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BMJ 2008; 337 doi: (Published 03 November 2008) Cite this as: BMJ 2008;337:a2391

Ontario’s natural experiment in influenza vaccination pays off

In 2000, the authorities in Ontario, Canada, launched the world’s first universal vaccination programme against influenza, offering free vaccination to anyone over 6 months of age. The other Canadian provinces opted to continue targeted vaccination. This large natural experiment seems to have paid off. An ecological study shows that while deaths from flu fell everywhere in Canada after 2000, they fell furthest in Ontario (74% v 57% in other provinces combined, P=0.002). Health service use, including hospital admissions and doctors’ visits for flu also fell significantly further in Ontario, particularly in people under 65, who had the most to gain from a universal programme.

The study essentially compared data on flu related outcomes before (1997-2000) and after (2000-4) the change in policy. The authors were limited to data available in regional and national records, but they did their best to strengthen the results with confirmatory sensitivity analyses.

The authors and a linked comment (doi:10.1371/journal.pmed.0050216) agree that this analysis of Ontario’s unique programme provides at least circumstantial evidence that universal vaccination helps prevent death and disease caused by flu, even when uptake rates are relatively low. Between 2000 and 2004 mean vaccination rates for people over 12 reached 38% in Ontario compared with just 24% in the other provinces (P<0.001).

Be selective with aggressive phototherapy in very premature babies

Phototherapy reduces the high serum concentrations of bilirubin associated with prematurity. But does it save lives or prevent disability? A team of researchers from the US recently compared more or less aggressive phototherapy in a carefully planned randomised trial. The more intensive regimen reduced the risk of neurodevelopmental impairment in premature infants but had no overall effect on mortality (24% (230/946) v 23% (218/944); relative risk 1.05, 95% CI 0.90 to 1.22). In fact, there was a worrying trend towards excess deaths in the smallest babies given aggressive phototherapy (39% …

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