Viral dynamics of the SARS-CoV-2 Omicron Variant in Paediatric Patients; A prospective cohort study.

BACKGROUND: There are limited data on the viral dynamics of SARS-CoV-2 in children. Understanding viral load changes over the course of illness and duration of viral shedding may provide insight into transmission dynamics to inform public health and infection control decisions. METHODS: We conducted a prospective cohort study of children 18 years and younger with PCR confirmed SARS-CoV-2 between February 1, 2022 and March 14, 2022. SARS-CoV-2 testing occurred on daily samples for 10 days; a subset of participants completed daily rapid antigen testing (RAT). Viral RNA trajectories were described in relation to symptom onset and resolution. The associations between both time since symptom onset/resolution and non-infectious viral load were evaluated using a Cox proportional hazards model. FINDINGS: Among 101 children aged 2 to 17 years, the median time to study-defined non-infectious viral load was 5 days post symptom onset, with 75% meeting this threshold by 7 days, and 90% by 10 days. On the day of and day after symptom resolution, 43 of 87 (49%) and 52 (60%) had met the non-infectious thresholds, respectively. Of the 50 participants completing RAT, positivity at symptom onset and on the day after symptom onset was 67% (16/24) and 75% (14/20). On the first day where the non-infectious threshold was met, 61% (n = 27/44) of participant RAT results were positive. INTERPRETATION: Children often met the study-defined non-infectiousness threshold on the day after symptom resolution. RAT tests were often negative early in the course of illness and should not be relied on to exclude infection. CLINICAL TRIALS REGISTRATION: NCT05240183.

Prevalence of SARS-CoV-2 infection among people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic.

OBJECTIVES: People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristics and prevalence rates. METHODS: The study included individuals who were staying at shelters, encampments, COVID-19 physical distancing sites, and drop-in and respite sites and completed outreach-based testing for SARS-CoV-2 during the period April 17 to July 31, 2020. We examined test positivity rates over time and compared them to rates in the general population of Toronto. Negative binomial regression was used to examine the relationship between each shelter-level characteristic and SARS-CoV-2 positivity rates. We also compared the rates across 3 time periods (T1: April 17-April 25; T2: April 26-May 23; T3: May 24-June 25). RESULTS: The overall prevalence of SARS-CoV-2 infection was 8.5% (394/4657). Site-specific rates showed great heterogeneity with infection rates ranging from 0% to 70.6%. Compared to T1, positivity rates were 0.21 times lower (95% CI: 0.06-0.75) during T2 and 0.14 times lower (95% CI: 0.04-0.44) during T3. Most cases were detected during outbreak testing (384/394 [97.5%]) rather than active case finding. CONCLUSION: During the first wave of the pandemic, rates of SARS-CoV-2 infection at sites for people experiencing homelessness in Toronto varied significantly over time. The observation of lower rates at certain sites may be attributable to overall time trends, expansion of outreach-based testing to include sites without known outbreaks, and/or individual site characteristics.

RéSUMé: OBJECTIFS: Les personnes en situation d'itinérance courent un risque accru de contracter une infection par le SRAS-CoV-2. Notre étude rend compte de la prévalence ponctuelle des infections par le SRAS-CoV-2 au cours de tests de dépistage menés dans des lieux de services aux personnes en situation d'itinérance de Toronto au cours de la première vague de la pandémie de COVID-19. Nous avons aussi exploré l'association entre les caractéristiques de ces lieux et les taux de prévalence. MéTHODE: L'étude a inclus les personnes séjournant dans des refuges, des campements, des lieux de distanciation physique et des centres d'accueil et de répit et ayant subi un test de dépistage de proximité du SRAS-CoV-2 entre le 17 avril et le 31 juillet 2020. Nous avons examiné les taux de positivité des tests au fil du temps et nous les avons comparés aux taux dans la population générale de Toronto. Des analyses de régression binomiales négatives ont été effectuées pour étudier la relation entre chaque caractéristique au niveau des refuges et les taux de positivité au SRAS-CoV-2. Nous avons aussi comparé les taux de trois intervalles (I1: 17 au 25 avril; I2: 26 avril au 23 mai; I3: 24 mai au 25 juin). RéSULTATS: La prévalence globale des infections par le SRAS-CoV-2 était de 8,5 % (394/4 657). Les taux d'infection spécifiques aux lieux de services ont présenté une grande hétérogénéité, soit de 0 % à 70,6 %. Comparés au 1er intervalle (I1), les taux de positivité ont été 0,21 fois plus faibles (IC de 95% : 0,06 ­ 0,75) durant l'I2 et 0,14 fois plus faibles (IC de 95% : 0,04 ­ 0,44) durant l'I3. La plupart des cas ont été détectés lors d'un dépistage en cours d'éclosion (384/394 [97,5%]) et non lors d'une recherche active de cas. CONCLUSION: Au cours de la première vague de la pandémie, les taux d'infection par le SRAS-CoV-2 dans les lieux de services aux personnes en situation d'itinérance de Toronto ont varié de façon significative au fil du temps. L'observation de taux plus faibles dans certains lieux pourrait s'expliquer par les tendances temporelles globales, par l'expansion des activités de dépistage de proximité pour inclure les lieux sans éclosion connue et/ou par les caractéristiques individuelles des lieux.

Caring for Caregivers: Challenging the Assumptions.

Informal and mostly unpaid caregivers - spouses, family, friends and neighbours - play a crucial role in supporting the health, well-being, functional independence and quality of life of growing numbers of persons of all ages who cannot manage on their own. Yet, informal caregiving is in decline; falling rates of engagement in caregiving are compounded by a shrinking caregiver pool. How should policymakers respond? In this paper, we draw on a growing international literature, along with findings from community-based studies conducted by our team across Ontario, to highlight six common assumptions about informal caregivers and what can be done to support them. These include the assumption that caregivers will be there to take on an increasing responsibility; that caregiving is only about an aging population; that money alone can do the job; that policymakers can simply wait and see; that front-line care professionals should be left to fill the policy void; and that caregivers should be addressed apart from cared-for persons and formal care systems. While each assumption has a different focus, all challenge policymakers to view caregivers as key players in massive social and political change, and to respond accordingly.

Letting youths choose for themselves: concept mapping as a participatory approach for program and service planning.

Ensuring that the voices of youths are heard is key in creating services that align with the needs and goals of youths. Concept mapping, a participatory mixed-methods approach, was used to engage youths, families, and service providers in an assessment of service gaps facing youth in an underserviced neighborhood in Toronto, Canada. We describe 6 phases of concept mapping: preparation, brainstorming, sorting and rating, analysis, interpretation, and utilization. Results demonstrate that youths and service providers vary in their conceptualizations of youth service needs and priorities. Implications for service planning and for youth engagement in research are discussed.

Caring for caregivers of high-needs children.

The Caregiver Framework for Children with Medical Complexity, led by the Hospital for Sick Children, is a ground-breaking initiative that validates and supports the vital role of unpaid, family caregivers. The project uses a supported self-management model that includes a modest amount of funding to address pressing needs, and relies on Key Workers who provide ongoing education, counselling and care management to assist caregivers in planning over the longer-term. This paper describes the findings from a multi-stage, mixed-methods evaluation to examine the design and outcomes of the Caregiver Framework.

Pandemic management in a pediatric hospital.

OBJECTIVES: To describe our experiences in the management of the second wave of influenza A H1N1 (pH1N1) pandemic in a tertiary-care children's hospital. METHODS: An autoethnographic study of the pandemic planning and management committee members involved in managing the second wave of pH1N1 was conducted. RESULTS: Staffing, surge capacity, communications and emergency operations planning by adding leaders of frontline workers and other key operational roles to the incident management team, and creating a tactical response team emerged as important factors in pandemic management in our hospital. The emergency department visits increased by 50%, necessitating increased staffing of the emergency department. Communications using existing chains of command had to be used to reach frontline staff during the pandemic. CONCLUSIONS: Incident management teams managing pandemics and other disasters have to be dynamic and create tactical teams to ensure implementation and facilitate bidirectional communication with frontline workers.

Integrated complex care model: lessons learned from inter-organizational partnership.

Providing integrated care for children with medical complexity in Canada is challenging as these children are, by definition, in need of coordinated care from disparate providers, organizations and funders across the continuum in order to optimize health outcomes. We describe the development of an inter-organizational team constructed as a unique tripartite partnership of an acute care hospital, a children's rehabilitation hospital and a home/community health organization focused on children who frequently use services across these three organizations. Model building and operationalization within the Canadian healthcare system is emphasized. Key challenges identified to date include communication and policy barriers as well as optimizing interactions with families; critical enablers have been alignment with policy trends in healthcare and inter-organizational commitment to integrate at the point of care. Considerations for policy developments supporting full integration across service sectors are raised. Early indicators of success include the enrolment of 34 clients and patients and the securing of funds to evaluate and expand the model to serve more children.

Kids in transition: the rehab experience.

Holland Bloorview Kids Rehabilitation Hospital (formerly Bloorview Kids Rehab) is Canada's largest teaching hospital for pediatric rehabilitation and the only in-patient pediatric rehabilitation centre in Ontario. SickKids is a quaternary-level academic health sciences centre. The acute care neuroscience and trauma patient population at SickKids represents the largest volume of transitioning clients between the two organizations. For years, the number of medically unnecessary days associated with patients awaiting transfer from SickKids to Holland Bloorview for off-site rehabilitation was consistently driven by inefficient processes, multiple handovers, duplicitous efforts, fragmented communication and a lack of timely or complete referral information. Recognizing this situation as a threat to access, as well as a significant risk to patient health outcomes, SickKids and Holland Bloorview embarked on an exciting partnership (Kids in Transition: The Rehab Experience) as part of a larger Ministry of Health and Long-Term Care-funded initiative, the Flo Collaborative.

Pandemic planning in pediatric care: a website policy review and national survey data.

OBJECTIVES: This study investigates current policies, key issues, and needs for pandemic planning in pediatrics in Canada. METHODS: Online pandemic plans from national, provincial and territorial government websites were reviewed to identify: plans for children and families, and psychosocial and ethical issues. A survey was administered to gather participants' perspectives on the needs in pediatric planning, as well as important elements of their organizations' and regions' pandemic plans. A thematic analysis was conducted on qualitative survey responses. RESULTS: The majority of existing plans did not adequately address the unique needs of pediatric populations, and mainly focused on medical and policy concerns. Several gaps in plans were identified, including the need for psychosocial supports and ethical decision-making frameworks for children and families. Similarly, survey respondents identified parallel gaps, in their organization's or region's plans. CONCLUSIONS: Although many plans provide guidelines for medical and policy issues in pediatrics, much more work remains in psychosocial and ethical planning. A focus on children and families is needed for pandemic planning in pediatrics to ensure best outcomes for children and families.

Innovation in managing the referral process at a Canadian pediatric hospital.

The provision of timely and optimal patient care is a priority in pediatric academic health science centres. Timely access to care is optimized when there is an efficient and consistent referral system in place. In order to improve the patient referral process and, therefore, access to care, an innovative web-based system was developed and implemented. The Ambulatory Referral Management System enables the electronic routing for submission, review, triage and management of all outpatient referrals. The implementation of this system has provided significant metrics that have informed how processes can be improved to increase access to care. Use of the system has improved efficiency in the referral process and has reduced the work associated with the previous paper-based referral system. It has also enhanced communication between the healthcare provider and the patient and family and has improved the security and confidentiality of patient information management. Referral guidelines embedded within the system have helped to ensure that referrals are more complete and that the patient being referred meets the criteria for assessment and treatment in an ambulatory setting. The system calculates and reports on wait times, as well as other measures.

Organizational change through Lean Thinking.

In production and manufacturing plants, Lean Thinking has been used to improve processes by eliminating waste and thus enhancing efficiency. In health care, Lean Thinking has emerged as a comprehensive approach towards improving processes embedded in the diagnostic, treatment and care activities of health-care organizations with cost containment results. This paper provides a case study example where Lean Thinking is not only used to improve efficiency and cost containment, but also as an approach to effective organizational change.

Pandemic influenza planning for children and youth: who's looking out for our kids?

Recent worldwide attention on influenza pandemics has mainly focused on planning and preparation. Some published plans appear to have missed some unique considerations relevant to children and youth, leaving a serious and potentially devastating gap in our pandemic response. This paper highlights those unique considerations and encourages health administrators and policy-makers to rise to the challenge and demonstrate leadership by ensuring that all institutions consider children and youth in their pandemic planning.