Self-reported tick exposure as an indicator of Lyme disease risk in an endemic region of Quebec, Canada.

BACKGROUND: Lyme disease (LD) and other tick-borne diseases are emerging across Canada. Spatial and temporal LD risk is typically estimated using acarological surveillance and reported human cases, the former not considering human behavior leading to tick exposure and the latter occurring after infection. OBJECTIVES: The primary objective was to explore, at the census subdivision level (CSD), the associations of self-reported tick exposure, alternative risk indicators (predicted tick density, eTick submissions, public health risk level), and ecological variables (Ixodes scapularis habitat suitability index and cumulative degree days > 0 °C) with incidence proportion of LD. A secondary objective was to explore which of these predictor variables were associated with self-reported tick exposure at the CSD level. METHODS: Self-reported tick exposure was measured in a cross-sectional populational health survey conducted in 2018, among 10,790 respondents living in 116 CSDs of the Estrie region, Quebec, Canada. The number of reported LD cases per CSD in 2018 was obtained from the public health department. Generalized linear mixed-effets models accounting for spatial autocorrelation were built to fulfill the objectives. RESULTS: Self-reported tick exposure ranged from 0.0 % to 61.5 % (median 8.9 %) and reported LD incidence rates ranged from 0 to 324 cases per 100,000 person-years, per CSD. A positive association was found between self-reported tick exposure and LD incidence proportion (ß = 0.08, CI = 0.04,0.11, p < 0.0001). The best-fit model included public health risk level (AIC: 144.2), followed by predicted tick density, ecological variables, self-reported tick exposure and eTick submissions (AIC: 158.4, 158.4, 160.4 and 170.1 respectively). Predicted tick density was the only significant predictor of self-reported tick exposure (ß = 0.83, CI = 0.16,1.50, p = 0.02). DISCUSSION: This proof-of-concept study explores self-reported tick exposure as a potential indicator of LD risk using populational survey data. This approach may offer a low-cost and simple tool for evaluating LD risk and deserves further evaluation.

The added value of One Health surveillance: data from questing ticks can provide an early signal for anaplasmosis outbreaks in animals and humans.

OBJECTIVE: In 2021, a first outbreak of anaplasmosis occurred in animals and humans in southern Québec, with 64% of confirmed human cases located in Bromont municipality. Ixodes scapularis ticks and Peromyscus mouse ear biopsies collected in Bromont from 2019 to 2021 were analyzed for Anaplasma phagocytophilum (Ap) with the objective of determining whether an early environmental signal could have been detected before the outbreak. METHODS: Samples were collected for a concurrent study aiming to reduce Lyme disease risk. Between 2019 and 2021, up to 14 experimental sites were sampled for ticks and capture of small mammals took place on three sites in 2021. Samples were screened for Ap using multiplex real-time PCR, and genetic strains were identified using a single-nucleotide polymorphism assay. RESULTS: Analyses showed an increase of 5.7% in Ap prevalence in ticks (CI95: 1.5-9.9) between 2019 and 2020, i.e., one year before the outbreak. A majority of Ap-positive ticks were infected with the zoonotic strain (68.8%; CI95: 50.0-83.9) during the study period. In 2021, 2 of 59 captured Peromycus mice were positive for Ap, for a prevalence of 3.4% (CI95: 0.4-11.7). CONCLUSION: We conclude that data collected in Bromont could have provided an early signal for an anaplasmosis risk increasing in the targeted region. This is a reminder that integrated surveillance of tick-borne diseases through structured One Health programs, i.e. systematically integrating data from humans, animals and the environment, can provide useful and timely information for better preparedness and response in public health.

RéSUMé: OBJECTIF: En 2021, suivant une éclosion d'anaplasmoses chez les animaux et les humains dans le sud du Québec, des tiques de l'espèce Ixodes scapularis et des biopsies de souris Peromyscus spp. échantillonées à Bromont, la municipalité où 64 % des cas humains confirmés était localisé, ont été testées pour Anaplasma phagocytophilum (Ap) avec pour objectif de déterminer si un signal environnemental précoce d'augmentation du risque aurait pu être détecté avant l'éclosion. MéTHODE: L'échantillonnage a été réalisé dans le cadre d'une étude visant à réduire le risque de maladie de Lyme. De 2019 à 2021, 14 sites expérimentaux ont été échantillonnés pour les tiques. En 2021, trois sites ont été sélectionnés pour la capture des micromammifères. Les échantillons ont été testés pour la présence d'Ap à l'aide d'un PCR multiplex en temps réelle et les lignées génétiques ont été identifiées grâce à un test de polymorphisme mononucléotidique. RéSULTATS: Les analyses ont montré une augmentation de 5,7 % (IC95% : 1,5­9,9) de la prévalence de Ap entre 2019 et 2020, c'est-à-dire un an avant l'éclosion. Cette augmentation est associée à la présence d'une majorité d'Ap de la lignée zoonotique (68,8 %; IC95% : 50,0­83,9) sur l'ensemble de la période étudiée. En 2021, deux Peromycus spp. capturées sur 59 étaient positives pour Ap pour une prévalence de 3,4 % (IC95% : 0,4­11,7). CONCLUSION: Les données environnementales échantillonnées à Bromont auraient pu fournir un signal précoce de l'augmentation du risque d'anaplasmose dans la région. C'est un rappel que la surveillance intégrée des maladies transmises par les tiques inspirée de l'approche Une seule santé, intégrant systématiquement des données humaines, animales et environnementales, peut fournir des informations utiles et opportunes aux autorités de santé publique.

Integrated human behavior and tick risk maps to prioritize Lyme disease interventions using a 'One Health' approach.

Lyme disease (LD) risk is emerging rapidly in Canada due to range expansion of its tick vectors, accelerated by climate change. The risk of contracting LD varies geographically due to variability in ecological characteristics that determine the hazard (the densities of infected host-seeking ticks) and vulnerability of the human population determined by their knowledge and adoption of preventive behaviors. Risk maps are commonly used to support public health decision-making on Lyme disease, but the ability of the human public to adopt preventive behaviors is rarely taken into account in their development, which represents a critical gap. The objective of this work was to improve LD risk mapping using an integrated social-behavioral and ecological approach to: (i) compute enhanced integrated risk maps for prioritization of interventions and (ii) develop a spatially-explicit assessment tool to examine the relative contribution of different risk factors. The study was carried out in the Estrie region located in southern Québec. The blacklegged tick, Ixodes scapularis, infected with the agent of LD is widespread in Estrie and as a result, regional LD incidence is the highest in the province. LD knowledge and behaviors in the population were measured in a cross-sectional health survey conducted in 2018 reaching 10,790 respondents in Estrie. These data were used to create an index for the social-behavioral component of risk in 2018. Local Empirical Bayes estimator technique were used to better quantify the spatial variance in the levels of adoption of LD preventive activities. For the ecological risk analysis, a tick abundance model was developed by integrating data from ongoing long-term tick surveillance programs from 2007 up to 2018. Social-behavioral and ecological components of the risk measures were combined to create vulnerability index maps and, with the addition of human population densities, prioritization index maps. Map predictions were validated by testing the association of high-risk areas with the current spatial distribution of human cases of LD and reported tick exposure. Our results demonstrated that social-behavioral and ecological components of LD risk have markedly different distributions within Estrie. The occurrence of human LD cases or reported tick exposure in a municipality was positively associated with tick density and the prioritization risk index (p < 0.001). This research is a second step towards a more comprehensive integrated LD risk assessment approach, examining social-behavioral risk factors that interact with ecological risk factors to influence the management of emerging tick-borne diseases, an approach that could be applied more widely to vector-borne and zoonotic diseases.

Current and future burden from Lyme disease in Québec as a result of climate change.

Context: Environmental changes will foster the spread of Ixodes scapularis ticks and increase the incidence of Lyme disease in Québec in the coming years. The objective of this study is to estimate the epidemiological and clinical burden and part of the current economic burden of Lyme disease in Québec and to estimate the number of cases expected by 2050. Methods: Cases of Lyme disease reported in Québec from 2015 to 2019 were used to describe their demographic, geographical and clinical characteristics and the cost of their initial care. Three incidence rate scenarios were then developed to estimate the number of cases expected by 2050, based on demographic and climate projections. Results: From 2016 to 2019, 1,473 cases of Lyme disease were reported in Québec. Over 90% of those cases were acquired in two regions of southern Québec (Estrie and Montérégie), while the individuals infected were residents from all over Québec. The average age of cases is 44 years and 66% of infections were at the localized stage, the first stage of Lyme disease. The cost of initial care is estimated at an average of $182 CAN per patient ($47 CAN at the localized stage and $443 CAN at the disseminated stage). According to projections, over 95% of the Québec population will live in a climate zone conducive to the establishment of ticks by 2050, with a number of cases acquired in Québec being 1.3 to 14.5 times higher than in 2019, depending on the incidence rate scenario used. Conclusion: The epidemiological burden is concentrated primarily in southern Québec, but the clinical and economic burden is already distributed throughout the province. The projections for 2050 should help the regions of Québec adapt and optimize public health protection measures.

An ecological approach to predict areas with established populations of Ixodes scapularis in Quebec, Canada.

Public health management of Lyme disease (LD) is a dynamic challenge in Canada. Climate warming is driving the northward expansion of suitable habitat for the tick vector, Ixodes scapularis. Information about tick population establishment is used to inform the risk of LD but is challenged by sampling biases from surveillance data. Misclassifying areas as having no established tick population underestimates the LD risk classification. We used a logistic regression model at the municipal level to predict the probability of I. scapularis population establishment based on passive tick surveillance data during the period of 2010-2017 in southern Quebec. We tested for the effect of abiotic and biotic factors hypothesized to influence tick biology and ecology. Additional variables controlled for sampling biases in the passive surveillance data. In our final selected model, tick population establishment was positively associated with annual cumulative degree-days > 0°C, precipitation and deer density, and negatively associated with coniferous and mixed forest types. Sampling biases from passive tick surveillance were controlled for using municipal population size and public health instructions on tick submissions. The model performed well as indicated by an area under the curve (AUC) of 0.92, sensitivity of 86% and specificity of 81%. Our model enables prediction of I. scapularis population establishment in areas which lack data from passive tick surveillance and may improve the sensitivity of LD risk categorization in these areas. A more sensitive system of LD risk classification is important for increasing awareness and use of protective measures employed against ticks, and decreasing the morbidity associated with LD.

Management and clinical outcomes of Lyme disease in acute care facilities in 2 endemic regions of Quebec, Canada: a multicentre retrospective cohort study.

BACKGROUND: Despite increases in cases of Lyme disease, little is known about the management and clinical course of the disease in Canada. We aimed to describe the management and clinical course of Lyme disease in patients treated in acute care facilities in Quebec and to assess adherence to the 2006 Infectious Diseases Society of America (IDSA) guideline. METHODS: This retrospective multicentre cohort study included pediatric and adult patients with serologically confirmed Lyme disease treated in acute care facilities (12 community hospitals and 2 tertiary care centres) of 2 endemic regions of Quebec (Estrie and Montérégie), from 2004 to 2017. We considered drug choice, prescribed dose and treatment duration in assessing adherence of prescriptions to the 2006 IDSA guideline. The main outcome was complete resolution of symptoms at 3 months after the initiation of treatment. RESULTS: We included 272 patients from 14 institutions (age range 3-87 yr). Early disseminated Lyme disease (140 patients [51%]) was predominant. Adherence to the IDSA guideline was observed in 235 (90%) of the 261 cases with complete information, and adherence was stable over time (2004-2013: 57/64 [89%]; 2014-2015: 64/71 [90%]; 2016-2017: 114/126 [90%]; p = 0.8). Non-adherence to the guideline (n = 26) was predominantly due to longer-than-recommended treatment duration (16/26 [62%]). Resolution of objective signs at 3 months after treatment initiation occurred in 265 (99%) of 267 patients, whereas post-treatment Lyme disease syndrome was observed in 27 patients (10%) with increasing incidence over time (2004-2013: 3/65 [5%]; 2014-2015: 4/73 [5%]; 2016-2017: 20/129 [16%]; p = 0.02). INTERPRETATION: We observed clinical resolution of Lyme disease in 99% of the patients, and most treatments (90%) complied with the 2006 IDSA guideline. The incidence of post-treatment Lyme disease syndrome increased over the study period, warranting further prospective studies.

Behavioral risk factors associated with reported tick exposure in a Lyme disease high incidence region in Canada.

BACKGROUND: Tick-borne diseases, and especially Lyme Disease (LD), are on the rise in Canada and have been met with increasing public health concern. To face these emerging threats, education on the prevention of tick bites remains the mainstay of public health intervention. The objective of this study was to assess the adoption of preventive behaviors toward tick bites and LD and to investigate the association between behavioral risk factors and reported tick exposure in a Canadian, LD high incidence region (Estrie region, Quebec, Canada). METHODS: A cross-sectional study was conducted in 2018 which used a telephone questionnaire administered to a random sample of 10,790 adult residents of the study region. Questions investigated tick exposure, LD awareness, attitudes towards LD risk, outdoor and preventive behaviors, as well as antibiotic post-exposure prophylaxis (PEP) treatments in the case of a tick bite. Descriptive and multivariable analyses were carried out, considering the nine administrative subregions and the stratified survey design. RESULTS: The sub-regional prevalence of reported tick exposure in the previous year ranged from 3.4 to 21.9%. The proportion of respondents that adopted preventive behaviors varied from 27.0% (tick checks) to 30.1% (tick repellent) and 44.6% (shower after outdoor activities). A minority of respondents (15.9%) that sought healthcare after a tick bite received a PEP treatment. Performing tick checks (Odds ratio = 4.33), time spent outdoors (OR = 3.09) and living in a subregion with a higher public health LD risk level (OR = 2.14) were associated with reported tick exposure in multivariable models. CONCLUSIONS: This study highlights the low level of adoption of preventive behaviors against tick bites in a region where LD risk is amongst the highest in Canada. This suggests a concerning lack of improvement in LD prevention, as low levels of adoption were already reported in studies conducted in the last decade. Innovative and evidence-based approaches to improve education on ticks and tick-borne diseases and to promote behavior changes are urgently needed in Canada.

Identification of an unusual cluster of human granulocytic anaplasmosis in the Estrie region, Québec, Canada in 2021.

Background: Human granulocytic anaplasmosis (HGA) is a potentially severe tick-borne infection caused by the bacterium Anaplasma phagocytophilum (A. phagocytophilum) of the genus Rickettsia. Here, we describe the epidemiological and clinical characteristics of an unusual cluster of HGA cases detected in the Estrie region in Québec, Canada, during the 2021 transmission season. Methods: Confirmed cases of HGA were defined as individuals with typical clinical manifestations and a positive polymerase chain reaction assay. The cases were interviewed using a structured questionnaire and clinical data was obtained from medical records. Results: A total of 25 confirmed cases were identified during the 2021 transmission season, thus constituting the largest known cluster of HGA in Canada. The most common symptoms reported were fever, fatigue and headaches. Laboratory investigations found that 20 (80%) of the patients had thrombocytopenia and 18 (72%) had leukopenia at presentation. Almost half of the patients required hospitalization (n=11, 44%), with a median duration of four days (interquartile range [IQR] 2.5-5 days), including one patient who required intensive care. No deaths were recorded during the study. Epidemiological investigation found that all cases were domestically acquired, and yard maintenance was the most prevalent at-risk activity identified. Only seven (28%) cases had been aware of a tick bite in the previous two weeks. Conclusion: Detection of this unusual cluster of HGA cases provides further evidence that A. phagocytophilum may now be established along the southern border of Québec. Clinicians should consider HGA when assessing patients with typical symptoms and recent exposure to high-risk environments for tick bite.

Determinants of vaccine hesitancy in Quebec: a large population-based survey.

Objectives: Vaccine hesitancy is a global phenomenon that needs to be measured and addressed. This study aimed to identify the determinants of vaccine hesitancy among a large regional population.Methods: A structured telephone survey was administered to a random digit sample in Quebec's Eastern Townships region. In addition to socioeconomic information, respondents were asked questions on several health topics such as knowledge and beliefs about immunization, medical consultations, health status, and life habits. Data were weighted according to age, sex, and territories. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model to determine independent factors for vaccine hesitancy (adjusted odds ratios [aOR] and 95% confidence intervals).Results: A total of 8,737 interviews were conducted (participation rate 48.3%). Among all respondents, 32.2% were vaccine-hesitant. Several beliefs were significantly associated with vaccine hesitancy: belief that children receive too many vaccines (aOR = 2.72; 2.32-3.18), belief that a healthy lifestyle can eliminate the need for vaccination (aOR = 2.48; 2.09-2.93), and belief that the use of alternative medicine practices can eliminate the need for vaccination (aOR = 1.39; 1.16-1.68). Other determinants associated with vaccine hesitancy were having consulted a massage therapist (aOR = 2.34; 1.46-3.75), not being vaccinated against influenza (aOR = 1.80; 1.49-2.16), having a low (<$30,000) (aOR = 1.58; 1.24-2.02) or moderate ($30,000-$79,000) (aOR = 1.37; 1.12-1.67) household income, distrust in public health authorities (aOR = 1.40; 1.21-1.63), perceived insufficient knowledge about immunization (aOR = 1.26; 1.04-1.51), and smoking (aOR = 1.22; 1.01-1.47).Conclusions: Many determinants are related to vaccine hesitancy. These determinants should be taken into account when health professionals engage with vaccine-hesitant individuals.

A complementary approach to the vaccination promotion continuum: An immunization-specific motivational-interview training for nurses.

AIM: To develop and validate immunization-specific motivational-interview (MI) training for immunization nurses. BACKGROUND: We previously demonstrated that a MI-based intervention on immunisation, performed during postpartum by MI-trained healthcare workers at the hospital maternity ward, reduced parental vaccine hesitancy (VH) and increased vaccine coverage of their children. In this study, we propose immunization-specific MI training for immunization nurses. Together, MI-based training and interventions provide complementary approaches to existing strategies along the vaccination promotion continuum. DESIGN: Multiple pretest/posttest design with questionnaires self-administered before and after each training days (4 time points). METHODS: We developed an in-person immunization-specific MI-training workshop for immunization nurses, held on two days three months apart, with 7 h of MI-training dispensed on day 1, and 4 h on day 2. The self-administered Motivational Interviewing Skills in Immunization (MISI) questionnaire was used at four time points (before and after each of the 2 training days) to evaluate three core aspects of participant MI training: (1) MI-knowledge acquisition; (2) MI-skills application and (3) self-rated self-confidence in applying MI knowledge and skills in vaccination clinical practice. Between November 2016 to December 2017, 34 immunization nurses enrolled in our MI-training workshops. RESULTS: The immunization-specific MI-training improved the three core areas evaluated in participants i.e. MI-knowledge acquisition, MI-skills application, and self-rated self-confidence in applying these in vaccination clinical practice. CONCLUSIONS: Our immunization-specific MI-training enabled immunization nurses to significantly improve MI knowledge, skills and self-confidence in applying MI in the clinic. These results, taken together with those on the MI-based intervention for parents that we previously reported, support the notion of proposing validated immunization-specific MI training for immunization nurses in order to curb parental VH. IMPACT: Immunization-specific MI-training would be easily amenable for the training of other health professionals in the field of immunization to help promote vaccination and curb parental VH.

Development of motivational interviewing skills in immunization (MISI): a questionnaire to assess MI learning, knowledge and skills for vaccination promotion.

Objective: Vaccine hesitancy is a complex problem. We previously demonstrated that motivational interviewing (MI) could be helpful to enhance parents' motivation to vaccinate their child. The aim of this study is to develop a new, simple and robust evaluation tool that is suitable for evaluating MI learning of vaccination health professionals. Methods: We designed the Motivational Interviewing Skills in Immunization (MISI), a short written questionnaire to evaluate the MI knowledge and skills of participants in an immunization context. It covers three key areas: knowledge of MI, ability to apply MI-related skills, participant self-confidence in using MI. Questionnaire content and face validity were assessed by MI experts and internal consistency, reliability and effect size were analyzed using a multiple pretest-posttest design. Results: Psychometric measures showed good to excellent internal consistency of the questionnaire for all three areas (Cronbach's and KR coefficient: 0.70 to 0.88). Test-retest reliability showed good measurement stability (ICC: 0.53). Good sensitivity to change was also obtained (Cohen's d: 0.80 to 1.66). Conclusion: The MISI questionnaire is the first paper/pencil evaluation method to assess MI training specific to immunization. Psychometric measures showed high reliability. Practice implications: This questionnaire could provide a convenient and inexpensive method to evaluate knowledge and competencies following immunization-specific MI training.

Determinants of influenza vaccination among a large adult population in Quebec.

OBJECTIVES: Very low uptake has been noted for influenza vaccination in the province of Quebec. This study aimed to identify the determinants of influenza vaccination among a large regional population. METHODS: A telephone survey was administered to a random digit sample in the Eastern Townships region (Quebec, Canada). Respondents were asked questions on several health topics such as perceived knowledge and beliefs about influenza immunization, medical consultations, perceived health status and life habits. Significant variables in the univariate analysis were introduced into a multivariate logistic regression model to determine independent factors for having received the influenza vaccine (aOR and 95% CI) among adults aged ≥60 years and younger adults with ≥1 chronic condition. RESULTS: A total of 4,620 interviews were analyzed. Among the target groups, 55.4% of adults aged ≥60 and 32.2% of adults aged 18-59 with at least one chronic disease had received the influenza vaccine during the 2013-2014 season. Several determinants were significantly associated with influenza vaccination in both groups such as having received a recommendation from a healthcare professional. Among adults aged ≥60, not having consulted a chiropractor over the last 12 months (aOR = 2.37; 1.09-5.19), non-smokers (aOR = 1.78; 1.22-2.59) and self-perceived poor health status (aOR = 1.45; 1.01-2.06) were significantly linked to flu vaccination. In the younger group, influenza vaccination was independently associated to low alcohol consumption (aOR = 2.14; 1.13-4.05) and being overweight (aOR = 1.63; 1.12-2.38). CONCLUSIONS: Many determinants influence the decision to get vaccinated against influenza. Specific messages should be tailored for high-risk groups to effectively increase influenza vaccine coverage.

Respiratory Diseases in University Students Associated with Exposure to Residential Dampness or Mold.

University students are frequently exposed to residential dampness or mold (i.e., visible mold, mold odor, dampness, or water leaks), a well-known contributor to asthma, allergic rhinitis, and respiratory infections. This study aims to: (a) describe the prevalence of these respiratory diseases among university students; and (b) examine the independent contribution of residential dampness or mold to these diseases. An online survey was conducted in March 2014 among the 26,676 students registered at the Université de Sherbrooke (Quebec, Canada). Validated questions and scores were used to assess self-reported respiratory diseases (i.e., asthma-like symptoms, allergic rhinitis, and respiratory infections), residential dampness or mold, and covariates (e.g., student characteristics). Using logistic regressions, the crude and adjusted odd ratios between residential dampness or mold and self-reported respiratory diseases were examined. Results from the participating students (n = 2097; response rate: 8.1%) showed high prevalence of allergic rhinitis (32.6%; 95% CI: 30.6-34.7), asthma-like symptoms (24.0%; 95% CI: 22.1-25.8) and respiratory infections (19.4%; 95% CI: 17.7-21.2). After adjustment, exposure to residential dampness or mold was associated with allergic rhinitis (OR: 1.25; 95% CI: 1.01-1.55) and asthma-like symptoms (OR: 1.70; 95% CI: 1.37-2.11), but not with respiratory infections (OR: 1.07; 95% CI: 0.85-1.36). Among symptomatic students, this exposure was also associated with uncontrolled and burdensome respiratory symptoms (p < 0.01). University students report a high prevalence of allergic rhinitis, asthma-like symptoms and respiratory infections. A common indoor hazard, residential dampness or mold, may play a role in increasing atopic respiratory diseases and their suboptimal control in young adults. These results emphasize the importance for public health organizations to tackle poor housing conditions, especially amongst university students who should be considered "at-risk".

Prevalence of Residential Dampness and Mold Exposure in a University Student Population.

The impact of residential dampness or mold on respiratory health is well established but few studies have focused on university students. This study aims to: (a) describe the prevalence of exposure to residential dampness or mold in university students according to socio-geographic factors and (b) identify associated housing characteristics. A web survey was conducted in 2014 among the 26,676 students registered at the Université de Sherbrooke (QC, Canada). Residential dampness and mold being closely intertwined, they were considered as a single exposure and assessed using a validated questionnaire. Exposure was compared according to socio-geographic and housing characteristics using chi-square tests and logistic regressions. Among the 2097 participants included in the study (response rate: 8.1%), over 80% were tenants. Residential exposure to dampness or mold was frequent (36.0%, 95% CI: 33.9-38.1). Marked differences for this exposure were noted according to home ownership (39.7% vs. 25.5% among tenants and owners respectively; OR = 1.92%, 95% CI: 1.54-2.38). Campus affiliation, household composition and the number of residents per building were associated with exposure to dampness or mold (p < 0.01), while sex and age were not. Exposure was also associated with older buildings, and buildings in need of renovations and lacking proper ventilation (p < 0.001). This study highlights the potential risk of university students suffering from mold-related health effects given their frequent exposure to this agent. Further research is needed to fully evaluate the mold-related health impact in this at risk group.

Breast cancer screening practices for women aged 35 to 49 and 70 and older.

OBJECTIVE: To describe physician practices with regard to opportunistic screening for breast cancer in women aged 35 to 49 years and 70 years of age and older, and to identify the determinants associated with the practice of prescribing screening mammography. DESIGN: Postal survey. SETTING: Quebec. PARTICIPANTS: Simple random sample of 1400 general practitioners practising in Quebec in 2009. MAIN OUTCOME MEASURES: Five cancer screening practices among 4 types of female clientele and the factors influencing physicians in their practice of prescribing screening mammography. RESULTS: The response rate was 36%. For women aged 35 to 49 years, more than 80% of physicians reported using practices judged adequate, except for the teaching of breast self-examination and referrals to genetic counseling (60% and 54%). For women 70 years of age and older with good life expectancy, only 50% of general practitioners prescribed screening mammography. For the 70 years of age and older age group without good life expectancy, for whom screening is not indicated, nearly half of physicians continued to do the clinical breast examination and more than one-third reviewed family history. The main determinants for the practice of prescribing mammography are a favourable attitude to screening, screening skills, peer support, belief in the efficacy of mammography, and sufficient knowledge of the issue and of recommendations. CONCLUSION: Improvements are needed in the practice of teaching breast self-examination to women aged 35 to 49 years and referring them to genetic counseling, as well as in prescribing mammography for women 70 years of age and older who are in good health. Public health actions to improve these practices should focus on physician attitudes and skills and on communicating clearer recommendations.

Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey.

OBJECTIVE: To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS). METHOD: Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics. OUTCOME MEASURES: Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS. RESULTS: CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35-2.37) or mixed (OR 1.22; 95% CI 1.01-1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41-2.38) compared to a single visit. CONCLUSION: Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.

Are vaccination information leaflets useful for vaccinators and parents?

Three vaccination information leaflets (VIL) were evaluated in the province of Québec in 2002-2003 to examine their use by vaccinators (nurses and physicians), and their success in reaching parents of infants and toddlers. Data were collected from vaccinators and parents by postal survey. Reception of all of the VIL was higher among nurses (98%) than among physicians (39%). Only 14% of parents were familiar with all the VIL. Vaccinators who used the VIL, and the parents who were familiar with them, were satisfied with their presentation, clarity, quantity of information, pertinence and credibility. While the information leaflets were useful for vaccinators, few parents were reached, limiting the impact of this method of promotion.

Effectiveness and cost comparison of two strategies for hepatitis B vaccination of schoolchildren.

CONTEXT: In 1994, immunization against hepatitis B was implemented in schools in Quebec, targeting grade 4 students. In 1996-1997 and 1997-1998, one Local Community Service Centre (CLSC) replaced the school-based program in its district with vaccination offered in community clinics after school hours. The aim of the current study was to compare the effectiveness and costs of school-based and clinic-based programs. METHODS: Vaccination coverage data were collected in the CLSC with the clinic-based program (CBP), and in three matched CLSCs with a school-based program (SBP), from 1994 to 2000. Surveys were conducted to estimate costs to parents, to schools and to CLSCs in 1997-1998. RESULTS: With the implementation of the CBP, the vaccination coverage fell to 73%, compared with over 90% in the SBPs. Coverage increased to 90% when the CBP was abandoned. Costs to the CLSC were not much lower in the CBP. Societal costs were $63 per student vaccinated in the CBP, and < or = $40 in the SBPs. CONCLUSION: Results demonstrate the advantage of a SBP over a CBP for the immunization of schoolchildren.