Preparing for Mpox Resurgence: Surveillance Lessons From Outbreaks in Toronto, Canada.

BACKGROUND: With many global jurisdictions, Toronto, Canada, experienced an mpox outbreak in spring/summer 2022. Cases declined following implementation of a large vaccination campaign. A surge in early 2023 led to speculation that asymptomatic and/or undetected local transmission was occurring in the city. METHODS: Mpox cases and positive laboratory results are reported to Toronto Public Health. Epidemic curves and descriptive risk factor summaries for the 2022 and 2023 outbreaks were generated. First- and second-dose vaccination was monitored. Mpox virus wastewater surveillance and whole genome sequencing were conducted to generate hypotheses about the source of the 2023 resurgence. RESULTS: An overall 515 cases were reported in spring/summer 2022 and 17 in the 2022-2023 resurgence. Wastewater data correlated with the timing of cases. Whole genome sequencing showed that 2022-2023 cases were distinct from 2022 cases and closer to sequences from another country, suggesting a new importation as a source. At the start of the resurgence, approximately 16% of first-dose vaccine recipients had completed their second dose. CONCLUSIONS: This investigation demonstrates the importance of ongoing surveillance and preparedness for mpox outbreaks. Undetected local transmission was not a likely source of the 2022-2023 resurgence. Ongoing preexposure vaccine promotion remains important to mitigate disease burden.

Notes from the Field: Furanyl-Fentanyl Overdose Events Caused by Smoking Contaminated Crack Cocaine - British Columbia, Canada, July 15-18, 2016.

On July 15 2016, Surrey Memorial Hospital's emergency department notified the medical health officer on call of a sharp increase in opioid overdose events in Surrey, Fraser Health Authority, in British Columbia, Canada. During July 15-18, the number of persons with suspected opioid overdose evaluated in Surrey Memorial Hospital's emergency department increased approximately 170%, from an average of four suspected cases per day during the period January-June 2016 to 43 (nearly 11 per day) during the 4-day period (Figure). Most patients (22 [51%]) became unconscious after smoking what they believed to be crack cocaine. The majority of overdose events occurred within a small geographic area in Surrey that has a high population of homeless persons and persons who use illicit drugs, including opioids and crack cocaine. Most cases occurred in males (36 cases [84%]); the average age of the patients was 42 years (range = 18-63 years). Forty (93%) patients were brought to the emergency department by ambulance. A total of 37 (86%) patients received injectable naloxone before arriving in the emergency department, including 12 who received it only from community members, 16 who received it only from paramedics, five who received it from both community members and paramedics, one who received it from the fire department and paramedics, and one who received it from the fire department, community, and paramedics; for two patients, the source of naloxone was not known. Reports from first responders, the community, and emergency department staff members indicated that patients required high doses of injectable naloxone, in some cases up to 3.0 mg (usual dose = 0.4 mg). Thirty-five (81%) patients were treated and discharged within a few hours, two patients left without being seen by a health care provider, and six patients were admitted to the hospital; among these, three were transferred to the intensive care unit, one of whom died.

Opening Canada's first Health Canada-approved supervised consumption sites.

SETTING: In response to the opioid overdose crisis, a Public Health Emergency was declared in British Columbia (BC) in April 2016. There were 1448 deaths in BC in 2017 (30.1 deaths per 100,000 individuals). INTERVENTION: Approximately one third of all overdose deaths in BC in 2016 (333/993) and 2017 (482/1448) occurred within the region served by Fraser Health Authority (FH). We identified a need for a supervised drug use site in Surrey, the city with FH's highest number of overdose deaths in 2016 (n = 122). In order to ensure low-barrier services, FH underwent an internal assessment for a supervised drug use site and determined that a supervised injection site was unlikely to meet the needs of individuals who consumed their drugs using other routes, choosing instead to apply for an exemption to the Controlled Drug and Substances Act in order to open a Supervised Consumption Site (SCS). OUTCOMES: In assessing population needs, injection was identified as the mode of drug administration in only 32.8% of overdose deaths in FH from 2011 to 2016. Other routes of drug (co-) administration included oral (30.6%); smoking (28.8%); intranasal (24.2%); and unknown/other (17.1%). Interviews with potential service users confirmed drug (co-) administration behaviours and identified other aspects of service delivery, such as hours and co-located services that would help align the services better with client needs. With Health Canada's approval, SafePoint in Surrey opened for supervised injection on June 8, 2017 and received an exemption to allow oral and intranasal consumption on June 26, 2017. IMPLICATIONS: By assessing drug use practices, the evolving needs of people who use substances, and tailoring services to local context, we can potentially engage with individuals earlier in their substance use trajectory to improve the utility of services and prevent more overdoses and overdose deaths.