Impact of statewide program to promote appropriate antimicrobial drug use.
The Wisconsin Antibiotic Resistance antibiotic resistance,
n the ability of certain strains of microorganisms to develop resistance to antibiotics.
antibiotic resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious ju·di·cious
Having or exhibiting sound judgment; prudent.
[From French judicieux, from Latin i antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. drug use. Public education included radio and television advertisements A television advertisement, advert or commercial is a form of advertising in which goods, services, organizations, ideas, etc. are promoted via the medium of television. , posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. , satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend secular trend
The relatively consistent movement of a variable over a long period. A stock in a secular uptrend is an indicator that the security has experienced an extended period of rising prices. of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.
Antimicrobial drug resistant strains of community-acquired pathogens, including Streptococcus pneumoniae Streptococcus pneu·mo·ni·ae
Streptococcus pneumoniae Microbiology A pathogenic streptococcus with 90 serotypes associated with pneumonia, bacteremia, meningitis Transmission Person to person Incidence and Staphylococcus aureus Staphylococcus au·re·us
A bacterium that causes furunculosis, pyemia, osteomyelitis, suppuration of wounds, and food poisoning.
Staphylococcus aureus Staphylococcus pyogenes , have emerged as serious global health threats (1-3). Multiple studies have demonstrated a strong and consistent link between antimicrobial drug use and antimicrobial resistance at both individual and population levels (4-9). Despite this link, inappropriate and ineffective use of antimicrobial agents Antimicrobial agents
Chemical compounds biosynthetically or synthetically produced which either destroy or usefully suppress the growth or metabolism of a variety of microscopic or submicroscopic forms of life. for viral respiratory infections Noun 1. respiratory infection - any infection of the respiratory tract
respiratory tract infection
infection - the pathological state resulting from the invasion of the body by pathogenic microorganisms is common (10-16). In 1998, the Institute of Medicine issued a workshop report that addressed the growing problem of antimicrobial drug resistance and potential strategies to prolong the effectiveness of existing drugs (17). The report found that physicians and patients have not received adequate information about the appropriate use of antimicrobial drugs and the short- and long-term risks of overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. . Several approaches were suggested, including multifaceted mul·ti·fac·et·ed
Having many facets or aspects. See Synonyms at versatile.
Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious clinician clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.
n. education, clinical practice protocols, feedback on local resistance trends, patient-oriented educational materials, and use of popular media for public education.
We describe the activities and impact of a 5-year, multifaceted educational campaign to reduce outpatient antimicrobial drug prescribing in Wisconsin. The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 as a federally funded demonstration project to educate primary care physicians and the public about drug resistance and judicious antimicrobial drug use. Antimicrobial drug prescribing rates were assessed annually and compared to Minnesota prescribing rates, where educational activities were limited before 2002.
WARN was established as a collaborative project involving the Marshfield Clinic Marshfield Clinic is a medical system with 41 centers located in northern, central and western Wisconsin as of 2006. It was founded in 1916 by six local physicians: K.W. Doege, M.D.; William Hipke, M.D.; Victor Mason, M.D.; Walter G. Sexton, M.D.; H.H. Milbee, M.D. and Roy P. Research Foundation, Wisconsin Medical Society, and Wisconsin Division of Public Health. The Wisconsin Medical Society collaborated with the Marshfield Clinic Research Foundation to develop the public education campaign, and the latter organization was responsible for data collection and evaluation. The Division of Public Health assisted with program planning and collected invasive pneumococcal pneumococcal /pneu·mo·coc·cal/ (-kok´al) pertaining to or caused by pneumococci. isolates for susceptibility testing susceptibility test Antimicrobial susceptibility test, see there .
For most of the project period, WARN employed 2 program managers and 2 health educators. Representatives of each position were based in Madison and in Marshfield to cover the southern and northern parts of the state. An advisory board was established with representation from managed care organizations, employers, local public health agencies, primary care practices, infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. experts, childcare centers, pharmacists This is a list of notable pharmacists.
respiratory disease, respiratory disorder
adult respiratory distress syndrome, ARDS, wet lung, white lung - acute lung injury characterized by coughing and rales; inflammation of the in Wisconsin. Educational needs were assessed through surveys of primary care clinicians and the general public (18). Limited public and physician educational activities were initiated in 2000, and the program was implemented in full from 2001 to 2003. Educational interventions were designed to be multifaceted and consistent with behavioral research that suggested a need for a variety of educational strategies with repetitive and reinforcing messages (19 21).
Public and Physician Education
The tag lines tag line also tag·line
1. An ending line, as in a play or joke, that makes a point.
2. An often repeated phrase associated with an individual, organization, or commercial product; a slogan.
Noun 1. for the public education campaign were "There's no excuse for overuse!" and "Get smart about antibiotics!" The campaign mascots Here is a list of several known mascots: College mascots
1. pertaining to life or living matter.
2. pertaining to the biota.
1. Relating to life or living organisms. and Moxie Cillin, were cartoon characters designed to appeal largely to children and parents. Public education materials included posters, brochures, stickers, coloring sheets, magnets, and disease-specific parent handouts (Table 1). All materials were available free of charge to healthcare providers, clinics, and community organizations. Spanish translations were also available for many of the written materials. A Web site was established through the Wisconsin Medical Society to describe WARN activities and facilitate ordering materials. The distribution volume for WARN educational materials is shown in Table 2.
Outreach to childcare centers was a major focus of community education because children attending group child care have high rates of respiratory illness. Annual mailings were sent to >5,000 licensed childcare centers, and on-site presentations were given at 170 centers. Additional presentations were made at childcare conferences and in college classes on early childhood education. Physician-education activities began in 2000 and included direct mailings with samples of WARN materials, development and distribution of guidelines for judicious antibiotic use, satellite broadcasts, dissemination dissemination Medtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there of pneumococcal antimicrobial resistance data, and professional presentations (Table 1).
The media campaign included paid advertising and strategies to maximize coverage. The campaign was launched with a press conference in 1999, followed by repeated news media coverage of WARN and antimicrobial resistance issues from 2000 through 2003 (Table 1). This coverage included newspaper reports in Milwaukee, Madison, and multiple smaller communities, as well as local television news stories in Milwaukee, Madison, and Wausau. Paid advertising was initiated on radio stations broadcasting throughout the state and on television stations. Because of the high cost, television advertisements were limited to periods of 2 to 4 weeks during the peak respiratory illness season.
Research Design and Outcome Measures
Multiple evaluation components were developed to measure the effect of the WARN educational campaign. The major outcome for this report was annual antimicrobial drug use, measured by the number of primary care prescriptions and the volume of retail antimicrobial drug sales.
During the late 1990s, a national secular trend of declining antimicrobial drug use occurred (22-24). To distinguish the impact of WARN from the secular trend, antimicrobial drug-prescribing measures were obtained for both Wisconsin and Minnesota. Although Minnesota is not representative of the entire country, the use of a comparison state provided the opportunity to distinguish intervention-related changes from regional trends in use that were unrelated to the intervention. Minnesota was chosen for geographic proximity and similarity in terms of population size and ethnic distribution. Before 2002, patient educational activities in Minnesota were limited. A group of 6 Minnesota managed care plans distributed [approximately equal to] 17,000 cough and cold kits to patients during the 2000-2001 respiratory illness season, and 31,000 kits during the 2001-2002 season. An article promoting appropriate antimicrobial drug use was published in the April 2001 issue of Minnesota Medicine (25), but no other formal programs to educate Minnesota physicians on appropriate antimicrobial drug use were implemented until late 2002, when sample materials (posters, buttons, "prescription pads" for symptomatic therapy) were mailed to managers at 377 Minnesota clinics and urgent care centers.
Measures of Antimicrobial Drug Use
Prescribing data and retail volume distribution data (measuring retail sales) were obtained from a commercial source (IMS Health IMS Health (NYSE: RX) is an international consulting and data services company that supplies the pharmaceutical industry with sales data and consulting services. IMS Health was founded in 1954 by Bill Frohlich and David Dubow. , Inc., Plymouth Meeting, PA, USA) for the states of Wisconsin and Minnesota. Physician prescribing data were available for 1998 and 2000 through 2003. Prescribing and volume distribution data were not available for individual drugs within each class. The source data did not include any information regarding the specific diagnosis or patient characteristics.
The prescribing databases included only new outpatient prescriptions, and they were derived from transactional data provided by 59% of all retail pharmacies in Wisconsin and Minnesota. Approximately 65% of chain pharmacies and 51% of independent retail pharmacies contributed raw prescribing data. Prescriptions from unsampled stores were estimated on the basis of prescription totals from matched nearby stores, with weighting to adjust for differences in total retail sales volume, which was available for nearly all stores. Estimates were also weighted to account for the distance between sampled stores and matched unsampled stores, with closer stores contributing more to the estimated prescription volume. The proportion of all prescriptions in each state that were based on estimated data from unsampled stores was 33%-37%.
Physician-level prescribing data included data for all licensed physicians with any of the following primary specialty codes: family (and general) practice, internal medicine, pediatrics, or emergency medicine. Physicians were classified geographically as practicing within or outside of the largest metropolitan statistical area in each state. These 2 metropolitan statistical areas were Milwaukee-Waukesha (4 counties) and Minneapolis-St. Paul (11 counties).
Retail volume distribution was determined by the volume of antimicrobial drugs distributed to retail outlets retail outlet n → punto de venta
retail outlet n → point m de vente
retail outlet retail n → on a monthly basis from 1999 to 2002. This distribution was derived from an independent data source relative to the physician-level prescribing data. Retail distribution data (measured in kilograms) were reported by wholesalers and distributors serving pharmacies in both states. Retail volume was not linked to specific prescriptions or providers and therefore represented a measure of total outpatient antimicrobial drug use in each state. Volume was based on distribution to retailers rather than actual sales to patients, and distributed drugs could be returned to wholesalers without being sold. In this situation, returned drugs were subtracted from the total distributed in a given month to yield the net retail distribution for each drug class. Inpatient pharmacies, prisons, veterinary offices, nursing homes, dialysis dialysis (dīăl`ĭsĭs), in chemistry, transfer of solute (dissolved solids) across a semipermeable membrane. Strictly speaking, dialysis refers only to the transfer of the solute; transfer of the solvent is called osmosis. clinics, and federal government sites were excluded from the volume distribution data. The retail volume sales database captured 93% of actual antimicrobial drug distribution in Wisconsin and Minnesota. Volume sales were divided by the annual population estimates in each state and reported as grams per capita [Latin, By the heads or polls.] A term used in the Descent and Distribution of the estate of one who dies without a will. It means to share and share alike according to the number of individuals. .
The following product groups were included in the assessment of outpatient prescribing and retail volume sales: amoxicillin/penicillin, amoxicillin-clavulanate, cephalosporins Cephalosporins Definition
Cephalosporins are medicines that kill bacteria or prevent their growth.
Cephalosporins are used to treat infections in different parts of the body—the ears, nose, throat, lungs, sinuses, and , macrolides, extended-spectrum macrolides (azithromycin, clarithromycin), fluoroquinolones, tetracyclines Tetracyclines Definition
Tetracyclines are medicines that kill certain infection-causing microorganisms.
Tetracyclines are called "broad-spectrum" antibiotics, because they can be used to treat a wide variety of , trimethoprim-sulfamethoxazole, and other sulfa drugs sulfa drugs
a group of chemical compounds used as antibacterial agents; called also sulfonamides. (including erythromycin/sulfisoxazole). Solid and liquid formulations were reported separately, and liquid formulations were used as surrogates for pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. prescribing. Broad-spectrum antimicrobial drugs were also analyzed separately. Although no standard definition of broad spectrum antimicrobial drugs exists, a previous report on national trends in antimicrobial drug use classified the following groups as broad-spectrum: extended-spectrum macrolides, fluoroquinolones, second- and third-generation cephalosporins, and amoxicillin-clavulanate (23). We used the same classification with 1 exception. In this study we classified all cephalosporins as broad-spectrum because we were unable to distinguish first-, second-, and third-generation cephalosporins.
A cohort of primary care physicians was established to monitor and compare longitudinal trends in prescribing antimicrobial drugs. The cohort was defined as primary care physicians in Minnesota and Wisconsin who prescribed at least 1 antimicrobial drug in each month during the baseline year (1998) and each of the follow-up years (2000-2003). This criterion was used to avoid including residents and other physicians in temporary practice settings. It also avoided including nonpractice time in prescribing rate calculations, since information on individual practice patterns was not available. The annual antimicrobial prescribing rate was calculated by dividing the number of new, filled prescriptions by the number of physicians in the cohort.
The original 1998 prescriber database included 9,164 primary care physicians in Minnesota or Wisconsin who prescribed any antimicrobial drug. Of those, 4,115 (45%) prescribed [greater than or equal to] 1 antimicrobial drug per month in 1998 and annually from 2000 through 2003. This group made up the final cohort for analysis of longitudinal prescribing trends. A secondary analysis of prescribing trends was performed based on the larger group of primary care physicians (n = 12,790) who prescribed [greater than or equal to] 1 antimicrobial drugs during any of the follow-up years but who were not necessarily in continuous practice.
Prescribing rates for the 4,115 physicians in practice throughout the study period were computed as the number of antimicrobial prescriptions in a given year divided by the number of physicians. Prescribing rates were therefore equivalent to the mean number of prescriptions for antimicrobial drugs per physician each year. Population-based or patient-based prescribing rates could not be calculated because the populations served by the prescribing cohort were undefined. To compare prescribing rates for each year of the intervention period (2000-2003) to baseline (1998), we fit Poisson regression In statistics, the Poisson regression model attributes to a response variable Y a Poisson distribution whose expected value depends on a predictor variable x, typically in the following way:
Differences in baseline antimicrobial prescribing were addressed by fitting additional Poisson-GEE models using data from the intervention period with the natural log of the baseline number of antimicrobial drug prescriptions included as an independent variable. Prescribing rates per physician-month were computed when analyzing the 12,790 physicians who wrote such prescriptions in [greater than or equal to] 1 month of the study period. Months where a physician wrote at least 1 prescription for an antimicrobial drug were included in the denominators of rates (i.e., a physician was assumed not to be in practice in months when he did not write any such prescriptions). Per capita antimicrobial drug sales were calculated based on annual population estimates (www.census.gov). Analyses were completed by using the SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. software (SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. Inc., Cary, NC, USA).
The 4,115 primary care physicians in long-term practice included 2,009 (49%) in Minnesota and 2,106 (51%) in Wisconsin. The proportion of physicians in family practice was higher in Wisconsin, and the proportion in internal medicine was higher in Minnesota (Table 3). During 1998, these physicians generated 1.5 million prescriptions for antimicrobial drugs in each state, and the crude antimicrobial prescribing rate was nearly identical across states. From 2000 through 2003, the prescribing rate for antimicrobial drugs in both states gradually declined (Figure 1). From 1998 to 2003, the antimicrobial prescribing rate was reduced by 19.8% in Minnesota and by 20.4% in Wisconsin. The percentage reduction was 19.5% and 18.6%, respectively, in the secondary analysis, which included the 12,790 primary care physicians who prescribed antimicrobial drugs at any time during the follow-up period.
[FIGURE 1 OMITTED]
Retail sales of antimicrobial drugs (grams per capita) declined by 27.4% in Minnesota and 17.3% in Wisconsin from 1999 through 2002 (Figure 1). Sales of amoxicillin amoxicillin /amox·i·cil·lin/ (ah-mok?si-sil´in) a semisynthetic derivative of ampicillin effective against a broad spectrum of gram-positive and gram-negative bacteria.
n. and penicillin penicillin, any of a group of chemically similar substances obtained from molds of the genus Penicillium that were the first antibiotic agents to be used successfully in the treatment of bacterial infections in humans. exceeded those of other product groups in each year and accounted for 37% of all retail antimicrobial distribution. In both states, retail sales of fluoroquinolones remained level, and sales of amoxicillin-clavulanate increased. Sales of most other product groups declined by 15% or more.
Stratification stratification (Lat.,=made in layers), layered structure formed by the deposition of sedimentary rocks. Changes between strata are interpreted as the result of fluctuations in the intensity and persistence of the depositional agent, e.g. of antimicrobial prescribing rates by specialty showed A specialty show is a dog show which reviews a single breed, unlike other dog shows, particularly conformation shows, which are generally referred to as "all-breed" because they are open to all breeds recognized by the sponsoring kennel club. that the reduction in prescribing differed only for physicians in internal medicine and pediatrics (Table 4). Antimicrobial prescribing declined more in Wisconsin than Minnesota among internal medicine physicians, but the opposite was true for pediatricians. In Minnesota, the reduction in antimicrobial use was similar for physicians practicing in the Minneapolis-St. Paul metropolitan statistical area and those practicing elsewhere in the state (Table 5). In Wisconsin, the reduction in antimicrobial prescribing was much less in the Milwaukee-Waukesha metropolitan statistical area than in the remainder of the state. Antimicrobial prescribing declined significantly more in the Minneapolis-St. Paul metropolitan statistical area than in the corresponding Milwaukee-Waukesha area.
Prescriptions for liquid antimicrobial drugs (a surrogate surrogate n. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. for pediatric use) declined 29% in Wisconsin and 32% in Minnesota from 1998 to 2003 (p = 0.17). Prescriptions for solid formulations declined 15%-17% in each state. The percentage of prescriptions for broad-spectrum agents was unchanged (within 2%) in each state from 1998 through 2003.
Regression models were fit to compare prescribing rates in Wisconsin and Minnesota during each year from 2000 to 2003, with adjustment for specialty and baseline prescribing in 1998. Two separate models were generated. The first included physicians practicing in the Minneapolis-St. Paul metropolitan statistical area or the Milwaukee-Waukesha metropolitan statistical area. The second included physicians practicing in other counties of Minnesota or Wisconsin. In the latter model, the prescribing rate ratio was <1 in 2002 and 2003, indicating that, when the 2 largest metropolitan areas were excluded, Wisconsin physicians had significantly lower prescribing rates than those in Minnesota (Figure 2). In contrast, the prescribing rate ratio was >1 in each year within the 2 largest metropolitan areas, indicating that physicians in the Milwaukee-Waukesha MSA (Metropolitan Service Area) An urban area with at least 50,000 people plus surrounding counties. There are 306 MSAs and 428 RSAs (rural service areas) in the U.S. MSAs and RSAs are used to allocate cellular licenses. had higher prescribing rates than those in the Minneapolis-St. Paul MSA, after adjusting for specialty and baseline prescribing.
[FIGURE 2 OMITTED]
WARN represents the largest program on appropriate antimicrobial drug use that has been evaluated to measure the effect on prescribing. Previously published studies demonstrated that interventions at the level of the physician, clinic, or community had a modest effect on prescribing (20,27-32). These focused programs are useful in evaluating specific intervention strategies in a relatively controlled setting. However, adoption of new practices may be slow even when the intervention is proven to be effective, and generalizability to larger populations may be limited. In contrast, large-scale programs can reach physicians and the general public in an entire state or large metropolitan area. The development of WARN reflected a need to implement and evaluate a large-scale demonstration project that could influence antimicrobial prescribing throughout Wisconsin in a relatively short time. At the time WARN was conceived and funded, knowledge of national trends in antimicrobial prescribing was limited, but we now know that prescribing declined substantially for both pediatric and adult populations in the 1990s (22-24,33).
Outpatient antimicrobial use declined substantially in both Wisconsin and Minnesota from 1998 to 2003, and no additional intervention-related effect was apparent in Wisconsin. Secondary analyses by specialty and practice location demonstrated variable reductions in prescribing of antimicrobial drugs, but to what extent these reductions were related to WARN interventions, as opposed to other factors that may be influencing secular trends, is unclear. The potential effect of these other factors is illustrated by the observation that Minnesota pediatricians improved their prescribing practices more than Wisconsin pediatricians, despite the absence of an organized, large-scale program to improve pediatric prescribing in Minnesota.
We found that changes in antimicrobial drug use were less pronounced in the Milwaukee-Waukesha metropolitan area than in other regions of Wisconsin. This finding contrasts with findings in Minnesota, where the decrease in antimicrobial drug use in the Minneapolis-St. Paul metropolitan area was similar to that in the rest of the state. When these large metropolitan areas were excluded from the analysis, prescribing of antimicrobial drugs decreased more in Wisconsin than in Minnesota. Several factors may have contributed to the relatively low impact of WARN in the Milwaukee area. These factors include the absence of paid staff working in Milwaukee, few connections with the Milwaukee medical community, and the large number of clinical practices and health plans.
Funding for WARN exceeded levels for other state-based programs on antimicrobial drug resistance, but it was far lower than the funding level for some other public education campaigns. Annual funding for WARN staffing, programs, and materials (excluding indirect costs Indirect costs are costs that are not directly accountable to a particular function or product; these are fixed costs. Indirect costs include taxes, administration, personnel and security costs. See also
One other published study reported the effect of interventions promoting appropriate antimicrobial drug use in a large, highly populated pop·u·late
tr.v. pop·u·lat·ed, pop·u·lat·ing, pop·u·lates
1. To supply with inhabitants, as by colonization; people.
2. area. In Knox County, Tennessee Knox County is a county in the U.S. state of Tennessee. Its 2005 population was estimated at 404,972 by the United States Census Bureau. Its county seat is Knoxville6, and has been since the creation of the county. , a 12-month multifaceted campaign was conducted in 1997 and early 1998 (34). The clinician intervention included professional presentations, distribution of pediatric principles of judicious antimicrobial drug use (35), and newsletter articles. Patient and public education included distribution of print materials, news media coverage, and public service announcements. In the Medicaid managed care program, antimicrobial drug prescribing for respiratory illness declined 19% in Knox County There are nine counties named Knox County in the United States, all apparently named after Henry Knox:
Evaluating large-scale, multifaceted educational programs such as WARN has several limitations. The control population in Minnesota was not isolated, and educational materials and messages may have diffused into the control area from a variety of sources. For example, during the WARN follow-up period, national guidelines on appropriate antimicrobial use were published and endorsed by the Centers for Disease Control and Prevention and major professional organizations (35-37). WARN also reached limited populations in Minnesota: radio advertisements included areas of eastern Minnesota, and some Minnesota physicians received the WARN satellite broadcasts on appropriate antimicrobial drug use. In addition, efforts within Minnesota to improve prescribing of antimicrobial drugs increased during the follow-up period, particularly during 2002 and 2003. A single state may not be the optimal comparison population, and Minnesota in particular has a highly educated population and a proactive public health infrastructure with strong ties to the healthcare delivery system. As a result, the improvements in antimicrobial drug prescribing within Minnesota may have been greater than those in many other states. Finally, the commercial prescribing data used for the WARN evaluation did not include any information on visits or diagnoses. We therefore cannot determine if the declines in antimicrobial prescribing in Wisconsin and Minnesota were associated with a declining rate of visits for acute respiratory illness or if the rate of prescribing declined for specific diagnoses.
The centralized cen·tral·ize
v. cen·tral·ized, cen·tral·iz·ing, cen·tral·iz·es
1. To draw into or toward a center; consolidate.
2. development of WARN programs and materials facilitated statewide distribution, but it also limited the level of clinician involvement at the local level. Direct, face-to-face communication with physicians was rarely possible. In contrast, practice-level interventions have shown modest success, and we speculate that these focused, participatory interventions may promote physician behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. more directly than a mass education campaign such as WARN. However, WARN succeeded in changing physicians' knowledge and attitudes regarding appropriate antimicrobial drug use, and WARN materials were widely used by primary care clinicians throughout the state. In a survey of primary care clinicians, 90% of respondents had heard of WARN, and 70% of those had used WARN materials for patient education (38). Models of behavior change suggest that changes in prescribing behavior are preceded by important cognitive changes that proceed in stepwise stepwise
incremental; additional information is added at each step.
stepwise multiple regression
used when a large number of possible explanatory variables are available and there is difficulty interpreting the partial regression fashion (39). Improvements in knowledge and beliefs among both physicians and patients may therefore be markers of progress, which may facilitate the future success of provider-level interventions developed by clinics and managed care organizations in Wisconsin.
Increased funding for state-level educational campaigns to promote appropriate antimicrobial drug use does not appear warranted by the results of this evaluation. However, the combined effect of national guidelines for appropriate use of such drugs, increasing attention by the media and professional organizations, and the Centers for Disease Control and Prevention national campaign may have contributed to the observed trend toward declining antimicrobial use. Progress toward decreasing inappropriate use is being made in many states, although antimicrobial prescribing rates remain excessive for bronchitis bronchitis (brŏnkī`tĭs), inflammation of the mucous membrane of the bronchial tubes. It can be caused by viral or bacterial infections or by allergic reactions to irritants such as tobacco smoke. , and use of broad-spectrum antimicrobial drugs is increasing nationally (22,27,33). State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development. These activities might include academic detailing academic detailing Therapeutics The use of educational 'props' by pharmaceutical companies and representatives–drug 'reps' to improve drug prescribing practices. Cf Detailing. by physician opinion leaders, feedback on antimicrobial prescribing performance (including Health Plan Employer Data and Information Set The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance. measures), and economic incentives for careful antimicrobial use. These strategies may have the greatest effect if implemented as quality improvement initiatives in collaboration with the leadership of health plans and clinic organizations. Ongoing assessment of prescribing trends and rates of antimicrobial drug resistance will be needed to measure the ultimate effect of these efforts.
Table 1. Major WARN activities and initiatives, 2000-2003 * Activity 2000 2001 Public education Mailing to all licensed family and group childcare X providers Exhibits at health fairs and community events X X Public appearances by costumed characters X X Distribution of sample materials to pharmacies X Slide presentations at childcare centers X X Newsletter copy distributed to healthcare X X organizations WARN paycheck stuffers for state employees X Slide presentations for community and state X X organizations Physician education Sample materials and order form mailed to >8,000 X licensed primary care clinicians and pharmacists Satellite broadcasts on management of respiratory X X illness Academic detailing packets distributed to health X X plans, clinics, public health staff Narrated slide presentation on CD-ROM mailed to X primary care clinicians Presentations at healthcare facilities, professional X X meetings, and conferences Distributed invasive pneumococcal susceptibility X X report for Wisconsin Distributed original (2000) and revised (2002) X clinical practice fact sheets to [approximately equal to] 9,000 clinicians and pharmacists WARN resource binder distributed to 16 health plans X Media campaign Advertisements on Wisconsin Radio Network or X X Wisconsin Public Radio Guest editorials in newspapers X X Governor declared "Get Smart About Antibiotics Month" X Television advertisements--Dick Van Dyke and Bill Nye Earned media--radio and/or television news coverage X X Earned media--newspaper coverage X X Activity 2002 2003 Public education Mailing to all licensed family and group childcare X X providers Exhibits at health fairs and community events X X Public appearances by costumed characters X X Distribution of sample materials to pharmacies Slide presentations at childcare centers X X Newsletter copy distributed to healthcare organizations WARN paycheck stuffers for state employees X X Slide presentations for community and state X X organizations Physician education Sample materials and order form mailed to >8,000 X X licensed primary care clinicians and pharmacists Satellite broadcasts on management of respiratory illness Academic detailing packets distributed to health X X plans, clinics, public health staff Narrated slide presentation on CD-ROM mailed to primary care clinicians Presentations at healthcare facilities, professional X X meetings, and conferences Distributed invasive pneumococcal susceptibility X X report for Wisconsin Distributed original (2000) and revised (2002) X clinical practice fact sheets to [approximately equal to] 9,000 clinicians and pharmacists WARN resource binder distributed to 16 health plans Media campaign Advertisements on Wisconsin Radio Network or X X Wisconsin Public Radio Guest editorials in newspapers X X Governor declared "Get Smart About Antibiotics Month" Television advertisements--Dick Van Dyke and Bill Nye X X Earned media--radio and/or television news coverage X X Earned media--newspaper coverage X X * WARN, Wisconsin Antibiotic Resistance Network. Table 2. Distribution of WARN educational materials (2000-2003) * Approximate Type of material no. distributed WARN parent brochures 700,000 WARN posters 26,000 CDC posters (new in 2003) 900 CDC adult brochures 400,000 Spanish-language posters 5,000 Viral illness card 18,000 CDC viral prescription pad (new in 2003) 300 Parent illness handouts 23,000 Coloring sheets 450,000 Stickers 620,000 Magnets 50,000 Clinical practice fact sheets for respiratory illness 20,000 Pneumococcal susceptibility reports 38,000 * WARN, Wisconsin Antibiotic Resistance Network; CDC, Centers for Disease Control and Prevention. Table 3. Characteristics of 4,115 primary care physicians in long-term practice, Minnesota and Wisconsin Minnesota, Wisconsin, Characteristic * n (%) n (%) Specialty Family practice ([dagger]) 1,245 (62.0) 1,043 (49.5) Internal medicine 396 (19.7) 565 (26.8) Pediatrics 256 (12.7) 309 (14.7) Emergency medicine 112 (5.6) 189 (9.0) Practice location ([double dagger]) Milwaukee-Waukesha MSA -- 726 (34.8) Minneapolis-St. Paul MSA 1,216 (61.5) -- Other counties 762 (38.5) 1,363 (65.2) * MSA, metropolitan statistical area. ([dagger]) Includes 67 physicians in general practice. ([double dagger]) 48 physicians excluded because practice location category changed during follow-up period. Table 4. Changes in antimicrobial drug prescribing by specialty and state, 1998-2003 * Wisconsin prescribing rate % Specialty 1998 2003 reduction Family practice 810 631 22 Internal medicine 540 447 17 Pediatrics 1,126 891 21 Emergency medicine 519 451 13 Minnesota prescribing rate % p value Specialty 1998 2003 reduction ([dagger]) Family practice 843 685 19 0.11 Internal medicine 366 329 10 0.03 Pediatrics 1,068 751 30 0.006 Emergency medicine 306 303 1 0.25 * The annual antimicrobial drug prescribing rate was calculated by dividing the number of new filled prescriptions by the number of prescribers in each specialty. ([dagger]) p value for comparison of reduction in Wisconsin vs. Minnesota. Table 5. Changes in prescribing rate for antimicrobial drugs, by practice location, 1998-2003 * Wisconsin prescribing rate % Practice location 1998 2003 reduction Major metropolitan area 719 639 11 ([double dagger]) Other areas of Minnesota and 778 583 25 Wisconsin Minnesota prescribing rate % p value Practice location 1998 2003 reduction ([dagger]) Major metropolitan area 711 568 20 <0.001 ([double dagger]) Other areas of Minnesota and 814 657 19 0.005 Wisconsin * The annual prescribing rate for antimicrobial drugs was calculated by dividing the number of new filled prescriptions by the number of prescribers in each specialty. ([dagger]) p value for comparison of reduction in Wisconsin vs. Minnesota. ([double dagger]) Includes the Milwaukee-Waukesha metropolitan statistical area (4 counties) for Wisconsin and the Minneapolis-St. Paul metropolitan statistical area (11 counties) for Minnesota. Two Wisconsin counties were excluded from the latter area.
We thank the following persons for their contribution to this project: Lorelle Benetti, Carol Beyer, Steve Busalacchi, Kathryn Como-Sabetti, Cathy Deming, Steven Ebert, Jane Harper, Cindy Helstad, Darcy Johnson Darcy Johnson (born February 11, 1983 in St. Augustine, Florida) is an American football tight end for the New York Giants of the National Football League.
An undrafted rookie, Johnson was a member of the Giants' practice squad for the 2006 season. , Paula Keller, Debra Kempf, Drew Kessel, Ruth Lynfield, Vicki Meyer, Jordon Ott, Renee Reback, Anna Rentmeester, Debbie Rickelman, David Salo This article is about the American linguist. For other uses of "salo", see Salo (disambiguation).
David Salo (born 1969) is a linguist who worked on the languages of J. R. R. , John Schmelzer, Heather Silbaugh, Judy Simpson Judy Simpson (née Livermore) (born 14 November,1960 in Kingston, Jamaica), is a former British heptathlete. She competed in three Commonwealth Games, 1982, 1986 and 1990, winning a silver, gold and bronze respectively in the heptathlon. , Jaclyn Smith Jaclyn Smith (born October 26, 1947) is a Golden Globe-nominated American actress. She is best known for the role of Kelly Garrett in the television series Charlie's Angels (1976–1981). , Megan Sondreal, Lynda Syth, Stephanie Taylor, Mary Vandermause, Marilyn Michels, Thomas Hirsch, Donn Fuhrmann, Maureen Van Dinter, Paul Rosowski, Linda Viney, Linda Caldert-Olson, Barry Fox, George Fox, George, 1624–91, English religious leader, founder of the Society of Friends, b. Fenny Drayton in Leicestershire. As a boy he was apprenticed to a shoemaker and wool dealer. Mejicano, Gregory DeMuri, William Agger, Peter Havens, Cynthia Jones-Nosacek, Paul McGinnis, Kathleen Schneider, and Jeffrey Young. We also thank the following members of the WARN Advisory Board who contributed their time and expertise to support the project: Donald Bukstein, Cheryl DeMars, Jean Durch, Seth Foldy, Jerry Ingalls, Lowell Keppel, Lisa Madagame, Dennis Maki, Sandra Matter, William McGill For the American major league baseball player, see Willie McGill.
William McGill (December 20 1814 – November 9, 1883) was an Ontario physician and political figure. , Mary Proctor Mary Proctor (1862–September 11, 1957) was an American astronomer.
She was the daughter of Mary and Richard Proctor. Her father was a British popularizer of astronomy, and she gained her knowledge of the subject from him. , Ben Schwartz, Bradley Sullivan, and Scott Whitmore.
Funding for this study was provided by a cooperative agreement with the US Centers for Disease Control and Prevention, Atlanta, Georgia (U50/CCU515878).
(1.) Whitney C, Farley M, Hadler J, Harrison L, Lexau C, Reingold A, et al. Increasing prevalence of multidrug resistant Streptococcus pneumoniae in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . N Engl J Med. 2000;343:1917-24.
(2.) Herold BC, Immergluck LC, Maranan MC, Lauderdale DS, Gaskin gaskin
the muscular portion of the hindleg between the stifle and hock, corresponding to the human calf. The term is used in horses and sometimes dogs. RE, Boyle-Vavra S, et al. Community-acquired methicillin-resistant Staphylococcus aureus methicillin-resistant Staphylococcus aureus Methicillin-aminoglycoside resistant Staphylococcus aureus, MRSA An organism with multiple antibiotic resistances–eg, aminoglycosides, chloramphenicol, clindamycin, erythromycin, rifampin, tetracycline, in children with no identified predisposing risk. JAMA JAMA
Journal of the American Medical Association . 1998;279:593-8.
(3.) Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, et al. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA 2003;290:2976-84.
(4.) Arason V, Kristinsson K, Sigurdsson J, Stefansdottir G, Molstad S, Gudmundsson S. Do antimicrobials increase the carriage rate of penicillin-resistant pneumococci in children? Cross-sectional prevalence study. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 1996;313:387-91.
(5.) Albrich W, Monnet D, Harbarth S. Antibiotic selection pressure and resistance in Streptococcus pneumoniae and Streptococcus pyogenes Streptococcus py·og·e·nes
A bacterium that causes the formation of pus or of fatal septicemias.
A common bacterium that causes strep throat and can also cause tonsillitis. . Emerg Infect infect /in·fect/ (in-fekt´)
1. to invade and produce infection in.
2. to transmit a pathogen or disease to.
1. Dis. 2004;10:514-7.
(6.) Ho PL, Tse WS, Tsang KWT KWT Kuwait (ISO Country code)
KWT Cryptographic Transmit Unit , Kwok TK, Ng TK, Cheng VCC An electronics designation that refers to voltage from a power supply connected to the "collector" terminal of a bipolar transistor. In an NPN bipolar (BJT) transistor, it would be +Vcc, while in a PNP transistor, it would be -Vcc. , et al. Risk factors for acquisition of levofloxacin-resistant Streptococcus pneumoniae: a case-control study case-control study,
n an investigation employing an epidemiologic approach in which previously existing incidents of a medical condition are used in lieu of gathering new information from a randomized population. . Clin Infect Dis. 2001;32:701-7.
(7.) Nava JM, Bella F, Garau J, Lite J, Morera MA, Marti C, et al. Predictive factors for invasive disease due to penicillin-resistant Streptococcus pneumoniae: a population-based study. Clin Infect Dis 1994;19:884-90.
(8.) Samore M, Magill M, Alder alder (ôl`dər), name for deciduous trees and shrubs of the genus Alnus of the family Betulaceae (birch family), widely distributed, especially in mountainous and moist areas of the north temperate zone and in the Andes. S, Severina E, Morrison-de Boer L, Lyon J, et al. High rates of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin cephalosporin (sĕf'əlōspôr`ĭn), any of a group of more than 20 antibiotics derived from species of fungi of the genus Cephalosporium and closely related chemically to penicillin. Cephalosporins, e.g. use and intrafamilial transmission. Pediatrics. 2001;108:856-65.
(9.) Tan TQ, Mason EO Jr, Kaplan SL. Penicillin-resistant systemic pneumococcal infections in children: a retrospective case-control study. Pediatrics. 1993;92:761-7.
(10.) McCaig L, Hughes J. Trends in antimicrobial drag prescribing among office-based physicians in the United States. JAMA. 1995;273:214-9.
(11.) Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections upper respiratory tract infection URI Infectious disease A nonspecific term used to describe acute infections involving the nose, paranasal sinuses, pharynx, and larynx, the prototypic URI is the common cold; flu/influenza is a systemic illness involving the URT , and bronchitis. JAMA. 1998;279:875-7.
(12.) Barden L, Dowell S, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents: results from physicians' and parents' focus group discussions. Clin Pediatr. 1998;37:665-71.
(13.) Bauchner H, Pelton S Pelton may refer to:
(14.) Watson R, Dowell S, Jayaraman M, Keyserling H, Kolczak M, Schwartz B. Antimicrobial use for pediatric upper respiratory infections Noun 1. upper respiratory infection - infection of the upper respiratory tract
respiratory infection, respiratory tract infection - any infection of the respiratory tract : reported practice, actual practice, and parent beliefs. Pediatrics. 1999;104:1251-7.
(15.) Wang E, Einarson T, Kellner J, Conly J. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis. 1999;29:155-60.
(16.) Schwartz RH, Freij B J, Ziai M, Sheridan MJ. Antimicrobial prescribing for acute purulent rhinitis purulent rhinitis
Chronic rhinitis in which pus formation is excessive. in children: a survey of pediatricians and family practitioners family practitioner
n. Abbr. FP
See family physician. . Pediatr Infect Dis J. 1997;16:185-90.
(17.) Harrison PF, Lederberg J, editors. Antimicrobial resistance: issues and options. Institute of Medicine workshop report. Washington: National Academy Press; 1998.
(18.) Belongia E, Naimi T, Gale C, Besser R. Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med. 2002;34:346-52.
(19.) Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education continuing medical education See CME. strategies. JAMA. 1995;274:700-5.
(20.) Gonzales R, Steiner J, Lura A, Barrett P. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional mul·ti·di·men·sion·al
Of, relating to, or having several dimensions.
multi·di·men intervention on the treatment of uncomplicated acute bronchitis acute bronchitis Pulmonology A lower RTI–up to 95% of which are viral–that causes reversible bronchial inflammation Clinical Cough, fever, sputum, wheezing, rhonchi DiffDx Asthma, aspergillosis, occupational exposure, chronic bronchitis, sinusitis, in adults. JAMA. 1999;281:1512-8.
(21.) Avorn J, Solomon DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics therapeutics
Treatment and care to combat disease or alleviate pain or injury. Its tools include drugs, surgery, radiation therapy, mechanical devices, diet, and psychiatry. . Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine.
in·tern or in·terne
n. Med. 2000; 133:128-35.
(22.) McCaig L, Besser R, Hughes J. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287:3096-102.
(23.) Steinman M, Gonzales R, Linder J, Landefeld C. Changing use of antibiotics in community-based outpatient practice, 1991-1999. Ann Intern Med. 2003;138:525-33.
(24.) Finkelstein JA, Stille C, Nordin J, Davis R, Raebel MA, Roblin D, et al. Reduction in antibiotic use among US children, 1996-2000. Pediatrics. 2003;112:620-7.
(25.) Naimi TS, Smith KE, Besser J, Lynfield R. Antimicrobial resistance and judicious antimicrobial use in Minnesota and the United States. Minn Med. 2001;84:27-31.
(26.) Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models Not to be confused with general linear model.
In statistics, the generalized linear model (GLM) is a useful generalization of ordinary least squares regression. It relates the random distribution of the measured variable of the experiment (the . Biometrika. 1986;73:13-22.
(27.) Gonzales R, Sauaia A, Corbett KK, Maselli JH, Erbacher K, Leeman-Castillo BA, et al. Antibiotic treatment of acute respiratory tract infections Noun 1. respiratory tract infection - any infection of the respiratory tract
infection - the pathological state resulting from the invasion of the body by pathogenic microorganisms in the elderly: effect of a multidimensional educational intervention. J Am Geriatr Soc. 2004;52:39-45.
(28.) Welschen I, Kuyvenhoven MM, Hoes AW, Verheij YJ. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract respiratory tract
The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi.
Respiratory tract symptoms in primary care: randomised Adj. 1. randomised - set up or distributed in a deliberately random way
irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. . BMJ. 2004;329:431.
(29.) Doyne EO, Alfaro MP, Siegel RM, Atherton HD, Schoettker P J, Bernier J, et al. A randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. to change antibiotic prescribing patterns in a community. Arch Pediatr Adolesc Med. 2004;158:577-83.
(30.) Finkelstein JA, Davis RL, Dowell SF, Metlay JP, Soumerai SB, Rifas-Shiman SL, et al. Reducing antibiotic use in children: a randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. trial in 12 practices. Pediatrics. 2001;108:1-7.
(31.) Macfarlane MacFarlane or Macfarlane is a surname shared by:
The X-PIL service, launched in the UK in November 2005, aimed to replicate these leaflets in more accessible formats, . BMJ. 2002;324:91-4.
(32.) Hennessy T, Petersen K, Bruden D, Parkinson A, Hurlburt D, Getty M, et al. Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: s controlled intervention trial in Alaska. Clin Infect Dis. 2002;34:1543-50.
(33.) Mainous AG, Hueston WJ, Davis MP, Pearson WS. Trends in antimicrobial prescribing for bronchitis and upper respiratory infections among adults and children. Am J Public Health. 2003;93:1910-4.
(34.) Perz J, Craig A, Coffey C, Jorgensen D, Mitchel E, Hall S, et al. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 2002;287:3103-9.
(35.) Dowell S. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics. 1998;101(Suppl): 163-84.
(36.) Gonzales R, Bartlett JG, Besser RE, Cooper RJ, Hickner JM, Hoffman JR, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med. 2001:134:479-86.
(37.) Gonzales R, Bartlett JG, Besser RE, Hickner JM, Hoffman JR. Sande MA. Principles of appropriate antibiotic use for treatment of nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik)
1. not due to any single known cause.
2. not directed against a particular agent, but rather having a general effect.
1. upper respiratory tract infections in adults: background. Ann Intern Med. 2001;134:490-4.
(38.) Kiang kiang: see ass. KM, Kieke BA, Como-Sabetti K, Lynfield R. Besser RE, Belongia EA. Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug education campaign. Emerg Infect Dis. 2005;11:904-11.
(39.) Finch finch, common name for members of the Fringillidae, the largest family of birds (including over half the known species), found in most parts of the world except Australia. RG. Metlay JP, Davey PG, Baker LJ. Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR IFAR International Fanconi Anemia Registry (research and support group)
IFAR International Foundation for Art Research (research organization for visual art works)
IFAR Institute for Aging Research ) colloquium col·lo·qui·um
n. pl. col·lo·qui·ums or col·lo·qui·a
1. An informal meeting for the exchange of views.
2. An academic seminar on a broad field of study, usually led by a different lecturer at each meeting. , 2002. Lancet Infect Dis. 2004:4:44-53.
Edward A. Belongia, * Mary Jo Knobloch, * Burney A. Kieke, Jr., * Jeffrey P. Davis, ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) Carolyn Janette, ([double dagger]) (1) and Richard E. Besser ([section])
* Marshfield Clinic Research Foundation, Marshfield, Wisconsin For other places with the same name, see Marshfield (town), Wisconsin.
Marshfield is a city in Wisconsin. It is the largest city in Wood County, but it straddles the border between Wood and Marathon counties. , USA; ([dagger]) Wisconsin Division of Public Health, Madison, Wisconsin Madison is the capital of the U.S. state of Wisconsin and the county seat of Dane County. It is also home to the University of Wisconsin–Madison.
The 2006 population estimate of Madison was 223,389, making it the second largest city in Wisconsin, after Milwaukee, and , USA; ([double dagger]) Wisconsin Medical Society, Madison, Wisconsin, USA; and ([section]) Centers for Disease Control and Prevention, Atlanta, Georgia, USA
(1) Carolyn Janette is currently affiliated with Meriter Hospital, Madison, Wisconsin, USA.
Dr. Belongia is an infectious disease epidemiologist and director of the Epidemiology Research Center at the Marshfield Clinic Research Foundation.
Address for correspondence: Edward A. Belongia, Epidemiology, Research Center (ML2), Marshfield Clinic Research Foundation. 1000 North Oak Axe, Marshfield, WI 54449. USA: fax: 715-389-3880; email: email@example.com