Preparing for mpox resurgence: Surveillance lessons from outbreaks in Toronto, Canada.

BACKGROUND: Along with many global jurisdictions, Toronto, Canada experienced an outbreak of mpox in the spring/summer of 2022. Case counts declined following the implementation of a large vaccination campaign. A surge of case reports in early 2023 led to speculation that asymptomatic and/or undetected local transmission was occurring in the city. METHODS: Mpox cases and positive laboratory results are reported to Toronto Public Health. Epidemic curves and descriptive risk factor summaries for the 2022 and 2023 outbreaks were generated. First and second dose vaccination was monitored. Monkeypox virus wastewater surveillance and whole genome sequencing (WGS) were conducted to generate hypotheses about the source of the 2023 resurgence. RESULTS: 515 cases were reported in the spring/summer outbreak of 2022 and 17 in the 2022-2023 resurgence. Wastewater data correlated with the timing of reported cases. WGS showed that the 2022-2023 resurgent cases were distinct from the other 2022 cases and closer to sequences from another country, suggesting a new importation as a source for recent cases. At the start of the 2022-2023 resurgence, it was estimated that only 16% of first dose vaccine recipients had completed their second dose vaccination. DISCUSSION: This investigation demonstrates the importance of ongoing surveillance and preparedness for mpox outbreaks. Undetected local transmission was not a likely source of the 2022-2023 resurgence. Ongoing pre-exposure vaccine promotion remains important to mitigate disease burden.

Estimating the Under-ascertainment of COVID-19 cases in Toronto, Ontario, March to May 2020.

Background: Public health surveillance data do not always capture all cases, due in part to test availability and health care seeking behaviour. Our study aimed to estimate under-ascertainment multipliers for each step in the reporting chain for COVID-19 in Toronto, Canada. Design and methods: We applied stochastic modeling to estimate these proportions for the period from March 2020 (the beginning of the pandemic) through to May 23, 2020, and for three distinct windows with different laboratory testing criteria within this period. Results: For each laboratory-confirmed symptomatic case reported to Toronto Public Health during the entire period, the estimated number of COVID-19 infections in the community was 18 (5th and 95th percentile: 12, 29). The factor most associated with under-reporting was the proportion of those who sought care that received a test. Conclusions: Public health officials should use improved estimates to better understand the burden of COVID-19 and other similar infections.

Proposed Core Set of Items for Measuring Disease Activity in Systemic Juvenile Idiopathic Arthritis.

OBJECTIVE: To date, there are no standardized disease activity tools for systemic juvenile idiopathic arthritis (sJIA). We developed a core set of disease activity measures for sJIA. METHODS: We conducted a validation study in patients with sJIA recruited from 3 Canadian institutions. Disease activity scores were based on questionnaires, clinical factors, and laboratory measures. The physician's global assessment was our criterion standard. We determined the strength of association of each item with the criterion standard. We then surveyed international experts to determine the top 10 items. Finally, we used the experts' responses to generate a proposed core set of disease activity measures. RESULTS: We enrolled 57 subjects - 26 with moderately or severely active disease, and 31 with mildly active or inactive disease. Items that most strongly correlated with the criterion standard were number of active joints (r = 0.79), parent's global assessment of disease activity (r = 0.53), erythrocyte sedimentation rate (ESR; r = 0.62), and C-reactive protein (CRP; r = 0.61). The response rate from international experts was 82% (154/187). Items with the most votes, in descending order, were number of active joints, number of days with fever in the preceding 2 weeks, patient's and parent's global assessments of disease activity, sJIA rash, ESR, CRP, and hemoglobin level. CONCLUSION: We propose a core set of items for measuring disease activity in sJIA. Future research should be aimed at further validation of this core set in the international context.

The Responsiveness of the Modified Childhood Health Assessment Questionnaire.

OBJECTIVE: To determine the ability of the revised version of the Childhood Health Assessment Questionnaire (CHAQ), the VASCHAQ, to detect clinical change over time in pediatric patients with juvenile idiopathic arthritis (JIA). We studied the relative responsiveness of the VASCHAQ as compared to the original CHAQ-30 and revised CHAQ-38, as well as the parent-patient, physician-patient, and physician-parent concordance. METHODS: The CHAQ-38 and VASCHAQ were administered to 30 parents and patients (if older than 8 years) with any subtype of JIA before and after the start of a new treatment. The standardized response means (SRM) were calculated for the VASCHAQ, the original CHAQ-30, and the CHAQ-38. Comparisons of SRM were made using the relative SRM. Parent-patient, physician-patient, and physician-parent concordances were assessed by calculating a series of intraclass correlation coefficients. RESULTS: Twenty-seven parents and 21 patients completed questionnaires at both visits. All questionnaires demonstrated large responsiveness; however, the VASCHAQ was found to be about 25% more responsive than both the original CHAQ-30 and CHAQ-38. CONCLUSION: The VASCHAQ was moderately more responsive than the CHAQ-30 and CHAQ-38 in both parent and patient groups and should be considered for use in studies evaluating change in function over time.

Determinants of quality of life in children with chronic somatic disease: pilot data from the GapS Questionnaire.

PURPOSE: Quality of life (QoL) is a ubiquitous yet poorly defined concept; the precise determinants of QoL are rarely identified. We used pilot data from the GapS Questionnaire to investigate the most important determinants of QoL in children with chronic somatic illness. METHODS: We enrolled 92 participants including 60 parents and 32 of their children. The sample comprised rheumatology, diabetes, epilepsy, gastroenterology, cystic fibrosis, and day unit patients. Trained interviewers administered the GapS Questionnaire to parents, and to children if ≥ 10 years. We determined the relative importance of different items for QoL. RESULTS: Child participants had a mean age of 14.7 years. Children identified "having good friendships", "being happy most days", and "getting along with parents" as most important. Parents ranked most highly "being allowed to do all the things you like doing", "getting told you have done a good job at something", and "being physically able to do everything you enjoy doing". CONCLUSIONS: Physical health items were not as important as social and psychological determinants of QoL in our pilot sample.

Sleep and fatigue and the relationship to pain, disease activity and quality of life in juvenile idiopathic arthritis and juvenile dermatomyositis.

OBJECTIVES: To determine and compare the prevalence of disturbed sleep in JIA and JDM and the relationship of sleep disturbance to pain, function, disease activity and medications. METHODS: One hundred fifty-five patients (115 JIA, 40 JDM) were randomly sampled and were mailed questionnaires. Sleep disturbance was assessed by the sleep self-report (SSR) and the children's sleep habits questionnaire (CSHQ). Fatigue, pain and function were assessed by the paediatric quality of life inventory (PedsQL) and disease activity by visual analogue scales (VASs). Joint counts were self-reported. RESULTS: Eighty-one per cent responded, of whom 44% reported disturbed sleep (CSHQ > 41); there were no differences between disease groups. Poor reported sleep (SSR) was highly correlated with PedsQL fatigue (r = 0.56, P < 0.0001). Fatigue was highly negatively correlated with quality of life (r = -0.77, P < 0.0001). The worst pain intensity in the last week was correlated to sleep disturbance (r = 0.32, P = 0.0005). Fatigue was associated with prednisone and DMARD use. CONCLUSIONS: Sleep disturbance and fatigue are prevalent among children with different rheumatic diseases. Sleep disturbance and fatigue are strongly associated with increased pain and decreased quality of life. Strategies aimed at improving sleep and reducing fatigue should be studied as possible ways of improving quality of life for children with rheumatic illness.

Treatment approaches to juvenile dermatomyositis (JDM) across North America: The Childhood Arthritis and Rheumatology Research Alliance (CARRA) JDM Treatment Survey.

OBJECTIVE: There are a number of different approaches to the initial treatment of juvenile dermatomyositis (JDM). We assessed the therapeutic approaches of North American pediatric rheumatologists to inform future studies of therapy in JDM. METHODS: A survey describing clinical cases of JDM was sent to pediatric rheumatologists. The cases described children with varying severity of typical disease, disease with atypical features, or refractory disease. Three open-ended questions were asked following each case: (1) What additional investigations would you order; (2) What medicine(s) would you start (dose, route, frequency, adjustment over time); and (3) What nonmedication treatment(s) would you start. RESULTS: The response rate was 84% (141/167). For typical cases of JDM, regardless of severity, almost all respondents used corticosteroids and another medication, methotrexate (MTX) being the most commonly used. The route and pattern of corticosteroid administration was variable. Intravenous immunoglobulin (IVIG) was used more frequently for more severe disease, for refractory disease, and for prominent cutaneous disease. Hydroxychloroquine was often used in milder cases and cases principally characterized by rash. Cyclophosphamide was reserved for ulcerative disease and JDM complicated by lung disease. CONCLUSION: For the majority of North American pediatric rheumatologists, corticosteroids and MTX appear to be the standard of care for typical cases of JDM. There is variability, however, in the route of administration of corticosteroids and use of IVIG and hydroxychloroquine.

Research priorities in pediatric rheumatology: The Childhood Arthritis and Rheumatology Research Alliance (CARRA) consensus.

BACKGROUND: North American pediatric rheumatologists have created an investigator-initiated research network (the Childhood Arthritis and Rheumatology Research Alliance - CARRA) to facilitate multi-centre studies. One of the first projects undertaken by this network was to define, by consensus, research priorities for the group, and if possible a first group-sponsored clinical trial in which all members could participate. METHODS: We determined consensus using the Delphi approach. This approach has been used extensively in health research to reach consensus in large groups. It uses several successive iterations of surveys eliciting ideas and opinions from specialists in the field. Three surveys were designed based on this method and were distributed to members of CARRA to elicit and rank-order research priorities. RESULTS: A response rate of 87.6% was achieved in the final survey. The most highly ranked research suggestion was to study infliximab treatment of uveitis unresponsive to methotrexate. Other highly ranked suggestions were to study i) the treatment of systemic arthritis with anakinra and ii) the treatment of pediatric systemic lupus erythematosus with mycophenolate mofetil. CONCLUSION: The Delphi approach was an effective and practical method to define research priorities in this group. Ongoing discussion and cooperation among pediatric rheumatologists in CARRA and others world-wide will help in developing further research priorities and to facilitate the execution of clinical trials in the future.

Validation of the oral mucositis assessment scale in pediatric cancer.

BACKGROUND: Our objective was to examine the construct validity of the Oral Mucositis Assessment Scale (OMAS) in children receiving doxorubicin chemotherapy. METHODS: Children between 6 and 18 years of age with cancer receiving doxorubicin-containing chemotherapy were included. OMAS was measured on days 7, 10, 14, and 17 after chemotherapy. Other measures of mucositis obtained concurrent with OMAS were the World Health Organization (WHO) mucositis scale and pain visual analogue scale (VAS). We also recorded analgesia administration. RESULTS: Sixteen children were studied for 45 post-chemotherapy cycles and 156 OMAS assessments were performed. OMAS was moderately correlated with WHO scores (r = 0.56; P = 0.0006) whereas correlation with the pain VAS was fair (r = 0.37; P = 0.002). OMAS also had fair correlation with the number of doses of topical analgesia (r = 0.43; P = 0.001) and with the cumulative dose of opioid analgesia (r = 0.38; P = 0.003). CONCLUSIONS: The OMAS is valid for use in mucositis clinical trials for children at least 6 years of age.