The influence of social norms in the context of reducing sugar-sweetened beverages consumption.

OBJECTIVES: This study aimed to examine the factors associated with low sugar-sweetened beverage (SSB) consumption and intention to avoid these products as well as investigate the role of different types of social norms in the adoption of this behaviour. STUDY DESIGN: This study reports the results of a secondary data analysis from a cross-sectional telephone survey. METHODS: A total of 1000 adults were randomly recruited in the province of Québec, Canada, using a random-digit dialling procedure. Eligibility criteria were to be aged between 18 and 64 years; able to answer a questionnaire in French or English; and to reside in the province of Québec. SSB consumption, social norms and variables from the theory of planned behaviour were assessed by means of a questionnaire. Logistic regression analyses were conducted to examine factors associated with behaviour and intention. RESULTS: Consuming <1 SSB per day was significantly associated with intention, perceived behavioural control, and risk perception about tooth decay. Descriptive (perceived prevalence in the close surroundings of one person) and perceived societal norms (perceived broad societal approval/disapproval of the behaviour) were associated with behaviour. All theory of planned behaviour variables (including injunctive norm) and risk perception pertaining to chronic diseases predicted intention to avoid the consumption of ≥1 SSB per day. Sex, age, income, and risk perception pertaining to chronic diseases were associated with perceived societal disapproval of SSB consumption. CONCLUSIONS: This study confirms the importance of social norms in the prediction of SSB consumption but also highlights the need to address motivation and capacities in public health interventions to reduce SSB consumption.

Hospitalisation for lower respiratory tract infection in children in the province of Quebec, Canada, before and during the pneumococcal conjugate vaccine era.

Streptococcus pneumoniae is an important cause of community-acquired pneumonia and pneumococcal conjugate vaccines (PCVs) may reduce this burden. This study's goal was to analyse trends in lower respiratory tract infections (LRTI) hospitalisations before and during a routine vaccination programme targeting all newborns with PCV was started in the province of Quebec, Canada in December 2004. The study population included hospital admissions with a main diagnosis of LRTI among 6-59 month-old Quebec residents from April 2000 to December 2014. Trends in proportions and rates were analysed using Cochran-Armitage tests and Poisson regression models. We observed a general downward trend in all LTRI hospitalisations rate: from 11·55/1000 person-years in 2000-2001 to 9·59/1000 in 2013-2014, a 17·0% reduction, which started before the introduction of PCV vaccination. Downward trends in hospitalisation rates were more pronounced for all-cause of pneumonia (minus 17·8%) than for bronchiolitis (minus 15·4%). There was also a decrease in the mean duration of hospital stay. There was little evidence that all-cause pneumonia decreased over the study period due mainly to the introduction of PCVs. Trends may be related to changes in clinical practice. This study casts doubt on the interpretation of ecological analyses of the implementation of PCV vaccination programmes.

Forecasting Trends in Invasive Pneumococcal Disease among Elderly Adults in Quebec.

Background. In Canada, the current recommendation is to offer PPV23 to adults ≥ 65 years. PCV13 is now licensed for adults. Methods. Invasive pneumococcal disease (IPD) cases in adults 65-74 years of age in the Quebec notifiable diseases registry were classified into five serotype categories. Poisson regression models were fitted to monthly rates observed in 2000-2014 and predictions were made for 2015-2024, using theoretical assumptions regarding indirect effects of childhood vaccination and serotype replacement. Results. IPD rates caused by PCV7 serotypes decreased markedly since PCV7 introduction for children in December 2004. This trend is also underway for additional PCV13 serotypes except serotype 3. Additional PPV23 serotypes and nonvaccine serotypes have been on rise since 2004 and this is expected to continue. A small decrease in overall IPD incidence in the next decade is predicted. The proportion of PCV13 serotypes represented 33% of IPD cases in 2014 and would be 20% (95% CI: 15% to 28%) in 2024. PPV23 coverage was 53% in 2014 and is expected to be 47% (95% CI: 26% to 85%) in 2024. Conclusion. The potential usefulness of a combined PCV13 + PPV23 program for elderly adults would decrease over time but PCV13 would be the only option to prevent serotype 3 IPD.

Predictors of hospitalization for lower respiratory tract infection in children aged <2 years in the province of Quebec, Canada.

Young age, adverse environmental conditions and infectious agents are established risk factors of lower respiratory tract infection (LRTI), whereas pneumococcal conjugate vaccines may be protective. To explore their relative role as predictors of hospitalizations under the continental climate prevailing in the province of Quebec, Canada, an ecological study was performed. Records with a main diagnosis of LRTI in children born during 2007-2010 and observed up to their second-year anniversary were extracted from the provincial hospital administrative database. Respiratory virus surveillance data and statistics on ambient air temperature were obtained. Vaccine use in different birth cohorts was derived from the Quebec City Immunization Registry. Additive and multiplicative Poisson regression models were applied to estimate attributable fractions. Age, month of birth, ambient temperature, and respiratory syncytial virus (RSV), human metapneumovirus (hMPV) and influenza-positive test proportions were significant predictors of LRTI hospitalizations. No substantial differences were observed in cohorts exposed to the 7-valent or 10-valent pneumococcal conjugate vaccines. In the additive model, the fraction of hospitalizations explained by temperature variation was 37%, whereas RSV circulation explained 28%, hMPV 4% and influenza 1%. Complex interplay between biological, environmental and social mechanisms may explain the important role of ambient air temperature in predicting LRTI hospitalization risk in young children.

Middle ear abnormalities at age 5 years in relation with early onset otitis media and number of episodes, in the Inuit population of Nunavik, Quebec, Canada.

Otitis media (OM) and their sequelae are a major health issue in the Inuit population of Nunavik, Quebec. Hypotheses of the study were: (i) early onset OM leads to repeated OM; (ii) repeated OM episodes leads to middle ear abnormalities (MEA) at age 5 years, (iii) pneumococcal conjugate vaccines (PCVs) may reduce multiple OM and MEA. Immunisation cards, medical records and audiology screening tests at age 5 years in a sample of 610 children born in 1994-2010 in 3 communities were reviewed. Children were classified into three categories using a score based on audiology screening tests: no abnormality, minor, or major MEA. The average number of OM episodes before age 5 years was 5.0 and 30% had minor and 17% major MEA at age 5 years. Community residency predicted both frequent (≥ 8) OM episodes and MEA. Early onset OM (age <6 months) was a predictor of frequent OM (RR = 1.71; 95%CI: 1.50-1.95) whereas PCV (≥1 dose ≥ age 2 months) has no significant effect. Frequent OM episodes were associated with major MEA (RR = 2.16; 95%CI: 1.20-3.85). Although associations were not statistically significant, there was a trend towards a protective effect of PCV administration on frequent OM and minor MEA, but not major MEA. In conclusion, results support an association between early onset OM, frequent OM and MEA that could represent a causal pathway.

Impact of a mass vaccination campaign against Serogroup B meningococcal disease in the Saguenay-Lac-Saint-Jean region of Quebec four years after its launch.

In the Saguenay-Lac-Saint-Jean region of Quebec, 83% of the population ≤20 years (n ≅ 59,500) was immunized in 2014 with the four-component Serogroup B meningococcal vaccine to control a long-lasting outbreak caused by a virulent ST-269 Serogroup B Neisseria meningitidis clone. Following the campaign, invasive meningococcal B disease (B-IMD) incidence fell sharply in the target population from 11.4/100,000 in 2006-2014 to 0.4/100,000 in 2014-2018 (p < 0.0001). Five B-IMD cases occurred in the region from July 2014 to June 2018, including one vaccinated child, one unvaccinated young adult and 3 unvaccinated elderly adults. Estimate of direct vaccine protection was 79% [95%CI:-231%;99%]. The overall campaign impact in the region taking into account the decrease in B-IMD incidence at provincial level was a 86% [95%CI:-2%;98%] decrease in B-IMD risk. The campaign impact was mostly seen in the target age-group suggesting no herd effect among unvaccinated older adults.

Prevalence of middle ear abnormalities from otitis media in relation with pneumococcal vaccine use in the Inuit population of Nunavik, province of Quebec, Canada.

BACKGROUND: Otitis media (OM) constitutes an important public health problem in the Inuit population of Nunavik, Northern Quebec. One of the objectives of the childhood pneumococcal vaccination program is to reduce OM burden. The program was implemented in 2002, and 7-, 10-, and 13-valent conjugate vaccines were used sequentially, with doses offered at 2, 4, 6 and 12-18 months, respectively. OBJECTIVE: To assess the prevalence of middle ear abnormalities at age 5 years in relation with exposure to different pneumococcal conjugate vaccines. METHODS: Immunization cards and audiology screening tests at age 5 years of children born in 1994-2010 were reviewed. Children were classified according to the vaccine schedule recommended for their birth cohort or to the vaccines they actually received. Log-linked binomial regression models were used to assess the relative abnormalities risk according to different vaccination schedules. RESULTS: Among 3517 children with complete documentation, the prevalences of minor and major abnormalities were 29% and 18%, respectively. Minor abnormalities frequency was higher in unvaccinated children (34%) and lower in children vaccinated with PCV7 (22%), PCV7 + PCV10 (17%), PCV10 (15%) and PCV10 + PCV13 (18%). No substantial differences among vaccine schedules were observed for major abnormalities. CONCLUSIONS: Pneumococcal conjugate vaccination was associated with a decreased frequency of middle ear abnormalities although no effect was seen for major abnormalities which may be trigger by OM with early onset. Clinicaltrials.gov registration number: NCT01694329.

The Quebec experience in promoting healthy lifestyles and preventing obesity: how can we do better?

Over the last years, many actions have been implemented in the Canadian province of Quebec to prevent health issues related to diet, physical activity and obesity. As a new public health programme is being launched, the 'How can we do better?' project aimed to identify priority areas for further action. An exhaustive search led to identify 166 interventions rolled out in Quebec between 2006 and 2014. We compared it with evidence-based recommendations. Findings were challenged during a 2-d deliberative forum gathering 25 key stakeholders. At the crossroads of these analyses, 50 proposals emerged to sustain/bolster current efforts or to implement new initiatives. Specific improvements were recommended, e.g. about food supply quality monitoring, healthy food accessibility and affordability, physical activity promotion through land use policies, schools and childcare facilities retrofit and urban planning. Crosscutting proposals stress the importance to implement a new governmental prevention strategy and to reinforce evaluation at all levels. This call for action takes place at a critical period for political commitment and should be maintained until and after curbing the prevalence of obesity and related diseases. Although Quebec-focused, 'How can we do better?' project outcomes may be informative for other jurisdictions, and the methods may be inspiring for those interested in combining knowledge syntheses and deliberative processes to inform decision makers in a limited time frame.

Methods for estimating the duration of bacterial carriage.

In two cohort studies on asymptomatic pharyngeal carriage of meningococci and of streptococci among schoolchildren, four methods are used to estimate the duration of bacterial carriage. A first estimate of the mean duration is given by the quotient of prevalence by incidence rate. A second method is based on the estimation of the actual length of truncated observations. A third estimate is given by the analysis of carriage survivorship according to a life table. A fourth method is the fitting of a negative exponential model to the carriage survival curve. For meningococci, the estimates of the median duration of carriage range from 7.7 up to 10.2 months, and from 11.1 up to 14.5 months for the mean. For streptococci, the median values vary from 1.9 up to 2.1 months, and from 2.3 up to 4.4 months for the mean duration. The validity and the consistency of the different estimates are discussed.

Evaluation of information systems for the surveillance of congenital malformations.

Many systems for the recording of congenital malformations in infants have been developed following the thalidomide epidemic of 1958 to 1962. Systems established for monitoring increases in rates of malformations have been of three main types: (1) prospective recording of information about all pregnancies; (2) the recording of malformations observed at birth; (3) the registration of children found to be malformed at birth or at any time after birth. The latter type involves many sources of information. International collaboration in monitoring has led to the establishment of the International Clearinghouse for Birth Defects Monitoring Systems and the EEC Concerted Action Project EUROCAT. The advantages of these two projects are discussed. It is shown that results from population based registers such as are included in EUROCAT can be used to validate the results of systems which carry out monitoring at birth.

Frequency of births with potentially avoidable serious chromosomal anomalies in EEC countries, 1979-1982.

Child bearing at an early age and prenatal cytogenetic diagnosis in pregnant women of advanced age, combined with selective abortion, make it possible to avoid the birth of many children with serious chromosomal anomalies. To see how many of such births were still avoidable in Europe, data from 16 regional EUROCAT registers of congenital anomalies in nine EEC countries were analysed. In the period 1979-1982 about 30% of children with unbalanced anomalies of autosomes were born (live- and still-births) to mothers over 35 years of age. This amounts to an estimated 1300 cases yearly in the entire population of the nine countries. The approach shows the possible use of registry data for monitoring effects of avoidance strategies.

Epidemiological evidence for immunity following Trypanosoma brucei gambiense sleeping sickness.

In order to investigate whether protective immunity appears after Trypanosoma brucei gambiense sleeping sickness, we undertook a retrospective cohort study of 3 remote villages in central Zaire (total population 1431), in which 38% of all adults had a past history of human African trypanosomiasis. Among adults previously diagnosed with trypanosomiasis and treated, the risk of a second episode of trypanosomiasis during the 10 years period of observation was only 15% (with a 24 months refractory period) and 30% (without a refractory period) of the risk of a first episode in adults never previously diagnosed. We could not demonstrate a similar difference among children, to some extent because only a few of them were diagnosed for a first time with trypanosomiasis. Our findings suggest that very significant immunity appears after Gambian sleeping sickness, and that developing a vaccine against this subspecies of trypanosomes is biologically plausible.

Familial aggregation of Trypanosoma brucei gambiense trypanosomiasis in a very high incidence community in Zaire.

Familial aggregation of Trypanosoma brucei gambiense human African trypanosomiasis (HAT) was investigated in 3 adjacent villages of central Zaire where 318/1431 inhabitants had previously suffered from HAT. Neither spatial nor familial aggregation was detected when analysing the distribution of cases in the whole community using Poisson, negative binomial and pairwise odds ratio models. However, clustering of cases was observed when specific familial relationships were examined. The risk of HAT for a child was significantly increased if the mother had also had HAT, but it was not influenced by a past history of HAT in the father. Sisters and brothers of cases of HAT had a higher risk of HAT than siblings of individuals who had never had HAT, but no such association was documented for half-sisters and half-brothers. Among married couples, a past history of HAT in one spouse had no impact on the other spouse's risk of HAT. Indirect arguments suggested that familial clustering was a consequence of shared exposure, either sequential or simultaneous, rather than of genetic susceptibility. The existence of familial clustering should be kept in mind when implementing passive or active case-finding activities.

Risk factors for encephalopathy and mortality during melarsoprol treatment of Trypanosoma brucei gambiense sleeping sickness.

This paper reviews the incidence of, and risk factors for, drug-induced encephalopathy and mortality (from all causes) during treatment with melarsoprol of 1083 patients with Trypanosoma brucei gambiense sleeping sickness in Nioki hospital (Zaire) between 1983 and 1990. Sixty-four patients (5.9%) developed encephalopathy and 62 (5.7%) died: 43 from reactive encephalopathy and 19 from other causes. Univariate and multivariate analyses showed that the administration of prednisolone reduced significantly the incidence of encephalopathy and mortality during treatment, especially in patients with trypanosomes observed in the cerebrospinal fluid (CSF) and/or with a CSF white blood cell (WBC) count of 100 or more per mm3. The risk of encephalopathy was associated more strongly with the CSF WBC count than with the presence of CSF trypanosomes. In the subgroup of patients with a CSF WBC count of 100 or more mm3, changing the melarsoprol regimen to 3 series of 3 injections instead of 3 series of 4 injections halved the mortality rate during treatment. Treatment of patients who do develop reactive encephalopathy with the heavy metal chelator dimercaprol, in addition to intravenous steroids and anticonvulsants, may be harmful. The data suggest that a further reduction of the total dose of melarsoprol may decrease toxicity without jeopardizing efficacy.

Home care as an alternative to hospitalization: a case study in Belgium.

In Belgium, primary health care services are well developed. Their efficiency is, however, handicapped by a general lack of coordination at a local level. Recently, pilot projects have been conducted to improve the integration of the various activities related to the practice of family medicine and especially those activities associated with the home care of chronic diseases and disabilities of the elderly. In one municipality where the coordination of primary care services is organized from a health centre, a retrospective study was carried out to measure the possible effect of such coordination on the use of health services. Indicators of the use of medical services were measured before and after the establishment of the coordinating centre, and were compared with the evolution observed in control areas. It is shown that the establishment of a health centre and the coordination of existing activities do not result in an inflationary use of primary care services. Moreover, the use of secondary care services seems to be reduced, indicating a net benefit in terms of costs.

Mortality in meningococcal disease in Belgium.

A survey of children admitted with meningococcal disease to 53 paediatric units in Belgium between 1975 and 1979 was made in order to assess the case mortality rate (CMR) and to identify risk factors associated with death. A total of 309 cases (226 bacteriologically confirmed and 83 unconfirmed) was recorded. The overall CMR was 6.1 per cent. It was 4.4 for bacteriologically confirmed cases and 10.8 for unconfirmed cases. The CMR was higher for septicaemia without meningitis (22.2 per cent) than for meningitis with or without signs of septicaemia (3.4 per cent). The risk of death was not related to the sex or nationality of the patients. Age was a major determinant of the CMR, independently of the clinical picture. The highest risk of death was in children under one year of age. Poor socio-economic conditions were a significant risk factor. Failure to recognise the severity of the disease by some poorly educated mothers, and the admission of the patient to a hospital lacking adequate facilities for managing severely affected children, were the two significant causes of delay of adequate treatment.

Longitudinal study of asymptomatic meningococcal carriage in two Belgian populations of schoolchildren.

In Brussels, a 15-month longitudinal survey was conducted in two primary schools, from March 1975 to May 1976, in order to analyse the dynamic of asymptomatic meningococcal carriage, during an epidemic mainly caused by serogroup B, serotype 2 Neisseria meningitidis. In the first school, which is situated in a suburban area with upper-middle socio-economic status of residents, a mean prevalence of carriers of 10 per cent, an acquisition rate of eight per 1000 months, and a mean duration of carriage of 12.4 months were observed among 158 schoolchildren aged six to 11 years old. In the second school, which is situated in a densely populated area with low socio-economic status of residents, a mean prevalence of carriers of 33 per cent, an acquisition rate of 28 per 1000 months, and a mean duration of carriage of 11.7 months were observed among 203 schoolchildren aged three to 14 years old. For both schools, the median duration of carriage was estimated at 9.4 months. The differences of prevalence and incidence of acquisition between the two schools cannot be explained by age, sex or ethnic factors and are probably related to socio familial variables. The theoretical relationship between prevalence, incidence and duration of meningococcal carriage was for the first time demonstrated in this study. The results also suggest that populations of low socio-economic status and living in densely populated areas constitute a target population for meningococcal disease prevention.

Meningococcal disease in Belgium. Secondary attack rate among household, day-care nursery and pre-elementary school contacts.

During a recrudescence of meningococcal disease mainly due to serogroup B, 1913 notified cases were investigated in Belgium from 1971 to 1976. From 1971 to 1973, 76 secondary cases were reported out of a total of 1455 cases (5.2 per cent); and from 1974 to 1976, nine secondary cases were reported of a total of 458 cases (2.0 per cent). Seventy per cent of the secondary cases occurred within seven days after the Index case. The 4.7 per cent fatality rate among secondary cases was lower than the 9.8 per cent fatality rate among primary cases. The estimated secondary attack rate was 685 per 100 000 among household contacts, 404 per 100 000 among day-care nursery contacts and 77 per 100 000 among pre-elementary school contacts. These attack rates were significantly higher (P less than 0.001) than the incidence rates in the corresponding age-groups in the general community, indicating the need for prophylaxis in these contacts.

Validity of the recording of meningococcal disease according to various sources of information.

A study was made in Belgium in order to assess the completeness and specificity of the recording of meningococcal disease by routine sources of information. Ninety-three cases identified in a hospital survey were linked with those recorded in mortality statistics, in the notification of communicable diseases, and by the National Reference Laboratory for meningococci. Statistics based on mortality data appeared to be of low validity. The overall completeness of recording was 44% for the notification of communicable disease, and 40% for the reference laboratory. When these two sources were used for surveillance, the completeness of case-finding increased to 56%. When the analysis was restricted to bacteriologically-confirmed cases, the completeness of recording was 62% for the notification system, 70% for the laboratory, and 84% for both sources. The surveillance of communicable diseases should rely on various sources of information. Laboratory data should be systematically used in order to improve both the completeness of recording and the specificity of case-ascertainment.

Correlates of care quality in long-term care facilities: a multilevel analysis.

Hierarchical modeling was employed to explore correlates of the quality of care provided in long-term care facilities. For this purpose, a multilevel analysis offers two advantages over traditional analytical approaches. First, it accounts for the correlated nature of data recorded on multiple residents from the same facility. Second, it enables the investigators to study the influence of both resident and facility characteristics on care quality. The analysis was performed on data from 301 residents randomly sampled from 88 facilities located in the Province of Quebec, Canada. Results revealed that the presence of cognitive deficits was the strongest correlate of the quality of care provided to a resident. However, this relationship was found to vary significantly across facilities. Four facility-level variables were found to influence the relationship between cognitive functioning and care quality: the number of external collaborators the facility has, the type of training the facility manager has, the size of the facility, and the age distribution of its clientele. From these results, we suggest means to improve the quality of care provided to cognitively impaired older adults living in long-term care facilities.