Defining Clinical Public Health.

PURPOSE: To solve complex health issues, an innovative and multidisciplinary framework is necessary. The Clinical Public Health (CPH) Division was established at the University of Toronto (UofT), Canada to foster inte-gration of primary care, preventive medicine and public health in education, practice and research. To better understand how the construct of CPH might be applied, we surveyed clinicians, researchers and public health professionals affiliated with the CPH Division to assess their understanding of the CPH concept and its utility in fostering broad collaboration. METHODS: A two-wave anonymous survey of the active faculty of the CPH Division, UofT was conducted across Canada. Wave 1 participants (n = 187; 2016) were asked to define CPH, while Wave 2 participants (n = 192; 2017) were provided a synthesis of Wave 1 results and asked to rank each definition. Both waves were asked about the need for a common definition, and to comment on CPH. RESULTS: Response rates for the first and second waves were 25% and 22%, respectively. Of the six definitions of CPH from Wave 1, "the intersection of clinical practice and public health," was most highly ranked by Wave 2 participants. Positive perceptions of CPH included multidisciplinary collaboration, new fields and insights, forward thinking and innovation. Negative perceptions included CPH being a confusing term, too narrow in scope or too clinical. CONCLUSION: The concept of Clinical Public Health can foster multidisciplinary collaboration to address com-plex health issues because it provides a useful framework for bringing together key disciplines and diverse professional specialties.

Clinical public health: harnessing the best of both worlds in sickness and in health. / Santé publique clinique : exploiter le meilleur des deux mondes pour la santé comme pour le traitement des maladies.

INTRODUCTION: Effective, sustained collaboration between clinical and public health professionals can lead to improved individual and population health. The concept of clinical public health promotes collaboration between clinical medicine and public health to address complex, real-world health challenges. In this commentary, we describe the concept of clinical public health, the types of complex problems that require collaboration between individual and population health, and the barriers towards and applications of clinical public health that have become evident during the COVID-19 pandemic. RATIONALE: The focus of clinical medicine on the health of individuals and the aims of public health to promote and protect the health of populations are complementary. Interdisciplinary collaborations at both levels of health interventions are needed to address complex health problems. However, there is a need to address the disciplinary, cultural and financial barriers to achieving greater and sustained collaboration. Recent successes, particularly during the COVID-19 pandemic, provide a model for such collaboration between clinicians and public health practitioners. CONCLUSION: A public health approach that fosters ongoing collaboration between clinical and public health professionals in the face of complex health threats will have greater impact than the sum of the parts.

INTRODUCTION: Une collaboration efficace et soutenue entre cliniciens et professionnels en santé publique peut améliorer la santé des individus et la santé de la population. Le concept de santé publique clinique favorise cette collaboration entre médecine clinique et santé publique et permet de relever des défis complexes en matière de santé. Dans ce commentaire, nous décrivons le concept de santé publique clinique, les types de problèmes complexes qui nécessitent une collaboration entre les professionnels responsables de la santé des individus et ceux responsables de la santé de la population, de même que les obstacles à la santé publique clinique et les applications de la santé publique clinique qui ont émergé pendant la pandémie de COVID-19. ARGUMENTAIRE: Il existe une complémentarité entre la médecine clinique, qui est axée sur la santé des individus, et la santé publique, qui est axée sur la promotion et la protection de la santé des populations. Une collaboration entre ces deux disciplines est nécessaire pour résoudre les problèmes de santé complexes. Pour ce faire, toutefois, il convient de s'attaquer aux obstacles relatifs aux disciplines, ainsi qu'aux obstacles culturels et financiers qui empêchent une collaboration accrue et durable en la matière. Les succès récents, particulièrement durant la pandémie de COVID-19, constituent un modèle de collaboration de ce type entre cliniciens et praticiens en santé publique. CONCLUSION: Une approche en matière de santé publique qui favorise une collaboration permanente entre cliniciens et professionnels en santé publique pour lutter contre des menaces sanitaires complexes aura plus d'impact que la somme de ses parties.

Symptomatic acute reactive arthritis after an outbreak of salmonella.

OBJECTIVE: In 2005, 592 individuals in Ontario developed acute gastroenteritis, predominantly after consuming bean sprouts contaminated with Salmonella enteritidis. Salmonella is a known trigger of reactive arthritis (ReA). We describe the population affected by the Salmonella outbreak in terms of clinical presentation of self-reported arthritic symptoms and HLA-B27 genotyping. METHODS: Subjects were mailed a questionnaire, which assessed symptoms consistent with ReA. Subsequently, subjects were asked to submit saliva samples, which were analyzed for HLA-B27. Simple descriptive statistics were performed for analysis of survey responses, and the genetic component was analyzed by chi-square or Fisher's exact tests. RESULTS: Most respondents were female (71.3%), with a mean age of 46.0 years. The mean duration of diarrhea symptoms was 16.5 days. 62.5% of respondents reported extraintestinal symptoms that were consistent with ReA. The most commonly reported features were joint pain, swelling or stiffness (46.2%), stiffness > 30 min (35.6%), ocular symptoms (24.0%), and visibly swollen joints (19.2%). Subjects with Salmonella infection had a similar incidence of HLA-B27, regardless of whether they developed symptoms consistent with ReA or not. Notably, HLA-B27 was present more frequently in those who developed Salmonella infection than in healthy controls (OR 3.0). CONCLUSION: The study, one of the largest for a dysenteric outbreak, revealed a high event rate of self-reported symptoms consistent with ReA in those infected with Salmonella. Our results showed that HLA-B27 may have rendered individuals more susceptible to Salmonella infection, but did not contribute to the development of symptoms consistent with ReA after infection. We note that the methods used in this study, including self-report, are not ideal for diagnosis of inflammatory arthritis. However, given the rarity of large outbreaks of Salmonella, the study adds valuable knowledge about the course of ReA.

Toll-like receptor 2 variants are associated with acute reactive arthritis.

OBJECTIVE: We previously reported a recent outbreak of salmonellosis in which some individuals developed complications of the enteric infection. The objective of this study was to identify genetic variants that might predispose infected individuals to develop articular and/or extraarticular sequelae after Salmonella enteritidis infection. METHODS: The entire exposed cohort was invited to participate in the study by sending a saliva sample for DNA analysis. Seventy-five Salmonella-infected subjects for whom there was clinical information agreed to participate and were stratified into 4 groups. Group 1 patients had arthritis and extraarticular features, group 2 patients had arthritis alone, group 3 patients had extraarticular features alone, and group 4 patients had neither. DNA samples from an uninfected cohort of 91 normal subjects were also genotyped. Genotyping was performed using 2 Toll-like receptor 2 (TLR-2) (rs5743708 and rs5743704) and 2 TLR-4 (rs4986790 and rs4986791) single-nucleotide polymorphisms (SNPs). Statistical analyses were carried out using chi-square tests. RESULTS: There was no association of TLR-4 exonic variants with any clinical events that were reported as accompanying the Salmonella infection. In contrast, compared with normal controls, one of the rare TLR-2 SNPs (rs5743708, R753Q) was associated with the development of arthritis and extraarticular features (P = 0.015 by chi-square test). The TLR-2 variant 753Q was not detected in any of the infected individuals with an uncomplicated course. Another TLR-2 variant, 631H, was associated with articular symptoms in infected males (P = 0.03 by chi-square test). CONCLUSION: In this outbreak, genetic variants of TLR-2, but not TLR-4, were associated with acute reactive arthritis following infection with S enteritidis.