An Evaluation of Hepatitis C Screening in Infants and Children Born to Seropositive Mothers in Saint John, New Brunswick.

BACKGROUND: The primary route of hepatitis C virus (HCV) infection in children is vertical transmission, from mother to fetus in utero. There is a lack of data on the prevalence of pediatric HCV acquired through vertical transmission in Saint John, New Brunswick. Furthermore, what risk factors may be associated with an increased likelihood for a child born to an HCV-seropositive mother should be known to direct screening practices. METHODS: A retrospective chart review of the active charts from the local HCV clinic, the Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP), identified HCV-seropositive women who had children at-risk of HCV through vertical transmission. Sociodemographic information and various risk factors were collected, including maternal HCV genotype, non-prescription drug use subcategorized into intravenous drug use and snorting, transfusion history, involvement in opiate substitution therapy, postal code as a proxy for socioeconomic status, and issues of custodianship within the family. A 2 x 2 chi-square analysis was conducted to assess the frequency of HCV screening for children by the presence or absence of familial custodianship issues. RESULTS: In total, data from 62 HCV-seropositive women and 123 infants and children at-risk for HCV were included in this study. HCV status at the time of pregnancy revealed 18 (14.6%) with a positive HCV screen, 14 (11.4%) with a positive viral load, and 91 (74.0%) with unknown status. A total of 30 children (24.4%) had HCV screening performed, of which three (10.0%) were HCV-antibody positive and had a detectable viral load. Results of the chi-square analysis indicated that issues of custodianship had no significant influence on child screening rates. CONCLUSION: Overall, this study highlighted the inconsistent screening practices of children at-risk for HCV through vertical transmission, as well as the need for improvement in chart documentation and follow-up. Clinicians and researchers should focus their efforts toward proactively identifying children at-risk for HCV through vertical transmission. This could involve screening during pregnancy and subsequent follow-up, or at other points of contact with the healthcare system, such as parental involvement with opioid substitution therapy or well-child visits. Implementation of a targeted screening program could be considered in urban centers similar to the one in this study to connect at-risk populations with essential medical and community services.

Jamestown Canyon and snowshoe hare virus seroprevalence in New Brunswick.

Background: Jamestown Canyon virus (JCV) and snowshoe hare virus (SSHV) are wide-ranging mosquito-borne arboviruses in the California serogroup viruses (CSGV) that are known to circulate in New Brunswick. Despite potential for debilitating central nervous system manifestations, the prevalence of human exposure to these viruses in New Brunswick is unknown. The goal of this study was to quantify rates of human exposure in New Brunswick to these neglected arboviruses. Methods: A retrospective, anonymized provincial serosurvey was performed using a stratified random sample of residual sera submitted between May 2015 and August 2016. To determine the seroprevalence of JCV and SSHV, competitive enzyme-linked immunosorbent assay-positive samples were confirmed positive using plaque-reduction neutralization testing (PRNT). Results: A total of 452 serum samples were screened. The seroprevalence of antibodies against CSGV was estimated to be 31.6% (95% CI 27.4% to 36.1%) with 143 positive samples. PRNT results indicated that most single virus exposures were due to JCV (38 of 143; 26.6%) rather than SSHV (3 of 143; 2.1%). The species of CSGV, to which the remaining 102 seropositive people were exposed, could not be precisely determined. Conclusions: The prevalence of human exposure to CSGV is high but comparable to rates observed in other Atlantic Canadian jurisdictions. Studies such as this provide important baseline epidemiological data regarding the risk of exposure to these neglected arboviruses. SSHV and JCV should be considered in the differential diagnosis for undiagnosed febrile and neuroinvasive illness during mosquito season, particularly when testing for common aetiologies is negative or inconclusive.

Historique : Le virus de Jamestown Canyon (VJC) et le virus du lièvre d'Amérique (VLA) sont des arbovirus à grande portée transmis par des moustiques des virus du sérogroupe Californie (VSGC) qui circulent au Nouveau-Brunswick (NB). Malgré le risque de manifestations débilitantes du système nerveux central, on ne connaît pas la prévalence d'exposition humaine à ces virus au NB. La présente étude visait à quantifier le taux d'exposition humaine à ces arbovirus négligés au NB. Méthodologie : Les chercheurs ont réalisé une enquête sérologique rétrospective provinciale anonymisée au moyen d'un échantillon randomisé stratifié de sérum résiduel soumis entre mai 2015 et août 2016 au dépistage systématique. Ils ont stratifié le processus de sélection selon l'âge, le sexe et la zone de santé régionale afin de garantir un échantillonnage proportionné. Pour déterminer la séroprévalence du VJC et du VLA, ils ont confirmé la positivité des résultats d'échantillons positifs au test ELISA au moyen de tests de séroneutralisation par réduction des plaques (TSRP). Résultats : Au total, 452 échantillons de sérum ont fait l'objet d'un dépistage. Au NB, la séroprévalence des anticorps anti-VSGC était évaluée à 31,6 % (IC à 95 %, 27,4 % à 36,1 %), pour 143 échantillons positifs. Selon les résultats du TSRP, la plupart des expositions à un seul virus étaient causées par le VJC (38 cas sur 143, 26,6 %) plutôt qu'au VLA (trois cas sur 143, 2,1 %). Les espèces de VSGC, auxquelles les 102 autres personnes séropositives ont été exposées, n'ont pas pu être établies avec précision. Conclusions : La prévalence d'exposition humaine au VSGC est élevée, mais comparable aux taux observés dans d'autres régions des provinces de l'Atlantique. Des études comme celle-ci fournissent des données épidémiologiques de référence importantes à l'égard du risque d'exposition humaine à ces arbovirus négligés. Il faut tenir compte du VLA et du VJC dans le diagnostic différentiel de maladie fébrile et neuro-invasive pendant la saison des moustiques, notamment lorsque les tests pour dépister d'autres étiologies courantes sont négatifs ou non concluants.

Randomized controlled trial of chlorhexidine gluconate, intranasal mupirocin, rifampin, and doxycycline versus chlorhexidine gluconate and intranasal mupirocin alone for the eradication of methicillin-resistant Staphylococcus aureus (MRSA) colonization.

Background: Several decolonization regimens have been studied to prevent recurrent methicillin-resistant Staphylococcus aureus (MRSA) infections. Clinical equipoise remains with regard to the role of MRSA decolonization. We compared initial MRSA clearance and subsequent MRSA recolonization rates over a 12-month period after standard decolonization (using topical chlorhexidine gluconate, and intranasal mupirocin) or systemic decolonization (using topical chlorhexidine gluconate, intranasal mupirocin, oral rifampin, and oral doxycycline). Methods: MRSA-colonized patients were randomized to receive either standard or systemic decolonization. Follow-up with MRSA screening was obtained at approximately 3, 6, and 12 months after completion of therapy. Kaplan-Meier survival curves were calculated and assessed for significant differences using log-rank tests. Results: Of 98 enrolled patients (25 standard decolonization, 73 systemic decolonization), 24 patients (7 standard decolonization, 17 systemic decolonization) did not complete the study. Univariate analysis showed a marginally significant difference in the probability of remaining MRSA-negative post-treatment (p = 0.043); patients who received standard decolonization had a 31.9% chance of remaining MRSA-negative compared with a 49.9% chance among those who received systemic decolonization. With multivariate analysis, there was no difference in the probability of remaining MRSA-negative between systemic and standard decolonization (p = 0.165). Initial MRSA clearance was more readily achieved with systemic decolonization (79.1%; 95% CI 32.4% to 71.6%) than with standard decolonization (52.0%; 95% CI 69.4% to 88.8%; p = 0.0102). Conclusions: Initial MRSA clearance is more readily achieved with systemic decolonization than with standard decolonization. There is no significant difference in the probability of sustained MRSA clearance.

Historique: Plusieurs schémas de décolonisation ont été étudiés pour prévenir la récurrence d'infections à Staphylococcus aureus résistant à la méthicilline (SARM). La pondération clinique demeure à l'égard du rôle de la décolonisation du SARM. Les chercheurs ont comparé la clairance initiale du SARM et les taux de recolonisation subséquents par le SARM sur une période de 12 mois après une décolonisation standard (au moyen de gluconate de chlorhexidine topique et de mupirocine intranasale) ou de décolonisation systémique (au moyen de gluconate de chlorhexidine topique, de mupirocine intranasale, de rifampine par voie orale et de doxycycline par voie orale). Méthodologie: Des patients colonisés par le SARM ont été choisis au hasard pour recevoir une décolonisation standard ou systémique. Les chercheurs ont obtenu les données de suivi par un dépistage du SARM environ trois, six et 12 mois après la fin du traitement. Ils ont calculé la courbe de survie de Kaplan-Meier et l'ont évaluée pour déterminer les différences importantes au moyen des tests logarithmiques par rang. Résultats: Des 98 patients inscrits (25 par décolonisation standard, 73 par décolonisation systémique), 24 n'ont pas terminé l'étude (sept par décolonisation standard, 17 par décolonisation systémique). L'analyse univariée a révélé une différence légèrement significative quant à la probabilité de demeurer négatif au SARM après le traitement (p = 0,043). En effet, les patients qui avaient reçu une décolonisation standard avaient 31,9 % de chances de demeurer négatifs au SARM, par rapport à 49,9 % de chances chez ceux qui avaient reçu une décolonisation systémique. À l'analyse multivariée, il n'y avait pas de différence entre la probabilité de demeurer négatif au SARM après une décolonisation systémique ou standard (p = 0,65). La clairance initiale du SARM était obtenue plus rapidement par la décolonisation systémique (79,1 %; IC à 95 % 32,4 % à 71,6 %) que standard (52,0 %; IC à 95 % 69,4 % à 88,8 %; p = 0,0102). Conclusions: La clairance initiale du SARM est plus facile à obtenir par une décolonisation systémique que standard. La clairance initiale du SARM était obtenue plus rapidement par la décolonisation systémique que standard. Il n'y a pas de différence significative dans la probabilité de clairance soutenue du SARM.

Epidemiology, Microbiology, and Clinical Outcomes Among Patients With Intravenous Drug Use-Associated Infective Endocarditis in New Brunswick.

BACKGROUND: Within the context of Canada's opioid crisis, medical complications associated with intravenous drug use (IVDU) are increasing. Infective endocarditis (IE) is a serious complication of IVDU, and understanding the characteristics of these patients could aid health systems, clinicians, and patients in the optimization of treatment and prevention of IVDU-IE. METHODS: At a tertiary care hospital in southern New Brunswick, we conducted a retrospective chart review to identify patients with IVDU-IE admitted between January 1, 2013, and December 31, 2017. We collected data related to the epidemiology, microbiology, clinical manifestations, echocardiography, complications during hospital admission, and outcomes. RESULTS: Forty-two cases of IVDU-IE met inclusion criteria. The rate of IVDU-IE increased from 2.28 per 100,000 population in 2014 to 4.00 in 2017, which, although not statistically significant, reflects patterns in other jurisdictions. Most patients (72.4%) were male, and the mean age was 38.3 (±11.5) years. Most patients (79.3%) injected opioids. The most common clinical sign was fever (90.5%), and Staphylococcus aureus (61.9%) was the most common microorganism. The tricuspid valve was most commonly infected (58.5%), 50% of cases had heart failure as a complication during admission, and 45.2% of cases required valve replacement or repair. The 2-year survival rate after admission for initial IVDU-IE episode was 62.0% (95% confidence interval: 36.5-79.7). CONCLUSION: IVDU-IE is common in New Brunswick and may be increasing. Despite the relatively young age of this patient population, IVDU-IE is associated with significant morbidity and mortality. Expanding effective harm reduction and addiction treatment strategies for this cohort is recommended.

CONTEXTE: Dans le contexte de la crise des opioïdes au Canada, les complications médicales liées à l'utilisation de drogues par voie intraveineuse (UDIV) sont en augmentation. L'endocardite infectieuse (EI) est une complication grave de l'UDIV, et la compréhension des caractéristiques de ces patients pourrait aider les systèmes de santé, les cliniciens et les patients à optimiser le traitement et la prévention de l'EI liée à l'UDIV (EI-UDIV). MÉTHODES: Dans un hôpital de soins tertiaires du sud du Nouveau-Brunswick, nous avons effectué un examen rétrospectif des dossiers afin d'identifier les patients atteints de l'EI-UDIV admis entre le 1er janvier 2013 et le 31 décembre 2017. Nous avons recueilli des données relatives à l'épidémiologie, la microbiologie, les manifestations cliniques, l'échocardiographie, les complications lors de l'admission à l'hôpital et les bilans. RÉSULTATS: Quarante-deux cas d'EI-UDIV ont répondu aux critères d'inclusion. Le taux d'EI-UDIV est passé de 2,28 pour 100 000 habitants en 2014 à 4,00 en 2017, ce qui, bien que non significatif statistiquement, reflète les tendances observées dans d'autres juridictions. La plupart des patients (72,4 %) étaient des hommes, et l'âge moyen était de 38,3 ans (±11,5). La plupart des patients (79,3 %) s'injectaient des opioïdes. Le signe clinique le plus fréquent était la fièvre (90,5 %), et le Staphylococcus aureus (61,9 %) était le micro-organisme le plus couramment observé. La valve tricuspide était le plus souvent infectée (58,5 %), 50 % des cas avaient une insuffisance cardiaque en tant que complication lors de l'admission, et 45,2 % des cas ont nécessité un remplacement ou une réparation de la valve. Le taux de survie à deux ans après l'admission pour l'épisode initial d'EI-UDIV était de 62,0 % (intervalle de confiance à 95 % : 36,5-79,7). CONCLUSION: L'EI-UDIV est fréquent au Nouveau-Brunswick et pourrait être en augmentation. Malgré l'âge relativement jeune de cette population de patients, l'UDIV-IE est associée à une morbidité et une mortalité importantes. Il est recommandé d'étendre les stratégies efficaces de réduction des risques et de traitement des dépendances pour cette cohorte.

Differences among hepatitis C patients seen in community and specialist outpatient care settings.

Background: In the province of New Brunswick, care for patients infected with hepatitis C is provided in both community-based care settings and specialist-based care settings, but little is known about the differences between these populations. The aim of the current study is to characterize the demographic, socioeconomic, mental health and substance use factors of patients seen in these settings. Methods: Enrolling sites for this study included four specialist office-based clinics and one community-based clinic in three communities in New Brunswick. Personal health data was collected with informed consent via questionnaires and medical records. Non-incarcerated patients seen between April 2014 and April 2016 were included in the analysis. Results: A total of 374 patients were included (34.8% community versus 65.2% specialist office). Patients seen in the community care setting were younger (median age 43.7 versus 49.1 years), less likely to have a primary care provider (p = .007), rely on social assistance as regular source of income (p <.001), have been incarcerated (p = .007), reported sharing drug paraphernalia (p = .025), had recent injection drug use (p <.001), reported snorting drugs recently (p <.001) and reported prior overdose (p = .025). Community clinic patients also had significantly younger mean age at first use of alcohol (13.6 versus 14.7 years, p = .044), marijuana (14.6 versus 15.8, p = .040), and opioids (23.9 versus 26.5 years, p = .036) over those seen in specialist offices. Conclusions: Unique differences exist between patients seen in community and specialist care settings in New Brunswick. Understanding these differences is an essential first step in developing patient-centred care models.

Early Successes in an Open Access, Provincially Funded Hepatitis C Treatment Program in Prince Edward Island.

INTRODUCTION: The availability of curative hepatitis C therapies has created an opportunity to improve treatment delivery and access. Local providers, government, industry, and community groups in Prince Edward Island developed an innovative province-wide care model. Our goal was to describe the first year of program implementation. MATERIAL AND METHODS: Using a communitybased prospective observational study design, all chronic hepatitis C referrals received from April 2015 to April 2016 were recorded in a database. Primary analysis assessed the time from referral to assessment/treatment, as well as the number of referrals, assessments, and treatment initiations. Secondary objectives included: (1) treatment effectiveness using intention-to-treat analysis; and (2) patient treatment experience assessed using demographics, adverse events, and medication adherence. RESULTS: During the study period 242 referrals were received, 123 patients were seen for intake assessments, and 93 initiated direct-acting antiviral therapy based on medical need. This is compared to 4 treatment initiations in the previous 2 years. The median time from assessment to treatment initiation was 3 weeks. Eighty-two of 84 (97.6%, 95% CI 91.7 - 99.7%) patients for whom outcome data were available achieved sustained virologic response at 12 weeks post-treatment; 1 was lost to follow-up and 1 died from an unrelated event. In the voluntary registry, 39.7% of patients reported missed treatment doses. CONCLUSION: In conclusion, results from the first 12 months of this multi-phase hepatitis C elimination strategy demonstrate improved access to treatment, and high rates of safe engagement and cure for patients living with chronic hepatitis C genotype 1 infections.

Early Successes in an Open Access, Provincially Funded Hepatitis C Treatment Program in Prince Edward Island.

INTRODUCTION: The availability of curative hepatitis C therapies has created an opportunity to improve delivery and access. Local providers, government, industry, and community groups in Prince Edward Island developed an innovative province-wide care model. Our goal was to describe the first year of program implementation. MATERIAL AND METHODS: Using a community based prospective observational study design, all chronic hepatitis C referrals received from April 2015 to April 2016 were recorded in a database. Primary analysis assessed the time from referral to assessment/treatment, as well as the number of referrals, assessments, and treatment initiations. Secondary objectives included: 1) Treatment effectiveness using intention-to-treat analysis; and 2) Patient treatment experience assessed using demographics, adverse events, and medication adherence. RESULTS: During the study period 242 referrals were received, 123 patients were seen for intake assessments, and 93 initiated direct-acting antiviral therapy based on medical need. This is compared to 4 treatment initiations in the previous 2 years. The median time from assessment to treatment initiation was 3 weeks. Eighty-two of 84 (97.6%, 95% CI 91.7 - 99.7%) patients for whom outcome data were available achieved sustained virologic response at 12 weeks post-treatment; 1 was lost to follow-up and 1 died from an unrelated event. In the voluntary registry, 39.7% of patients reported missed treatment doses. CONCLUSION: In conclusion, results from the first 12 months of this multi-phase hepatitis C elimination strategy demonstrate improved access to treatment, and high rates of safe engagement and cure for patients living with chronic hepatitis C genotype 1 infections.