A descriptive analysis of the spatio-temporal distribution of enteric diseases in New Brunswick, Canada.

BACKGROUND: Enteric diseases affect thousands of Canadians annually and several large outbreaks have occurred due to infection with enteric pathogens. The objectives of this study were to describe the spatial and temporal distributions of reportable Campylobacter, Escherichia coli, Giardia, Salmonella and Shigella from 1994 to 2002 in New Brunswick, Canada. By examining the spatial and temporal distributions of disease incidence, hypotheses as to potential disease risk factors were formulated. METHODS: Time series plots of monthly disease incidence were examined for seasonal and secular trends. Seasonality of disease incidence was evaluated using the temporal scan statistic and seasonal-trend loess (STL) decomposition methods. Secular trends were evaluated using negative binomial regression modeling. The spatial distribution of disease incidence was examined using maps of empirical Bayes smoothed estimates of disease incidence. Spatial clustering was examined by multiple methods, which included Moran's I and the spatial scan statistic. RESULTS: The peak incidence of Giardia infections occurred in the spring months. Salmonella incidence exhibited two peaks, one small peak in the spring and a main peak in the summer. Campylobacter and Escherichia coli O157 disease incidence peaked in the summer months. Moran's I indicated that there was significant positive spatial autocorrelation for the incidence of Campylobacter, Giardia and Salmonella. The spatial scan statistic identified clusters of high disease incidence in the northern areas of the province for Campylobacter, Giardia and Salmonella infections. The incidence of Escherichia coli infections clustered in the south-east and north-east areas of the province, based on the spatial scan statistic results. Shigella infections had the lowest incidence rate and no discernable spatial or temporal patterns were observed. CONCLUSIONS: By using several different spatial and temporal methods a robust picture of the spatial and temporal distributions of enteric disease in New Brunswick was produced. Disease incidence for several reportable enteric pathogens displayed significant geographic clustering indicating that a spatially distributed risk factor may be contributing to disease incidence. Temporal analysis indicated peaks in disease incidence, including previously un-reported peaks.

Tools for thoughtful action: the role of ecosystem approaches to health in enhancing public health.

The intimate interdependence of human health and the ecosystems in which we are embedded is now a commonplace observation. For much of the history of public health, this was not so obvious. After over a century of focus on diseases, their biologic causes and the correction of exposures (clean water and air) and facilitation of responses (immunizations and nutrition), public health discourse shifted to embrace the concept of determinants of health as extending to social, economic and environmental realms. This moved the discourse and science of public health into an unprecedented level of complexity just as public concern about the environment heightened. To address multifactorial, dynamic impacts on health, a new paradigm was needed which would overcome the separation of humans and ecosystems. Ecosystem approaches to health arose in the 1990s from a rich background of intellectual ferment as Canada wrestled with diverse problems ranging from Great Lakes contamination to zoonotic diseases. Canada's International Development Research Centre (IDRC) played a lead role in supporting an international community of scientists and scholars who advanced ecosystem approaches to health. These collective efforts have enabled a shift to a research paradigm that embraces transdisciplinarity, social justice, gender equity, multi-stakeholder participation and sustainability.

[Post-Normal Pandemics: why CoViD-19 requires a new approach to science.] / Pandemie post-normali. Perché CoViD-19 richiede un nuovo approccio alla scienza.

In addressing pandemics, science has never seemed more needed and useful, while at the same time limited and powerless. The existing contract between science and society is falling apart. A new covenant is urgently needed to navigate the days ahead.

Incidence of acquisition of methicillin-resistant Staphylococcus aureus, Clostridium difficile, and other health-care-associated pathogens by dogs that participate in animal-assisted interventions.

OBJECTIVE: To determine whether dogs that visited human health-care facilities were at greater risk of acquiring certain health-care-associated pathogens, compared with dogs performing animal-assisted interventions in other settings, and to identify specific behaviors of dogs associated with an increased risk of acquiring these pathogens. DESIGN: Prospective cohort and nested case-control studies. ANIMALS: 96 dogs that visited human health-care facilities and 98 dogs involved in other animal-assisted interventions. PROCEDURES: Fecal samples and nasal swab specimens were collected from dogs at the time of recruitment and every 2 months for 1 year and were tested for methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, and other selected bacteria. Information was also obtained on facilities visited during animal-assisted interventions, dog diet, dog illnesses, and antimicrobial use within the home. At the end of the study, dog handlers were asked about the behavior of their dogs during visits to health-care facilities. RESULTS: Rates of acquisition of MRSA and C difficile were 4.7 and 2.4 times as high, respectively, among dogs that visited human health-care facilities, compared with rates among dogs involved in other animal-assisted interventions. Among dogs that visited human health-care facilities, those that licked patients or accepted treats during visits were more likely to be positive for MRSA and C difficile than were dogs that did not lick patients or accept treats. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that dogs that visited human health-care facilities were at risk of acquiring MRSA and C difficile, particularly when they licked patients or accepted treats during visits.

Responding to globalised food-borne disease: risk assessment as post-normal science.

Since the 1960s, global trade in food and feed has increased rapidly, and the number of countries at least partially reliant on this trade has sprouted into complex International Agrifood Trade Networks (IATN). IATNs have obscured the already-labyrinthine causal webs of food-borne diseases, and the usual methods for demonstrating causal links between IATNs and food-borne diseases yield results that are, at best, inconclusive. At the same time, responses are being offered which will, if implemented, likely to have unintended negative consequences. In this context, risk analysis (RA) is being used in situations for which it was not designed, in which facts are uncertain, values are in dispute and assessments are embedded in contested power arrangements, with heterogeneous consequences for diverse stakeholders around the world. To characterise and manage the most serious unintended food-borne disease consequences of globalisation, the most effective way forward will require reframing of RA as a post-normal science.

Advancing biological hazards risk assessment.

This paper focusses on biological hazards at the global level and considers the challenges to risk assessment (RA) from a One Health perspective. Two topics - vector-borne diseases (VBD) and antimicrobial resistance (AMR) - are used to illustrate the challenges ahead and to explore the opportunities that new methodologies such as next-generation sequencing can offer. Globalisation brings complexity and introduces drivers for infectious diseases. Cooperation and the application of an integrated RA approach - one that takes into consideration food farming and production systems including social and environmental factors - are recommended. Also needed are methodologies to identify emerging risks at a global level and propose prevention strategies. AMR is one of the biggest threats to human health in the infectious disease environment. Whereas new genomic typing techniques such as whole genome sequencing (WGS) provide further insights into the mechanisms of spread of resistance, the role of the environment is not fully elucidated, nor is the role of plants as potential vehicles for spread of resistance. Historical trends and recent experience indicate that (re)-emergence and/or further spread of VBD within the EU is a matter of when rather than if. Standardised and validated vector monitoring programs are required to be implemented at an international level for continuous surveillance and assessment of potential threats. There are benefits to using WGS - such as a quicker and better response to outbreaks and additional evidence for source attribution. However, significant challenges need to be addressed, including method standardisation and validation to fully realise these benefits; barriers to data sharing; and establishing epidemiological capacity for cluster triage and response.

Zoonoses, One Health and complexity: wicked problems and constructive conflict.

Infectious zoonoses emerge from complex interactions among social and ecological systems. Understanding this complexity requires the accommodation of multiple, often conflicting, perspectives and narratives, rooted in different value systems and temporal-spatial scales. Therefore, to be adaptive, successful and sustainable, One Health approaches necessarily entail conflicts among observers, practitioners and scholars. Nevertheless, these integrative approaches have, both implicitly and explicitly, tended to marginalize some perspectives and prioritize others, resulting in a kind of technocratic tyranny. An important function of One Health approaches should be to facilitate and manage those conflicts, rather than to impose solutions.This article is part of the themed issue 'One Health for a changing world: zoonoses, ecosystems and human well-being'.

Engaging research with policy and action: what are the challenges of responding to zoonotic disease in Africa?

Zoonotic diseases will maintain a high level of public policy attention in the coming decades. From the spectre of a global pandemic to anxieties over agricultural change, urbanization, social inequality and threats to natural ecosystems, effectively preparing and responding to endemic and emerging diseases will require technological, institutional and social innovation. Much current discussion emphasizes the need for a 'One Health' approach: bridging disciplines and sectors to tackle these complex dynamics. However, as attention has increased, so too has an appreciation of the practical challenges in linking multi-disciplinary, multi-sectoral research with policy, action and impact. In this commentary paper, we reflect on these issues with particular reference to the African sub-continent. We structure the themes of our analysis on the existing literature, expert opinion and 11 interviews with leading One Health scholars and practitioners, conducted at an international symposium in 2016. We highlight a variety of challenges in research and knowledge production, in the difficult terrain of implementation and outreach, and in the politicized nature of decision-making and priority setting. We then turn our attention to a number of strategies that might help reconfigure current pathways and accepted norms of practice. These include: (i) challenging scientific expertise; (ii) strengthening national multi-sectoral coordination; (iii) building on what works; and (iv) re-framing policy narratives. We argue that bridging the research-policy-action interface in Africa, and better connecting zoonoses, ecosystems and well-being in the twenty-first century, will ultimately require greater attention to the democratization of science and public policy.This article is part of the themed issue 'One Health for a changing world: zoonoses, ecosystems and human well-being'.

Characteristics of programs involving canine visitation of hospitalized people in Ontario.

OBJECTIVES: To determine the distribution of canine-visitation programs in Ontario and to characterize the nature of the programs the dogs are affiliated with. DESIGN: A cross-sectional survey of hospitals in Ontario was used to determine whether they permitted dogs to visit patients and, if so, where the dogs originated. On the basis of this information, dog owners were then contacted through their respective associations and interviewed using a standardized questionnaire. SETTING: A cross-section of hospitals in Ontario. PARTICIPANTS: A total of 223 (97%) of the 231 hospitals surveyed responded. Ninety owners of 102 visitation dogs were interviewed. RESULTS: A total of 201 (90%) of the 223 hospitals indicated that dogs were permitted in their facilities. Origins ranged from national therapy-dog agencies to the patients' families. Acute care wards were 5.1 times as likely than other wards to disallow animals (95% confidence interval, 2.2-12.2; P<.001). According to the 90 dog owners included in the study, the screening protocols that dogs were required to pass to participate in their respective visitation programs were highly variable, as were the owners' infection control practices. Eighteen owners (20%) said they did not practice any infection control. Sixty-six owners (73%) allowed their dogs on patients' beds, and 71 (79%) let their dogs lick patients. Thirty-six owners (40%) were unable to name one zoonotic disease that may be transmitted from their dog. CONCLUSIONS: Although canine-visitation programs have become standard practice in nonacute human healthcare facilities, infection control and dog-screening practices are highly variable and potentially deficient. Hospital staff, visitation groups, pet owners, and veterinarians need to work together to protect both people and pets.

Exposure assessment in investigations of waterborne illness: a quantitative estimate of measurement error.

BACKGROUND: Exposure assessment is typically the greatest weakness of epidemiologic studies of disinfection by-products (DBPs) in drinking water, which largely stems from the difficulty in obtaining accurate data on individual-level water consumption patterns and activity. Thus, surrogate measures for such waterborne exposures are commonly used. Little attention however, has been directed towards formal validation of these measures. METHODS: We conducted a study in the City of Hamilton, Ontario (Canada) in 2001-2002, to assess the accuracy of two surrogate measures of home water source: (a) urban/rural status as assigned using residential postal codes, and (b) mapping of residential postal codes to municipal water systems within a Geographic Information System (GIS). We then assessed the accuracy of a commonly-used surrogate measure of an individual's actual drinking water source, namely, their home water source. RESULTS: The surrogates for home water source provided good classification of residents served by municipal water systems (approximately 98% predictive value), but did not perform well in classifying those served by private water systems (average: 63.5% predictive value). More importantly, we found that home water source was a poor surrogate measure of the individuals' actual drinking water source(s), being associated with high misclassification errors. CONCLUSION: This study demonstrated substantial misclassification errors associated with a surrogate measure commonly used in studies of drinking water disinfection byproducts. Further, the limited accuracy of two surrogate measures of an individual's home water source heeds caution in their use in exposure classification methodology. While these surrogates are inexpensive and convenient, they should not be substituted for direct collection of accurate data pertaining to the subjects' waterborne disease exposure. In instances where such surrogates must be used, estimation of the misclassification and its subsequent effects are recommended for the interpretation and communication of results. Our results also lend support for further investigation into the quantification of the exposure misclassification associated with these surrogate measures, which would provide useful estimates for consideration in interpretation of waterborne disease studies.

A philosophy and approach to teaching the epidemiology of food-borne, waterborne, and zoonotic diseases.

Faculty members from veterinary colleges that teach courses on food-borne, waterborne, and zoonotic diseases to non-veterinary students face unique challenges. The diversity of students' backgrounds, skills, and goals and the public nature of the science require some ingenuity in combining good science with the ability to communicate clearly in a variety of public forums. Drawing on pedagogical theory, the nature of the material, and the diverse abilities of the students, we have put together an effective teaching package for non-veterinary courses on these subjects, which includes a range of methods from outbreak investigations to town hall meetings and food diaries.

Public perception of drinking water from private water supplies: focus group analyses.

BACKGROUND: Over four million Canadians receive their drinking water from private water supplies, and numerous studies report that these supplies often exceed the minimal acceptable standards for contamination. Canadians in rural areas test their water intermittently, if at all, and treatment of water from private supplies is not common. Understanding the perceptions of drinking water among residents served by private systems will enable public health professionals to better target education and outreach activities, and to address the needs and concerns of residents in their jurisdictions. The purpose of this study was to explore the drinking water perceptions and self-described behaviours and needs of participants served by private water systems in the City of Hamilton, Ontario (Canada). METHODS: In September 2003, three focus group discussions were conducted; two with men and women aged 36-65 years, and one with men and women 20-35 years of age. RESULTS: Overall, participants had positive perceptions of their private water supplies, particularly in the older age group. Concerns included bacterial and chemical contamination from agricultural sources. Testing of water from private supplies was minimal and was done less frequently than recommended by the provincial government. Barriers to water testing included the inconvenience of the testing process, acceptable test results in the past, resident complacency and lack of knowledge. The younger participants greatly emphasized their need for more information on private water supplies. Participants from all groups wanted more information on water testing, and various media for information dissemination were discussed. CONCLUSION: While most participants were confident in the safety of their private water supply, the factual basis for these opinions is uncertain. Improved dissemination of information pertaining to private water supplies in this population is needed. Observed differences in the concerns expressed by users of different water systems and age groups may suggest the need for targeted public education strategies. These focus groups provided significant insight into the public perception of private water supplies and the need for public health outreach activities; however, to obtain a more representative understanding of the perceptions in this population, it is important that a larger scale investigation be performed.

Vulnerability of waterborne diseases to climate change in Canada: a review.

This project addresses two important issues relevant to the health of Canadians: the risk of waterborne illness and the health impacts of global climate change. The Canadian health burden from waterborne illness is unknown, although it presumably accounts for a significant proportion of enteric illness. Recently, large outbreaks with severe consequences produced by E. coli O157:H7 and Cryptosporidium have alarmed Canadians and brought demands for political action. A concurrent need to understand the health impacts of global climate changes and to develop strategies to prevent or prepare for these has also been recognized. There is mounting evidence that weather is often a factor in triggering waterborne disease outbreaks. A recent study of precipitation and waterborne illness in the United States found that more than half the waterborne disease outbreaks in the United States during the last half century followed a period of extreme rainfall. Projections of international global climate change scenarios suggest that, under conditions of global warming most of Canada may expect longer summers, milder winters, increased summer drought, and more extreme precipitation. Excess precipitation, floods, high temperatures, and drought could affect the risk of waterborne illness in Canada. The existing scientific information regarding most weather-related adverse health impacts and on the impacts of global climate change on health in Canada is insufficient for informed decision making. The results of this project address this need through the investigation of the complex systemic interrelationships between disease incidence, weather parameters, and water quality and quantity, and by projecting the potential impact of global climate change on those relationships.

Owned dog demography in Todos Santos Cuchumatán, Guatemala.

A thorough knowledge of the dog demography should be an integral element in the planning, implementation and evaluation of dog population control measures. In May 2008, a door-to-door household census of human and owned canine populations was conducted in 12 contiguous neighbourhoods in the town of Todos Santos Cuchumatán, Guatemala. During the census, household and footpath data were recorded using a handheld Global Positioning System (GPS), and used to create digital census route maps, and perimeter and area estimates of the study region. Approximately 99% of all households (472/476) participated in the census, representing 2461 people in the overall estimated study region area of 80 hectares (ha). A total of 382 dogs were owned by 50.8% (240/472) of households, yielding means of 0.8 (382/472) owned dogs per household and 1.6 (382/240) dogs per dog-owning household. Of the total 382 owned dogs, 88.2% (337/382) were aged three months or older; of these, 68.5% (231/337) were reported as not normally being confined on the household property during the average day, and 9.7% (24/247) of the males and none of the females (0/81) were reported to be neutered. Of the households that owned female dogs, 89.7% (52/58) and 91.4% (53/58) reported that they would have females surgically or non-surgically neutered, respectively, if these services were available. Of the households that owned male dogs, 90.3% (176/195) and 92.3% (180/195) reported that they would have males surgically or non-surgically neutered, respectively, if these services were available. Approximately 72% (238/330) of owned dogs were vaccinated for rabies, and 80% (187/238) of these were males. The owned dog male:female ratio was 2.6:1 (275/107), the owned dog:human ratio was 1:6.4 (382/2461), and the absolute density was 478 (382/0.80) owned dogs/km(2). This knowledge of the owned dog demography was generated using simple means and has been of direct use in support of, and as baseline data for the planning, implementation and evaluation of subsequent dog population control measures in this population; they may be of similar use in other comparable populations.