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The global burden of viral hepatitis B is substantial, and monitoring infections across the care cascade is important for elimination efforts. There is little information on care disparities by immigration status, and we aimed to quantify disease burden among immigrant subgroups.In this population-based, retrospective cohort study, we used linked laboratory and health administrative records to describe the HBV care cascade in five distinct stages: (1) lifetime prevalence; (2) diagnosis; (3) engagement with care; (4) treatment initiation; and (5) treatment continuation. Infections were identified based on at least one reactive antigen or nucleic acid test, and lifetime prevalence was estimated as the sum of diagnosed and estimated undiagnosed cases. Care cascades were compared between long-term residents and immigrant groups, including subgroups born in hepatitis B endemic countries. Stratified analyses and multivariable Poisson regression were used to identify drivers for cascade progression. Between January 1997 and December 2014, 2,014,470 persons were included, 50,475 with infections, of whom 30,118 were engaged with care, 11,450 initiated treatment, and 6554 continued treatment1 year. Lifetime prevalence was estimated as 163,309 (1.34%) overall, 115,722 (3.42%) among all immigrants, and 50,876 (9.37%) among those from highly endemic countries. Compared to long-term residents, immigrants were more likely to be diagnosed (adjusted rate ratio [aRR], 4.55; 95% CI, 4.46, 4.63), engaged with care (aRR, 1.07; 95% CI, 1.04, 1.09), and initiate treatment (aRR, 1.09; 95% CI, 1.03, 1.16).In conclusion, immigrants fared well compared to long-term residents along the care cascade, having higher rates of diagnosis and slightly better measures in subsequent cascade stages, although intensified screening efforts and better strategies to facilitate linkage to care are still needed.

Hepatitis C virus (HCV) elimination has evolved into a coordinated global effort. Canada, with more than 250,000 chronically infected individuals, is among the countries leading this effort. The 9th Canadian Symposium on HCV, held in February 2020, thus established and addressed its theme, ‘advances in HCV research and treatment towards elimination’, by gathering together basic scientists, clinicians, epidemiologists, social scientists, and community members interested in HCV research in Canada. Plenary sessions showcased topical research from prominent international and national researchers, complemented by select abstract presentations. This event was hosted by the Canadian Network on Hepatitis C (CanHepC), with support from the Public Health Agency of Canada and the Canadian Institutes of Health Research and in partnership with the Canadian Liver Meeting. CanHepC has an established record in HCV research by its members and in its advocacy activities to address the care, treatment, diagnosis, and immediate and long-term needs of those affected by HCV infection. Many challenges remain in tackling chronic HCV infection, such as the need for a vaccine; difficult-to-treat populations and unknown aspects of patient subgroups, including pregnant women and children; vulnerable people; and issues distinct to Indigenous peoples. There is also increasing concern about long-term clinical outcomes after successful treatment, with the rise in comorbidities such as diabetes, cardiovascular disease, and fatty liver disease and the remaining risk for hepatocellular carcinoma in cirrhotic individuals. The symposium addressed these topics in highlighting research advances that will collectively play an important role in eliminating HCV and minimizing subsequent health challenges.

Digital evolution is a computer-based instantiation of Darwinian evolution in which short self-replicating computer programs compete, mutate, and evolve. It is an excellent platform for addressing topics in long-term evolution and paleobiology, such as mass extinction and recovery, with experimental evolutionary approaches. We evolved model communities with ecological interdependence among community members, which were subjected to two principal types of mass extinction: a pulse extinction that killed randomly, and a selective press extinction involving an alteration of the abiotic environment to which the communities had to adapt. These treatments were applied at two different strengths, along with unperturbed control experiments. We examined how stability in the digital communities was affected from the perspectives of division of labor, relative shift in rank abundance, and genealogical connectedness of the community's component ecotypes. Mass extinction that was due to a Strong Press treatment was most effective in producing reshaped communities that differed from the pre-treatment ones in all of the measured perspectives; weaker versions of the treatments did not generally produce significant departures from a Control treatment; and results for the Strong Pulse treatment generally fell between those extremes. The Strong Pulse treatment differed from others in that it produced a slight but detectable shift towards more generalized communities. Compared to Press treatments, Pulse treatments also showed a greater contribution from re-evolved ecological doppelgangers rather than new ecotypes. However, relatively few Control communities showed stability in any of these metrics over the whole course of the experiment, and most did not represent stable states (by some measure of stability) that were disrupted by the extinction treatments. Our results have interesting, broad qualitative parallels with findings from the paleontological record, and show the potential of digital evolution studies to illuminate many aspects of mass extinction and recovery by addressing them in a truly experimental manner.

Background The management and outcomes of preterm births can vary greatly even among developed nations with the same access to medicine, technology and expertise. We aimed to compare aspects of obstetrical management and mortality for preterm infants in France and Ontario, Canada. Methods The Better Outcomes Registry & Network (BORN) Information System in Ontario and Epidemiologique sur les petits âges gestationnels (EPIPAGE-2) in France collected information on maternal demographics, obstetrical characteristics, obstetrical interventions and neonatal outcomes for infants born between 22 and 34 weeks gestation. We used standardized covariate definitions and extracted data from 2011 (for EPIPAGE-2) and from 2012 and 2013 (for BORN) to conduct a cohort study comparing the 2 data sets (stratified into gestational age groups of 22-26, 27-31 and 32-34 wk) using multivariable logistic regression models. Results Mothers in the BORN cohort were older (30.7 yr v. 29.6 yr) but less likely to have gestational hypertension (13.4% v. 17.9%) than those in the EPIPAGE-2 cohort. Infants from EPIPAGE-2 had lower birth weights (1.3 kg v. 1.5 kg) and were more likely to be born in an institution with level 3 care (71.9% v. 55.8%). After adjustment for these differences, there was significantly higher neonatal mortality among infants from EPIPAGE-2 in the 22-26 week gestation age group (adjusted odds ratio 2.81; 95% confidence interval 1.17 to 6.74). Interpretation Even after we adjusted for both intrinsic population differences and differences in management between Ontario and France, we found a higher rate of neonatal mortality at earlier gestational ages in France. This may be related to differences in ethical approaches and/or postnatal management and should be explored further.

Background & aims Viral hepatitis C represents a major global burden, particularly among immigrant-receiving countries such as Canada, where knowledge of disparities in hepatitis C virus among immigrant groups for micro-elimination efforts is lacking. We quantify the hepatitis C cascades of care among immigrants and long-term residents prior to the introduction of direct-acting antiviral medications. Methods Using laboratory and health administrative records, we described the hepatitis C virus cascades of care in terms of diagnosis, engagement with care, treatment initiation, and clearance in Ontario, Canada (1997-2014). We stratified the cascade by immigrant and long-term resident groups and identify drivers at each stage using multivariable Poisson regression. Results We included 940,245 individuals in the study with an estimated hepatitis C prevalence of 167,923 (1.4%) overall, 23,759 (0.7%) among all immigrants, and 6,019 (1.1%) among immigrants from hepatitis C endemic countries. Overall there were 104,616 individuals with reactive antibody results, 73,861 tested for viral RNA, 52,388 with viral RNA detected, 50,805 genotyped, 13,159 on treatment, and 3,919 with evidence of viral clearance. Compared to long-term residents, immigrants showed increased nucleic-acid testing (aRR: 1.09 [95%CI: 1.08, 1.10]), treatment initiation (aRR: 1.46 [95%CI: 1.38, 1.54]), and higher clearance rates (aRR: 1.07 [95%CI: 1.03, 1.11]). Conclusions Hepatitis C virus is more prevalent among long-term residents compared to immigrants overall, however immigrants from endemic countries are an important subgroup to consider for future screening and linkage to care initiatives. These findings are prior to the introduction of newer medications and provide a population-based benchmark for follow-up studies and evaluation of treatment programs and surveillance activities.

We aimed to determine the criterion validity of using diagnosis codes for hepatitis B virus (HBV) and hepatitis C virus (HCV) to identify infections.Using linked laboratory and administrative data in Ontario, Canada, from January 2004 to December 2014, we validated HBV/HCV diagnosis codes against laboratory-confirmed infections. Performance measures (sensitivity, specificity, and positive predictive value) were estimated via cross-validated logistic regression and we explored variations by varying time windows from 1 to 5 years before (i.e., prognostic prediction) and after (i.e., diagnostic prediction) the date of laboratory confirmation. Subgroup analyses were performed among immigrants, males, baby boomers, and females to examine the robustness of these measures.A total of 1,599,023 individuals were tested for HBV and 840,924 for HCV, with a resulting 41,714 (2.7%) and 58,563 (7.0%) infections identified, respectively. HBV/HCV diagnosis codes ± 3 years of laboratory confirmation showed high specificity (99.9% HBV; 99.8% HCV), moderate positive predictive value (70.3% HBV; 85.8% HCV), and low sensitivity (12.8% HBV; 30.8% HCV). Varying the time window resulted in limited changes to performance measures. Diagnostic models consistently outperformed prognostic models. No major differences were observed among subgroups.HBV/HCV codes should not be the only source used for monitoring the population burden of these infections, due to low sensitivity and moderate positive predictive values. These results underscore the importance of ongoing laboratory and reportable disease surveillance systems for monitoring viral hepatitis in Ontario.RéSUMé: OBJECTIF: Nous avons cherché à déterminer le critère de validité de l’utilisation des codes de diagnostic du virus de l’hépatite B (VHB) et du virus de l’hépatite C (VHC) pour identifier les infections. MéTHODES: En utilisant des données de laboratoire et administratives couplées en Ontario, au Canada, de janvier 2004 à décembre 2014, nous avons validé les codes de diagnostic du VHB/VHC contre les infections confirmées en laboratoire. Les mesures du rendement (sensibilité, spécificité et valeur prédictive positive) ont été estimées par régression logistique croisée et nous avons exploré les variations en variant les fenêtres temporelles de 1 à 5 ans avant (c.-à-d. prédiction pronostique) et après (c.-à-d. prédiction diagnostique) la date de confirmation en laboratoire. Des analyses de sous-groupes ont été effectuées auprès d’immigrants, d’hommes, de baby-boomers et de femmes pour examiner la robustesse de ces mesures. RéSULTATS: 1 599 023 individus ont été testés pour le VHB et 840 924 pour le VHC, dont 41 714 (2,7 %) et 58 563 (7,0 %) infections ont été identifiées, respectivement. Les codes de diagnostic VHB/VHC ± 3 ans de confirmation en laboratoire ont montré une spécificité élevée (99,9 % VHB; 99,8 % VHC), une valeur prédictive positive modérée (70,3 % VHB; 85,8 % VHC) et une faible sensibilité (12,8 % VHB; 30,8 % VHC). La variation de la fenêtre temporelle a entraîné des changements limités aux mesures du rendement. Les modèles diagnostiques ont constamment surpassé les modèles pronostiques. Aucune différence majeure n’a été observée entre les sous-groupes. CONCLUSION: Les codes VHB/VHC ne devraient pas être la seule source utilisée pour surveiller la charge de population de ces infections, en raison de la faible sensibilité et des valeurs prédictives positives modérées. Ces résultats soulignent l’importance des systèmes continus de surveillance des maladies à déclaration obligatoire en laboratoire pour surveiller l’hépatite virale en Ontario.

BackgroundSexually transmitted infections (STI) prevention in the Northwest Territories (NWT), Canada is an urgent concern as STI prevalence is seven-fold the national average. The study objective was to explore factors associated with sexual activity and condom use among adolescents in the NWT.MethodsWe conducted a cross-sectional survey with youth aged 13–18-years-old in 17 NWT communities. We use Poisson regression models with a robust sandwich error variance to estimate adjusted relative risks estimates of the likelihood of experiencing the primary outcomes of sexual activity (vaginal/anal/oral sex) and consistent condom use (oral/anal sex) in the past 3 months by gender.ResultsParticipants (n=607; mean age: 14.2 years; SD: 1.5) included adolescent cisgender girls (n=302; 49.5%), cisgender boys (n=298; 48.9%) and transgender persons (n=7; 1.2%). Most identified as Indigenous (n=444; 73.1%) and 14.0% (n=85) as lesbian, gay, bisexual or queer sexuality (LGBQ+). Among sexually active individuals (n=115), less than half (n=54; 47.0%) reported past 3 month consistent condom use. In adjusted analyses among girls, sexual activity was associated with age, STI knowledge, and alcohol/drug use; LGBQ+ identity and alcohol/drug use were associated with reduced likelihood of condom use. Among boys, sexual activity was associated with age and alcohol/drug use; LGBQ+ identity was associated with increased likelihood of condom use.ConclusionsFindings demonstrate sexual activity among adolescents in the NWT varies by gender, age, and alcohol/drug use. Consistent condom utilisation was low, particularly for those using alcohol/drugs. Gender-tailored STI prevention strategies with Northern adolescents should address alcohol/drug use and build protective factors.

There are many ways to account for the return on investment (ROI) in healthcare: improved communication, teamwork, culture, patient satisfaction, staff satisfaction, and clinical outcomes are but a few. Some of these are easier to quantify and associate to an intervention than others. What if the outcomes listed were not just independent results, but beget one another? In 2001, the Society of Obstetricians and Gynaecologists of Canada created the Managing Obstetrical Risk Efficiently (MORE

Background There are few data about the utility of the Canadian tuberculosis medical surveillance system for detecting tuberculosis in children and adolescents. We sought to assess the prevalence of tuberculosis infection and disease in children and adolescents referred by the tuberculosis medical surveillance program who were evaluated at The Hospital for Sick Children (SickKids) tuberculosis program. Methods We retrospectively studied clinical records, radiographic findings and results of interferon-γ release assays (IGRAs) of all children less than 18 years of age referred by the tuberculosis medical surveillance program and evaluated at SickKids between November 2012 and June 2016. Results The median age of the 216 children was 10.0 years. Most were born in the Philippines (157 [72.7%]) or India (39 [18.0%]). Of the 216, 166 (76.8%) had a history of prior treatment for tuberculosis, and 34 (15.7%) were federal-sponsored refugees from settings with a high tuberculosis burden. Negative IGRA results were found in 110/130 (84.6%) of those with prior tuberculosis treatment. Thirty-one children (14.4%) had any chest radiographic abnormality, of whom 4 had changes thought to be due to tuberculosis. No child received a diagnosis of active tuberculosis at assessment or during follow-up; 3 (1.4%) were treated for latent tuberculosis infection following IGRA testing at SickKids. A positive IGRA result was associated with contact with infectious tuberculosis (odds ratio [OR] 5.97, 95% confidence interval [CI] 2.06-17.52) and older age at first clinic visit (OR 2.98, 95% CI 1.24-8.30) but not with radiographic abnormalities or history of prior tuberculosis treatment. Interpretation Most children were referred because of a history of prior treatment for tuberculosis; few had clinical or laboratory evidence of infection or prior disease. The tuberculosis medical surveillance process did not identify any children who required treatment for active disease and requires improvement.

Late preterm birth (LPB) is increasingly common and associated with higher morbidity and mortality than term birth. Yet, little is known about the influence of previous cesarean section (PCS) and the occurrence of LPB in subsequent pregnancies. We aim to evaluate this association along with the potential mediation by cesarean sections in the current pregnancy.We use population-based birth registry data (2005-2012) to establish a cohort of live born singleton infants born between 34 and 41 gestational weeks to multiparous mothers. PCS was the primary exposure, LPB (34-36 weeks) was the primary outcome, and an unplanned or emergency cesarean section in the current pregnancy was the potential mediator. Associations were quantified using propensity weighted multivariable Poisson regression, and mediating associations were explored using the Baron-Kenny approach.The cohort included 481,531 births, 21,893 (4.5%) were LPB, and 119,983 (24.9%) were predated by at least one PCS. Among mothers with at least one PCS, 6307 (5.26%) were LPB. There was increased risk of LPB among women with at least one PCS (adjusted Relative Risk (aRR): 1.20 (95%CI [1.16, 1.23]). Unplanned or emergency cesarean section in the current pregnancy was identified as a strong mediator to this relationship (mediation ratio = 97%).PCS was associated with higher risk of LPB in subsequent pregnancies. This may be due to an increased risk of subsequent unplanned or emergency preterm cesarean sections. Efforts to minimize index cesarean sections may reduce the risk of LPB in subsequent pregnancies.

Background Identifying social and structural factors associated with sexually transmitted infections (STI) vulnerability is urgent in the Northwest Territories (NWT), where STI prevalence is 7-fold the Canadian average. The NWT also experiences higher food insecurity and intimate partner violence (IPV) than the national average. Safer sex efficacy (SSE) comprises knowledge, intention, and relationship dynamics for safer sex negotiation. We examined social and structural factors associated with SSE among Northern and Indigenous adolescents in the NWT. Methods With an Indigenous sexual health agency, we conducted a cross-sectional survey with adolescents aged 13–17 in 17 NWT communities. Summary statistics and statistical comparisons were conducted, followed by crude and multivariable regression models, with a canonical link function, to compare factors associated with SSE and within gender stratifications. We conducted post-hoc sensitivity analyses among Indigenous youth. Results There were 610 participants (mean age: 14.2 years [SD: 1.5]; 49.5% cisgender women, 48.9% cisgender men, 1.6% transgender persons); three-quarters (n=447; 73.3%) were Indigenous. One-quarter (n=144; 23,6%) reported food insecurity and nearly one-fifth (n=111; 18.2%) IPV. Among young women, food insecurity (β: -1.89[CI: -2.98, -0.80], p=0.001) and IPV (β: -1.31[CI: -2.53, -0.09], p=0.036) were associated with lower SSE in adjusted analyses, and currently dating was associated with increased SSSE (β: 1.17[CI: 0.15, 2.19], p=0.024). Among young men, food insecurity (β: -2.27[CI: -3.39, -1.15), p=0.014) was associated with reduced SSE. Among sexually active participants (n=115), increased SSE was associated with increased condom use among young women (β: 1.40[0.19, 2.61], p=0.024) and men (β: 2.14[0.14, 4.14], p=0.036). No differences emerged by Indigenous identity across analyses. Conclusion Food insecurity and IPV emerged as syndemic factors associated with lower SSE—a protective factor associated with condom use among Northern and Indigenous adolescents in the NWT. Poverty and violence compromise Indigenous and Northern youth’s sexual agency and in turn contribute to STI vulnerabilities, requiring urgent attention. Disclosure No significant relationships.

Syndemic approaches explore the synergistic relationships between social and health inequities. Such approaches are particularly salient for the Northwest Territories, Canada, that experiences national social (food insecurity, intimate partner violence [IPV]) and health (sexually transmitted infections [STI]) disparities. Safer sex efficacy (SSE) includes knowledge, intention, and relationship dynamics that facilitate safer sex negotiation. We examined factors associated with SSE among NWT adolescents. We conducted a cross-sectional survey with a venue-based sample of adolescents aged 13–17 in 17 NWT communities from 2016 to 2017. Summary statistics and statistical comparisons were conducted, followed by crude and adjusted multivariable regression models to assess factors associated with SSE. Among participants (n = 610; mean age 14.2 years [SD 1.5]; 49.5% cisgender women, 48.9% cisgender men, 1.6% transgender persons; 73.3% Indigenous), one-quarter (n = 144; 23.6%) reported food insecurity and nearly one-fifth (n = 111; 18.2%) IPV. In adjusted analyses, among young women, food insecurity (β − 1.89[CI − 2.98, − 0.80], p = 0.001) and IPV (β − 1.31[CI − 2.53, − 0.09], p = 0.036) were associated with lower SSE, and currently dating was associated with increased SSE (β 1.17[CI 0.15, 2.19], p = 0.024). Among young men, food insecurity (β − 2.27[CI − 3.39, − 1.15], p = 0.014) was associated with reduced SSE. Among sexually active participants (n = 115), increased SSE was associated with consistent condom use among young women (β 1.40[0.19, 2.61], p = 0.024) and men (β 2.14[0.14, 4.14], p = 0.036). Food insecurity and IPV were associated with lower SSE—a protective factor associated with consistent condom use—underscoring the need to address poverty and violence to advance adolescent sexual health in the NWT.

BACKGROUND There are few data on the utility of screening paediatric immigrants for tuberculosis (TB) in low TB burden countries. OBJECTIVE To evaluate the utility of the Canadian immigration medical examination and TB Medical Surveillance (TBMS) for detecting paediatric TB disease. DESIGN A 10-year population-based retrospective cohort study of foreign-born children (ages 0-10 years) and adolescents (ages 11-17 years) immigrating to Ontario, Canada, using linked immigration and public health databases. RESULTS Among 232 169 individuals (median follow-up of 5.7 years), active TB was diagnosed at or after immigration in 125 cases (20 children and 105 adolescents), at an overall rate of 54/100 000 (14/100 000 children, 116/100 000 adolescents). All cases originated from 34 countries. Active TB was diagnosed in 0/419 children and 10/418 adolescents referred for medical surveillance, representing only 8.0% of all cases. TBMS referrals were correlated with a previous diagnosis of TB (κ = 0.8) and were driven by country of origin (e.g., hazard ratio 31.2 for the Philippines). Rates of pre-immigration TB diagnosis varied considerably among high TB burden countries. CONCLUSIONS The current Canadian system detects little TB disease, and reveals very different rates of pre-immigration paediatric TB diagnosis in different high TB burden countries. These data provide a basis for improving TB screening strategies for immigrants to low TB burden countries.

BACKGROUND Xpert MTB/RIF testing for Mycobacterium tuberculosis and rifampin resistance is being used extensively in countries with a high burden of TB. However, recent evidence suggests that it may not have the same accuracy or impact in high-income, low-burden TB countries. METHODS A prospective, pragmatic study was done between March 2012 and March 2014 to determine the feasibility, accuracy, and impact on TB disease management provided by the Xpert test in a remote, medically underserved, predominantly Inuit population in Iqaluit, Nunavut, Canada. RESULTS A total of 453 Xpert tests were run on sputum samples from 344 patients with suspected TB. Twenty-seven patients were identified as having active TB disease by culture. There were no cases of drug-resistant TB. Using culture as the gold standard, one Xpert test compared with one, two, or three sputum samples cultured per patient had a sensitivity of 85% (95% CI, 66%-95%) and a specificity of 99% (95% CI, 97%-100%) for detection of M tuberculosis. The indeterminate rate was 4.4% of all samples run. Treatment initiation was significantly shortened using Xpert vs the national standard of three smears (1.8 days vs 7.7 days, P ≤ .007) and particularly shorter in smear-negative, culture-positive cases (1.8 days vs 37.1 days, P≤ .008). CONCLUSIONS In a predominantly Inuit population in a remote region of Canada where the burden of TB is high and no TB testing facilities are available, onsite Xpert testing was feasible and accurate and shortened the time to TB treatment initiation.

Objective To compare rates of Caesarean section between mothers of advanced age (35 to 40, and over 40 years) and those aged 20 to 34, using the Robson classification system to examine additional maternal factors. Methods A total of 134 088 hospital deliveries in Ontario between April 1, 2011, and March 31, 2012, were grouped into Robson's 10 mutually exclusive and totally inclusive classification categories. Records from the three Robson groups that made the greatest contribution to the overall CS rate were stratified by maternal age, health condition, obstetrical complication, assisted reproductive technology usage, smoking during pregnancy, and socioeconomic status. Results Rates of CS increased with advancing maternal age; in women aged 20 to 34, 35 to 40, and over 40, the rates were 26.2%, 35.9%, and 43.1%, respectively. The top three Robson groups by contribution to CS rates involved women who had one or more of the following factors: previous Caesarean section, primiparity, conception by means of assisted reproductive technology, chronic hypertension, gestational diabetes, diabetes mellitus, preeclampsia, placenta previa, placental abruption, or large for gestational age infants. The prevalence of these factors increased with advancing maternal age, yet mothers aged ≥ 35 with one or more health conditions or obstetrical complications had higher CS rates than mothers aged 20 to 34 with the same condition(s) or complication(s). Conclusion Health conditions and obstetrical complications alone in older women do not account for increased rates of CS. The preferences of the individual care provider and the mother on CS rates may play a key role and require further investigation.

Supplemental Digital Content is available in the text., Background: Daily changes in aeroallergens during pregnancy could trigger early labor, but few investigations have evaluated this issue. This study aimed to investigate the association between exposure to aeroallergens during the week preceding birth and the risk of early delivery among preterm and term pregnancies. Methods: We identified data on 225,234 singleton births that occurred in six large cities in the province of Ontario, Canada, from 2004 to 2011 (April to October) from a birth registry. We obtained daily counts of pollen grains and fungal spores from fixed-site monitoring stations in each city and assigned them to pregnancy period of each birth. Associations between exposure to aeroallergens in the preceding week and risk of delivery among preterm (

Background: There are increasing concerns regarding the role of exposure to ambient air pollution during pregnancy in the development of early childhood cancers. Objective: This population based study examined whether prenatal and early life (

Two linked research papers by Urquia and colleagues examine infant sex selection, a long-standing and controversial topic.[1][1],[2][2] In their first study, the authors investigate birth certificate data to examine skewed infant sex ratios among mothers born in India compared with mothers born in

Perinatal exposure to ambient air pollution has been associated with childhood asthma incidence; however, less is known regarding the potential effect modifiers in this association. We examined whether maternal and infant characteristics modified the association between perinatal exposure to air pollution and development of childhood asthma. 761 172 births occurring between 2006 and 2012 were identified in the province of Ontario, Canada. Associations between exposure to ambient air pollutants and childhood asthma incidence (up to age 6 years) were estimated using Cox regression models. 110 981 children with asthma were identified. In models adjusted for postnatal exposures, second-trimester exposures to particulate matter with a 50% cut-off aerodynamic diameter ≤2.5 μm (hazard ratio (HR) per interquartile range (IQR) increase 1.07, 95% CI 1.06–1.09) and nitrogen dioxide (HR per IQR increase 1.06, 95% CI 1.03–1.08) were associated with childhood asthma development. Enhanced impacts were found among children born to mothers with asthma, who smoked during pregnancy or lived in urban areas during pregnancy, males and children born preterm or of low birthweight. Prenatal exposure to air pollution may have a differential impact on the risk of asthma development, according to maternal and infant characteristics., Maternal asthma enhances the effect of air pollution during pregnancy on the risk of developing asthma in children http://ow.ly/eeWp30hSsIb

Children with cerebral palsy (CP) are at an increased risk for aspiration, and subsequent pneumonia or pneumonitis. Pneumonia is a common cause of hospital admission, intensive care unit (ICU) admission, and death in patients with CP, and may disproportionately contribute to mortality. The role of respiratory microflora is unknown. This study examined the relationship between respiratory infections with Gram-negative bacteria (GNB), particularly Pseudomonas aeruginosa, and the frequency/severity of pneumonia hospitalization. Retrospective chart review of 69 patients with CP and hospitalization for pneumonia. Eligible patients required hospitalization for bacterial pneumonia, at least one respiratory culture, and fulfillment of Bax definition of CP. Group assignment was based on respiratory culture. Charts were analyzed for comorbid illness, hospitalization demographics, and disease severity. Children with isolation of P. aeruginosa or other GNB had increased frequency of ICU admission (77.4, 65.1, vs. 26.9 %, respectively, p < 0.01), intubation (45.2, 39.5 vs. 11.5 %, p = 0.02, p = 0.03 respectively), and large pleural effusions (37.5, vs. 0 %) than children without GNB. Children with isolation of GNB had more prolonged hospitalizations and were more likely to have multiple hospitalizations than those without GNB. Colonization with P. aeruginosa and other Gram-negative organisms in children with CP is associated with increased morbidity, prolonged hospitalization, and severity of pneumonia including need for PICU admission and intervention. Further research is required to determine causality, the role of antimicrobials active against Gram negative in pneumonia treatment, and the role of GNB eradication therapy in children with CP.

Aim To assess the diagnostic accuracy of the JM 103 as a screening tool for neonatal jaundice and explore differential effects based on skin colour. Methods We prospectively compared the transcutaneous bilirubin (TcB) and serum bilirubin (TSB) measurements of newborns over a 3 month-period. Skin colour was assigned via reference colour swatches. Diagnostic measures of the TcB/TSB comparison were made and clinically relevant TcB cut-off values were determined for each skin colour group. Results 451 infants (51 light, 326 medium and 74 dark skin colour) were recruited. The association between TcB and TSB was high for all skin colours (r s >0.9). The Bland-Altman analysis showed an absolute mean difference between the two measures of 13.3±26.4 µmol/L with broad limits of agreement (−39.4–66.0 µmol/L), with TcB underestimating TSB in light and medium skin colours and overestimating in dark skin colour. Diagnostic measures were also consistently high across skin colours, with no clinically significant differences observed. Conclusions The JM 103 is a useful screening tool to identify infants in need of serum bilirubin, regardless of skin colour. The effect of skin colour on the accuracy of this device at high levels of serum bilirubin could not be assessed fully due to small numbers in the light and dark groups.

Objective To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL). Design Multiple baseline time-series design. Setting Canadian province of Ontario. Population A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010. Methods International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution. Main outcome measure Rate of obstetrical hospital admission for PTL. Results Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (−0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], −1.02 to −0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation. Conclusions Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Few Canadian studies have examined the association between adolescent pregnancy and adverse pregnancy outcomes. The objective of this cohort study was to characterize the association between adolescent pregnancy and specific adverse maternal, obstetrical, and neonatal outcomes, as well as maternal health behaviours.We conducted a retrospective population-based cohort study of all singleton births in Ontario between January 2006 and December 2010, using the Better Outcomes Registry and Network database. Outcomes for pregnant women20 years of age (adolescent) were compared with those of women 20 to 35 years old (adult).This study included 551 079 singleton birth records, 23 992 (4.35%) of which derived from adolescent pregnancies. Adolescents had a higher rate of smoking and substance use than adult women and were within the lowest education and family income quintiles. Adolescents had a significantly lower risk of gestational hypertension (adjusted relative risk [aRR] 0.73) and gestational diabetes (aRR 0.34), placental abruption (aRR 0.80), and placenta previa (aRR 0.36), but their risk of preterm premature rupture of membranes was significantly higher (RR 1.16). Adolescents had a significantly higher proportion of spontaneous vaginal delivery (aRR 1.76), significantly lower rates of use of epidural analgesia (aRR 0.93), of Caesarean section (aRR 0.57), and of assisted vaginal delivery (aRR 0.76), but a significantly higher risk of emergency CS (aRR 1.31). Neonates with an adolescent mother had significantly higher risks of admission to NICU (aRR 1.08) and very preterm birth (aRR 1.16). There was no significant difference between the two groups in rates of small for gestational age babies, low birth weight, preterm birth, and fetal death. Adolescents had significantly lower rates of prenatal class attendance, prenatal visits in the first trimester, and breastfeeding.This large Canadian cohort study confirms that, compared with adults, adolescents have improved outcomes such as lower rates of gestational hypertension, gestational diabetes, antepartum hemorrhage, and operative deliveries. However, adolescents also have higher sociodemographic risk factors and seek prenatal care later than adults. These risk factors in combination with young age, lead to other important maternal, obstetrical, and neonatal adverse outcomes. These findings highlight the importance of multidisciplinary prenatal management in the adolescent population to address their high-risk needs, to ensure healthy pregnancies, and to reduce adverse perinatal outcomes.

Importance RSV is a common illness among young children that causes significant morbidity and health care costs. Objective Routinely collected health administrative data can be used to track disease incidence, explore risk factors and conduct health services research. Due to potential for misclassification bias, the accuracy of data-elements should be validated prior to use. The objectives of this study were to validate an algorithm to accurately identify pediatric cases of hospitalized respiratory syncytial virus (RSV) from within Ontario’s health administrative data, estimate annual incidence of hospitalization due to RSV and report the prevalence of major risk factors within hospitalized patients. Study Design and Setting A retrospective chart review was performed to establish a reference-standard cohort of children from the Ottawa region admitted to the Children’s Hospital of Eastern Ontario (CHEO) for RSV-related disease in 2010 and 2011. Chart review data was linked to Ontario’s administrative data and used to evaluate the diagnostic accuracy of algorithms of RSV-related ICD-10 codes within provincial hospitalization and emergency department databases. Age- and sex-standardized incidence was calculated over time, with trends in incidence assessed using Poisson regression. Results From a total of 1411 admissions, chart review identified 327 children hospitalized for laboratory confirmed RSV-related disease. Following linkage to administrative data and restriction to first admissions, there were 289 RSV patients in the reference-standard cohort. The best algorithm, based on hospitalization data, resulted in sensitivity 97.9% (95%CI: 95.5–99.2%), specificity 99.6% (95%CI: 98.2–99.8%), PPV 96.9% (95%CI: 94.2–98.6%), NPV 99.4% (95%CI: 99.4–99.9%). Incidence of hospitalized RSV in Ontario from 2005–2012 was 10.2 per 1000 children under 1 year and 4.8 per 1000 children aged 1 to 3 years. During the surveillance period, there was no identifiable increasing or decreasing linear trend in the incidence of hospitalized RSV, hospital length of stay and PICU admission rates. Among the Ontario RSV cohort, 16.3% had one or more major risk factors, with a decreasing trend observed over time. Conclusion Children hospitalized for RSV-related disease can be accurately identified within population-based health administrative data. RSV is a major public health concern and incidence has not changed over time, suggesting a lack of progress in prevention.

To explore the relationship between overweight and obesity and breastfeeding behaviors, a cohort study was conducted among 22,131 women who delivered in Ontario hospitals between April 1 2008 and March 31 2010.Data regarding maternal characteristics, maternal body mass index (BMI), infant characteristics, and breastfeeding practices were obtained through the Better Outcomes RegistryNetwork birth records Database. Multivariate linear regression analysis was used to determine the rates of three outcome measures - intention to breastfeed, exclusive breastfeeding in hospital, and exclusive breastfeeding upon discharge from hospital - between non-obese, overweight and obese patients.While overweight mothers have similar intentions to breastfeed compared to non-overweight mothers (OR 1.03 (0.87-1.21), obese mothers were less likely to intend to breastfeed (OR 0.84 (0.70-0.99). Overweight and obese mothers were less likely to exclusively breastfeed in hospital compared to non-overweight mothers (aOR 0.67 (0.60-0.75) and 0.67 (0.60-0.75), respectively), and overweight and obese mothers were less likely to exclusively breastfeed on discharge (aOR 0.68 (0.61-0.76) and 0.68 (0.61-0.76), respectively).This study highlights that while overweight and obese women may benefit more from exclusive breastfeeding compared to non-overweight women, they are less likely to exclusively breastfeed in the immediate post-partum period.

Aims To explore intention to breastfeed and breastfeeding rates in hospital and on discharge across women with pre-gestational or gestational diabetes mellitus, or no diabetes. Methods A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study. Unadjusted and adjusted odds ratios were calculated for each outcome measure and were used to compare the breastfeeding rates among women with and without diabetes. Results After controlling for potential confounders, women with insulin-treated diabetes were less likely to intend to breastfeed, when compared with women without diabetes (adjusted odds ratio 0.49, 95% CI 0.27–0.89). In hospital, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.42, 95% CI 0.26–0.67), followed by women with non-insulin-treated diabetes (odds ratio 0.50, 95% CI 0.26–0.96) and women with gestational diabetes (odds ratio 0.77, 95% CI 0.68–0.87) when compared with women without diabetes. On discharge, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.38, 95% CI 0.24–0.60), followed by women with gestational diabetes (odds ratio 0.75, 95% CI 0.66–0.85); rates of breastfeeding among women with non-insulin-treated diabetes were comparable on discharge with those of women without diabetes. Women seeking care from an antenatal provider other than a physician were 2–3 times more likely to breastfeed in hospital and on discharge. Conclusions Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.

Objectives. We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009–2010 H1N1 pandemic. Methods. We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy. Results. Of the 55 570 mothers with a singleton birth, 23 340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR] = 0.90; 95% confidence interval [CI] = 0.85, 0.96) and 3rd (adjusted RR = 0.81; 95% CI = 0.72, 0.92) growth percentiles; PTB at less than 32 weeks’ gestation (adjusted RR = 0.73; 95% CI = 0.58, 0.91) and fetal death (adjusted RR = 0.66; 95% CI = 0.47, 0.91) were also less likely among these women. Conclusions. Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.

OBJECTIVES: Influenza vaccination rate among pregnant women has typically been low, and there is little population-based information on predictors of vaccination uptake within this group. This study aimed to evaluate the rate of influenza vaccination in pregnant women during the 2009 H1N1 influenza pandemic and explore predictors associated with receiving vaccination during pregnancy. METHODS: We conducted a retrospective population-based cohort analysis involving women who gave birth in an Ontario hospital between November 2, 2009 and April 30, 2010. Rates of influenza vaccination were calculated according to maternal, obstetrical, behavioural and neighbourhood characteristics. Women who received influenza vaccination during pregnancy were compared with women who were not vaccinated using log-binomial regression to calculate adjusted relative risks (aRR) and 95% confidence intervals (CI). RESULTS: Among 56,654 women who gave birth in the study period, 42.6% had received influenza vaccination during pregnancy. Vaccine uptake was lower among women: of age

Background Antimicrobial use is very common in hospitalized children. An assessment of clinician’s prevailing knowledge and clinical approach to prescribing antimicrobials is helpful in order to develop the best strategies for successful stewardship programs. The objectives of the study were to determine fundamental knowledge of principles, approach to antimicrobial use through the clinical vignettes and to identify perceived challenges in decreasing antimicrobial use. Methods A questionnaire was developed by subject matter experts and pretested to ensure validity. Using a cross-sectional prospective design, the questionnaire was completed anonymously by staff and trainee physicians at a single tertiary care pediatric hospital between late November 2011 and February 2012. Results Of 159 eligible physicians, 86 (54.1%) responded, of which 77 (46 staff and 31 trainees) reported regularly prescribing antimicrobials. The majority of physicians had modest knowledge of factors that would increase risk of resistance however, less than 20% had correct knowledge of local resistance patterns for common bacteria. Almost half of physicians correctly answered the clinical vignettes. Over half of trainees and one third of staff relied most on online manuals for information regarding antimicrobials to assist prescription decision-making. Overall, physicians perceived that discontinuing empiric antimicrobials was the most difficult to achieve to decrease antibiotic use. Conclusions Our results highlight several challenges that pediatric practioners face with respect to knowledge and approach to antimicrobial prescribing. Pediatric stewardship programs could in this setting focus on discontinuing antimicrobials appropriately and promoting local antibiograms in the proper clinical setting to decrease overall use of antimicrobials.

Objective There is concern that obstetric interventions (prelabor cesarean section and induced delivery) are drivers of late preterm (LP) birth. Our objective was to evaluate the independent association between obstetric interventions and LP birth and explore associated independent maternal and fetal risk factors for LP birth. Study Design In this population-based cross-sectional study, the BORN Information System was used to identify all infants born between 34 and 40 completed weeks of gestation between 2005 and 2012 in Ontario, Canada. The association between obstetric interventions (preterm cesarean section and induced delivery) and LP birth (34 to 36 completed weeks' gestation vs 37 to 40 completed weeks' gestation) was assessed using generalized estimating equation regression. Results Of 917,013 births between 34 and 40 weeks, 49,157 were LP (5.4%). In the adjusted analysis, "any obstetric intervention" (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.57–0.74), induction (RR, 0.71; 95% CI, 0.61–0.82) and prelabor cesarean section (RR, 0.66; 95% CI, 0.59–0.74) were all associated with a lower likelihood of LP vs term birth. Several independent potentially modifiable risk factors for LP birth were identified including previous cesarean section (RR, 1.28; 95% CI, 1.16–1.40), smoking during pregnancy (RR, 1.28; 95% CI, 1.21–1.36) and high material (RR, 1.1; 95% CI, 1.03–1.18) and social (RR, 1.09; 95% CI, 1.02–1.16) deprivation indices. Conclusion After accounting for differences in maternal and fetal risk, LP births had a 35% lower likelihood of obstetric interventions than term births. Obstetric care providers may be preferentially avoiding induction and prelabor cesarean section between 34 and 37 weeks' gestation.

This study was undertaken to examine the association between maternal oseltamivir treatment for influenza and infant outcomes during the 2009 HINI influenza pandemic.This was a retrospective cohort study using a population-based maternal newborn database including women who gave birth to a singleton infant in the Canadian province of Ontario from November 2009 through April 2010. Risks of small for gestational age (SGA) (10th percentile and 3rd percentile), preterm birth (37 weeks of gestation), very preterm birth (32 weeks of gestation), and 5-minute Apgar score7 associated with maternal exposure to oseltamivir were analyzed by multivariable regression.A total of 55,355 women with a singleton birth were included in this study. Among them, 1237 (2.2%) women received oseltamivir for treatment or prevention of influenza during pregnancy. Women who took oseltamivir during pregnancy were less likely to have a SGA infant based on the 10th percentile for growth (adjusted risk ratio, 0.77; 95% confidence interval, 0.60-0.98). No association between maternal use of oseltamivir with SGA on 3rd percentile, preterm birth, very preterm birth, and low Apgar score was observed.There is no evidence of an association between maternal use of oseltamivir for influenza and early birth, low Apgar at birth, and poor fetal growth.

Objective Few Canadian studies have examined the association between adolescent pregnancy and adverse pregnancy outcomes The objective of this cohort study was to characterize the association between adolescent pregnancy and specific adverse maternal, obstetrical, and neonatal outcomes, as well as maternal health behaviours. Methods We conducted a retrospective population-based cohort study of all singleton births in Ontario between January 2006 and December 2010, using the Better Outcomes Registry & Network database Outcomes for pregnant women Results This study included 551 079 singleton birth records, 23 992 (4.35%) of which derived from adolescent pregnancies. Adolescents had a higher rate of smoking and substance use than adult women and were within the lowest education and family income quintiles. Adolescents had a significantly lower risk of gestational hypertension (adjusted relative risk [aRR] 0.73) and gestational diabetes (aRR 0.34), placental abruption (aRR 0.80), and placenta previa (aRR 0.36), but their risk of preterm premature rupture of membranes was significantly higher (RR 1.16). Adolescents had a significantly higher proportion of spontaneous vaginal delivery (aRR 1.76), significantly lower rates of use of epidural analgesia (aRR 0.93), of Caesarean section (aRR 0.57), and of assisted vaginal delivery (aRR 0.76), but a significantly higher risk of emergency CS (aRR 1.31). Neonates with an adolescent mother had significantly higher risks of admission to NICU (aRR 1.08) and very preterm birth (aRR 1.16). There was no significant difference between the two groups in rates of small for gestational age babies, low birth weight, preterm birth, and fetal death. Adolescents had significantly lower rates of prenatal class attendance, prenatal visits in the first trimester, and breastfeeding. Conclusion This large Canadian cohort study confirms that, compared with adults, adolescents have improved outcomes such as lower rates of gestational hypertension, gestational diabetes, antepartum hemorrhage, and operative deliveries However, adolescents also have higher sociodemographic risk factors and seek prenatal care later than adults These risk factors in combination with young age, lead to other important maternal, obstetrical, and neonatal adverse outcomes. These findings highlight the importance of multidisciplinary prenatal management in the adolescent population to address their high-risk needs, to ensure healthy pregnancies, and to reduce adverse perinatal outcomes.

BackgroundPrenatal exposure to ambient air pollution has been associated with adverse birth outcomes, but the potential modifying effect of maternal comorbidities remains understudied. Our objective was to investigate whether associations between prenatal air pollution exposures and birth outcomes differ by maternal comorbidities.MethodsA total of 818,400 singleton live births were identified in the province of Ontario, Canada from 2005 to 2012. We assigned exposures to fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ozone (O3) to maternal residences during pregnancy. We evaluated potential effect modification by maternal comorbidities (i.e. asthma, hypertension, pre-existing diabetes mellitus, heart disease, gestational diabetes and preeclampsia) on the associations between prenatal air pollution and preterm birth, term low birth weight and small for gestational age.ResultsInterquartile range (IQR) increases in PM2.5 (2μg/m3), NO2 (9ppb) and O3 (5ppb) over the entire pregnancy were associated with a 4% (95% CI: 2.4–5.6%), 8.4% (95% CI: 5.5–10.3%) and 2% (95% CI: 0.5–4.1%) increase in the odds of preterm birth, respectively. Increases of 10.6% (95% CI: 0.2–2.1%) and 23.8% (95% CI: 5.5–44.8%) in the odds of preterm birth were observed among women with pre-existing diabetes while the increases were of 3.8% (95% CI: 2.2–5.4%) and 6.5% (95% CI: 3.7–8.4%) among women without this condition for pregnancy exposure to PM2.5 and NO2, respectively (Pint