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Background Hepatitis A (HepA) global burden is estimated to be > 100 million new cases/year. HepA is vaccine-preventable, but outbreaks still occur in regions with low endemicity such as Europe. Guidelines for HepA vaccination in adult risk groups are available in European countries, but adherence to vaccination recommendations is not systematically documented. Here we review European data on HepA infection outcomes, we discuss the HepA risk in the population in order to assess the adequacy of HepA vaccination strategies. Methods A systematic search in PubMed and Embase was performed from January 2001 to April 2021. Relevant data from ECDC, ProMED, ESCAIDE and national public health websites was also reviewed. We included articles in all languages, covering all ages and data published on 11 countries (Denmark, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland and the United Kingdom [UK]). Studies on seroprevalence and risk factors for HepA virus (HAV) were excluded. Results Overall, 134 articles and 85 grey literature reports were included in our review. In Europe, in the last 20 years, HepA infections were reported in all ages. Annual hospitalization rates exceeded 50% in 8 of the surveyed countries during 2016–2019. HAV complications were reported by 28 publications (ps): 8 liver transplantation cases in 6 ps ; liver failures in 0%–25% of HepA patients reported by 23 ps and hemorrhagic complications in 0%–51% of HepA patients reported by 8 ps. Fatality rates, reported by 12 ps for Italy, Hungary, Denmark, Germany and Spain were 0.05%–0.26%, mostly in adults/older adults. Conclusion In Europe, HepA infections are recorded in all ages despite not being consistently reported. Although the fatality rate is low, the hospitalization rates and the morbidity are high in adults/older adults. Considering the current epidemiological situation and HepA-related costs, authorities should raise awareness on HepA risk and adapt or improve compliance with the vaccination recommendations. Adherence to the existing recommendations should be monitored more closely. Universal HepA vaccination may be considered, similarly to the strategy adopted in the United States after widespread and ongoing HepA outbreaks. Funding GlaxoSmithKline Biologicals SA Disclosures Anar Andani, BSc, Medical director, GSK group of companies: Employee|GSK group of companies: Stocks/Bonds Eveline Bunge, PhD, GSK group of companies: My institution received grants and payment for developing studies Jennifer Eeuwijk, MSc, GSK group of companies: My institution received grants and payment for developing studies George Kassianos, MD (Hons), FRCGP, FESC, FBGTHA, FFTM RCPS(Glasg), FBHS, FHEA, FAcadMEd, DRCOG, LRCP (Edin.), LRCS (Edin.), LRCP&S (Glas.), DMedAcup., DMedHypn., DFP, AstraZeneca: Advisor/Consultant|British Global and Travel Health Association: President|European Scientific Working Group on Influenza (ESWI): Board Member|European Scientific Working Group on Influenza (ESWI): Lectures|MSD: Advisor/Consultant|Northern European Conference on Travel Medicine: Lectures|Novavax: Advisor/Consultant|Pfizer: Advisor/Consultant|RAISE Pan-European Committee on Influenza: Chair|Royal College of General Practitioners: National Immunisation Lead|Sanofi Vaccines: Advisor/Consultant|Seqirus: Advisor/Consultant|UK National Health Service: Lectures|Valneva: Advisor/Consultant Robert Steffen, MD, GSK group of companies: Advisor/Consultant|GSK group of companies: Honoraria.

Introduction Influenza is associated with significant morbidity and mortality worldwide. Whilst vaccination is key for the prevention of influenza infection, there are many factors which may contribute to reduced vaccine effectiveness, including antigenic evolution via both antigenic drift and egg-adaptations. Due to the currently dissociated and indirect evidence supporting both the occurrence of these two phenomena in the egg-based manufacturing process and their effects on vaccine effectiveness, this topic remains a subject of debate. Objective To review the evidence and level of agreement in expert opinion supporting a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing, using an expert consensus-based methodology and literature reviews. Methods Ten European influenza specialists were recruited to the expert panel. The overall research question was deconstructed into four component principles, which were examined in series using a novel, online, two-stage assessment of proportional group awareness and consensus. The first stage independently generated a list of supporting references for each component principle via literature searches and expert assessments. In the second stage, a summary of each reference was circulated amongst the experts, who rated their agreement that each reference supported the component principle on a 5-point Likert scale. Finally, the panel were asked if they agreed that, as a whole, the evidence supported a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing. Results All component principles were reported to have a majority of strong or very strong supporting evidence (70–90%). Conclusions On reviewing the evidence for all component principles, experts unanimously agreed that there is a mechanistic basis for reduced vaccine effectiveness resulting from candidate influenza virus variation due to egg-based manufacturing, particularly in the influenza A/H3N2 strain. Experts pointed to surveillance, candidate vaccine virus selection and manufacturing stages involving eggs as the most likely to impact vaccine effectiveness.

Background In 2012, the World Health Organization recommended influenza vaccination for all pregnant women worldwide and the prioritisation of pregnant women in national influenza vaccination programmes. Nevertheless, vaccination rates in pregnant women often remain much lower than national targets. Objectives To assess the benefits and risks associated with influenza infection and vaccination during pregnancy, and to consider obstacles that work against influenza vaccine uptake during pregnancy. Results There is strong evidence that maternal and foetal outcomes can be compromised if women develop influenza infections during pregnancy. Influenza vaccines have been administered to millions of pregnant women and have demonstrated benefits in terms of disease prevention in mothers and their infants. There is a consensus amongst several recommending authorities that influenza vaccines may be safely administered during all stages of pregnancy. Healthcare professionals are recognised as the most important influencers of vaccine uptake, being well placed to recommend vaccination and directly address safety concerns. Conclusions Despite data supporting the value of influenza vaccination during pregnancy, vaccine uptake remains low globally. Low uptake appears to be largely due to ineffective communication with pregnant women about the risks and benefits of influenza vaccination. A graphical abstract is available online.

Immunization programmes have been globally recognized as one of the most successful medical interventions against infectious diseases. Despite the proven efficacy and safety profiles of coronavirus disease 2019 (COVID-19) vaccines, there are still a substantial number of people who express vaccine hesitancy. Factors that influence vaccine decision-making are heterogenous, complex, and context specific and may be caused or amplified by uncontrolled online information or misinformation. With respect to COVID-19, the recent emergence of novel variants of concern that give rise to milder disease also drives vaccine hesitancy. Healthcare professionals remain one of the most trusted groups to advise and provide information to those ambivalent about COVID-19 vaccination and should be equipped with adequate resources and information as well as practical guidance to empower them to effectively discuss concerns. This article seeks to summarize the currently available information to address the most common concerns regarding COVID-19 vaccination.

Background\ud In response to the coronavirus disease (COVID-19) outbreak that unfolded across Europe in 2020, the World Health Organisation (WHO) called for repurposing existing influenza surveillance systems to monitor COVID-19. This analysis aimed to compare descriptively the extent to which influenza surveillance systems were adapted and enhanced and how COVID-19 surveillance could ultimately benefit or disrupt routine influenza surveillance.\ud \ud Methods\ud We used a previously developed framework in France, Germany, Italy, Spain and the United Kingdom to describe COVID-19 surveillance and its impact on influenza surveillance. The framework divides surveillance systems into seven subsystems and 20 comparable outcomes of interest and uses five evaluation criteria based on WHO guidance. Information on influenza and COVID-19 surveillance systems were collected from publicly available resources shared by European and national public health agencies.\ud \ud Results\ud Overall, non-medically attended, virological, primary care and mortality surveillance were adapted in most countries to monitor COVID-19, although community, outbreak and hospital surveillance were reinforced in all countries. Data granularity improved, with more detailed demographic and medical information recorded. A shift to systematic notification for cases and deaths enhanced both geographic and population representativeness, although the sampling strategy benefited from the roll out of widespread molecular testing. Data communication was greatly enhanced, contributing to improved public awareness.\ud \ud Conclusions\ud Well-established influenza surveillance systems are a key component of pandemic preparedness, and their upgrade allowed European countries to respond to the COVID-19 pandemic. However, uncertainties remain on how both influenza and COVID-19 surveillance can be jointly and durably implemented.

On 23 April 2019, the authors of this roundtable discussion met to deliberate the vaccinations that fall outside of the Section 7A immunisation programme. The 3-hour meeting resulted in the production of this article. Funding for vaccinations that fall outside of the Section 7a programme is mired in confusion. Who is responsible for the payments? What are the outliers? What are the loopholes in vaccination commissioning? What are the regional differences? Where can best practice be found? When will these issues be resolved? These questions and more were discussed at length and in great detail. This article explains where these discrepancies lie, analyses specific issues that require clear guidance, and discusses the competing interests of health professionals. This discussion aims to inform the national vaccination review and hopes to shed light on areas that cause GPs and practice nurses confusion during their daily tasks. We all enjoyed the meeting, and its discussion and transformation into a working document. We hope you find this article useful and that it impacts your understanding of vaccinations that fall outside of the Section 7A programme.

In 2012, the Joint Committee on Vaccination and Immunisation recommended that the United Kingdom's (UK) National Vaccination Programme (NVP) for influenza was extended to include healthy children and adolescents aged 2 to17 years. Previously, the UK's NVP focused on seasonal vaccination of the elderly and people (including children) with underlying health conditions that put them at high risk of hospitalisation if they contracted influenza. The extension of the UK's programme began in the 2013/14 influenza season through the vaccination of children aged 2-3 years in primary care across England and the devolved administrations of Scotland, Wales, and Northern Ireland. School-aged children were generally vaccinated in a school setting, with several implementation pilots in England and Scotland. Due to the scale of the programme, it has been phased in over several years and expanded to include broader childhood age groups. This article reviews the experiences from the implementation of the UK's childhood influenza NVP over the first six influenza seasons (between 2013/14 and 2018/19) from the perspectives of England, Scotland, Wales, and Northern Ireland. The processes used to deliver the vaccination programme in general practice and the school-based setting are described in terms of governance, contracting, workforce management, communication, administrative tasks, vaccination sessions, vaccine supply and distribution, and surveillance. In addition, the available evidence regarding the clinical impact of the UK's childhood influenza NVP over the first six influenza seasons is reviewed. We also share lessons learned from the programme and recommendations to provide guidance to other countries looking to implement childhood influenza vaccination programmes.

Seasonal influenza can have serious morbid consequences and can even result in death, particularly in at-risk populations, including healthcare professionals (HCPs), elderly and those living with a medical risk condition. Although in Europe recommendations exist for annual influenza vaccination in these populations in most countries, the vaccination coverage rate (VCR) is often well below the World Health Organization target of 75% coverage. In our previous survey in 2009 we showed that some elements of national vaccination policies, e.g. reminder systems, strong official recommendation, and easy access, seemed to contribute to achieving higher influenza VCRs among elderly. We repeated the survey in 2016, using the same methodology to assess changes in influenza VCRs among the elderly and in the impact of policy elements on these VCRs. In addition, we collected information about VCRs among HCPs, and those living with a medical risk condition. The median VCR in the 21 countries that had recommendations for influenza vaccination in the elderly was 35.3%, ranging from 1.1% in Estonia to 74.5% in Scotland. The average VCRs for HCPs and those living with medical risk conditions, available in 17 and 10 countries, respectively, were 28.3% (range 7% in Czech Republic to 59.1% in Portugal) and 32.2% (range from 20.0% in the Czech Republic and Hungary to 59.6% in Portugal), respectively. Fewer countries were able to provide data from HCP and those living with medical risk conditions. Since the initial survey during the 2007–2008 influenza season, VCRs have decreased in the elderly in the majority of countries, thus, achieving high VCRs in the elderly and the other target groups is still a major public health challenge in Europe. This could be addressed by the identification, assessment and sharing of best practice for influenza vaccination policies.

Background: The Middle East and North Africa (MENA) region faces a dual challenge with regard to influenza infection due to severe zoonotic influenza outbreaks episodes and the circulation of Northern Hemisphere human influenza viruses among pilgrims. Methods: The MENA Influenza Stakeholder Network (MENA-ISN) was set-up with the aim of increasing seasonal influenza vaccination coverage by (i) enhancing evidence-based exchanges, and (ii) increasing awareness on the safety and benefits of seasonal vaccination. During the 7th MENA-ISN meeting, representatives from 8 countries presented their influenza surveillance, vaccination coverage and actions achieved and provided a list of country objectives for the upcoming 3 years. Results: MENA-ISN countries share the goal to reduce influenza related morbidity and mortality. Participants admitted that lack of knowledge about influenza, its consequences in terms of morbidity, mortality and economy are the major barrier to attaining higher influenza vaccination coverage in their countries. The cost of the vaccine is another key barrier that could contribute to low vaccination coverage. Participants drew a list of strategic interventions to bridge gaps in the knowledge of influenza burden in this region. Conclusions: Participating countries concluded that despite an increase in vaccine uptake observed during the last few years, influenza vaccination coverage remains relatively low. Priority areas should be identified and action plans tailored to each country situation set-up to investigate the best way to move forward. Keywords: Influenza, Vaccination coverage, Surveillance, Middle East and North Africa

Objective: Our aim was to assess whether the recommendations and guidelines for thromboprophylaxis in patients with atrial fibrillation (AF) have been adopted in general practice (GP). Methods: We conducted a retrospective study using the GP computer database (Hatfield, UK) on all 9400 patients to assess the quality of anticoagulation in patients with a recorded diagnosis of AF. Results: Of the 180 patients with a diagnosis of AF, 107 (59.4%) were treated with warfarin, 19 (10.6%) with a novel oral anticoagulant (NOAC), 31 (17.2%) with aspirin or clopidogrel, and 23 (12.8%) received none. Thirty-seven patients (34.6%) who were taking warfarin had a time in the therapeutic range (TTR) of less than 65%. Forty-five (27.6%) of the 163 patients who had a CHA2DS2VASc score of two or more were not prescribed a vitamin K antagonist (VKA) or a NOAC. None had a HAS-BLED greater than the CHA2DS2VASc score. Conclusion: Our study demonstrates that one in four patients with non-valvular AF, at risk of a stroke, is not being adequately treated with an oral anticoagulant in primary care. The majority were treated with warfarin, a third of which had a low TTR. A high proportion of patients are prescribed antiplatelet therapy instead. This is despite overwhelming evidence that VKAs and NOACs, and not aspirin or clopidogrel, improve outcome in patients with non-valvular AF. We suggest that a review of GP practice databases should be considered to identify patients with non-valvular AF, at risk of a disabling or fatal event, and measures taken to initiate anticoagulant therapy.

Longer life expectancy and decreasing fertility rates mean that the proportion of older people is continually increasing worldwide, and particularly in Europe. Ageing is associated with an increase in the risk and severity of infectious diseases. These diseases are also more difficult to diagnose and manage in seniors who often have at least one comorbid condition (60% of seniors have two or more conditions). Infectious diseases increase the risk of hospitalization, loss of autonomy and death in seniors. Effective vaccines are available in Europe for infectious diseases such as influenza, pneumococcal diseases, herpes zoster, diphtheria, tetanus and pertussis. Their effectiveness has been demonstrated in terms of reducing the rates of hospitalization, disability, dependency and death. The prevention of diseases in seniors also results in savings in healthcare and societal costs each year in Europe. Despite the availability of vaccines, vaccine-preventable diseases affect millions of European citizens annually, with the greatest burden of disease occurring in seniors, and the medical and economic benefits associated with are not being achieved. Vaccination coverage rates must be improved to achieve the full benefits of vaccination of seniors in Europe.

Background Annual vaccination is the most effective way to prevent and control the health and economic burden caused by seasonal influenza. Healthcare workers (HCWs) play a crucial role in vaccine acceptance and advocacy for their patients. This study explored the drivers of HCWs’ vaccine acceptance and advocacy in six European countries. Methods Healthcare workers (mainly general practitioners, specialist physicians, and nurses) voluntarily completed a questionnaire in Bulgaria (N = 485), Czech Republic (N = 518), Kosovo (N = 466), Poland (N = 772), Romania (N = 155), and the United Kingdom (N = 80). Twelve-item scales were used to analyse sentiment clusters for influenza vaccination acceptance and engagement with vaccination advocacy. Past vaccination behaviour and patient recommendation were also evaluated. All data were included in a single analysis. Results For vaccination acceptance, the main cluster (engaged sentiment: 68%) showed strong positive attitudes for influenza vaccination. A second cluster (hesitant sentiment: 32%) showed more neutral attitudes. Cluster membership was predicted by country of origin and age. The odds ratio for past vaccination in the engaged cluster was 39.6 (95% CI 12.21–128.56) although this varied between countries. For vaccination advocacy, the main cluster (confident sentiment: 73%) showed strong positive attitudes towards advocacy; a second cluster (diffident sentiment: 27%) showed neutral attitudes. Cluster membership was predicted by country of origin, age and profession, with specialist physicians being the least likely to belong to the confident sentiment cluster. HCWs characterised by confident advocacy sentiments were also more likely recommend flu vaccination. Again, this association was moderated by country of origin. Conclusions These data show that there is room to improve both vaccination acceptance and advocacy rates in European HCWs, which would be expected to lead to higher rates of HCW vaccination. Benefits that could be expected from such an outcome are improved advocacy and better control of morbidity and mortality related to seasonal influenza infection.

Background: Atrial fibrillation (AF) management represents a significant burden on the UK NHS. Understanding this burden will be important in informing future health care planning and policy development. Aim: To describe the non-anticoagulation costs associated with AF management in routine UK clinical practice. Materials, patients and methods: A retrospective observational study of 825 patients with AF undertaken in eight UK primary care practices. Data collected from routine clinical and prescribing records of all eligible, consenting patients, for a period of up to 3 years. The first 12 weeks following diagnosis was defined as the ‘initiation phase’; the period after week 12 was defined as the ‘maintenance phase’. Results: Mean (SD) total cost of AF management was £941 (£1094) per patient in the initiation phase and £426 (£597) per patient-year in the maintenance phase. AF-related inpatient admissions contributed most to total costs; the mean (SD) total cost per patient in the initiation phase was £2285 (£900) for admitted and £278 (£252) for non-admitted patients. Mean maintenance phase costs per year were £1323 (£755) and £168 (£234), respectively, for admitted and non-admitted patients. Significant patient variables contributing to high cost in the initiation phase were hypertension and younger patient age, although only accounting for 6% of cost variability. Significant variables in the maintenance phase (18% of cost variability) were the presence of congestive heart failure, structural heart disease or diabetes and the frequency of day case admissions, ECGs and hospitalisations in the initiation phase. Conclusions: Inpatient admissions contributed most to total AF management costs. Given the burden of hospital care, future work should focus on evaluating the appropriateness and reasons for hospitalisation in patients with AF and the factors affecting length of stay, with the aim of identifying opportunities to safely reduce inpatient costs. A number of significant patient characteristics and initiation phase variables were identified, which accounted for 18% of the variability in total maintenance phase costs. However, none of these could adequately predict high maintenance phase costs.

Currently there is no influenza vaccination guidance for European general practitioners. Furthermore, although the European Council recommends a target seasonal influenza vaccination rate of 75% in the elderly (65 years and above) and in anyone aged >6 months with a chronic medical condition, there remain wide discrepancies throughout Europe. A harmonised guideline regarding not only vaccination strategy but also for the consistent diagnosis of influenza across Europe is essential to support a common approach for the implementation of seasonal influenza vaccination across Europe. This document is based on pre-existing guidelines available in the UK and Netherlands and has been approved by a group of European experts for use throughout Europe. As well as providing a standardised influenza diagnosis, it also reviews the current recommendations for influenza vaccination, the types of vaccine available, the contraindications, vaccine use in special populations (in pregnancy, children, and in those with egg allergy), and concomitant administration with other vaccines. The effectiveness, safety, and timing of the seasonal influenza vaccine are also reviewed. A second section provides practical guidance for general practitioners for the implementation of a seasonal influenza vaccination program, including the selection and notification of those eligible for vaccination, as well as suggestions for the organisation of a vaccination programme. Finally, suggested responses to common patient misconceptions and frequently asked questions are included. The aim of this article is to harmonise the diagnosis of seasonal influenza and the approach of European general practitioners to seasonal influenza vaccination in order to better identify influenza outbreaks and to move towards reaching the target vaccination rate of 75% throughout Europe.

ObjectivesThis study assessed cardiovascular disease (CVD) risk classification according to QRISK2, JBS3 ‘heart age’ and the prevalence of elevated high-sensitivity C reactive protein (hsCRP) in UK primary prevention patients.MethodThe European Study on Cardiovascular Prevention and Management in Usual Daily Practice (EURIKA) (NCT00882336) was a cross-sectional study conducted in 12 European countries. 673 UK outpatients aged ≥50 years, without clinical CVD but with at least one conventional CVD risk factor, were recruited. 10-year CVD risk was calculated using QRISK2. JBS3 ‘heart age’ and hsCRP level were assessed according to risk category.ResultsQRISK2 and JBS3 heart age was calculated for 285 of the 305 patients free from diabetes mellitus and not receiving a statin. QRISK2 classified 28%, 39% and 33% of patients as low (≥5 years and ≥10 years higher than their chronological age, respectively. Half of low-risk patients had hsCRP levels ≥2 mg/L and approximately 40% had levels ≥3 mg/L. Approximately 80% of low-risk patients had both elevated hsCRP and heart age relative to their chronological age.ConclusionsAlmost 40% more patients in this ‘at risk’ group would be eligible for statin therapy following the lowering of the National Institute for Health and Care Excellence treatment threshold to ≥10% 10-year risk. Of patients falling below this treatment threshold, almost all were at increased lifetime risk as measured by JBS3, and of these, the majority had elevated hsCRP levels. These patients with high absolute risk may benefit from early primary CVD prevention.

Echinococcosis (hydatid cyst disease) in humans is a rare parasitic disease that primarily involves the liver and the lungs. Skeletal manifestation of the disease is seldom and often presents as a clinical and radiological problem. The contamination of the primary hydatid cyst complicates the treatment which is also difficult because of the invasive nature of bone involvement and the spillage of fluid with subsequent contamination seeding. We present a case of pathological femoral fracture secondary to contaminated primary hydatid cyst that has been finally treated with static intramedullary nailing. We highlight the importance of including the hydatid bone disease in the differential diagnosis of destructive bone lesions, and we suggest the intramedullary nailing as the final treatment of specific type of pathological fractures.

Purpose of the study Domperidone is associated with QTc prolongation, predisposing to the development of ventricular arrhythmias. In 2014, The Medicines and Healthcare Regulatory Agency (MHRA) recommended restricting its use. We assessed whether these recommendations have been implemented in a general practice. Study design We conducted a prospective study using the general practitioner (GP) computer database on patients who had at least one repeat prescription for domperidone in 12 months. Data were presented to the doctors and the survey was repeated 7 months later. Results Sixty-four patients (mean age 61.3±16.4 years) were identified who had received at least one repeat prescription of domperidone. Twenty patients were being prescribed over the recommended daily dose. Nineteen patients were coprescribed medications known to prolong the QTc interval and two CYP3A4 inhibitors. The repeat survey performed 7 months later demonstrated a 70% reduction in the number of patients prescribed domperidone to a total of 19 (three patients prescribed above the recommended dose) none of which had a history of cardiac disease or were being coprescribed drugs known to prolong the QTc interval. Conclusions Following the publication of the MHRA recommendations and presentation of our initial survey, there has been a significant reduction in the number of patients treated with domperidone and those coprescribed drugs known to prolong the QTc interval. We suggest that regular review of GP practice database should be performed to identify those patients prescribed domperidone and at risk of life-threatening arrhythmias and measures taken to use alternative pharmacological agents.

In 2012, the Joint Committee on Vaccination and Immunisation recommended that the National Immunisation Programme for influenza be extended to include healthy children/adolescents aged 2–17 years. In the UK, extension of this new immunisation programme began in 2013–2014 and targeted children aged 2 years and 3 years in primary care. Several implementation pilots were undertaken in primary schools across England, Scotland, Wales and Northern Ireland, as well as a single pilot in a secondary school in England. This article shares lessons learnt from experiences in England and Scotland to provide guidance for other countries considering the addition of childhood influenza vaccination into their national immunisation programmes. Recommendations are provided to help ensure effective preparation and management of new childhood influenza vaccination programmes in other countries. This article describes the processes utilised in England and Scotland for programme setup, workforce management, identification and care of contraindicated patients, collection of data on vaccine uptake, communication strategies, and education of parents and children.

The NICE guideline on the management of hypertension in primary care has recently been updated. Here, the author discusses the major impact this will have on prescribing practice. Copyright © 2006 Wiley Interface Ltd

Uptake of vaccination against seasonal influenza in healthcare workers (HCWs) is, in general, low (vaccine coverage of 6–54%), as is awareness of its importance, and has been decreasing in most European Union (EU) countries in recent years. By virtue of their working environment, HCWs are at an increased risk of influenza infection and of subsequently transmitting the virus to vulnerable patients, in whom disease burden is significant. It could be argued that a similar or higher target vaccination rate to that recommended for older age groups and people with chronic medical conditions (75%) should be applied to HCWs, and the European Council recommends Member States to improve vaccination coverage in this population. In this context, better education of HCWs is needed to increase awareness and highlight the importance of HCW vaccination for the benefit of public health, particularly for their patients, who may be at risk of serious complications that could lead to disability or death. Secondary to these professional responsibilities, personal benefits (as well as benefits to close family and friends) should also be emphasised. Misconceptions that create barriers to vaccination need to be discussed openly and objections placed in the context of public health.

Elderly people and adults with chronic disease or compromised immune status are at increased risk of pneumococcal infection, with pneumonia being the most common serious presentation and a significant cause of morbidity and mortality. Most European countries have recommendations for pneumococcal vaccination but vaccination rates have remained low. In the present article, the authors present the results of a European survey that investigated the current level of awareness of pneumococcal infection among primary care physicians and specialists, and attitudes to vaccination in these physicians and members of the general public aged50 years.Primary care physicians (n = 1,300) and specialists (n = 926) from 13 Western European countries participated in online/face-to-face interviews, and a further 6,534 individuals aged50 years from a population sample reflecting local socio-demographic structure participated in telephone/face-to-face interviews.Pneumonia was the most well-known of the pneumococcal infections amongst primary care physicians and specialists. However, there was a relatively low awareness of the term invasive pneumococcal disease (IPD), with only 50% of primary care physicians and 71% of specialists reporting knowledge of the term IPD. Key factors influencing a physician's decision to prescribe pneumococcal vaccination were the patient's health condition, recommendations from health authorities, and the tolerability of the vaccine. Perceptions regarding vaccination were good amongst the members of the general public; individuals did not fear vaccines or their side effects. The main drivers for vaccination were recommendations from a healthcare professional and, to a lesser extent, that vaccination provides reassurance against contracting a disease.These findings highlight the low awareness of the term IPD in comparison with individual pneumococcal conditions. Given the importance of physician recommendations in encouraging patients to be vaccinated, primary care physicians need to be vigilant of patients at risk of pneumococcal infections in order to increase vaccination rates.

Aims The present study aims to investigate patterns of beta-blocker usage in a national primary care cohort. Methods and results This is a retrospective cohort study utilising the UK General Practice Research Database from 2004 to 2008. Inclusion criteria were (i) a first diagnosis of chronic heart failure (CHF), myocardial infarction (MI) or angina, and (ii) first-ever prescription of beta-blocker on or after 1st April 2004. Outcome measures were discontinuation of beta-blockers over time, initiation dosages, titration patterns, incidence of adverse events (AEs) and associated prescribing actions. A total of 12,493 patients (68.0% male; mean age 58.0±SD 17.6years) were included. Of these, 27% had discontinued beta-blockers within 1year of initiation, increasing to 39% by 2years and 50% by 3years. Persistence appeared to be greater in the MI cohort compared with angina or CHF cohorts. Beta-blocker dose at initiation averaged approximately 33% of guideline recommended target, rising to 40% in those who continued with therapy. Dyspnoea, fatigue and dizziness were the most common incident AEs at 98, 53 and 49 per 1000 patient years, with little difference between indications. Conclusion A quarter of patients with cardiovascular disease who are commenced on a beta-blocker are no longer taking the drug by one year. This rises to 50% by three years, a finding that is consistent irrespective of whether the prescription is for prognostic (CHF or post MI) or symptomatic (angina) benefit. There is an urgent need to understand and address the prescribing difficulties of beta-blockers in these at-risk patients.