Three sequential outbreaks of Group A Streptococcus over a two-year period at the Canadian Forces Leadership and Recruit School, St. Jean Garrison, Québec.

BACKGROUND: Since December 2016, the basic military training (BMT) facility for the Canadian Armed Forces (CAF) has experienced repeated outbreaks of Group A Streptococcus (GAS). In 2018, a voluntary mass antibiotic prophylaxis (MAP) program was implemented to interrupt GAS transmission among recruits. The objective of this study was to describe the epidemiology of three GAS outbreaks and a period of increased pharyngitis infections at the CAF BMT facility in Québec over a two-year span, and to detail the prevention and control measures implemented to mitigate the risk to recruit health. METHODS: Descriptive data were collected on invasive and severe GAS cases along with laboratory data including genotyping of throat swabs from recruits presenting with pharyngitis. A laboratory-based acute respiratory infection surveillance system was used to aid in monitoring and decision-making. Close contacts of recruits were assessed for asymptomatic GAS carriage and MAP adverse events surveillance was conducted. RESULTS: Three distinct GAS outbreaks occurred at the Canadian Forces Leadership and Recruit School totaling eight invasive (iGAS) and 13 severe (sGAS) cases over two years. All iGAS/sGAS cases, apart from one instructor, were among recruits. The predominant strain in all three outbreaks was type emm6.4. A total of 11,293 recruits received MAP (penicillin G benzathine or azithromycin) between March 7, 2018 and November 18, 2019. There were eight reported serious adverse events related to penicillin administration. CONCLUSION: The CAF BMT facility experienced three GAS outbreaks over the course of two years, and despite the use of enhanced hygiene measures, only MAP has been effective in quelling these outbreaks.

Adverse events following mass antibiotic prophylaxis during a Group A Streptococcus outbreak in the Canadian Forces Leadership and Recruit School.

BACKGROUND: Between December 2016 and March 2018, two outbreaks of Group A Streptococcus (GAS) infection occurred at the Canadian Forces Leadership and Recruit School. A voluntary mass antibiotic prophylaxis (MAP) program was implemented in March 2018, to interrupt an ongoing GAS outbreak, and to prevent future outbreaks. METHODS: Instructors and recruits were offered a one-time intramuscular injection of 1.2 million units penicillin G benzathine (PGB). Individuals with a penicillin allergy were offered azithromycin; 500 mg orally once weekly for four consecutive weeks. Instructors and recruits were also asked to complete a voluntary and anonymous survey one week after receipt of MAP, to detect MAP-related adverse events. RESULTS: MAP was offered to 2,749 individuals; 2,707 of whom agreed to receive it (98.5% uptake). The majority of personnel experienced adverse events in the days following MAP; 92.3% of personnel who received PGB reported localized pain at the injection site, and 70.2% of personnel who received azithromycin reported gastrointestinal symptoms. However, only five cases of serious adverse events were reported, and less than 1% of recruits could not complete their basic military training course because of MAP-related adverse events. CONCLUSION: The MAP program implemented in March 2018 was the first of its kind in the Canadian Armed Forces, and the largest single use of PGB in a defined group in Canada. It resulted in very few serious adverse events and with minimal impact on military recruits' successful completion of recruit training.

Group A Streptococcus Outbreak in a Canadian Armed Forces Training Facility.

Between December 2016 and April 2017, two cases of invasive Group A Streptococcus (GAS) infections were reported at a Canadian military training facility. An outbreak was declared and a field investigation was launched to characterize the outbreak and identify associated risk factors to limit transmission. Throat culture data from military personnel at the garrison were analyzed. Investigators tracked invasive GAS cases and non-invasive hospitalized GAS cases, and conducted site visits and case interviews. Sensitivity and specificity for a rapid antigen detection test were evaluated. Molecular typing and phylogenomic relationships of outbreak isolates were analyzed using whole-genome sequencing. During this outbreak, four invasive cases were reported and six non-invasive cases were hospitalized. In a sample of 705 throat cultures examined, 35.2% were GAS-positive. Among 65 platoon contacts of one invasive case, 30.2% were GAS-positive. Reluctance to seek medical care, challenges in following cough etiquette, and low compliance with antibiotics were identified among recruits. The rapid antigen detection test had low sensitivity (31.6%) during the outbreak. The outbreak sequence type was emm6.4 and outbreak isolates were highly related phylogenetically, differing by 0-4 single nucleotide variants. This is the first report of a GAS outbreak among Canadian military trainees. Increased surveillance of GAS infections, increased control measures and outbreak-specific clinical guidelines were implemented in-garrison. No further invasive GAS cases were identified. A GAS surveillance system was implemented and efforts to improve antibiotic compliance and medical consultation were recommended.

Canadian forces evaluation of the EPINATO Health Surveillance System in Bosnia-Herzegovina.

The Canadian Forces (CF) adopted the EPINATO surveillance system in 1996 to monitor disease and injury morbidity in deployed settings. The Directorate of Force Health Protection, CF Health Services Group initiated an evaluation of EPINATO in Task Force Bosnia-Herzegovina in August 2003. Two methods were used to assess coding reliability: a chart audit and Sick Parade Register review. Stakeholder interviews were conducted evaluating data flow, reporting structure, and key system attributes. Reliability (K, 95% confidence interval) was good in 4 of 24 categories--sexually transmitted diseases, K = 0.75 (0.50, 1.00); eye disorders, K = 0.51 (0.15, 0.88); ears/nose/ throat, K = 0.51 (0.33, 0.69); lower respiratory infections, K = 0.49 (95% confidence interval 0.34, 0.65)-but otherwise was poor. EPINATO is not an effective, reliable tool for CF deployment health surveillance. An improved health surveillance system is required to ensure disease and injury aberrations are detected and optimal preventive programs and policies are in place for deployed CF military members.

Oculo-respiratory syndrome: a new influenza vaccine-associated adverse event?

During the 2000-2001 influenza immunization campaign in Canada, a new adverse event, oculo-respiratory syndrome (ORS), was noted in association with administration of vaccine supplied by one manufacturer. The original case definition for ORS specified bilateral conjunctivitis, facial edema, or respiratory symptoms beginning 2-24 h after influenza vaccination and resolving within 48 h after onset. To characterize the spectrum, severity, and impact of ORS, we contacted persons who had reported any influenza vaccine-associated adverse event in British Columbia, Canada, during the 2000-2001 vaccination campaign. With use of a standardized telephone interview, we collected information from 609 (79%) of 769 eligible persons. Thirteen percent of ORS-affected persons reported onset 48 h, and 42% considered the symptoms to be severe. The surveillance case definition for ORS for 2001-2002 was revised to include onset

On the rise: The current and projected future burden of congestive heart failure hospitalization in Canada.

BACKGROUND: The incidence of congestive heart failure (CHF) has increased due, in part, to an aging population and improvements in the diagnosis and treatment of myocardial infarction. This has been reported internationally but no systematic epidemiological assessment of CHF has been conducted for Canada nationally. OBJECTIVES: To estimate length of stay, mortality and readmission rates and projected number of future CHF hospital patients. METHODS: Health insurance numbers were used to link all hospital visits for 1996/97 CHF patients who had no CHF discharges within the previous two years. All patients were followed up for one year from the date of their initial visit. RESULTS: The numbers of males and females in the study were similar: 40,958 males and 42,255 females. Within the first year, CHF patients used an average of 26.9 hospital days and nearly 50% were readmitted to hospital. Within the index episode, 16.5% of the CHF patients died in hospital. Under the age of 70, female patients had higher mortality than males, while after the age of 70, males were more likely to die. The number of CHF incident hospital cases per year is projected to more than double by the year 2025. To keep the current number of incident patients the same as in 1996/97, the incidence of would have to decrease by 2.6% per year. CONCLUSIONS: Patients admitted with CHF have high rates of mortality and prolonged and recurrent hospitalization. If the current rates are not reduced, health care costs related to CHF could increase substantially.

Low risk of recurrence of oculorespiratory syndrome following influenza revaccination.

BACKGROUND: During the 2000-2001 influenza vaccination season, a new adverse event associated with the influenza vaccine, called oculorespiratory syndrome (ORS), was identified in Canada. We examined the risk of recurrence of ORS for individuals affected in 2000-2001 who were revaccinated in the community setting in 2001-2002. METHODS: We conducted a telephone survey in May 2002 in which participants were asked whether they had been revaccinated in the 2001-2002 immunization season and whether they had experienced any recurrence of ORS or any other adverse event. Eligible individuals (n = 609) included residents of British Columbia aged 18 years or more who had reported any type of adverse event associated with the influenza vaccine in 2000 and who had participated in a survey in September 2001 that characterized their adverse event experience. RESULTS: The response rate to this survey was 92% (561 of 609 people approached). Of the 561 participants, 202 were revaccinated in 2001. Among the 202 revaccinated, 122 individuals had previously reported ORS in 2000: 40 had described their ORS experience in 2000 as mild (present but not bothersome), 44 as moderate (interrupting daily activities), 35 as severe (preventing daily activities) and 3 did not provide specific details. Six of the 122 individuals experienced a recurrence of ORS following revaccination. The estimated risk of recurrence for ORS following revaccination in the community setting was 5% (95% confidence interval 2.2%-10.5%). Four of the 6 individuals described their ORS recurrence in 2001 as milder than the ORS they had experienced in 2000. INTERPRETATION: We found a low risk of recurrence of ORS for individuals previously affected in 2000 when they were revaccinated in 2001, including those whose ORS in 2000 had prevented daily activities but was not clinically severe. Health care providers should be confident in the safety of recommending revaccination of these individuals. As with all vaccines, however, a detailed risk-benefit assessment should be undertaken before revaccination of people whose previous adverse event experience may have included collapse, respiratory difficulty (including throat tightness) and/or chest discomfort requiring emergency intervention.