Increase in ST-11 serogroup W Neisseria meningitidis invasive meningococcal disease in Canada, 2016-2018.

BACKGROUND: Many countries have experienced increases in invasive meningococcal disease (IMD) due to a serogroup W Neisseria meningitidis (MenW) strain of the multilocus sequence type (ST)-11 clonal complex (CC). MenW ST-11 was first reported in Ontario, Canada, in 2014. By 2016, this strain caused IMD in five provinces and was responsible for 18.8% of the IMD cases in Canada. OBJECTIVE: To provide an update on invasive MenW disease in Canada including the strain characteristics, specimen source of isolates, age, sex and geographic distribution of cases. METHODS: N. meningitidis from culture-positive IMD cases are routinely submitted to the National Microbiology Laboratory (NML) for serogroup, serotype, serosubtype and sequence type analysis. The data from January 1, 2016 to December 31, 2018 were analyzed by calculating the proportion of IMD cases caused by MenW compared with other serogroups. In addition, trends based on age, sex and geographic distribution of cases and specimen source of isolates were analyzed based on information on specimen requisition forms. RESULTS: Over the 3-year period, 292 individual IMD case isolates were analyzed. The percentage of IMD case isolates typed as MenW more than doubled from 19% (n=15) to 44% (n=51) in 2018 when MenW became the most common serogroup, exceeded the number of MenB, MenC or MenY. In total, 93 MenW case isolates were identified, 91% (n=85) belonged to the ST-11 CC. The increase in MenW affected all age groups (but was most common in those older than 60) and both sexes, and occurred across the country but most prevalent in western Canada. The most common specimen source was blood. CONCLUSION: In 2018, MenW was the most common serogroup for isolates received by the NML from culture-positive IMD cases in Canada. Over 90% of the MenW serogroup isolates belonged to the ST-11 CC. The quadrivalent ACWY meningococcal conjugate vaccine protects against IMD caused by strains in the A, C, W or Y serogroups and therefore may protect against IMD caused by the new MenW ST-11 strain; however, more research is needed. The emergence of variant strains highlight the importance of strain characterization in IMD surveillance and research.

Multidrug-resistant and extensively drug-resistant Neisseria gonorrhoeae in Canada, 2012-2016.

BACKGROUND: Neisseria gonorrhoeae have acquired resistance to many antimicrobials, including third generation cephalosporins and azithromycin, which are the current gonococcal combination therapy recommended by the Canadian Guidelines on Sexually Transmitted Infections. OBJECTIVE: To describe antimicrobial susceptibilities for N. gonorrhoeae circulating in Canada between 2012 and 2016. METHODS: Antimicrobial resistance profiles were determined using agar dilution of N. gonorrhoeae isolated in Canada 2012-2016 (n=10,167) following Clinical Laboratory Standards Institute guidelines. Data were analyzed by applying multidrug-resistant gonococci (MDR-GC) and extensively drug-resistant gonococci (XDR-GC) definitions. RESULTS: Between 2012 and 2016, the proportion of MDR-GC increased from 6.2% to 8.9% and a total of 19 cases of XDR-GC were identified in Canada (0.1%, 19/18,768). The proportion of isolates with decreased susceptibility to cephalosporins declined between 2012 and 2016 from 5.9% to 2.0% while azithromycin resistance increased from 0.8% to 7.2% in the same period. CONCLUSION: While XDR-GC are currently rare in Canada, MDR-GC have increased over the last five years. Azithromycin resistance in N. gonorrhoeae is established and spreading in Canada, exceeding the 5% level at which the World Health Organization states an antimicrobial should be reviewed as an appropriate treatment. Continued surveillance of antimicrobial susceptibilities of N. gonorrhoeae is necessary to inform treatment guidelines and mitigate the impact of resistant gonorrhea.

Impact of a social media campaign targeting men who have sex with men during an outbreak of syphilis in Winnipeg, Canada.

BACKGROUND: The city of Winnipeg has experienced a surge of infectious syphilis cases since the fall of 2012, concentrated among men who have sex with men (MSM) and who use social media technologies-including phone applications-to meet sexual contacts. OBJECTIVE: To evaluate the acceptability, cost and effectiveness of a campaign promoting syphilis testing on popular websites and applications used by MSM in the Winnipeg Health Region (WHR). METHODS: The Winnipeg Regional Health Authority developed a campaign in March 2014 highlighting the syphilis outbreak and the importance of seeking testing. Over one month, advertisements appeared on four web-platforms: Grindr, Facebook, Squirt and the Gay Ad Network. When clicked, ads would direct the user to an information website. Acceptability was assessed using the number of 'clicks' elicited by advertisements on each platform. The cost of each platform's run of advertisements was compared to the number clicks elicited to produce a cost-per-click ratio for each platform. Effectiveness was assessed by comparing the number of syphilis tests ordered for male residents of the Winnipeg Health Region in the seven-week period before and after the campaign, as well as to the same time periods in 2012 and 2013. RESULTS: Out of 800,000 appearances purchased, the advertisements elicited 2,166 clicks, suggesting good acceptability. Grindr and Squirt advertisements had a better cost-per-click ratio than Facebook or the Gay Ad Network. There was no significant difference in testing before (2,049 tests) versus after (2,025 tests) the campaign and these findings were similar to testing trends in 2012 and 2013. CONCLUSION: Although this web-based campaign showed good acceptability and low cost, it did not appear to increase syphilis testing. This may be due to a poor campaign design; it also suggests that an education campaign alone may be insufficient to change behaviour.

Serratia marcescens harbouring SME-type class A carbapenemases in Canada and the presence of blaSME on a novel genomic island, SmarGI1-1.

OBJECTIVES: An increasing prevalence since 2010 of Serratia marcescens harbouring the Ambler class A carbapenemase SME prompted us to further characterize these isolates. METHODS: Isolates harbouring bla(SME) were identified by PCR and sequencing. Phenotypic analysis for carbapenemase activity was carried out by a modified Hodge test and a modified Carba NP test. Antimicrobial susceptibilities were determined by Etest and Vitek 2. Typing was by PFGE of macrorestriction digests. Whole-genome sequencing of three isolates was carried out to characterize the genomic region harbouring the bla(SME)-type genes. RESULTS: All S. marcescens harbouring SME-type enzymes could be detected using a modified Carba NP test. Isolates harbouring bla(SME) were resistant to penicillins and carbapenems, but remained susceptible to third-generation cephalosporins, as well as fluoroquinolones and trimethoprim/sulfamethoxazole. Isolates exhibited diverse genetic backgrounds, though 57% of isolates were found in three clusters. Analysis of whole-genome sequence data from three isolates revealed that the bla(SME) gene occurred in a novel cryptic prophage genomic island, SmarGI1-1. CONCLUSIONS: There has been an increasing occurrence of S. marcescens harbouring bla(SME) in Canada since 2010. The bla(SME) gene was found on a genomic island, SmarGI1-1, that can be excised and circularized, which probably contributes to its dissemination amongst S. marcescens.

Interim estimates of 2013/14 vaccine effectiveness against influenza A(H1N1)pdm09 from Canada s sentinel surveillance network, January 2014.

The 2013/14 influenza season to date in Canada has been characterised by predominant (90%) A(H1N1)pdm09 activity. Vaccine effectiveness (VE) was assessed in January 2014 by Canada's sentinel surveillance network using a test-negative case-control design. Interim adjusted-VE against medically-attended laboratory-confirmed influenza A(H1N1)pdm09 infection was 74% (95% CI: 58-83). Relative to vaccine, A(H1N1)pdm09 viruses were antigenically similar and genetically well conserved, with most showing just three mutations across the 50 amino acids comprising antigenic sites of the haemagglutinin protein.

Retrospective TREC testing of newborns with Severe Combined Immunodeficiency and other primary immunodeficiency diseases.

In Manitoba, Canada, the overall incidence of Severe Combined Immunodeficiency (SCID) is three-fold higher than the national average, with SCID overrepresented in two population groups: Mennonites and First Nations of Northern Cree ancestries. T-cell receptor excision circle (TREC) assay is being used increasingly for neonatal screening for SCID in North America. However, the majority of SCID patients in Manitoba are T-cell-positive. Therefore it is likely that the TREC assay will not identify these infants. The goal of this study was to blindly and retrospectively perform TREC analysis in confirmed SCID patients using archived Guthrie cards. Thirteen SCID patients were tested: 5 T-negative SCID (3 with adenosine deaminase deficiency, 1 with CD3δ deficiency, and 1 unclassified) and 8 T-positive SCID (5 with zeta chain-associated protein kinase (ZAP70) deficiency and 3 with inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase beta (IKKß) deficiency). As a non-SCID patient group, 5 Primary Immunodeficiency Disease (PID) patients were studied: 1 T-negative PID (cartilage-hair hypoplasia) and 4 T-positive PID (2 common immune deficiency (CID), 1 Wiskott-Aldrich syndrome, and 1 X-linked lymphoproliferative disease). Both patient groups required hematopoietic stem cell transplantation. In addition, randomly-selected de-identified controls (n = 982) were tested. Results: all T-negative SCID and PID had zero TRECs. Low-TRECs were identified in 2 ZAP70 siblings, 1 CID patient as well as 5 preterm, 1 twin, and 4 de-identified controls. Conclusions: TREC method will identify T-negative SCID and T-negative PID. To identify other SCID babies, newborn screening in Manitoba must include supplemental targeted screening for ethnic-specific mutations.

Interim estimates of influenza vaccine effectiveness in 2012/13 from Canada's sentinel surveillance network, January 2013.

The 2012/13 influenza season in Canada has been characterised to date by early and moderately severe activity, dominated (90%) by the A(H3N2) subtype. Vaccine effectiveness (VE) was assessed in January 2013 by Canada's sentinel surveillance network using a test-negative case-control design. Interim adjusted-VE against medically attended laboratory-confirmed influenza A(H3N2) infection was 45% (95% CI: 13-66). Influenza A(H3N2) viruses in Canada are similar to the vaccine, based on haemagglutination inhibition; however, antigenic site mutations are described in the haemagglutinin gene.

Evaluation of a new chromogenic agar medium for detection of Shiga toxin-producing Escherichia coli (STEC) and relative prevalences of O157 and non-O157 STEC in Manitoba, Canada.

This study assesses the detection performance of CHROMagar STEC medium relative to a reference cytotoxin assay and describes the current relative prevalence of O157 and non-O157 Shiga toxin-producing Escherichia coli (STEC) serotypes within the province of Manitoba, Canada. Over a 10-month period, 205 nonfrozen routine stool submissions to Cadham Provincial Laboratory (CPL) were used to assess the performance of CHROMagar STEC. Of the 205 stools, 14 were identified as true positives by a cytotoxin assay, with resultant CHROMagar STEC sensitivity, specificity, and positive predictive and negative predictive values of 85.7%, 95.8%, 60.0%, and 98.9%, respectively. Using a separate panel of 111 STEC strains, CHROMagar STEC was shown to support the growth of 96 (86.5%) isolates. To assess relative prevalence, attempts were made to isolate by any means all STEC strains identified at CPL over a 17-month period. Of 49 isolates (representing 86.0% of all STEC infections detected), only 28.6% were O157 STEC strains. Of the 35 non-O157 STEC strains, 29 were subjected to further molecular analysis. In contrast to earlier results from our area, carriage of stx(2) appears to have increased. Overall, although CHROMagar STEC is not recommended as a primary screen, our results indicate that it is an effective supplemental medium for the isolation of probable STEC strains. Increased isolation of these serotypes is warranted to better understand their prevalence, clinical characteristics, and epidemiology and aid in the development or enhancement of food safety control programs targeting all STEC serotypes.

The relationship of meteorological conditions to the epidemic activity of respiratory syncytial virus.

Our aim was to obtain knowledge of how meteorological conditions affect community epidemics of respiratory syncytial virus (RSV) infection. To this end we recorded year-round RSV activity in nine cities that differ markedly in geographic location and climate. We correlated local weather conditions with weekly or monthly RSV cases. We reviewed similar reports from other areas varying in climate. Weekly RSV activity was related to temperature in a bimodal fashion, with peaks of activity at temperatures above 24-30 degrees C and at 2-6 degrees C. RSV activity was also greatest at 45-65% relative humidity. RSV activity was inversely related to UVB radiance at three sites where this could be tested. At sites with persistently warm temperatures and high humidity, RSV activity was continuous throughout the year, peaking in summer and early autumn. In temperate climates, RSV activity was maximal during winter, correlating with lower temperatures. In areas where temperatures remained colder throughout the year, RSV activity again became nearly continuous. Community activity of RSV is substantial when both ambient temperatures and absolute humidity are very high, perhaps reflecting greater stability of RSV in aerosols. Transmission of RSV in cooler climates is inversely related to temperature possibly as a result of increased stability of the virus in secretions in the colder environment. UVB radiation may inactivate virus in the environment, or influence susceptibility to RSV by altering host resistance.

Serological studies of West Nile virus in a liver transplant population.

BACKGROUND: Solid organ transplant populations are at increased risk for serious clinical manifestations of West Nile virus (WNV) infection. OBJECTIVE: To monitor liver transplant recipients during the 2003 WNV season in Manitoba and to identify incidence, clinical presentation and serology. METHODS: Serial blood specimens were obtained from adult patients followed at the liver transplant outpatient clinic between May 2003 and October 2003. Studies for WNV infection included immunoglobulin (Ig) G and IgM enzyme immunoassay (EIA), hemagglutination inhibition (HI), plaque reduction neutralization test and reverse transcriptase-polymerase chain reaction. RESULTS: None of the 79 patients had clinical presentations suggestive of WNV infection. On testing of the final serum specimen obtained, 14 patients (18%) had positive IgG anti-WNV by EIA and six patients (7%) had indeterminate IgG anti-WNV by EIA, although all were negative by IgM EIA. Four (20%) of the EIA-positive samples were reactive by HI, but all of these were negative by WNV plaque reduction neutralization test; this is consistent with the presence of non-West Nile flavivirus antibody in these sera. Blood specimens obtained throughout the season from EIA- and HI-positive individuals were uniformly negative for WNV-RNA by reverse transcriptasepolymerase chain reaction. Age, sex, hematology and biochemistry findings, hepatitis B or C virus status, immunosuppressive regimen (cyclosporin or tacrolimus) and pretransplant diagnosis of liver disease were similar for EIA-positive and EIA-negative patients. For the 10 patients with a positive IgG EIA maintained on cyclosporin, the cyclosporin level was 129.1+/-28.6 microg/L compared with 85.6+/-36.7 microg/L in 26 patients who were EIA-negative (P=0.002). CONCLUSIONS: False-positive IgG EIA serology for WNV was common in this cohort of liver transplant recipients, and was associated with elevated serum cyclosporin levels.

Molecular characterization of the vanE gene cluster in vancomycin-resistant Enterococcus faecalis N00-410 isolated in Canada.

The vanE operon was characterized from Enterococcus faecalis N00-410 (MIC of vancomycin = 24 microg/ml). The organization of the vanE operon was identical to that of the vanC1 operon from Enterococcus gallinarum, with protein identities ranging from 46 to 63%. An open reading frame located downstream of the vanE operon showed significant homology to a number of integrase genes, all of which are located downstream of the chromosomal GMP synthase gene guaA.

Rapid pharmacotherapeutic intervention for an influenza A outbreak in the Canadian Arctic: lessons from the Sanikiluaq experience.

In January of 2000 an outbreak of influenza-like illness (ILI) was identified by Health Centre nursing staff in the remote island Inuit community of Sanikiluaq, Nunavut. A staged approach to an intervention strategy was adopted and an intervention team dispatched within 48 hours with diagnostic, prophylactic, and therapeutic capabilities and the intent to evaluate the response as well. The presence of influenza virus was determined on site in 3 out of thirteen initial cases of ILI using portable kit based rapid detection. This permitted the use of zanamivir (an inhaled neuraminidase inhibitor) for prophylaxis in 201, and for treatment in 12 persons. Amantadine was only used in 16 and 52 were ineligible for medical intervention, mostly because they fell outside of the window of opportunity or for maternal/reproductive reasons. The intervention strategy framework adopted was felt to be successful and is presented for consideration in future intervention initiatives.

Assessment of the FAN anaerobic bottle for culture of continuous ambulatory peritoneal dialysis fluid using the BacT/Alert system.

The purpose of this study was to determine if the newly available FAN anaerobic bottle (FANAN) alone would be comparable to the combination of the FAN aerobic (FANAE) plus the standard BacT/Alert anaerobic (REGAN) bottles for culture of continuous ambulatory peritoneal dialysis (CAPD) fluid from patients with CAPD peritonitis. CAPD fluid (10 mL) was injected into each bottle, which was then monitored by the BacT/Alert instrument by using a 7-day protocol. Aerobic and anaerobic terminal subculture were performed on all bottles before they were classified as being culture negative. There were 181 effluents received that were suitable for analysis. Growth was detected in 76 (42%) effluents by at least one method. FANAE was the single best medium detecting 84/96 (88%) of all organisms whereas the FANAN and REGAN each detected 69/96 (72%). The combination of FANAE and REGAN bottles detected 92/96 (96%) isolates, which was significantly better than the FANAN or FANAE alone for isolate recovery (p < 0.001). The isolates that were missed by the FANAN but that were recovered by either FANAE or REGAN were all facultative anaerobes commonly detected in CAPD fluids. Terminal subculture revealed otherwise undetected pathogens in 3.9% of positive effluents, usually Pseudomonas aeruginosa. Based on our data, FANAE was the single best bottle for detection of CAPD peritonitis and, in combination with an anaerobic bottle, detected growth from the most effluents. FANAN alone could not substitute for the FANAE/REGAN combination. Although terminal subculture remains controversial, we recommend routine aerobic subculture to ensure that no P. aeruginosa isolates are missed.