Oral cholera vaccine in cholera prevention and control, Malawi.

PROBLEM: With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed. APPROACH: In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use. LOCAL SETTING: Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s. RELEVANT CHANGES: The government's application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017-2018. LESSONS LEARNT: Augmenting advanced mapping techniques with local information helped us extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.

Comparing Class-Based and Home-Based Exercise for Older Adults With Chronic Health Conditions: 12-Month Follow-Up of a Randomized Clinical Trial.

OBJECTIVE: To assess the maintenance of physical activity (PA) and health gains among participants in a class-based (CB) or home-based (HB) PA intervention over a 12-month study period. METHODS: A total of 172 adults aged 50 years and older were randomly allocated to either a CB or an HB intervention, each involving an intensive 3-month phase with a 9-month follow-up period. Measures at baseline, 3, 6, and 12 months included self-reported PA and health, body mass index, waist circumference (WC), blood pressure, cardiovascular endurance (6-min walk test), physical function, and functional fitness (senior fitness test). Outcomes were analyzed using generalized estimating equations. RESULTS: Maximum improvement was typically observed at 3 or 6 months followed by a modest diminution, with no differences between groups. For body mass index, waist circumference, 6-min walk test, and senior fitness test, there was progressive improvement through the study period. Greater improvement was seen in the CB group compared with the HB group on three items on the senior fitness test (lower body strength and endurance [29% vs. 21%, p < .01], lower body flexibility [2.8 cm vs. 0.4 cm, p < .05], and dynamic agility [14% vs. 7%, p < .05]). CONCLUSION: The interventions were largely comparable; thus, availability, preferences, and cost may better guide program choice.

Predictors of Physical Activity Levels in Community-Dwelling Older Adults: A Multivariate Approach Based on a Socio-Ecological Framework.

The purpose of this study was to explore cross-sectional relationships between self-reported physical activity (PA) and personal, social, and environmental factors in community-dwelling adults aged 50 years and older. Accounting for clustering by neighborhood, generalized estimating equations were used to examine associations between selected correlates and the Physical Activity Scale for the Elderly (PASE) score while adjusting for confounders. Data for 601 participants were analyzed: 79% female, 37% married, mean age 76.8 (± 8.7) years, mean PASE score 112.6 (± 64.8). Age, living in seniors' housing, using nursing/home care services, receiving encouragement to be active, and having benches available in the neighborhood were inversely associated with PASE. Self-efficacy, SF-12 score, PA barriers, social support, and the presence of trails showed positive associations. Several personal, social, and environmental factors associated with PA were identified. The inverse association between PA and living in seniors' housing units should be considered when developing PA programs for older adults.

Regional Lymph Nodes Status and Ratio of Metastatic to Examined Lymph Nodes Correlate with Survival in Stage IV Colorectal Cancer.

BACKGROUND: Although lymph nodes status and the ratio of metastatic to examined lymph node (LNR) are important prognostic factors in early-stage colorectal cancer (CRC), their significance in patients with metastatic disease remains unknown. The study aims to determine prognostic importance of nodal status and LNR in patients with stage IV CRC. METHODS: A cohort of 1109 eligible patients who were diagnosed with synchronous metastatic CRC in Saskatchewan during 1992-2010 and underwent primary tumor resection was evaluated. We conducted the Cox proportional multivariate analyses to determine the prognostic significance of nodal status and LNR. RESULTS: Median age was 70 years (22-98) and M:F was 1.2:1. Rectal cancer was found in 26 % of patients; 96 % had T3/T4 tumor, and 82 % had node positive disease. The median LNR was 0.36 (0-1.0). Fifty-four percent received chemotherapy. Median overall survival of patients who had LNR of <0.36 and received chemotherapy was 29.7 months (95 % CI 26.6-32.9) compared with 15.6 months (95 % CI 13.6-17.6) with LNR of ≥0.36 (P < .001). On multivariate analyses, no chemotherapy (HR 2.36 [2.0-2.79]), not having metastasectomy (HR 1.94 [1.63-2.32]), LNR ≥0.36 (HR 1.59 [1.38-1.84]). nodal status (HR 1.34 [1.14-1.59]), and T status (HR 1.23 [1.07-1.40]) were correlated with survival. Test for interaction was positive for LNR and high-grade cancer (HR 1.51 [1.10-2.10]). CONCLUSIONS: Our results suggest that nodal status and LNR are important prognostic factors independent of chemotherapy and metastasectomy in stage IV CRC patients.

Predictive Factors of the Use of Systemic Therapy in Stage IV Colorectal Cancer: Who Gets Chemotherapy?

BACKGROUND: Chemotherapy improves survival in patients with stage IV colorectal cancer (CRC). Although in a clinical trial setting, strict eligibility criteria are used for chemotherapy, little is known about the use of chemotherapy in the general population. The study aims to assess clinicopathological variables that correlate with the use of chemotherapy in patients with stage IV CRC. METHODS: A retrospective cohort study involving patients with stage IV CRC, diagnosed between 1992 and 2005, in the province of Saskatchewan was carried out. A logistic regression analysis was performed to assess the correlation of various clinicopathological factors with the use of chemotherapy. RESULTS: A total of 1,237 eligible patients were identified. Their median age was 70 years (range: 22-98) and the male:female ratio was 1.3:1. 23.8% had an ECOG performance status (PS) of ≥2 and 61.8% of the patients had a comorbid illness. 46.8% of the patients received chemotherapy. The multivariate logistic regression analysis revealed that an age of <65 years [odds ratio (OR) 3.82, 95% CI: 2.59-5.63], metastasectomy (OR 3.60, 95% CI: 1.82-7.10), normal albumin (OR 3.26, 95% CI: 2.44-4.36), no comorbid illness (OR 2.87, 95% CI: 1.34-6.16), ECOG PS of <2 (OR 2.72, 95% CI: 1.94-3.82), normal blood urea nitrogen (OR 2.24, 95% CI: 1.40-3.59), palliative radiation (OR 2.03, 95% CI: 1.38-2.99), primary tumor resection (OR 2.00, 95% CI: 1.47-2.73), and the time period (OR 1.85, 95% CI: 1.41-2.42) were significantly correlated with the use of chemotherapy. CONCLUSIONS: The use of chemotherapy appears to be increasing in stage IV CRC. Patients treated with curative intention or who underwent primary tumor resection were more likely to receive chemotherapy. Despite a known benefit of chemotherapy in elderly patients, a differential use of chemotherapy was noted in this population.

Survival impact of surgical resection of primary tumor in patients with stage IV colorectal cancer: results from a large population-based cohort study.

BACKGROUND: Currently, there is very low-quality evidence available regarding benefit of surgical resection of the primary tumor (SRPT), in patients with stage IV colorectal cancer (CRC). In the absence of randomization, the reported benefit may reflect selection of younger and healthier patients with good performance status. A large population-based cohort study was undertaken to determine the survival benefit of SRPT in advanced CRC by eliminating various biases reported in the literature. METHODS: A retrospective cohort study involving patients with stage IV CRC, diagnosed between 1992 and 2005, in the province of Saskatchewan, Canada. Survival was estimated by using the Kaplan-Meier method. Survival distribution was compared by log-rank test. Cox proportional multivariate regression analysis was performed to determine survival benefit of SRPT by controlling other prognostic variables. RESULTS: A total of 1378 eligible patients were identified. Their median age was 70 years (range, 22-98 years) and male:female ratio was 1.3:1; 944 (68.5%) of them underwent SRPT. Among 1378 patients, 42.3% received chemotherapy and 19.1% received second-generation therapy. Patients who underwent SRPT and received chemotherapy had median overall survival of 18.3 months (95% confidence interval [CI] = 16.6-20 months) compared with 8.4 months (95% CI = 7.1-9.7 months) if they were treated with chemotherapy alone (P < .0001). Cox proportional analysis revealed that use of chemotherapy (hazard ratio [HR] = 0.47, 95% CI = 0.41-0.54), SRPT (HR = 0.49, 95% CI = 0.41-0.58), second-line chemotherapy (HR = 0.47, 95% CI = 0.45-0.64), and metastasectomy (HR = 0.54, 95% CI = 0.45-0.64) were correlated with superior survival. CONCLUSIONS: SRPT improves survival in patients with stage IV CRC, independent of other prognostic variables including age, performance status, comorbid illness and chemotherapy.

Evidence for a decrease in transmission of Ebola virus--Lofa County, Liberia, June 8-November 1, 2014.

Lofa County has one of the highest cumulative incidences of Ebola virus disease (Ebola) in Liberia. Recent situation reports from the Liberian Ministry of Health and Social Welfare (MoHSW) have indicated a decrease in new cases of Ebola in Lofa County. In October 2014, the Liberian MoHSW requested the assistance of CDC to further characterize recent trends in Ebola in Lofa County. Data collected during June 8-November 1, 2014 from three sources were analyzed: 1) aggregate data for newly reported cases, 2) case-based data for persons admitted to the dedicated Ebola treatment unit (ETU) for the county, and 3) test results for community decedents evaluated for Ebola. Trends from all three sources suggest that transmission of Ebola virus decreased as early as August 17, 2014, following rapid scale-up of response activities in Lofa County after a resurgence of Ebola in early June 2014. The comprehensive response strategy developed with participation from the local population in Lofa County might serve as a model to implement in other affected areas to accelerate control of Ebola.

Body mass index and risk of cardiovascular disease, cancer and all-cause mortality.

OBJECTIVES: To determine the dose-response relationship between body mass index (BMI) and cause-specific mortality among Canadian adults. METHODS: The sample includes 10,522 adults 18-74 years of age who participated in the Canadian Heart Health Surveys (1986-1995). Participants were divided into 5 BMI categories (< 18.5, 18.5-24.9, 25-29.9, 30-34.9, and > or = 35 kg/m2). Multivariate-adjusted (age, sex, exam year, smoking status, alcohol consumption and education) hazard ratios for all-cause, cardiovascular disease (CVD) and cancer mortality were estimated using Cox proportional hazards regression. RESULTS: There were 1,149 deaths (402 CVD; 412 cancer) over an average of 13.9 years (range 0.5 to 19.1 years), and the analyses are based on 145,865 person-years. The hazard ratios (95% CI) across successive BMI categories for all-cause mortality were 1.25 (0.83-1.90), 1.00 (reference), 1.06 (0.92-1.22), 1.27 (1.07-1.51) and 1.65 (1.29-2.10). The corresponding hazard ratios for CVD mortality were 1.30 (0.60-2.83), 1.00 (reference), 1.57 (1.22-2.01), 1.72 (1.27-2.33) and 2.09 (1.35-3.22); and for cancer, the hazard ratios were 1.02 (0.48-2.21), 1.00 (reference), 1.14 (0.90-1.44), 1.34 (1.01-1.78) and 1.82 (1.22-2.71). There were significant linear trends across BMI categories for all-cause (p = 0.0001), CVD (p < 0.0001) and cancer mortality (p = 0.003). CONCLUSIONS: The results demonstrate significant relationships between BMI and mortality from all causes, CVD and cancer. The increased risk of all-cause, CVD and cancer mortality associated with an elevated BMI was significant at levels above 30 kg/m2; however, overweight individuals (BMI 25-29.9 kg/m2) also had an approximately 60% higher risk of CVD mortality.

Developing a rapid evidence response to COVID-19: The collaborative approach of Saskatchewan, Canada.

Introduction: The COVID-19 Evidence Support Team (CEST) was a provincial initiative that combined the support of policymakers, researchers, and clinical practitioners to initiate a new learning health cycle (LHS) in response to the pandemic. The primary aim of CEST was to produce and sustain the best available COVID-19 evidence to facilitate decision-making in Saskatchewan, Canada. To achieve this objective, four provincial organizations partnered to establish a single, data-driven system. Methods: The CEST partnership was driven by COVID-19 questions from Emergency Operational Committee (EOC) of the Saskatchewan Health Authority. CEST included three processes: (a) clarifying the nature and priority of COVID-19 policy and clinical questions; (b) providing Rapid Reviews (RRR) and Evidence Search Reports (ESR); and (c) seeking the requestors' evaluation of the product. A web-based repository, including a dashboard and database, was designed to house ESRs and RRRs and offered a common platform for clinicians, academics, leaders, and policymakers to find COVID-19 evidence. Results: In CEST's first year, 114 clinical and policy questions have been posed resulting in 135 ESRs and 108 RRRs. While most questions (41.3%) originated with the EOC, several other teams were assembled to address a myriad of questions related to areas such as long-term care, public health and prevention, infectious diseases, personal protective equipment, vulnerable populations, and Indigenous health. Initial challenges were mobilization of diverse partners and teams, remote work, lack of public access, and quality of emerging COVID-19 literature. Current challenges indicate the need for institutional commitment for CEST sustainability. Despite these challenges, the CEST provided the Saskatchewan LHS with a template for successful collaboration. Conclusions: The urgency of COVID-19 pandemic and the implementation of the CEST served to catalyze collaboration between different levels of a Saskatchewan LHS.

Evaluating a learning health system initiative: Lessons learned during COVID-19 in Saskatchewan, Canada.

Introduction: Evaluating a learning health system (LHS) encourages continuous system improvement and collaboration within the healthcare system. Although LHS is a widely accepted concept, there is little knowledge about evaluating an LHS. To explore the outputs and outcomes of an LHS model, we evaluated the COVID-19 Evidence Support Team (CEST) in Saskatchewan, Canada, an initiative to rapidly review scientific evidence about COVID-19 for decision-making. By evaluating this program during its formation, we explored how and to what extent the CEST initiative was used by stakeholders. An additional study aim was to understand how CEST could be applied as a functional LHS and the value of similar knowledge-to-action cycles. Methods: Using a formative evaluation design, we conducted qualitative interviews with key informants (KIs) who were involved with COVID-19 response strategies in Saskatchewan. Transcripts were analyzed using reflexive thematic analysis to identify key themes. A program logic model was created to represent the inputs, activities, outputs, and outcomes of the CEST initiative. Results: Interview data from 11 KIs were collated under three overarching categories: (1) outputs, (2) short-term outcomes, and (3) long-term outcomes from the CEST initiative. Overall, participants found the CEST initiative improved speed and access to reliable information, supported and influenced decision-making and public health strategies, leveraged partnerships, increased confidence and reassurance, and challenged misinformation. Themes relating to the long-term outcomes of the initiative included improving coordination, awareness, and using good judgment and planning to integrate CEST sustainably into the health system. Conclusion: This formative evaluation demonstrated that CEST was a valued program and a promising LHS model for Saskatchewan. The future direction involves addressing program recommendations to implement this model as a functional LHS in Saskatchewan.

Burden of Cervical Cancer in the Eastern Mediterranean Region During the Years 2000 and 2017: Retrospective Data Analysis of the Global Burden of Disease Study.

BACKGROUND: Cervical cancer is a growing health concern, especially in resource-limited settings. OBJECTIVE: The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally between the years 2000 and 2017 by using a pooled data analysis approach. METHODS: We used an ecological approach at the country level. This included extracting data from publicly available databases and linking them together in the following 3 steps: (1) extraction of data from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2) categorization of EMR countries according to the World Bank gross domestic product per capita, and (3) linking age-specific population data from the Population Statistics Division of the United Nations (20-29 years, 30-49 years, and >50 years) and GBD's data with gross national income per capita and globally extracted data, including cervical cancer mortality and DALY numbers and rates per country. The cervical cancer mortality rate was provided by the GBD study using the following formula: number of cervical cancer deaths × 100,000/female population in the respective age group. RESULTS: The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326) to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this disease decreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). According to age-specific data, the age group ≥50 years showed the highest mortality rate in both EMR countries and globally, and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR were lower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rate per 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000; respectively). However, the relative difference in the number of DALYs due to cervical cancer between the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9 vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively). CONCLUSIONS: We found an increase in the burden of cervical cancer in the EMR as per the data on the absolute number of deaths and DALYs. Further, we found that the health care system has an increased number of cases to deal with, despite the decrease in the absolute number of deaths and DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and early screening is performed. Therefore, we recommend identifying effective vaccination programs and interventions to reduce the burden of this disease.

Advancing the future of physical activity guidelines in Canada: an independent expert panel interpretation of the evidence.

The Canadian Society for Exercise Physiology, in partnership with the Public Health Agency of Canada, has initiated a review of their physical activity guidelines to promote healthy active living for Canadian children, youth, adults and older adults; previous guidelines were released in 2002, 2002, 1998 and 1999 respectively. Several background papers from this project were published recently and provide foundation evidence upon which to base new guidelines. Furthermore, comprehensive systematic reviews were completed to ensure a rigorous evaluation of evidence informing the revision of physical activity guidelines for asymptomatic populations. The overall guideline development process is being guided and assessed by the AGREE II instrument. A meeting of experts was convened to present the evidence complied to inform the guideline revisions. An independent expert panel was assembled to review the background materials and systematic reviews; listen to the presentations and discussions at the expert meeting; ask for clarification; and produce the present paper representing their interpretation of the evidence including grading of the evidence and their identification of needs for future research. The paper includes also their recommendations for evidence-informed physical activity guidelines.

Technology-enhanced learning of community health in undergraduate medical education.

OBJECTIVES: The purpose of this evaluation study was to identify the feasibility of repurposing specific online modules developed by the Public Health Agency of Canada as continuing education modules for front-line practitioners, in teaching clinical epidemiology to undergraduate medical students. Specifically, relevancy of the content, quality of online material, time-effectiveness of using the online component, required resources, and student satisfaction were investigated. METHOD: Both qualitative and quantitative data were collected. Semi-structured interviews were conducted with stakeholders from the Skills Enhancement Program, technical support personnel, instructors, a web administrator and an assignment marker. Surveys measuring student satisfaction were administered to students in the middle of the online component and at the end of the course. Two student focus groups were conducted. As well, other documents (e.g., online materials, course packages) were reviewed. RESULTS: Instructors felt that the content of the modules was appropriate and would enhance learning, although making changes was time consuming. Medical students reported that the content was relevant and they enjoyed the flexibility allowed by the online components. However, students reported that there were too many assignments and too much content for the allotted time frame. CONCLUSION: The Public Health Agency's online content seems to be relevant to medical students, but needs to be fine-tuned further to cater to their specific needs. Instructors required a lot of time to review and revise the content. The time allocated for online content in this course was too little compared to the volume of information. It is feasible to repurpose the online modules in undergraduate medical education.

The relationship of chronic disease and demographic variables to physical activity in a sample of women aged 65 to 79 years.

This study explored the relationship between physical activity, marital status, income, education, and chronic disease in older women to determine which individuals are at risk of being inactive and to identify potential moderators of physical activity behavior. This was an analysis of cross-sectional data from a convenience sample of 271 community-dwelling women aged 65 to 79 years. Self-reported physical activity was measured using the Physical Activity Scale for the Elderly. Socio-demographic characteristics (including age, gender, marital status, education, employment, and income) and self-reported health were measured using previously validated instruments. To avoid seasonal variations in physical activity, data were collected during the summer months. Physical activity was negatively associated with age and the presence of cardio-respiratory disease and positively associated with income greater than $20,000 (p < 0.05). After controlling for other co-variates, no significant differences were observed in physical activity between married and unmarried individuals. Given the strong association between cardio-respiratory disease and income with physical activity, women 65 years of age and older in lower income brackets and suffering from these health conditions should be targeted for exercise counseling and support. Intervention research is needed to determine the most effective means to decrease inactivity among these women.

The health benefits of a physical activity program for older adults living in congregate housing.

BACKGROUND: In Saskatoon in 2002, as one of the key strategies for the in motion health promotion strategy, the Forever...in motion program was developed with the general goal of increasing opportunities for physical activity among older adults living in congregate housing. The three components of the program were a low-intensity exercise program, informal socialization and educational sessions. The objective of the present study was to examine whether participation in this program positively influenced participants' physical, emotional, psychological and social well-being. METHODS: A quasi-experimental, pretest/post-test design was employed to examine the impact of the program on various aspects of participant well-being. Thirty-six program participants and a comparison group of 22 non-participants from two congregate housing facilities took part in the study. The pretest was administered to the study and comparison groups before or shortly after the 12-week session commenced, and the post-test was administered after the 12-week session had concluded. Pretest and post-test assessment consisted of self-report measures of (1) vitality, (2) self-rated health, 3) mental health, (4) social functioning, (5) role limitations due to emotional problems, 6) physical activity-related knowledge, and (7) self-efficacy for exercise. A multivariate analysis of covariance (MANCOVA) was conducted using the seven post-test scores as dependent variables and the pretest scores as covariates. RESULTS: After adjusting for differences in baseline characteristics, the findings revealed statistically significant improvements in self-reported health and self-efficacy for exercise in the program participant group as compared with non-participants. CONCLUSION: The results of this study suggest that a relatively low-cost, low-intensity exercise program such as the Forever...in motion program may positively influence the well-being of older adults living in congregate housing. However, additional research with a larger number of participants and a more rigorous study design is needed to further elucidate the health benefits of the Forever...in motion program.

Examining physician counselling to promote the adoption of physical activity.

BACKGROUND: While the benefits of physical activity are generally recognized, over half of adult Canadians are not active enough to receive those benefits. Physicians may influence patient activity through counselling; however, research is inconsistent regarding their effectiveness in doing so. Increasing patients' use of self-regulatory skills in managing their activity and additional telephone support are suggested as two means of improving physician counselling. When assessing the effectiveness of physician counselling, it may be important to measure both outcome and treatment adherence. We compared physician-directed activity counselling (modified PACE protocol) with a modified PACE protocol augmented with telephone-based counselling for patient support for both outcome and treatment adherence. METHODS: Physicians counselled 90 patients using a modified PACE protocol that included self-regulatory skills. Physical activity was assessed by questionnaire at baseline (prior to counselling) and one month later. Participants were divided into two groups: counselling (modified PACE counselling) and enhanced counselling (modified PACE counselling plus telephone support). RESULTS: The main outcome (mean energy expenditure) and secondary outcomes of treatment adherence (frequency, frequency of moderate activity, and duration) significantly increased over time (p < 0.05). No significant interactions between group and time were found. INTERPRETATION: Our results support the effectiveness of physician counselling for activity that included the use of self-regulation skills. The effectiveness of telephone support over and above that of physician counselling was not supported. Our results demonstrate that assessing treatment adherence provides a means of discerning whether the counselling intervention was delivered as intended.

SMS-based smartphone application for disease surveillance has doubled completeness and timeliness in a limited-resource setting - evaluation of a 15-week pilot program in Central African Republic (CAR).

BACKGROUND: It is a challenge in low-resource settings to ensure the availability of complete, timely disease surveillance information. Smartphone applications (apps) have the potential to enhance surveillance data transmission. METHODS: The Central African Republic (CAR) Ministry of Health and Médecins Sans Frontières (MSF) conducted a 15-week pilot project to test a disease surveillance app, Argus, for 20 conditions in 21 health centers in Mambéré Kadéi district (MK 2016). Results were compared to the usual paper-based surveillance in MK the year prior (MK 2015) and simultaneously in an adjacent health district, Nana-Mambére (NM 2016). Wilcoxon rank sum and Kaplan-Meier analyses compared report completeness and timeliness; the cost of the app, and users' perceptions of its usability were assessed. RESULTS: Two hundred seventy-one weekly reports sent by app identified 3403 cases and 63 deaths; 15 alerts identified 28 cases and 4 deaths. Median completeness (IQR) for MK 2016, 81% (81-86%), was significantly higher than in MK 2015 (31% (24-36%)), and NM 2016 (52% (48-57)) (p < 0.01). Median timeliness (IQR) for MK 2016, 50% (39-57%) was also higher than in MK 2015, 19% (19-24%), and NM 2016 29% (24-36%) (p < 0.01). Kaplan-Meier Survival Analysis showed a significant progressive reduction in the time taken to transmit reports over the 15-week period (p < 0.01). Users ranked the app's usability as greater than 4/5 on all dimensions. The total cost of the 15-week pilot project was US$40,575. It is estimated that to maintain the app in the 21 health facilities of MK will cost approximately US$18,800 in communication fees per year. CONCLUSIONS: The app-based data transmission system more than doubled the completeness and timeliness of disease surveillance reports. This simple, low-cost intervention may permit the early detection of disease outbreaks in similar low-resource settings elsewhere.

The impact of control strategies and behavioural changes on the elimination of Ebola from Lofa County, Liberia.

The Ebola epidemic in West Africa was stopped by an enormous concerted effort of local communities and national and international organizations. It is not clear, however, how much the public health response and behavioural changes in affected communities, respectively, contributed to ending the outbreak. Here, we analyse the epidemic in Lofa County, Liberia, lasting from March to November 2014, by reporting a comprehensive time line of events and estimating the time-varying transmission intensity using a mathematical model of Ebola transmission. Model fits to the epidemic show an alternation of peaks and troughs in transmission, consistent with highly heterogeneous spread. This is combined with an overall decline in the reproduction number of Ebola transmission from early August, coinciding with an expansion of the local Ebola treatment centre. We estimate that healthcare seeking approximately doubled over the course of the outbreak, and that isolation of those seeking healthcare reduced their reproduction number by 62% (mean estimate, 95% credible interval (CI) 59-66). Both expansion of bed availability and improved healthcare seeking contributed to ending the epidemic, highlighting the importance of community engagement alongside clinical intervention.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Surgical Management of the Primary Tumor in Stage IV Colorectal Cancer: A Confirmatory Retrospective Cohort Study.

BACKGROUND: Observational studies have suggested that patients with stage IV colorectal cancer who undergo surgical resection of the primary tumor (SRPT) have better survival. Yet the results are not confirmed in the setting of a randomized controlled trial. Lack of randomization and failure to control prognostic variables such as performance status are major critiques to the findings of the observational studies. We previously have shown that SRPT, independent of chemotherapy and performance status, improves survival of stage IV CRC patients. The current study aims to validate our findings in patients with stage IV CRC who were diagnosed during the period of modern chemotherapy. METHODS: A cohort of 569 patients with stage IV CRC diagnosed during 2006-2010 in the province of Saskatchewan was evaluated. Cox regression model was used for the adjustment of prognostic variables. RESULTS: Median age was 69 years (59-95) and M: F was 1.4:1. Fifty-seven percent received chemotherapy, 91.4% received FOLFIRI or FOLFOX & 67% received a biologic agent. Median overall survival (OS) of patients who underwent SRPT and received chemotherapy was 27 months compared with 14 months of the non-resection group (p<0.0001). Median OS of patients who received all active agents and had SRPT was 39 months (95%CI: 25.1-52.9). On multivariate analysis, SRPT, hazard ratio (HR):0.44 (95%CI: 0.35-0.56), use of chemotherapy, HR: 0.33 (95%CI: 0.26-0.43), metastasectomy, HR: 0.43 (95%CI: 0.31-0.58), second line therapy, HR: 0.50 (95%CI: 0.35-0.70), and third line therapy, HR: 0.58 (95%CI: 0.41-0.83) were correlated with superior survival. CONCLUSIONS: This study confirms our findings and supports a favorable association between SRPT and survival in patients with stage IV CRC who are treated with modern therapy.

Profile of physical activity levels in community-dwelling older adults.

PURPOSE: To examine relationships between selected sociodemographic, health-related and environmental factors and levels of physical activity in older adults across three age groups. METHODS: Seven hundred sixty-four older adults (mean age = 77.4 +/- 8.6 yr) from a midsize Canadian city completed a self-administered questionnaire under researcher supervision. Level of physical activity was determined using the Physical Activity Scale for the Elderly (PASE). Correlates of physical activity were examined using previously validated questionnaires. The findings pertaining to personal and environmental factors are presented. RESULTS: Overall, significantly higher mean PASE scores were seen in those individuals in the following categories: male (P < 0.001), married or common-law (P < 0.001), not living alone (P < 0.001), not living in senior's housing (P < 0.001), higher levels of education (P < 0.001) and higher incomes (P < 0.001). Better physical health showed significant positive associations (P < 0.001) with PASE score. Individuals reporting at least four or more chronic health conditions had significantly lower PASE scores than those reporting no chronic conditions (P < 0.001). Significantly lower PASE scores were also reported in those using domestic services (P < 0.001). Higher PASE scores were related to the presence of hills, biking and walking trails, street lights, various recreation facilities, seeing others active and unattended dogs (P < 0.001 to P < 0.05). CONCLUSION: An understanding of the factors that influence physical activity behavior in older adults is critical to developing effective intervention strategies that will address the problem of physical inactivity in this population, and in doing so, improve the health status and quality of life of the older adult, while having a significant impact on healthcare expenditures.