jsp?tableID=002&ID=0&productType=8. Accessed 3 Sep 2020.
5. Hung IF, Tantawichien T, Tsai YH, Patil S, Zotomayor R. Regional epidemiology of invasive pneumococcal disease in Asian adults: epidemiology, disease burden, serotype distribution, and antimicrobial resistance patterns and prevention. Int J Infect Dis 2013;17:e364-73. Crossref
6. Koivula I, Stén M, Leinonen M, Mäkelä PH. Clinical efficacy of pneumococcal vaccine in the elderly: a randomized, single-blind population-based trial. Am J Med 1997;103:281-90. Crossref
7. Domínguez À, Salleras L, Fedson DS, et al. Effectiveness of pneumococcal vaccination for elderly people in Catalonia, Spain: a case-control study. Clin Infect Dis 2005;40:1250-7. Crossref
8. Jackson LA, Neuzil KM, Yu O, et al. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med 2003;348:1747-55. Crossref
9. Lamontagne F, Garant MP, Carvalho JC, Lanthier L, Smieja M, Pilon D. Pneumococcal vaccination and risk of myocardial infarction. CMAJ 2008;179:773-7. Crossref
10. Vila-Corcoles A, Ochoa-Gondar O, Rodriguez-Blanco T, et al. Clinical effectiveness of pneumococcal vaccination against acute myocardial infarction and stroke in people over 60 years: the CAPAMIS study, one-year follow-up. BMC Public Health 2012;12:222. Crossref
11. Williams WW, Lu PJ, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations—United States, 2015. MMWR Morb Mortal Wkly Rep Surveill Summ 2017;66:1-28. Crossref
12. Public Health England. Pneumococcal polysaccharide vaccine (PPV) coverage report, England, April 2014 to March 2015. 2015. Available from: https://assetspublishingservicegovuk/government/uploads/system/uploads/attachment_data/file/448406/hpr2615_ppv.pdf. Accessed 5 Jul 2018.
13. Information Services Department, Hong Kong SAR Government. Pneumococcal vaccination for elderly persons. 18 Nov 2015. Available from: http://www.info.gov.hk/gia/general/201511/18/P201511180642.htm. Accessed 3 Jan 2018.
14. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Government Vaccination Programme (GVP) 2019/20. Available from: https://www.chp.gov.hk/en/features/18630.html. Accessed 6 Jan 2020.
15. Department of Health, Hong Kong SAR Government. Child health—immunisation. Available from: https://www.fhs.gov.hk/english/main_ser/child_health/child_health_recommend.html. Accessed 27 Aug 2020.
16. Department of Health, Hong Kong SAR Government. Cervical Screening Programme. Available from: https://www.cervicalscreening.gov.hk/eindex.php. Accessed 27 Aug 2020.
17. Department of Health, Hong Kong SAR Government. Colorectal Cancer Screening Programme background. Available from: ttps://www.colonscreen.gov.hk/en/service/primary_care_doctor/programme_background.html. Accessed 27 Aug 2020.
18. Centre for Health Protection. Department of Health, Hong Kong SAR Government. Smoking. Available from: https://www.chp.gov.hk/en/healthtopics/content/25/8806.html. Accessed 27 Aug 2020.
19. Man MY, Shum HP, Yu JS, Wu A, Yan WW. Burden of pneumococcal disease: 8-year retrospective analysis from a single centre in Hong Kong. Hong Kong Med J 2020;26:372-81. Crossref
20. Arbyn M, Xu L, Simoens C, Martin-Hirsch PP: Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev 2018;(5):CD009069. Crossref
21. Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. IARC Working Group on evaluation of cervical cancer screening programmes. Br Med J (Clin Res Ed) 1986;293:659-64. Crossref
22. Wang J, Andrae B, Sundström K, et al. Effectiveness of cervical screening after age 60 years according to screening history: Nationwide cohort study in Sweden. PLoS Med 2017;14:e1002414. Crossref
23. Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (Hemoccult): An update. Am J Gastroenterol 2008;103:1541-9. Crossref
24. Nishihara R, Wu KN, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. New Engl J Med 2013;369:1095-105. Crossref
25. Godtfredsen NS, Prescott E, Osler M. Effect of smoking reduction on lung cancer risk. JAMA 2005;294:1505-10. Crossref
26. Santibanez TA, Zimmerman RK, Nowalk MP, Jewell IK, Bardella IJ. Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status. Ann Fam Med 2004;2:41-8. Crossref
27. Higuchi M, Narumoto K, Goto T, Inoue M. Correlation between family physician’s direct advice and pneumococcal vaccination intention and behavior among the elderly in Japan: a cross-sectional study. BMC Fam Pract 2018;19:153. Crossref
28. Bish A, Yardley L, Nicoll A, Michie S. Factors associated with uptake of vaccination against pandemic influenza: a systematic review. Vaccine 2011;29:6472-84. Crossref
29. Gyulai A, Nagy A, Pataki V, Tonté D, Ádány R, Vokó Z. General practitioners can increase participation in cervical cancer screening—a model program in Hungary. BMC Fam Pract 2018;19:67. Crossref
30. Leinonen MK, Campbell S, Klungsøyr O, Lönnberg S, Hansen BT, Nygård M. Personal and provider level factors influence participation to cervical cancer screening: a retrospective register-based study of 1.3 million women in Norway. Prev Med 2017;94:31-9. Crossref
31. Sung JJ, Choi SY, Chan FK, Ching JY, Lau JT, Griffiths S. Obstacles to colorectal cancer screening in Chinese: a study based on the health belief model. Am J Gastroenterol 2008;103:974-81. Crossref
32. Litwin O, Sontrop JM, McArthur E, et al. Uptake of colorectal cancer screening by physicians is associated with greater uptake by their patients. Gastroenterology 2020;158:905-14. Crossref
33. Dülger S, Doğan C, Dikiş ÖŞ, et al. Analysis of the role of physicians in the cessation of cigarette smoking based on medical specialization. Clinics (Sao Paulo) 2018;73:e347. Crossref