Exercising medical judgement: resuscitation and "Decision-Making for End-of-Life Care," a new policy from the College of Physician and Surgeons of Ontario.

In March 2023, the College of Physicians and Surgeons of Ontario (CPSO) updated their policy entitled Decision-Making for End-of-Life Care. This policy will significantly change the landscape and clinical practice in Canada's most populous province with respect to decision-making for resuscitation. The update interrupts approximately eight years of CPSO policy that has mandated physicians to perform cardiopulmonary resuscitation (CPR) and other resuscitative measures unless they can explicitly obtain consent in the form of a do-not-resuscitate or no-CPR order. The policy is now aligned with the Wawrzyniak v. Livingstone, 2019 court decision which reaffirmed that physicians must only offer treatments that they think are within the standard of care and not offer treatments that are not likely to benefit their patient. In this commentary, we review the historical aspects of the CPSO policy from 2015 to 2023 and discuss how such a policy of a "consent to withhold" paradigm was ethically problematic and likely led to significant harm. We then review the updated CPSO policy, outline some remaining areas of uncertainty and challenges, and make recommendations for how to interpret this policy in clinical practice.

RéSUMé: En mars 2023, l'Ordre des médecins et chirurgiens de l'Ontario (OMCO) a mis à jour sa politique intitulée Prise de décision pour les soins de fin de vie. Cette politique changera considérablement le paysage et la pratique clinique dans la province la plus peuplée du Canada en ce qui concerne la prise de décision en matière de réanimation. Cette mise à jour met fin à environ huit ans de politique de l'OMCO qui mandatait les médecins de procéder à la réanimation cardiorespiratoire (RCR) et de pratiquer d'autres mesures de réanimation, à moins d'avoir explicitement obtenu le consentement sous la forme d'une ordonnance de non-réanimation ou d'interdiction de RCR. La politique s'aligne maintenant sur la décision de la Cour dans Wawrzyniak c. Livingstone, 2019, qui a réaffirmé que les médecins ne doivent offrir que des traitements jugés conformes à la norme de soins et ne doivent pas offrir de traitements qui ne sont pas susceptibles d'être bénéfiques pour leur patient·e. Dans ce commentaire, nous passons en revue les aspects historiques de la politique de l'OMCO de 2015 à 2023 et discutons de la façon dont une telle politique fondée sur un paradigme de « consentement à retenir les soins ¼ était problématique sur le plan éthique et a probablement entraîné un préjudice important. Nous passons ensuite en revue la politique mise à jour de l'OMCO, décrivons certains domaines d'incertitude et de défis qui subsistent, et formulons des recommandations sur la façon d'interpréter cette politique dans la pratique clinique.

The Impact of Multiple Rounds of Indoor Residual Spraying on Malaria Incidence and Hemoglobin Levels in a High-Transmission Setting.

BACKGROUND: Indoor residual spraying (IRS) is widely used as a vector control measure, although there are conflicting findings of its effectiveness in reducing malaria incidence. The objective of this study was to estimate the effect of multiple IRS rounds on malaria incidence and hemoglobin levels in a cohort of children in rural southeastern Uganda. METHODS: The study was based upon a dynamic cohort of children aged 0.5-10 years enrolled from August 2011 to June 2017 in Nagongera Subcounty. Confirmed malaria infections and hemoglobin levels were recorded over time for each participant. After each of 4 rounds of IRS, malaria incidence, hemoglobin levels, and parasite density were evaluated and compared with pre-IRS levels. Analyses were carried out at the participant level while accounting for repeated measures and clustering by household. RESULTS: Incidence rate ratios comparing post-IRS to pre-IRS incidence rates for age groups 0-3, 3-5, and 5-11 were 0.108 (95% confidence interval [CI], .078-.149), 0.173 (95% CI, .136-.222), and 0.226 (95% CI, .187-.274), respectively. The mean hemoglobin levels significantly increased from 11.01 (pre-IRS) to 12.18 g/dL (post-IRS). CONCLUSIONS: Our study supports the policy recommendation of IRS usage in a stable and perennial transmission area to rapidly reduce malaria transmission.

Reconstruction of Zika Virus Introduction in Brazil.

We estimated the speed of Zika virus introduction in Brazil by using confirmed cases at the municipal level. Our models indicate a southward pattern of introduction starting from the northeastern coast and a pattern of movement toward the western border with an average speed of spread of 42 km/day or 15,367 km/year.

Two Birds With One Stone: Estimating Population Vaccination Coverage From a Test-negative Vaccine Effectiveness Case-control Study.

Vaccination program evaluation includes assessment of vaccine uptake and direct vaccine effectiveness (VE). Often examined separately, we propose a design to estimate rotavirus vaccination coverage using controls from a rotavirus VE test-negative case-control study and to examine coverage following implementation of the Quebec, Canada, rotavirus vaccination program. We present our assumptions for using these data as a proxy for coverage in the general population, explore effects of diagnostic accuracy on coverage estimates via simulations, and validate estimates with an external source. We found 79.0% (95% confidence interval, 74.3%, 83.0%) ≥2-dose rotavirus coverage among participants eligible for publicly funded vaccination. No differences were detected between study and external coverage estimates. Simulations revealed minimal bias in estimates with high diagnostic sensitivity and specificity. We conclude that controls from a VE case-control study may be a valuable resource of coverage information when reasonable assumptions can be made for estimate generalizability; high rotavirus coverage demonstrates success of the Quebec program.

A latent process model for forecasting multiple time series in environmental public health surveillance.

This paper outlines a latent process model for forecasting multiple health outcomes arising from a common environmental exposure. Traditionally, surveillance models in environmental health do not link health outcome measures, such as morbidity or mortality counts, to measures of exposure, such as air pollution. Moreover, different measures of health outcomes are treated as independent, while it is known that they are correlated with one another over time as they arise in part from a common underlying exposure. We propose modelling an environmental exposure as a latent process, and we describe the implementation of such a model within a hierarchical Bayesian framework and its efficient computation using integrated nested Laplace approximations. Through a simulation study, we compare distinct univariate models for each health outcome with a bivariate approach. The bivariate model outperforms the univariate models in bias and coverage of parameter estimation, in forecast accuracy and in computational efficiency. The methods are illustrated with a case study using healthcare utilization and air pollution data from British Columbia, Canada, 2003-2011, where seasonal wildfires produce high levels of air pollution, significantly impacting population health. Copyright © 2016 John Wiley & Sons, Ltd.

Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support.

BACKGROUND AND OBJECTIVES: Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support. METHODS: This was a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation of care before 72 hours were excluded. For each ICH score, mortality at 30- and 90-days, and the modified Rankin Scale (mRS) within 1-year were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 (interquartile range [IQR] 0.4-4.4) years. RESULTS: Among 319 patients with spontaneous ICH (median age was 69 [IQR 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS score 4-6) was 50% at a median 3.1 months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH scores 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (odds ratio [OR] 0.29, 95% CI 0.09-0.9, p = 0.032) and 80% (OR 0.2, 95% CI 0.04-0.91, p = 0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome. DISCUSSION: This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.

Trends in the uptake of pediatric measles-containing vaccine in the United States: A Disneyland effect?

BACKGROUND: The measles outbreak that began in December 2014 at the California Disneyland theme park in the United States (U.S.) received a high amount of media attention. Media attention can influence health-related behaviors. We investigated the effect of the Disneyland outbreak on measles-containing vaccine (MCV) uptake among U.S. children. METHODS: We used 2012-2017 National Immunization Survey-Child (NIS-Child) data to examine MCV uptake among U.S. children by 19 months of age. We classified MCV coverage among birth cohorts as exposed based on age at the time of the outbreak. A difference-in-differences design with adjustment for categorical birth cohort was implemented in base models to estimate the exposure effect on the outcomes, ≥1-dose MCV coverage or age at first MCV dose, with pneumococcal conjugate vaccination as a control. Primary analyses included this model adjusted for geographic region, maternal education, race/ethnicity, household income, and insurance status, and an exposure-interaction term with maternal education. All analyses included sampling weights. RESULTS: The study population represented 34,471,357 children. In base models, the Disneyland outbreak was associated with a 1.0% (95% CI: 0.2%, 1.8%) increase in ≥1-dose MCV coverage and a 6.6 (95% CI: 4.8, 8.5)-day decrease in MCV administration age. In primary analyses, the outbreak was associated with a 3.9% (95% CI: 3.1%, 4.8%) increase in ≥1-dose MCV coverage among children of college-educated mothers, and a 3.2% (95% CI: 0.6%, 5.9%) decrease among children of mothers earning less than a high school degree. Decreases in MCV administration age ranging from 5.9 (95% CI: 3.3, 8.5) to 9.1 (95% CI: 6.8, 11.4) days were observed across maternal education categories. CONCLUSIONS: The Disneyland outbreak was associated with differential effects on MCV coverage by maternal education and decreases in MCV administration age among U.S. children. These findings may provide useful insights to inform methods to address pediatric MCV undervaccination.

Staying Ahead of the Epidemiologic Curve: Evaluation of the British Columbia Asthma Prediction System (BCAPS) During the Unprecedented 2018 Wildfire Season.

Background: The modular British Columbia Asthma Prediction System (BCAPS) is designed to reduce information burden during wildfire smoke events by automatically gathering, integrating, generating, and visualizing data for public health users. The BCAPS framework comprises five flexible and geographically scalable modules: (1) historic data on fine particulate matter (PM2.5) concentrations; (2) historic data on relevant health indicator counts; (3) PM2.5 forecasts for the upcoming days; (4) a health forecasting model that uses the relationship between (1) and (2) to predict the impacts of (3); and (5) a reporting mechanism. Methods: The 2018 wildfire season was the most extreme in British Columbia history. Every morning BCAPS generated forecasts of salbutamol sulfate (e.g., Ventolin) inhaler dispensations for the upcoming days in 16 Health Service Delivery Areas (HSDAs) using random forest machine learning. These forecasts were compared with observations over a 63-day study period using different methods including the index of agreement (IOA), which ranges from 0 (no agreement) to 1 (perfect agreement). Some observations were compared with the same period in the milder wildfire season of 2016 for context. Results: The mean province-wide population-weighted PM2.5 concentration over the study period was 22.0 µg/m3, compared with 4.2 µg/m3 during the milder wildfire season of 2016. The PM2.5 forecasts underpredicted the severe smoke impacts, but the IOA was relatively strong with a population-weighted average of 0.85, ranging from 0.65 to 0.95 among the HSDAs. Inhaler dispensations increased by 30% over 2016 values. Forecasted dispensations were within 20% of the observed value in 71% of cases, and the IOA was strong with a population-weighted average of 0.95, ranging from 0.92 to 0.98. All measures of agreement were correlated with HSDA population, where BCAPS performance was better in the larger populations with more moderate smoke impacts. The accuracy of the health forecasts was partially dependent on the accuracy of the PM2.5 forecasts, but they were robust to over- and underpredictions of PM2.5 exposure. Conclusions: Daily reports from the BCAPS framework provided timely and reasonable insight into the population health impacts of predicted smoke exposures, though more work is necessary to improve the PM2.5 and health indicator forecasts.

High Community SARS-CoV-2 Antibody Seroprevalence in a Ski Resort Community, Blaine County, Idaho, US. Preliminary Results.

Community-level seroprevalence surveys are needed to determine the proportion of the population with previous SARS-CoV-2 infection, a necessary component of COVID-19 disease surveillance. In May, 2020, we conducted a cross-sectional seroprevalence study of IgG antibodies for nucleocapsid of SARS-CoV-2 among the residents of Blaine County, Idaho, a ski resort community with high COVID-19 attack rates in late March and Early April (2.9% for ages 18 and older). Participants were selected from volunteers who registered via a secure web link, using prestratification weighting to the population distribution by age and gender within each ZIP Code. Participants completed a survey reporting their demographics and symptoms; 88% of volunteers who were invited to participate completed data collection survey and had 10 ml of blood drawn. Serology was completed via the Abbott Architect SARS-CoV-2 IgG immunoassay. Primary analyses estimated seroprevalence and 95% credible intervals (CI) using a hierarchical Bayesian framework to account for diagnostic uncertainty. Stratified models were run by age, sex, ZIP Code, ethnicity, employment status, and a priori participant-reported COVID-19 status. Sensitivity analyses to estimate seroprevalence included base models with post-stratification for ethnicity, age, and sex, with or without adjustment for multi-participant households. IgG antibodies to the virus that causes COVID-19 were found among 22.7% (95% CI: 20.1%, 25.5%) of residents of Blaine County. Higher levels of antibodies were found among residents of the City of Ketchum 34.8% (95% CI 29.3%, 40.5%), compared to Hailey 16.8% (95%CI 13.7%, 20.3%) and Sun Valley 19.4% (95% 11.8%, 28.4%). People who self-identified as not believing they had COVID-19 had the lowest prevalence 4.8% (95% CI 2.3%, 8.2%). The range of seroprevalence after correction for potential selection bias was 21.9% to 24.2%. This study suggests more than 80% of SARS-CoV-2 infections were not reported. Although Blaine County had high levels of SARS-CoV-2 infection, the community is not yet near the herd immunity threshold.

Prevalence and Predictors of Food Insecurity among Older People in Canada.

Background: Food insecurity research has been mainly examined among young people. The root causes of food insecurity are closely linked to poverty, and social policies and income supplements, including public and private pensions, have been shown to sharply curb food insecurity into later life. However, social, economic, and political trends that are closely connected to social and health inequalities threaten to undermine the conditions that have limited food insecurity among older people until now. Exploring the prevalence and predictors of food insecurity among older people across Canada has important implications for domestic policies concerning health, healthcare, and social welfare. Methods: Data come from the Canadian Community Health Survey 2012 Annual Component (n = 14,890). Descriptive statistics and a generalized linear model approach were used to determine prevalence and estimate the associations between food insecurity-as measured by the Household Food Security Survey Module-and social, demographic, geographic, and economic factors. Results: Approximately 2.4% of older Canadians are estimated to be moderately or severely food insecure. Income was by far the strongest predictor of food insecurity (total household income <$20,000 compared to >$60,000, OR: 46.146, 95% CI: 12.523⁻170.041, p < 0.001). Younger older people, and those with a non-white racial background also had significantly greater odds of food insecurity (ages 75+ compared to 65⁻74, OR: 0.322, 95% CI: 0.212⁻0.419, p < 0.001; and OR: 2.429, 95% CI: 1.438⁻4.102, p < 0.001, respectively). Sex, home ownership, marital status, and living arrangement were all found to confound the relationship between household income and food insecurity. Prevalence of food insecurity varied between provinces and territories, and odds of food insecurity were approximately five times greater for older people living in northern Canada as compared to central Canada (OR: 5.189, 95% CI: 2.329⁻11.562, p < 0.001). Conclusion: Disaggregating overall prevalence of food insecurity among older people demonstrates how disparities exist among sub-groups of older people. The seemingly negligible existence of food insecurity among older people has obscured the importance, practicality, and timeliness of including this age group in research on food insecurity. The current research underscores the critical importance of an income floor in preventing food insecurity among older people, and contributes a Canadian profile of the prevalence and predictors of food insecurity among older people to the broader international literature.

Trends in the contribution of major causes of death to the black-white life expectancy gap by US state.

Life expectancy has increased in the United States over many decades. The difference in life expectancy between black and white Americans has also decreased, but some states have made much more progress towards racial equality than others. This paper describes the pattern of contributions of six major causes of death to the black-white life expectancy gap within US states and the District of Columbia between 1969 and 2013, and identifies states diverging from the overall pattern. Across multiple causes, the District of Columbia, Illinois, Wisconsin, and Michigan had the highest contributions to black-white inequality, while New York, Massachusetts, and Rhode Island had the lowest contributions and have either achieved or are the closest to achieving black-white equality in life expectancy.

Spatial Determinants of Ebola Virus Disease Risk for the West African Epidemic.

INTRODUCTION: Although many studies have investigated the probability of Ebola virus disease (EVD) outbreaks while other studies have simulated the size and speed of EVD outbreaks, few have investigated the environmental and population-level predictors of Ebola transmission once an outbreak is underway. Identifying strong predictors of transmission could help guide and target limited public health resources during an EVD outbreak. We examined several environmental and population-level demographic predictors of EVD risk from the West African epidemic. METHODS: We obtained district-level estimates from the World Health Organization EVD case data, demographic indicators obtained from the Demographic and Health surveys, and satellite-derived temperature, rainfall, and land cover estimates. A Bayesian hierarchical Poisson model was used to estimate EVD risk and to evaluate the spatial variability explained by the selected predictors. RESULTS:  We found that districts had greater risk of EVD with increasing proportion of households not possessing a radio (RR 2.79, 0.90-8.78; RR 4.23, 1.16-15.93), increasing rainfall (RR 2.18; 0.66-7.20; 5.34, 1.20-23.90), and urban land cover (RR 4.87, 1.56-15.40; RR 5.74, 1.68-19.67). DISCUSSION:  The finding of radio ownership and reduced EVD transmission risk suggests that the use of radio messaging for control and prevention purposes may have been crucial in reducing the EVD transmission risk in certain districts, although this association requires further study. Future research should examine the etiologic relationships between the identified risk factors and human-to-human transmission of EVD with a focus on factors related to population mobility and healthcare accessibility, which are critical features of epidemic propagation and control.

Effectiveness of monovalent rotavirus vaccine in a high-income, predominant-use setting.

BACKGROUND AND OBJECTIVES: We assessed monovalent rotavirus (RV1) vaccine effectiveness (VE) in a high-income setting with RV1 predominant use, and examined the burden of pediatric rotavirus gastroenteritis following the implementation of an RV1-only vaccination program. METHODS: We conducted active rotavirus gastroenteritis surveillance among children 8 weeks to <3 years of age at three hospitals. Participant information and vaccination histories were collected via parent/guardian interview and medical records. Stool specimens were tested for rotavirus; positive specimens were genotyped. The effect of increasing RV1 coverage on rotavirus prevalence was examined as a weekly time series via binomial regression with a log link function, using either categorical season or mean 2-dose rotavirus seasonal vaccine coverage as the exposure variable. As compared with RV1 vaccine formulation, rotavirus genotypes were classified as homotypic, partly-heterotypic, or heterotypic; prevalence of each was compared by season. A test-negative case-control design was used to examine RV1 VE against hospitalization or emergency visits. RESULTS: We enrolled 866 participants in active surveillance; of these, 384 (44.3%) were eligible for VE analyses. After adjustment for season, we detected a 70.1% (95% CI: 21.9%, 88.6%) relative decrease in rotavirus prevalence in the 2013-14 season compared with 2012-13 season. On average, a 1% increase in ≥2-dose rotavirus coverage among children 1 year of age was associated with a 3.8% (95% CI: 1.8%, 5.8%) relative decrease in rotavirus prevalence. Rotavirus homotypic strain prevalence decreased, with 77% (95% CI: 68%, 89%) versus 8% (95% CI: 0%, 36%) prevalence during the 2011-12 and 2013-14 seasons, respectively. Adjusted 2-dose RV1 VE was 91.2% (95% CI: 61.6%, 98.0%). CONCLUSIONS: RV1 vaccine was highly effective to prevent rotavirus hospitalizations and emergency visits among children <3 years of age in a high-income setting with its predominant use. Our estimates were similar to high-income settings with concurrent RV1 and pentavalent vaccine use.

The impact of geographical location of residence on disease outcomes among Canadian First Nations populations during the 2009 influenza A(H1N1) pandemic.

We sought to evaluate the effect of geographical location of residence on disease burden in Canadian First Nations (FN) populations during the 2009 pandemic influenza A(H1N1). Descriptive statistics and regression analysis of data for cases of pandemic A(H1N1) infection and hospitalization in the province of Manitoba, Canada, were conducted to estimate the odds of hospitalization and delay in time-to-hospitalization for on-reserve and off-reserve FN populations, while considering their geographical proximity to urban centers. We found that on-reserve FN individuals experienced a longer delay between infection and hospitalization compared to off-reserve FN individuals (p<0.001). The average fraction of FN cases that experienced a delay longer than 4 days for hospitalization was 20% higher for on-reserve compared to off-reserve residence. The odds of hospitalization were twice as high for FN people living on-reserve as compared to off-reserve (odds ratio=2.34; 95% CI: 1.16-4.73). Given the independent effect of on-reserve residency, higher disease burden among FN people cannot be attributed entirely to limited healthcare access due to remoteness from urban centers.

A health and nutritional evaluation of changes in agriculture in the past quarter century in British Columbia: implications for food security.

This paper describes change in local food production in British Columbia with a focus on changes in the production of foods recommended for increased consumption by nutritionists. We determine, in one of the most productive agricultural provinces in Canada, whether secular trends in agricultural land use and food production, over the past quarter century, have resulted in increased production of foods recommended by nutritionists as more healthy and nutritious. In particular we are concerned with estimating the extent to which changes in agriculture and food production are congruent with official nutrition advice to avoid less healthy foods and to consume more vegetables, fruit, and whole grains. We demonstrate, using regularly collected agricultural census data, in spite of nutritionists' advocacy for improved access to locally produced fruits, vegetables, and grains, since 1986, that BC agriculture is moving firmly in the opposite direction with greater production of animal fats, and hay and grain for animal feed and much reduced production of traditional fruits, vegetables, and grains designed mainly for human consumption. While nutritionists advise us to increase consumption especially of whole grains, vegetables and fruit, local production capacity of these foods in BC has decreased markedly between 1986 and 2006. In conclusion, there is a structural disconnect between the kinds of foods produced in BC and the nutritional needs of the population.