Search

The novel coronavirus disease of 2019 (COVID-19) pandemic has severely impacted the training of health care professional students because of concerns of potential asymptomatic transmission to colleagues and vulnerable patients. From May 27th, 2020, to June 23rd 2021; at a time when B.1.1.7 (alpha) and B.1.617.2 (delta) were the dominant circulating variants, PCR testing was conducted on 1,237 nasopharyngeal swabs collected from 454 asymptomatic health care professional students as they returned to their studies from across Canada to Kingston, ON, a low prevalence area during that period for COVID-19. Despite 46.7% of COVID-19 infections occurring in the 18–29 age group in Kingston, severe-acute-respiratory coronavirus-2 was not detected in any of the samples suggesting that negligible asymptomatic infection occurred in this group and that PCR testing in this setting may not be warranted as a screening tool.

Background If untreated, Lyme disease can lead to long-term sequelae and post-treatment Lyme disease syndrome (PTLDS), resulting in reduced health-related quality of life. The objective of this study was to develop a microsimulation model to estimate the population-level health burden of Lyme disease in Ontario, Canada. Methods We developed a Lyme disease history model using microsimulation, simulating 100 000 people (mean age 37.6 yr, 51% female) from 2017 in Ontario over a lifetime risk of infection and time horizon. We extracted the sensitivity and specificity of the 2-tier testing recommended by the Canadian Public Health Laboratory Network, probabilities and health state utility values from the published literature and health administrative data. Our reported outcomes from our stochastic analysis include diagnosed cases of Lyme disease (stratified by stage), undiagnosed infections, sequelae, individuals with PTLDS and quality-adjusted life-years (QALYs) lost. Results Our model estimated 333 (95% confidence interval [CI] 329-337) infections over the lifetime of 100 000 simulated people (mean age 37.6 yr, 51% female), with 92% (95% CI 91%-93%) of infections diagnosed. Of those 308 people with Lyme Disease diagnoses, 67 (95% CI 65-69) developed sequelae (e.g., arthritic, cardiac, neurologic sequelae), and 34 (95% CI 33-35) developed PTLDS. Lyme disease resulted in a loss of 84.5 QALYs (95% CI 82.9-86.2) over the lifetime of the simulated cohort. Sensitivity and scenario analysis showed that increasing incidence rates of Lyme disease, potential underreporting, duration of PTLDS and quality of life (health state utility) associated with PTLDS had the greatest impact on health burden. Interpretation Lyme disease contributes considerable health burden in terms of QALYs lost. Our analysis provides evidence to understand the disease burden and lays the foundation to assess the cost-effectiveness of pharmaceutical and nonpharmaceutical interventions.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 pneumonia. We hypothesize that SARS-CoV-2 causes alveolar injury and hypoxemia by damaging mitochondria in airway epithelial cells (AEC) and pulmonary artery smooth muscle cells (PASMC), triggering apoptosis and bioenergetic impairment, and impairing hypoxic pulmonary vasoconstriction (HPV), respectively.We examined the effects of: A) human betacoronaviruses, SARS-CoV-2 and HCoV-OC43, and individual SARS-CoV-2 proteins on apoptosis, mitochondrial fission, and bioenergetics in AEC; and B) SARS-CoV-2 proteins and mouse hepatitis virus (MHV-1) infection on HPV.We used transcriptomic data to identify temporal changes in mitochondrial-relevant gene ontology (GO) pathways post-SARS-CoV-2 infection. We also transduced AECs with SARS-CoV-2 proteins (M, Nsp7 or Nsp9) and determined effects on mitochondrial permeability transition pore (mPTP) activity, relative membrane potential, apoptosis, mitochondrial fission, and oxygen consumption rates (OCR). In human PASMC, we assessed the effects of SARS-CoV-2 proteins on hypoxic increases in cytosolic calcium, an HPV proxy. In MHV-1 pneumonia, we assessed HPV via cardiac catheterization and apoptosis using the TUNEL assay.SARS-CoV-2 regulated mitochondrial apoptosis, mitochondrial membrane permeabilization and electron transport chain (ETC) GO pathways within 2 hours of infection. SARS-CoV-2 downregulated ETC Complex I and ATP synthase genes, and upregulated apoptosis-inducing genes. SARS-CoV-2 and HCoV-OC43 upregulated and activated dynamin-related protein 1 (Drp1) and increased mitochondrial fission. SARS-CoV-2 and transduced SARS-CoV-2 proteins increased apoptosis inducing factor (AIF) expression and activated caspase 7, resulting in apoptosis. Coronaviruses also reduced OCR, decreased ETC Complex I activity and lowered ATP levels in AEC. M protein transduction also increased mPTP opening. In human PASMC, M and Nsp9 proteins inhibited HPV. In MHV-1 pneumonia, infected AEC displayed apoptosis and HPV was suppressed. BAY K8644, a calcium channel agonist, increased HPV and improved SpOCoronaviruses, including SARS-CoV-2, cause AEC apoptosis, mitochondrial fission, and bioenergetic impairment. SARS-CoV-2 also suppresses HPV by targeting mitochondria. This mitochondriopathy is replicated by transduction with SARS-CoV-2 proteins, indicating a mechanistic role for viral-host mitochondrial protein interactions. Mitochondriopathy is a conserved feature of coronaviral pneumonia that may exacerbate hypoxemia and constitutes a therapeutic target.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant burden on healthcare systems. We compared

We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015-2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015-2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.

The novel coronavirus disease of 2019 (COVID-19) pandemic has severely impacted the training of health care professional students because of concerns of potential asymptomatic transmission to colleagues and vulnerable patients. From May 27th, 2020, to June 23rd 2021; at a time when B.1.1.7 (alpha) and B.1.617.2 (delta) were the dominant circulating variants, PCR testing was conducted on 1,237 nasopharyngeal swabs collected from 457 asymptomatic health care professional students as they returned to their studies from across Canada to Kingston, ON, a low prevalence area during that period for COVID-19. Despite 46.7% of COVID-19 infections occurring in the 18–29 age group in Kingston, severe-acute-respiratory coronavirus-2 was not detected in any of the samples suggesting that negligible asymptomatic infection occurred in this group and that PCR testing in this setting may not be warranted as a screening tool.

The purpose of this study was to evaluate the effect of chlorhexidine and essential oils containing mouth rinses on oral wound healing after periodontal flap surgery. Eighty subjects participated in the study and were randomly assigned to use water, 0.12% chlorhexidine (CHX), essential oils (EO), 5% CHX, and 10% EO. Subjects were examined at 1, 2, and 3 weeks postoperatively. Plaque index (PI) and the modified gingival index (GI) were recorded, while wound epithelialization was measured to evaluate the healing process. Numerical data were analyzed with parametric test for multiple comparisons (ANOVA) with Bonferroni correction. Categorical data were analyzed using Chi-square test/fisher exact test. All groups demonstrated a gradual GI reduction from first to third visit. Patients in the CHX group presented statistically significant lower PI scores than patients in the water group at the all-time points of the study. Wound epithelialization analysis demonstrated that 100% of the sites in the CHX group were healing by secondary intention at visit 1. This finding was statistically significant. Full strength concentrations of CHX and EO did not show any detrimental effects on healing after traditional periodontal surgery at the end of the observation period. The use of chlorhexidine and EO containing mouthwashes does not appear to delay wound healing. Diluting these commercial mouthwashes may present an approach that could possibly reduce the adverse effects (such as tooth staining) associated with their use, while maintaining their antibacterial properties.

KEY POINTS In an attempt to mitigate excess transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Canadian hospitals adopted “no visitor” policies during the first wave of the pandemic. A reflexive and almost complete restriction of visitors occurred across all hospitals

During the COVID-19 global pandemic, the cancer community faces many difficult questions. We will first discuss safety considerations for patients with cancer requiring treatment in SARS-CoV-2 endemic areas. We will then discuss a general framework for prioritizing cancer care, emphasizing the precautionary principle in decision making.

Lyme disease (LD) is the most commonly reported vector-borne disease, but its clinical consequences remain uncertain. We conducted a systematic review of the long-term sequelae and health-related quality of life (HRQoL) associated with LD in North America and Europe. We performed searches in 6 electronic databases up to December 2018 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including observational studies reporting long-term sequelae, HRQoL, and prognostic factors. We included 46 studies, published between 1994 and 2019. Based on 21 studies reporting attributable outcomes, higher proportions of sequelae reported from exposed patients were: neck pain, myalgia, arthralgia, paresthesia, sleep disorder, poor appetite, and concentration difficulties. Patients with PTLDS reported impaired HRQoL compared to the general US population. Included studies were highly heterogeneous in terms of study design, settings, patient characteristics, and quality. Patients with LD are more likely to report nonspecific long-term sequelae, especially those experiencing persistent symptoms posttreatment. Opportunities exist for prospective longitudinal studies to better understand LD outcomes.

This document updates the previous AMMI Canada Foundation Guidance (2013) on the use of antiviral therapy for influenza.Le présent document est une mise à jour des précédentes directives d’AMMI Canada (2013) sur l’utilisation des antiviraux contre la grippe.

The science of getting people to start something new is different from the science of getting them to continue positive behaviours. Amid rising rates of new SARS-CoV-2 variants of concern, Ontario needs a refreshed approach to maintaining and enhancing adherence to public health measures. Promising strategies to increase effective masking and physical distancing include persuasion, enablement, modelling the behaviour, and clear education.

New variants of concern (VOCs) now account for 67% of all Ontario SARS-CoV-2 infections. Compared with early variants of SARS-CoV-2, VOCs are associated with a 63% increased risk of hospitalization, a 103% increased risk of intensive care unit (ICU) admission and a 56% increased risk of death due to COVID-19. VOCs are having a substantial impact on Ontario’s healthcare system. On March 28, 2021, the daily number of new SARS-CoV-2 infections in Ontario reached the daily number of cases observed near the height of the second wave, at the start of the province-wide lockdown, on December 26, 2020. The number of people hospitalized with COVID-19 is now 21% higher than at the start of the province-wide lockdown, while ICU occupancy is 28% higher (Figure 1). The percentage of COVID-19 patients in ICUs who are younger than 60 years is about 50% higher now than it was prior to the start of the province-wide lockdown. Because the increased risk of COVID-19 hospitalization, ICU admission and death with VOCs is most pronounced 14 to 28 days after diagnosis, there will be significant delays until the full burden to the health care system becomes apparent.

SARS-CoV-2 screen testing is routine serial testing of asymptomatic individuals outside of outbreak or known exposure settings to identify staff infectious with SARS-CoV-2 and exclude them from work. Routine asymptomatic screen testing of staff has been proposed as a potential mitigating strategy to reduce SARS-CoV-2 introduction and transmission in long-term care (LTC) homes. A rapid review of the literature found no real-world evidence to either support or refute screen testing in preventing LTC home COVID-19 outbreaks. There are several direct harms associated with screen testing, as well as opportunity costs, including exacerbating LTC staffing shortages. On the basis of the evidence reviewed, and given the high rates of protection of COVID-19 vaccines against symptomatic and asymptomatic SARS-CoV-2 infection, the potential harms and costs of screen testing among vaccinated LTC home staff likely outweigh the benefits.

Health Care Workers (HCWs) are the backbone of Ontario’s COVID-19 pandemic response and are a key vaccination priority group. About 80% of Ontario HCWs intend to receive COVID-19 vaccine.1 Challenges include the logistics of delivering the vaccine to this mobile and diverse group and improving vaccine confidence in the remaining 20%. These challenges can be overcome by allaying safety concerns and highlighting personal benefits; tailoring messages to factors associated with lower intention (e.g. age, gender, ethnicity and work setting); employing trusted leaders to set the tone and peers to build social norms; and leveraging public health organizations and health institutions as existing channels of influence.

As Ontario expands access to the COVID-19 vaccine beyond the Phase 1 priority populations, strategic planning and execution of mass vaccine rollout will have a significant impact on the health and safety of Ontario’s 14.5 million residents. There are six key elements of Israel’s successful COVID-19 vaccine campaign that can be readily applied to Ontario to expedite and expand the province’s vaccine rollout strategy: a simple vaccine prioritization process; modification to the transport, storage, and distribution of the vaccines; effective communication to promote vaccine confidence; decentralization of vaccination sites; centralized organization through Health Maintenance Organizations (HMOs) using a fully integrated information technology (IT) system in a universal health care system; and the engagement of community-based personnel, infrastructure, and resources.

Key Message Accelerating the rollout of Ontario’s COVID-19 vaccine such that all LTC residents receive the first dose of a COVID-19 vaccine by January 31, 2021, would prevent a projected 600 COVID-19 cases and 115 deaths by March 31, 2021 when compared with the province’s current plan to vaccinate all LTC residents by February 15, 2021. Projections indicate that further acceleration of the rollout would prevent even more COVID-19 cases and deaths. If vaccine supply is limited, the early provision of first doses of a COVID-19 vaccine to LTC home residents is likely to be more beneficial than the on-schedule provision of second doses to health care workers outside of LTC homes. All LTC residents should receive the second dose according to approved vaccination schedules.

Key Message Ontario long-term care (LTC) home residents have experienced disproportionately high morbidity and mortality, both from COVID-19 and from the conditions associated with the COVID-19 pandemic. There are several measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes, if implemented. First, temporary staffing could be minimized by improving staff working conditions. Second, homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Third, the risk of SARS-CoV-2 infection in staff could be minimized by approaches that reduce the risk of transmission in communities with a high burden of COVID-19. Summary Background The Province of Ontario has 626 licensed LTC homes and 77,257 long-stay beds; 58% of homes are privately owned, 24% are non-profit/charitable, 16% are municipal. LTC homes were strongly affected during Ontario’s first and second waves of the COVID-19 pandemic. Questions What do we know about the first and second waves of COVID-19 in Ontario LTC homes? Which risk factors are associated with COVID-19 outbreaks in Ontario LTC homes and the extent and death rates associated with outbreaks? What has been the impact of the COVID-19 pandemic on the general health and wellbeing of LTC residents? How has the existing Ontario evidence on COVID-19 in LTC settings been used to support public health interventions and policy changes in these settings? What are the further measures that could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes? Findings As of January 14, 2021, a total of 3,211 Ontario LTC home residents have died of COVID-19, totaling 60.7% of all 5,289 COVID-19 deaths in Ontario to date. There have now been more cumulative LTC home outbreaks during the second wave as compared with the first wave. The infection and death rates among LTC residents have been lower during the second wave, as compared with the first wave, and a greater number of LTC outbreaks have involved only staff infections. The growth rate of SARS-CoV-2 infections among LTC residents was slower during the first two months of the second wave in September and October 2020, as compared with the first wave. However, the growth rate after the two-month mark is comparatively faster during the second wave. The majority of second wave infections and deaths in LTC homes have occurred between December 1, 2020, and January 14, 2021 (most recent date of data extraction prior to publication). This highlights the recent intensification of the COVID-19 pandemic in LTC homes that has mirrored the recent increase in community transmission of SARS-CoV-2 across Ontario. Evidence from Ontario demonstrates that the risk factors for SARS-CoV-2 outbreaks and subsequent deaths in LTC are distinct from the risk factors for outbreaks and deaths in the community (Figure 1). The most important risk factors for whether a LTC home will experience an outbreak is the daily incidence of SARS-CoV-2 infections in the communities surrounding the home and the occurrence of staff infections. The most important risk factors for the magnitude of an outbreak and the number of resulting resident deaths are older design, chain ownership, and crowding. Figure 1. Anatomy of Outbreaks and Spread of COVID-19 in LTC Homes and Among Residents Figure from Peter Hamilton, personal communication. Many Ontario LTC home residents have experienced severe and potentially irreversible physical, cognitive, psychological, and functional declines as a result of precautionary public health interventions imposed on homes, such as limiting access to general visitors and essential caregivers, resident absences, and group activities. There has also been an increase in the prescribing of psychoactive drugs to Ontario LTC residents. The accumulating evidence on COVID-19 in Ontario’s LTC homes has been leveraged in several ways to support public health interventions and policy during the pandemic. Ontario evidence showed that SARS-CoV-2 infections among LTC staff was associated with subsequent COVID-19 deaths among LTC residents, which motivated a public order to restrict LTC staff from working in more than one LTC home in the first wave. Emerging Ontario evidence on risk factors for LTC home outbreaks and deaths has been incorporated into provincial pandemic surveillance tools. Public health directives now attempt to limit crowding in LTC homes by restricting occupancy to two residents per room. The LTC visitor policy was also revised to designate a maximum of two essential caregivers who can visit residents without time limits, including when a home is experiencing an outbreak. Several further measures could be effective in preventing COVID-19 outbreaks, hospitalizations, and deaths in Ontario’s LTC homes. First, temporary staffing could be minimized by improving staff working conditions. Second, the risk of SARS-CoV-2 infection in staff could be minimized by measures that reduce the risk of transmission in communities with a high burden of COVID-19. Third, LTC homes could be further decrowded by a continued disallowance of three- and four-resident rooms and additional temporary housing for the most crowded homes. Other important issues include improved prevention and detection of SARS-CoV-2 infection in LTC staff, enhanced infection prevention and control (IPAC) capacity within the LTC homes, a more balanced and nuanced approach to public health measures and IPAC strategies in LTC homes, strategies to promote vaccine acceptance amongst residents and staff, and further improving data collection on LTC homes, residents, staff, visitors and essential caregivers for the duration of the COVID-19 pandemic. Interpretation Comparisons of the first and second waves of the COVID-19 pandemic in the LTC setting reveal improvement in some but not all epidemiological indicators. Despite this, the second wave is now intensifying within LTC homes and without action we will likely experience a substantial additional loss of life before the widespread administration and time-dependent maximal effectiveness of COVID-19 vaccines. The predictors of outbreaks, the spread of infection, and deaths in Ontario’s LTC homes are well documented and have remained unchanged between the first and the second wave. Some of the evidence on COVID-19 in Ontario’s LTC homes has been effectively leveraged to support public health interventions and policies. Several further measures, if implemented, have the potential to prevent additional LTC home COVID-19 outbreaks and deaths.

Administering Pfizer-BioNTech’s COVID-19 vaccine during the early stage of the vaccine rollout (January/February 2021) to as many individuals as possible would prevent more COVID-19 cases in Ontario as compared to reserving half of the initial allotments as second booster doses (Figure 1). On-label use of the vaccine with the administration of two doses is important, as the second dose significantly boosts the immune response and results in a substantial increase in neutralizing antibodies. However, using 100% of the initial allotments immediately to vaccinate as many individuals as possible does not preclude on-label use with two doses, even though the interval between first and second booster dose may become longer than 21 days.

We provide an update to the Association of Medical Microbiology and Infectious Disease Canada foundation guidance for the upcoming 2020-2021 influenza season in Canada. Important issues for this year include the implications of co-circulation of SARS-CoV-2, the role of diagnostic testing, and a restatement of dosing and administration recommendations for neuraminidase inhibitors in various age groups and underlying health conditions. Although peramivir and baloxivir are now licensed in Canada, neither is currently marketed, so this guidance focuses on further optimizing the use of oseltamivir and zanamivir.Nous actualisons l’information sur les directives de la Fondation de l’Association pour la microbiologie médicale et l'infectiologie Canada en vue de la saison grippale 2020–2021 au Canada. Cette année, les enjeux importants touchent les conséquences de la co-circulation de la maladie à coronavirus 2019, le rôle des tests diagnostiques et la réaffirmation des recommandations relatives aux maladies sous-jacentes ainsi qu’à la posologie et à l’administration des inhibiteurs de la neuraminidase dans divers groupes d’âge. Même si le péramivir et le baloxivir sont désormais homologués au Canada, ces médicaments n’y sont pas encore commercialisés, et c’est pourquoi les présentes directives visent à optimiser l’utilisation de l’oseltamivir et du zanamivir.

The emergence and global spread of SARS-CoV-2 has had profound social and economic consequences and has shed light on the importance of continued and additional investment in global health and infectious disease surveillance. Identifying changes in viral genomes provides key insights into viral diversity, how viruses spread within populations, and viral strategies for evasion of host immune systems. Here we report twenty-five SARS-CoV-2 genome sequences collected from some of the first COVID-19 cases in eastern Ontario, Canada (March 18-30, 2020). The reported genomes belong to the S-clade (n=2) and G-clade (n=23) of SARS-CoV-2 and contain 45 polymorphic sites including one shared missense and three unique synonymous variants in the gene encoding the spike protein. A phylogenetic analysis enabled the tracing of viral origin and potential transmission into and within Canada. There may be as many as sixteen unique infection events represented in these samples, including at least three that were likely introduced from Europe and seven from the USA. In addition, four separate genomes are each shared by multiple patients, suggesting a common origin or community spread even during this early stage of infection. These results demonstrate how molecular epidemiology and evolutionary phylogenetics can help local health units track origins and vectors of spread for emerging diseases like SARS-CoV-2. Earlier detection and screening in this way could improve the effectiveness of regional public health interventions to prevent future pandemics.

Background: The clinical and molecular epidemiology of health care–associated Clostridium difficile infection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care–associated C. difficile infection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain. Methods: Adult inpatients with C. difficile infection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends. Results: Over a 7-year period, 20 623 adult patients admitted to hospital with health care–associated C. difficile infection were reported to CNISP, and microbiological data were available for 2690 patients. From 2009 to 2015, the national rate of health care–associated C. difficile infection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficile infection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29–2.82). Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care–associated C. difficile infection; for every 10% increase in the proportion of NAP1 strains, the rate of health care–associated C. difficile infection increased by 3.3% (95% CI 1.7%–4.9%). Interpretation: Rates of health care–associated C. difficile infection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.

In preparation for an influenza pandemic, knowledge of how disease spreads as well as having effective intervention strategies in place are critical to mitigate its impacts. We propose a simulation-based optimization model that minimizes the costs associated with the pandemic occurrence, while capturing how influenza spreads among individuals based on the socio-demographic characteristics of the population. Multiple intervention strategies, including school closure and home confinement, are considered to incorporate the changes of a pandemic course in our model and to measure the corresponding effects on the number of infected people. In addition, we apply the NSGS (Nelson, Swann, Goldsman, Song) procedure to achieve computationally efficient and tractable solutions to the resulting large-scale problem. Using real data from Jefferson County, Kentucky, with a population of more than 700,000 obtained from the US Census Bureau, we present computational results to demonstrate the efficacy of applying ...

Background: Bloodstream infections (BSIs) due to methicillin-resistant Staphylococcus aureus (MRSA) are important causes of morbidity and mortality in hospitalized patients. Long-term national MRSA BSI surveillance establishes rates for internal and external comparison and provide insight into epidemiologic, molecular, and resistance trends. Here, we present and discuss National MRSA BSI incidence rates and trends over time in Canadian acute-care hospitals from 2008 to 2018. Methods: The Canadian Nosocomial Infection Surveillance Programme (CNISP) is a collaborative effort of the Association of Medical Microbiology and Infectious Disease Canada and the Public Health Agency of Canada. Since 1995, the CNISP has conducted hospital-based sentinel surveillance of MRSA BSIs. Data were collected using standardized definitions and forms from hospitals that participate in the CNISP (48 hospitals in 2008 to 62 hospitals in 2018). For each MRSA BSI identified, the medical record was reviewed for clinical and demographic information and when possible, 1 blood-culture isolate per patient was submitted to a central laboratory for further molecular characterization and susceptibility testing. Results: From 2008 to 2013, MRSA BSI rates per 10,000 patient days were relatively stable (0.60–0.56). Since 2014, MRSA BSI rates have gradually increased from 0.66 to 1.05 in 2018. Although healthcare-associated (HA) MRSA BSI has shown a minimal increase (0.40 in 2014 to 0.51 in 2018), community-acquired (CA) MRSA BSI has increased by 150%, from 0.20 in 2014 to 0.50 in 2018 (Fig. 1). Laboratory characterization revealed that the proportion of isolates identified as CMRSA 2 (USA 100) decreased each year, from 39% in 2015 to 28% in 2018, while CMRSA 10 (USA 300) has increased from 41% to 47%. Susceptibility testing shows a decrease in clindamycin resistance from 82% in 2013 to 41% in 2018. Conclusions: Over the last decade, ongoing prospective MRSA BSI surveillance has shown relatively stable HA-MRSA rates, while CA-MRSA BSI rates have risen substantially. The proportion of isolates most commonly associated with HA-MRSA BSI (CMRSA2/USA 100) are decreasing and, given that resistance trends are tied to the prevalence of specific epidemic types, a large decrease in clindamycin resistance has been observed. MRSA BSI surveillance has shown a changing pattern in the epidemiology and laboratory characterization of MRSA BSI. The addition of hospitals in later years that may have had higher rates of CA-MRSA BSI could be a confounding factor. Continued comprehensive national surveillance will provide valuable information to address the challenges of infection prevention and control of MRSA BSI in hospitals.Funding: NoneDisclosures: None

Influenza vaccine is recommended annually to reduce the influenza-associated disease burden, particularly among those at high risk of serious influenza complications ( 1 ). However, a potential for low vaccine effectiveness (VE) has been identified for the 2017–2018 influenza season. To address that concern, the following antiviral drug recommendations have been revised (see Table 1 , changes in bold) from the AMMI Canada Foundation Document ( 2 ).

Mycobacterium szulgai is an uncommonly isolated non-tuberculous mycobacterium (NTM) of clinical and pathological significance that is usually managed with antimycobacterial therapy alone. We descri...

This chapter will provide, first, some basic information about criminal justice systems in the United States, including definitions, costs, and the need to view such systems from a systems perspective. Following this introduction, a review of the research involving the intersection of (1) analytical methodologies including simulation and (2) the design and operation of criminal justice systems will be given. The review will cover the areas of (1) prediction of crime, criminal detection, and arrest; (2) adjudication; (3) incarceration and rehabilitation; and (4) multi-aspects of criminal justice systems. The chapter will close out with sections on suggestions for future research and conclusions.

OBJECTIVETo assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE).DESIGNQuasi-experimental ecological study over 3.5 years.METHODSAll VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome.RESULTSThe incidence rate ratio (IRR) for VRE infections was 0.59 and the associatedPvalue was .34. For VRE bacteremias, the IRR was 0.54 andP=.38; for all-cause mortality the IRR was 0.70 andP=.66; and for VRE attributable death, the IRR was 0.35 andP=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance.CONCLUSIONClinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact.Infect Control Hosp Epidemiol2016;1–7

We consider a special case of the vehicle routing problem where not only each customer has specified delivery time window, but each route has limited time duration. We propose a solution algorithm using network reduction techniques and simulated annealing meta-heuristic. The objective is twofold: minimising the travel time and minimising the total number of vehicles required. The time-window constraint ensures delivery without delay, thus, a potentially higher level of customer satisfaction. The algorithm has helped the transportation planning team at General Electric Appliances & Lighting to significantly reduce the number of required trucks in two real cases, while its performance on randomly generated cases is also efficient when compared to properly selected benchmarking algorithms.

BACKGROUND: Overuse of investigations, treatments, and procedures contribute to rising health care costs and may cause patient harm. In an attempt to promote higher-value health care, the Choosing Wisely Canada campaign has encouraged professional societies to develop statements that are directly actionable by their members. Currently, there are variations in infectious diseases practice that lead some patients to receive therapies and investigations that lack benefit and are potentially harmful. METHODS: The Association of Medical Microbiology and Infectious Disease Canada (AMMI) Canada established its Choosing Wisely Canada top five list of recommendations using the framework put forward by Choosing Wisely Canada. Following an electronic survey of its members regarding low-value practices within infectious diseases, AMMI Canada convened a working group that developed a list of draft recommendations and ranked the top five recommendations by consensus. This list was shared with the AMMI Canada membership electronically and during a national open forum. Following revisions based on feedback received, the AMMI Canada Executive Council and Guidelines Committee endorsed the final list, which was disseminated online. RESULTS: The top five declarative statements on infectious diseases practices that physicians and patients should question include: do not routinely prescribe intravenous forms of highly bioavailable antimicrobial agents for patients who can reliably take and absorb oral medications; do not prescribe alternative second-line antimicrobials to patients reporting nonsevere reactions to penicillin when beta-lactams are the recommended first-line therapy; do not routinely repeat CD4 measurements in patients with HIV infection with HIV-1 RNA suppression for >2 years and CD4 counts >500/μL, unless virological failure occurs or intercurrent opportunistic infection develops; do not routinely repeat radiologic imaging in patients with osteomyelitis demonstrating clinical improvement following adequate antimicrobial therapy; and do not prescribe aminoglycosides for synergy to patients with bacteremia or native valve infective endocarditis caused by Staphylococcus aureus. CONCLUSIONS: The Choosing Wisely Canada statements in infectious diseases endorsed by AMMI Canada represent a starting point to engage AMMI Canada members in broader discussions related to resource stewardship within infectious diseases practice and to take action.