The viral hepatitis B care cascade: A population-based comparison of immigrant groups.

BACKGROUND AND AIMS: The global burden of viral hepatitis B is substantial, and monitoring infections across the care cascade is important for elimination efforts. There is little information on care disparities by immigration status, and we aimed to quantify disease burden among immigrant subgroups. APPROACH AND RESULTS: In this population-based, retrospective cohort study, we used linked laboratory and health administrative records to describe the HBV care cascade in five distinct stages: (1) lifetime prevalence; (2) diagnosis; (3) engagement with care; (4) treatment initiation; and (5) treatment continuation. Infections were identified based on at least one reactive antigen or nucleic acid test, and lifetime prevalence was estimated as the sum of diagnosed and estimated undiagnosed cases. Care cascades were compared between long-term residents and immigrant groups, including subgroups born in hepatitis B endemic countries. Stratified analyses and multivariable Poisson regression were used to identify drivers for cascade progression. Between January 1997 and December 2014, 2,014,470 persons were included, 50,475 with infections, of whom 30,118 were engaged with care, 11,450 initiated treatment, and 6554 continued treatment >1 year. Lifetime prevalence was estimated as 163,309 (1.34%) overall, 115,722 (3.42%) among all immigrants, and 50,876 (9.37%) among those from highly endemic countries. Compared to long-term residents, immigrants were more likely to be diagnosed (adjusted rate ratio [aRR], 4.55; 95% CI, 4.46, 4.63), engaged with care (aRR, 1.07; 95% CI, 1.04, 1.09), and initiate treatment (aRR, 1.09; 95% CI, 1.03, 1.16). CONCLUSIONS: In conclusion, immigrants fared well compared to long-term residents along the care cascade, having higher rates of diagnosis and slightly better measures in subsequent cascade stages, although intensified screening efforts and better strategies to facilitate linkage to care are still needed.

Exploring uptake of HIV/STI knowledge and safer sex-efficacy in an arts-based sexual health workshop among Northern and Indigenous adolescents in the Northwest Territories, Canada.

ABSTRACTLimited research has evaluated sexual health promotion projects with adolescents living in Arctic regions. The study objective was to examine changes in STI knowledge and safer sex efficacy among youth in the Northwest Territories (NWT), Canada who participated in arts-based sexual health workshops. We used a pre/post-test design with a convenience sample of students aged 13-18 years recruited from 17 NWT communities. We conducted summary statistics and comparisons between pre and post-test scores using paired t-tests. Among participants (n = 610), we found statistically significant increases in STI knowledge overall (mean difference = 3.9; p < 0.001) and across gender and age stratifications. There were statistically significant increases in safer sex efficacy overall (mean difference = 0.9, p < 0.001), across genders, and among participants: aged <15 years, in rural communities, reporting food insecurity, reporting dating violence, and Indigenous youth. No statistically significant differences in safer sex efficacy were observed among participants who were aged ≥15, sexually active, reporting consistent condom use, and using drugs/alcohol. Findings signal the promise of youth-targeted, arts-based sexual health workshops for improving STI knowledge and safer sex efficacy among adolescents in the NWT. Further research can explore how safer sex efficacy may be shaped by age, substance use, and sexual experience to inform tailored interventions.

Viral hepatitis C cascade of care: A population-level comparison of immigrant and long-term residents.

BACKGROUND & AIMS: Viral hepatitis C represents a major global burden, particularly among immigrant-receiving countries such as Canada, where knowledge of disparities in hepatitis C virus among immigrant groups for micro-elimination efforts is lacking. We quantify the hepatitis C cascades of care among immigrants and long-term residents prior to the introduction of direct-acting antiviral medications. METHODS: Using laboratory and health administrative records, we described the hepatitis C virus cascades of care in terms of diagnosis, engagement with care, treatment initiation, and clearance in Ontario, Canada (1997-2014). We stratified the cascade by immigrant and long-term resident groups and identify drivers at each stage using multivariable Poisson regression. RESULTS: We included 940 245 individuals in the study with an estimated hepatitis C prevalence of 167 923 (1.4%) overall, 23 759 (0.7%) among all immigrants, and 6019 (1.1%) among immigrants from hepatitis C endemic countries. Overall there were 104 616 individuals with reactive antibody results, 73 861 tested for viral RNA, 52 388 with viral RNA detected, 50 805 genotyped, 13 159 on treatment and 3919 with evidence of viral clearance. Compared to long-term residents, immigrants showed increased nucleic-acid testing (aRR: 1.09 [95%CI: 1.08, 1.10]), treatment initiation (aRR: 1.46 [95%CI: 1.38, 1.54]), and higher clearance rates (aRR: 1.07 [95%CI: 1.03, 1.11]). CONCLUSIONS: Hepatitis C virus is more prevalent among long-term residents compared to immigrants overall, however, immigrants from endemic countries are an important subgroup to consider for future screening and linkage to care initiatives. These findings are prior to the introduction of newer medications and provide a population-based benchmark for follow-up studies and evaluation of treatment programs and surveillance activities.

Spatiotemporal Variations in Ambient Ultrafine Particles and the Incidence of Childhood Asthma.

Rationale: Little is known regarding the impact of ambient ultrafine particles (UFPs; <0.1 µm) on childhood asthma development. Objectives: To examine the association between prenatal and early postnatal life exposure to UFPs and development of childhood asthma. Methods: A total of 160,641 singleton live births occurring in the City of Toronto, Canada between April 1, 2006, and March 31, 2012, were identified from a birth registry. Associations between exposure to ambient air pollutants and childhood asthma incidence (up to age 6) were estimated using random effects Cox proportional hazards models, adjusting for personal- and neighborhood-level covariates. We investigated both single-pollutant and multipollutant models accounting for coexposures to particulate matter ≤2.5 µm in aerodynamic diameter (PM2.5) and NO2. Measurements and Main Results: We identified 27,062 children with incident asthma diagnosis during the follow-up. In adjusted models, second-trimester exposure to UFPs (hazard ratio per interquartile range increase, 1.09; 95% confidence interval, 1.06-1.12) was associated with asthma incidence. In models additionally adjusted for PM2.5 and nitrogen dioxide, UFPs exposure during the second trimester of pregnancy remained positively associated with childhood asthma incidence (hazard ratio per interquartile range increase, 1.05; 95% confidence interval, 1.01-1.09). Conclusions: This is the first study to evaluate the association between perinatal exposure to UFPs and the incidence of childhood asthma. Exposure to UFPs during a critical period of lung development was linked to the onset of asthma in children, independent of PM2.5 and NO2.

Syndemic Factors Associated with Safer Sex Efficacy Among Northern and Indigenous Adolescents in Arctic Canada.

BACKGROUND: Syndemic approaches explore the synergistic relationships between social and health inequities. Such approaches are particularly salient for the Northwest Territories, Canada, that experiences national social (food insecurity, intimate partner violence [IPV]) and health (sexually transmitted infections [STI]) disparities. Safer sex efficacy (SSE) includes knowledge, intention, and relationship dynamics that facilitate safer sex negotiation. We examined factors associated with SSE among NWT adolescents. METHODS: We conducted a cross-sectional survey with a venue-based sample of adolescents aged 13-17 in 17 NWT communities from 2016 to 2017. Summary statistics and statistical comparisons were conducted, followed by crude and adjusted multivariable regression models to assess factors associated with SSE. RESULTS: Among participants (n = 610; mean age 14.2 years [SD 1.5]; 49.5% cisgender women, 48.9% cisgender men, 1.6% transgender persons; 73.3% Indigenous), one-quarter (n = 144; 23.6%) reported food insecurity and nearly one-fifth (n = 111; 18.2%) IPV. In adjusted analyses, among young women, food insecurity (ß - 1.89[CI - 2.98, - 0.80], p = 0.001) and IPV (ß - 1.31[CI - 2.53, - 0.09], p = 0.036) were associated with lower SSE, and currently dating was associated with increased SSE (ß 1.17[CI 0.15, 2.19], p = 0.024). Among young men, food insecurity (ß - 2.27[CI - 3.39, - 1.15], p = 0.014) was associated with reduced SSE. Among sexually active participants (n = 115), increased SSE was associated with consistent condom use among young women (ß 1.40[0.19, 2.61], p = 0.024) and men (ß 2.14[0.14, 4.14], p = 0.036). CONCLUSIONS: Food insecurity and IPV were associated with lower SSE-a protective factor associated with consistent condom use-underscoring the need to address poverty and violence to advance adolescent sexual health in the NWT.

Effect modification of perinatal exposure to air pollution and childhood asthma incidence.

Perinatal exposure to ambient air pollution has been associated with childhood asthma incidence, however, less is known regarding the potential effect modifiers in this association. We examined whether maternal and infant characteristics modified the association between perinatal exposure to air pollution and development of childhood asthma.761 172 births occurring between 2006 and 2012 were identified in the province of Ontario, Canada. Associations between exposure to ambient air pollutants and childhood asthma incidence (up to age 6) were estimated using Cox regression models.110,981 children with asthma were identified. In models adjusted for postnatal exposures, second trimester exposures to particulate matter with a diameter ≤2.5 µm (PM2.5) (Hazard Ratio (HR) per interquartile (IQR) increase=1.07, 95% CI: 1.06-1.09) and nitrogen dioxide (NO2) (HR per IQR increase=1.06, 95% CI: 1.03-1.08) were associated with childhood asthma development. Enhanced impacts were found among children born to mothers with asthma, those who smoked during pregnancy, boys, those born preterm, of low birth weight and among those born to mothers living in urban areas during pregnancy.Prenatal exposure to air pollution may have a differential impact on the risk of asthma development according to maternal and infant characteristics.

Examining Community Stability in the Face of Mass Extinction in Communities of Digital Organisms.

Digital evolution is a computer-based instantiation of Darwinian evolution in which short self-replicating computer programs compete, mutate, and evolve. It is an excellent platform for addressing topics in long-term evolution and paleobiology, such as mass extinction and recovery, with experimental evolutionary approaches. We evolved model communities with ecological interdependence among community members, which were subjected to two principal types of mass extinction: a pulse extinction that killed randomly, and a selective press extinction involving an alteration of the abiotic environment to which the communities had to adapt. These treatments were applied at two different strengths, along with unperturbed control experiments. We examined how stability in the digital communities was affected from the perspectives of division of labor, relative shift in rank abundance, and genealogical connectedness of the community's component ecotypes. Mass extinction that was due to a Strong Press treatment was most effective in producing reshaped communities that differed from the pre-treatment ones in all of the measured perspectives; weaker versions of the treatments did not generally produce significant departures from a Control treatment; and results for the Strong Pulse treatment generally fell between those extremes. The Strong Pulse treatment differed from others in that it produced a slight but detectable shift towards more generalized communities. Compared to Press treatments, Pulse treatments also showed a greater contribution from re-evolved ecological doppelgangers rather than new ecotypes. However, relatively few Control communities showed stability in any of these metrics over the whole course of the experiment, and most did not represent stable states (by some measure of stability) that were disrupted by the extinction treatments. Our results have interesting, broad qualitative parallels with findings from the paleontological record, and show the potential of digital evolution studies to illuminate many aspects of mass extinction and recovery by addressing them in a truly experimental manner.

Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs.

There are many ways to account for the return on investment (ROI) in healthcare: improved communication, teamwork, culture, patient satisfaction, staff satisfaction, and clinical outcomes are but a few. Some of these are easier to quantify and associate to an intervention than others. What if the outcomes listed were not just independent results, but beget one another? In 2001, the Society of Obstetricians and Gynaecologists of Canada created the Managing Obstetrical Risk Efficiently (MOREOB) programme, to improve healthcare culture and patient outcomes in obstetrics by leveraging front-line ownership. Our study provides evidence that MOREOB lowers the frequency and cost of reportable events in maternity units. We sought to review the impact of this intervention on the frequency and cost of reportable events at the insurer level of a clinically focused, three-year interprofessional culture change intervention applied to the maternity unit. We compared the impact of reportable events both in the obstetrical and in the non-obstetrical areas of the same hospitals during the same time periods. We analysed these data using an interrupted time series (ITS) design, among 34 Ontario Canada hospitals. The ITS design assessed changes in the frequency and cost of reportable events before and after the implementation of the intervention. The method was ideally suited as the various maternity units had differing programme commencement and completion dates. The frequency of reportable events showed little change during the three-year intervention. As culture change grew, the changes in behaviour and processes that impact patient outcomes took longer to accrue. A large reduction in the frequency of reportable events occurred in the following three-year (14% reduction) and six-year (25% reduction) tranches. Our results show statistically significant reductions in the frequency and costs associated with reportable events at the level of an insurer. The results also give insight as to the investment of time required to achieve a level of sustainability.

Maternal Exposure to Aeroallergens and the Risk of Early Delivery.

BACKGROUND: Daily changes in aeroallergens during pregnancy could trigger early labor, but few investigations have evaluated this issue. This study aimed to investigate the association between exposure to aeroallergens during the week preceding birth and the risk of early delivery among preterm and term pregnancies. METHODS: We identified data on 225,234 singleton births that occurred in six large cities in the province of Ontario, Canada, from 2004 to 2011 (April to October) from a birth registry. We obtained daily counts of pollen grains and fungal spores from fixed-site monitoring stations in each city and assigned them to pregnancy period of each birth. Associations between exposure to aeroallergens in the preceding week and risk of delivery among preterm (<37 gestational weeks), early-term (37-38 weeks), and full-term (≥39 weeks) pregnancies were evaluated with Cox regression models, adjusting for maternal characteristics, meteorologic parameters, and air pollution concentrations, and pooled across the six cities. RESULTS: The risk of delivery increased by 3% per interquartile range width (IQRw = 22.1 grains/m) increase in weed pollen the day before birth among early-term (hazard ratio [HR] = 1.03; 95% confidence interval [CI]: 1.01, 1.05) and full-term pregnancies (HR = 1.03; 95% CI: 1.01, 1.04). Exposure to fungal spores cumulated over 0 to 2 lagged days was associated with increased risk of delivery among full-term pregnancies only (HR = 1.07; 95% CI: 1.01, 1.12). We observed no associations among preterm deliveries. CONCLUSIONS: Increasing concentrations of ambient weed pollen and fungal spores may be associated with earlier delivery among term births.

Ambient air pollution and adverse birth outcomes: Differences by maternal comorbidities.

BACKGROUND: Prenatal exposure to ambient air pollution has been associated with adverse birth outcomes, but the potential modifying effect of maternal comorbidities remains understudied. Our objective was to investigate whether associations between prenatal air pollution exposures and birth outcomes differ by maternal comorbidities. METHODS: A total of 818,400 singleton live births were identified in the province of Ontario, Canada from 2005 to 2012. We assigned exposures to fine particulate matter (PM2.5), nitrogen dioxide (NO2) and ozone (O3) to maternal residences during pregnancy. We evaluated potential effect modification by maternal comorbidities (i.e. asthma, hypertension, pre-existing diabetes mellitus, heart disease, gestational diabetes and preeclampsia) on the associations between prenatal air pollution and preterm birth, term low birth weight and small for gestational age. RESULTS: Interquartile range (IQR) increases in PM2.5 (2µg/m(3)), NO2 (9ppb) and O3 (5ppb) over the entire pregnancy were associated with a 4% (95% CI: 2.4-5.6%), 8.4% (95% CI: 5.5-10.3%) and 2% (95% CI: 0.5-4.1%) increase in the odds of preterm birth, respectively. Increases of 10.6% (95% CI: 0.2-2.1%) and 23.8% (95% CI: 5.5-44.8%) in the odds of preterm birth were observed among women with pre-existing diabetes while the increases were of 3.8% (95% CI: 2.2-5.4%) and 6.5% (95% CI: 3.7-8.4%) among women without this condition for pregnancy exposure to PM2.5 and NO2, respectively (Pint<0.01). The increase in the odds of preterm birth for exposure to PM2.5 during pregnancy was higher among women with preeclampsia (8.3%, 95% CI: 0.8-16.4%) than among women without (3.6%, 95% CI: 1.8-5.3%) (Pint=0.04). A stronger increase in the odds of preterm birth was found for exposure to O3 during pregnancy among asthmatic women (12.0%, 95% CI: 3.5-21.1%) compared to non-asthmatic women (2.0%, 95% CI: 0.1-3.5%) (Pint<0.01). We did not find statistically significant effect modification for the other outcomes investigated. CONCLUSIONS: Findings of this study suggest that associations of ambient air pollution with preterm birth are stronger among women with pre-existing diabetes, asthma, and preeclampsia.

Association Between Chronic Aspiration and Chronic Airway Infection with Pseudomonas aeruginosa and Other Gram-Negative Bacteria in Children with Cerebral Palsy.

PURPOSE: Children with cerebral palsy (CP) are at an increased risk for aspiration, and subsequent pneumonia or pneumonitis. Pneumonia is a common cause of hospital admission, intensive care unit (ICU) admission, and death in patients with CP, and may disproportionately contribute to mortality. The role of respiratory microflora is unknown. This study examined the relationship between respiratory infections with Gram-negative bacteria (GNB), particularly Pseudomonas aeruginosa, and the frequency/severity of pneumonia hospitalization. METHODS: Retrospective chart review of 69 patients with CP and hospitalization for pneumonia. Eligible patients required hospitalization for bacterial pneumonia, at least one respiratory culture, and fulfillment of Bax definition of CP. Group assignment was based on respiratory culture. Charts were analyzed for comorbid illness, hospitalization demographics, and disease severity. RESULTS: Children with isolation of P. aeruginosa or other GNB had increased frequency of ICU admission (77.4, 65.1, vs. 26.9 %, respectively, p < 0.01), intubation (45.2, 39.5 vs. 11.5 %, p = 0.02, p = 0.03 respectively), and large pleural effusions (37.5, vs. 0 %) than children without GNB. Children with isolation of GNB had more prolonged hospitalizations and were more likely to have multiple hospitalizations than those without GNB. CONCLUSION: Colonization with P. aeruginosa and other Gram-negative organisms in children with CP is associated with increased morbidity, prolonged hospitalization, and severity of pneumonia including need for PICU admission and intervention. Further research is required to determine causality, the role of antimicrobials active against Gram negative in pneumonia treatment, and the role of GNB eradication therapy in children with CP.

Factors Associated With Increased Rates of Caesarean Section in Women of Advanced Maternal Age.

OBJECTIVE: To compare rates of Caesarean section between mothers of advanced age (35 to 40, and over 40 years) and those aged 20 to 34, using the Robson classification system to examine additional maternal factors. METHODS: A total of 134 088 hospital deliveries in Ontario between April 1, 2011, and March 31, 2012, were grouped into Robson's 10 mutually exclusive and totally inclusive classification categories. Records from the three Robson groups that made the greatest contribution to the overall CS rate were stratified by maternal age, health condition, obstetrical complication, assisted reproductive technology usage, smoking during pregnancy, and socioeconomic status. RESULTS: Rates of CS increased with advancing maternal age; in women aged 20 to 34, 35 to 40, and over 40, the rates were 26.2%, 35.9%, and 43.1%, respectively. The top three Robson groups by contribution to CS rates involved women who had one or more of the following factors: previous Caesarean section, primiparity, conception by means of assisted reproductive technology, chronic hypertension, gestational diabetes, diabetes mellitus, preeclampsia, placenta previa, placental abruption, or large for gestational age infants. The prevalence of these factors increased with advancing maternal age, yet mothers aged ≥ 35 with one or more health conditions or obstetrical complications had higher CS rates than mothers aged 20 to 34 with the same condition(s) or complication(s). CONCLUSION: Health conditions and obstetrical complications alone in older women do not account for increased rates of CS. The preferences of the individual care provider and the mother on CS rates may play a key role and require further investigation.

Objectif : Comparer les taux de césarienne des mères d'âge avancé (de 35 à 40 ans et de plus de 40 ans) à ceux des mères âgées de 20 à 34 ans, en utilisant le système de classification de Robson en vue d'examiner des facteurs maternels additionnels. Méthodes : Au total, 134 088 accouchements s'étant déroulés en milieu hospitalier en Ontario entre le 1er avril 2011 et le 31 mars 2012 ont été groupés en fonction des 10 catégories mutuellement exclusives et totalement inclusives de Robson. Les dossiers des trois groupes Robson ayant le plus contribué au taux global de césarienne ont été stratifiés en fonction de l'âge maternel, de l'état de santé, des complications obstétricales, du recours à des techniques de procréation assistée, du tabagisme pendant la grossesse et du statut socioéconomique. Résultats : Les taux de césarienne étaient proportionnels à l'âge maternel : chez les femmes de 20 à 34 ans, de 35 à 40 ans et de plus de 40 ans, les taux ont été de 26,2 %, de 35,9 % et de 43,1 %, respectivement. Les trois groupes Robson ayant le plus contribué au taux global de césarienne étaient composés de femmes qui présentaient un ou plusieurs des facteurs suivants : antécédents de césarienne, primiparité, conception au moyen de techniques de procréation assistée, hypertension chronique, diabète gestationnel, diabète sucré, prééclampsie, placenta praevia, décollement placentaire ou hypertrophie fœtale. Bien que la prévalence de ces facteurs ait été proportionnelle à l'âge maternel, les mères âgées de 35 ans ou plus qui comptaient un ou plusieurs troubles de santé (ou complications obstétricales) présentaient des taux de césarienne supérieurs à ceux des mères âgées de 20 à 34 ans qui comptaient le ou les mêmes troubles (ou complications). Conclusion : Les taux accrus de césarienne chez les femmes plus âgées ne peuvent être attribués qu'à la seule présence de troubles de santé et de complications obstétricales. Les préférences des fournisseurs de soins et des mères en matière d'accouchement pourraient jouer un rôle clé en ce qui concerne les taux de césarienne, ce qui nécessite la tenue d'études plus approfondies.

The association between obstetrical interventions and late preterm birth.

OBJECTIVE: There is concern that obstetric interventions (prelabor cesarean section and induced delivery) are drivers of late preterm (LP) birth. Our objective was to evaluate the independent association between obstetric interventions and LP birth and explore associated independent maternal and fetal risk factors for LP birth. STUDY DESIGN: In this population-based cross-sectional study, the BORN Information System was used to identify all infants born between 34 and 40 completed weeks of gestation between 2005 and 2012 in Ontario, Canada. The association between obstetric interventions (preterm cesarean section and induced delivery) and LP birth (34 to 36 completed weeks' gestation vs 37 to 40 completed weeks' gestation) was assessed using generalized estimating equation regression. RESULTS: Of 917,013 births between 34 and 40 weeks, 49,157 were LP (5.4%). In the adjusted analysis, "any obstetric intervention" (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.57-0.74), induction (RR, 0.71; 95% CI, 0.61-0.82) and prelabor cesarean section (RR, 0.66; 95% CI, 0.59-0.74) were all associated with a lower likelihood of LP vs term birth. Several independent potentially modifiable risk factors for LP birth were identified including previous cesarean section (RR, 1.28; 95% CI, 1.16-1.40), smoking during pregnancy (RR, 1.28; 95% CI, 1.21-1.36) and high material (RR, 1.1; 95% CI, 1.03-1.18) and social (RR, 1.09; 95% CI, 1.02-1.16) deprivation indices. CONCLUSION: After accounting for differences in maternal and fetal risk, LP births had a 35% lower likelihood of obstetric interventions than term births. Obstetric care providers may be preferentially avoiding induction and prelabor cesarean section between 34 and 37 weeks' gestation.

Antimicrobial stewardship in pediatrics: focusing on the challenges clinicians face.

BACKGROUND: Antimicrobial use is very common in hospitalized children. An assessment of clinician's prevailing knowledge and clinical approach to prescribing antimicrobials is helpful in order to develop the best strategies for successful stewardship programs. The objectives of the study were to determine fundamental knowledge of principles, approach to antimicrobial use through the clinical vignettes and to identify perceived challenges in decreasing antimicrobial use. METHODS: A questionnaire was developed by subject matter experts and pretested to ensure validity. Using a cross-sectional prospective design, the questionnaire was completed anonymously by staff and trainee physicians at a single tertiary care pediatric hospital between late November 2011 and February 2012. RESULTS: Of 159 eligible physicians, 86 (54.1%) responded, of which 77 (46 staff and 31 trainees) reported regularly prescribing antimicrobials. The majority of physicians had modest knowledge of factors that would increase risk of resistance however, less than 20% had correct knowledge of local resistance patterns for common bacteria. Almost half of physicians correctly answered the clinical vignettes. Over half of trainees and one third of staff relied most on online manuals for information regarding antimicrobials to assist prescription decision-making. Overall, physicians perceived that discontinuing empiric antimicrobials was the most difficult to achieve to decrease antibiotic use. CONCLUSIONS: Our results highlight several challenges that pediatric practioners face with respect to knowledge and approach to antimicrobial prescribing. Pediatric stewardship programs could in this setting focus on discontinuing antimicrobials appropriately and promoting local antibiograms in the proper clinical setting to decrease overall use of antimicrobials.

Infant outcomes among pregnant women who used oseltamivir for treatment of influenza during the H1N1 epidemic.

OBJECTIVE: This study was undertaken to examine the association between maternal oseltamivir treatment for influenza and infant outcomes during the 2009 HINI influenza pandemic. STUDY DESIGN: This was a retrospective cohort study using a population-based maternal newborn database including women who gave birth to a singleton infant in the Canadian province of Ontario from November 2009 through April 2010. Risks of small for gestational age (SGA) (10th percentile and 3rd percentile), preterm birth (<37 weeks of gestation), very preterm birth (<32 weeks of gestation), and 5-minute Apgar score <7 associated with maternal exposure to oseltamivir were analyzed by multivariable regression. RESULTS: A total of 55,355 women with a singleton birth were included in this study. Among them, 1237 (2.2%) women received oseltamivir for treatment or prevention of influenza during pregnancy. Women who took oseltamivir during pregnancy were less likely to have a SGA infant based on the 10th percentile for growth (adjusted risk ratio, 0.77; 95% confidence interval, 0.60-0.98). No association between maternal use of oseltamivir with SGA on 3rd percentile, preterm birth, very preterm birth, and low Apgar score was observed. CONCLUSION: There is no evidence of an association between maternal use of oseltamivir for influenza and early birth, low Apgar at birth, and poor fetal growth.

Adolescent pregnancy outcomes in the province of Ontario: a cohort study.

OBJECTIVE: Few Canadian studies have examined the association between adolescent pregnancy and adverse pregnancy outcomes. The objective of this cohort study was to characterize the association between adolescent pregnancy and specific adverse maternal, obstetrical, and neonatal outcomes, as well as maternal health behaviours. METHODS: We conducted a retrospective population-based cohort study of all singleton births in Ontario between January 2006 and December 2010, using the Better Outcomes Registry and Network database. Outcomes for pregnant women < 20 years of age (adolescent) were compared with those of women 20 to 35 years old (adult). RESULTS: This study included 551 079 singleton birth records, 23 992 (4.35%) of which derived from adolescent pregnancies. Adolescents had a higher rate of smoking and substance use than adult women and were within the lowest education and family income quintiles. Adolescents had a significantly lower risk of gestational hypertension (adjusted relative risk [aRR] 0.73) and gestational diabetes (aRR 0.34), placental abruption (aRR 0.80), and placenta previa (aRR 0.36), but their risk of preterm premature rupture of membranes was significantly higher (RR 1.16). Adolescents had a significantly higher proportion of spontaneous vaginal delivery (aRR 1.76), significantly lower rates of use of epidural analgesia (aRR 0.93), of Caesarean section (aRR 0.57), and of assisted vaginal delivery (aRR 0.76), but a significantly higher risk of emergency CS (aRR 1.31). Neonates with an adolescent mother had significantly higher risks of admission to NICU (aRR 1.08) and very preterm birth (aRR 1.16). There was no significant difference between the two groups in rates of small for gestational age babies, low birth weight, preterm birth, and fetal death. Adolescents had significantly lower rates of prenatal class attendance, prenatal visits in the first trimester, and breastfeeding. CONCLUSION: This large Canadian cohort study confirms that, compared with adults, adolescents have improved outcomes such as lower rates of gestational hypertension, gestational diabetes, antepartum hemorrhage, and operative deliveries. However, adolescents also have higher sociodemographic risk factors and seek prenatal care later than adults. These risk factors in combination with young age, lead to other important maternal, obstetrical, and neonatal adverse outcomes. These findings highlight the importance of multidisciplinary prenatal management in the adolescent population to address their high-risk needs, to ensure healthy pregnancies, and to reduce adverse perinatal outcomes.

H1N1 influenza vaccination during pregnancy and fetal and neonatal outcomes.

OBJECTIVES: We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009-2010 H1N1 pandemic. METHODS: We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy. RESULTS: Of the 55,570 mothers with a singleton birth, 23,340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR]=0.90; 95% confidence interval [CI]=0.85, 0.96) and 3rd (adjusted RR=0.81; 95% CI=0.72, 0.92) growth percentiles; PTB at less than 32 weeks' gestation (adjusted RR=0.73; 95% CI=0.58, 0.91) and fetal death (adjusted RR=0.66; 95% CI=0.47, 0.91) were also less likely among these women. CONCLUSIONS: Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.

Validating viral hepatitis B and C diagnosis codes: a retrospective analysis using Ontario's health administrative data.

OBJECTIVE: We aimed to determine the criterion validity of using diagnosis codes for hepatitis B virus (HBV) and hepatitis C virus (HCV) to identify infections. METHODS: Using linked laboratory and administrative data in Ontario, Canada, from January 2004 to December 2014, we validated HBV/HCV diagnosis codes against laboratory-confirmed infections. Performance measures (sensitivity, specificity, and positive predictive value) were estimated via cross-validated logistic regression and we explored variations by varying time windows from 1 to 5 years before (i.e., prognostic prediction) and after (i.e., diagnostic prediction) the date of laboratory confirmation. Subgroup analyses were performed among immigrants, males, baby boomers, and females to examine the robustness of these measures. RESULTS: A total of 1,599,023 individuals were tested for HBV and 840,924 for HCV, with a resulting 41,714 (2.7%) and 58,563 (7.0%) infections identified, respectively. HBV/HCV diagnosis codes ± 3 years of laboratory confirmation showed high specificity (99.9% HBV; 99.8% HCV), moderate positive predictive value (70.3% HBV; 85.8% HCV), and low sensitivity (12.8% HBV; 30.8% HCV). Varying the time window resulted in limited changes to performance measures. Diagnostic models consistently outperformed prognostic models. No major differences were observed among subgroups. CONCLUSION: HBV/HCV codes should not be the only source used for monitoring the population burden of these infections, due to low sensitivity and moderate positive predictive values. These results underscore the importance of ongoing laboratory and reportable disease surveillance systems for monitoring viral hepatitis in Ontario.

RéSUMé: OBJECTIF: Nous avons cherché à déterminer le critère de validité de l'utilisation des codes de diagnostic du virus de l'hépatite B (VHB) et du virus de l'hépatite C (VHC) pour identifier les infections. MéTHODES: En utilisant des données de laboratoire et administratives couplées en Ontario, au Canada, de janvier 2004 à décembre 2014, nous avons validé les codes de diagnostic du VHB/VHC contre les infections confirmées en laboratoire. Les mesures du rendement (sensibilité, spécificité et valeur prédictive positive) ont été estimées par régression logistique croisée et nous avons exploré les variations en variant les fenêtres temporelles de 1 à 5 ans avant (c.-à-d. prédiction pronostique) et après (c.-à-d. prédiction diagnostique) la date de confirmation en laboratoire. Des analyses de sous-groupes ont été effectuées auprès d'immigrants, d'hommes, de baby-boomers et de femmes pour examiner la robustesse de ces mesures. RéSULTATS: 1 599 023 individus ont été testés pour le VHB et 840 924 pour le VHC, dont 41 714 (2,7 %) et 58 563 (7,0 %) infections ont été identifiées, respectivement. Les codes de diagnostic VHB/VHC ± 3 ans de confirmation en laboratoire ont montré une spécificité élevée (99,9 % VHB; 99,8 % VHC), une valeur prédictive positive modérée (70,3 % VHB; 85,8 % VHC) et une faible sensibilité (12,8 % VHB; 30,8 % VHC). La variation de la fenêtre temporelle a entraîné des changements limités aux mesures du rendement. Les modèles diagnostiques ont constamment surpassé les modèles pronostiques. Aucune différence majeure n'a été observée entre les sous-groupes. CONCLUSION: Les codes VHB/VHC ne devraient pas être la seule source utilisée pour surveiller la charge de population de ces infections, en raison de la faible sensibilité et des valeurs prédictives positives modérées. Ces résultats soulignent l'importance des systèmes continus de surveillance des maladies à déclaration obligatoire en laboratoire pour surveiller l'hépatite virale en Ontario.

A population-based comparison of preterm neonatal deaths (22-34 gestational weeks) in France and Ontario: a cohort study.

BACKGROUND: The management and outcomes of preterm births can vary greatly even among developed nations with the same access to medicine, technology and expertise. We aimed to compare aspects of obstetrical management and mortality for preterm infants in France and Ontario, Canada. METHODS: The Better Outcomes Registry & Network (BORN) Information System in Ontario and Épidémiologique sur les petits âges gestationnels (EPIPAGE-2) in France collected information on maternal demographics, obstetrical characteristics, obstetrical interventions and neonatal outcomes for infants born between 22 and 34 weeks gestation. We used standardized covariate definitions and extracted data from 2011 (for EPIPAGE-2) and from 2012 and 2013 (for BORN) to conduct a cohort study comparing the 2 data sets (stratified into gestational age groups of 22-26, 27-31 and 32-34 wk) using multivariable logistic regression models. RESULTS: Mothers in the BORN cohort were older (30.7 yr v. 29.6 yr) but less likely to have gestational hypertension (13.4% v. 17.9%) than those in the EPIPAGE-2 cohort. Infants from EPIPAGE-2 had lower birth weights (1.3 kg v. 1.5 kg) and were more likely to be born in an institution with level 3 care (71.9% v. 55.8%). After adjustment for these differences, there was significantly higher neonatal mortality among infants from EPIPAGE-2 in the 22-26 week gestation age group (adjusted odds ratio 2.81; 95% confidence interval 1.17 to 6.74). INTERPRETATION: Even after we adjusted for both intrinsic population differences and differences in management between Ontario and France, we found a higher rate of neonatal mortality at earlier gestational ages in France. This may be related to differences in ethical approaches and/or postnatal management and should be explored further.