Mental health-related healthcare service utilisation and psychotropic drug dispensation trends in British Columbia during COVID-19 pandemic: a population-based study.

Background: The impact of the COVID-19 pandemic on the population's mental health is vital for informing public health policy and decision-making. However, information on mental health-related healthcare service utilisation trends beyond the first year of the pandemic is limited. Aims: We examined mental health-related healthcare service utilisation patterns and psychotropic drug dispensations in British Columbia, Canada, during the COVID-19 pandemic compared with the prepandemic period. Methods: We conducted a retrospective population-based secondary analysis using administrative health data to capture outpatient physician visits, emergency department visits, hospital admissions and psychotropic drug dispensations. We examined time trends of mental health-related healthcare service utilisation and psychotropic drug dispensations between January to December 2019 (prepandemic period) and January 2020 to December 2021 (pandemic period). In addition, we calculated age-standardised rates and rate ratios to compare mental health-related healthcare service utilisation before and during the first two years of the COVID-19 pandemic, stratified by year, sex, age and condition. Results: By late 2020, except for emergency department visits, utilisation of healthcare services recovered to prepandemic levels. Between 2019 and 2021, the monthly average rate for overall mental health-related outpatient physician visits, emergency department visits and psychotropic drug dispensations increased significantly by 24%, 5% and 8%, respectively. Notable and statistically significant increases were observed among 10-14 year-olds (44% in outpatient physician visits, 30% in emergency department visits, 55% in hospital admissions and 35% in psychotropic drug dispensations) and 15-19 year-olds (45% in outpatient physician visits, 14% in emergency department visits, 18% in hospital admissions and 34% in psychotropic drug dispensations). Additionally, these increases were more prominent among females than males, with some variation for specific mental health-related conditions. Conclusions: The increase in mental health-related healthcare service utilisation and psychotropic drug dispensations during the pandemic likely reflects significant societal consequences of both the pandemic and pandemic management measures. Recovery efforts in British Columbia should consider these findings, especially among the most affected subpopulations, such as adolescents.

British Columbia's COVID-19 surveys on population experiences, action, and knowledge (SPEAK): methods and key findings from two large cross-sectional online surveys.

OBJECTIVES: To describe the methodology and key findings of British Columbia's (BC) COVID-19 SPEAK surveys, developed to understand the experiences, knowledge, and impact of the COVID-19 pandemic on British Columbians. METHODS: Two province-wide, cross-sectional, web-based population health surveys were conducted one year apart (May 2020 and April/May 2021). Questions were drawn from validated sources grounded within the social determinants of health to assess COVID-19 testing and prevention; mental and physical health; risk and protective factors; and healthcare, social, and economic impacts during the pandemic. Quota-based non-probability sampling by geography was applied to recruit a representative sample aged 18 years and older. Recruitment included strategic outreach and longitudinal follow-up of a subgroup of respondents from round one to round two. Post-collection weighting using Census data by age, sex, education, ethnicity, and geography was conducted. RESULTS: Participants included 394,382 and 188,561 British Columbians for the first and second surveys, respectively, including a longitudinal subgroup of 141,728. Key findings showed that societal impacts, both early in the pandemic and one year later, were inequitably distributed. Families with children, young adults, and people from lower socioeconomic backgrounds have been most impacted. Significant negative impacts on mental health and stress and a deterioration in protective resiliency factors were found. CONCLUSION: These population health surveys consisting of two large cross-sectional samples provided valuable insight into the impacts and experiences of British Columbians early in the pandemic and one year later. Timely, actionable data informed several high-priority public health areas during BC's response to the COVID-19 pandemic.

RéSUMé: OBJECTIFS: Décrire la méthode et les principaux constats des enquêtes SPEAK de la Colombie-Britannique sur la COVID-19, élaborées pour comprendre l'expérience des Britanno-Colombiens durant la pandémie, ainsi que leurs connaissances de la pandémie et les effets qu'elle a eus sur eux. MéTHODE: Deux enquêtes en ligne transversales sur la santé de la population ont été menées dans toute la province à un an d'intervalle (en mai 2020 et en avril-mai 2021). Les questions, qui provenaient de sources validées ancrées dans les déterminants sociaux de la santé, ont servi à évaluer le dépistage et la prévention de la COVID-19; la santé mentale et physique; les facteurs de risque et de protection; et les effets sociaux, économiques et sur les soins de santé ressentis durant la pandémie. Un échantillonnage contingentaire non probabiliste par lieu géographique a été appliqué pour recruter un échantillon représentatif de personnes de 18 ans et plus. Le recrutement a inclus une prise de contact stratégique et un suivi longitudinal auprès d'un sous-groupe de répondants entre les cycles un et deux. Après la collecte, les données ont été pondérées selon l'âge, le sexe, le niveau d'instruction, l'ethnicité et le lieu géographique à l'aide des données du Recensement. RéSULTATS: Les participants étaient 394 382 Britanno-Colombiens au cours du premier cycle de l'enquête et 188 561 au deuxième cycle, dont un sous-groupe longitudinal de 141 728 personnes. Selon les principaux constats, la répartition des effets sociétaux, tant au début de la pandémie qu'un an plus tard, a été inéquitable. Les familles avec enfants, les jeunes adultes et les personnes de statut socioéconomique plus faible ont été les plus touchés. D'importants effets nuisibles sur la santé mentale et le stress ont été constatés, ainsi qu'une détérioration des facteurs de résilience protecteurs. CONCLUSION: Ces enquêtes sur la santé de la population comprenant deux grands échantillons transversaux ont jeté un éclairage précieux sur les effets subis et les expériences vécues par les Britanno-Colombiens au début de la pandémie et un an plus tard. Ces données opportunes et exploitables ont éclairé plusieurs domaines hautement prioritaires de la santé publique durant la riposte de la Colombie-Britannique à la pandémie de COVID-19.

A qualitative model of the HIV care continuum in Vancouver, Canada.

A team of health care stakeholders and researchers collaboratively developed a qualitative model and graphic representation of the continuum of HIV care in Vancouver to inform delivery of antiretroviral therapy and other HIV health services. The model describes the patient journey through the HIV care continuum, including states of infection, health services, and care decisions. We used a Unified Modelling Language (UML) activity diagram to capture patient and provider activities and to guide the construction of a UML state machine diagram. The state machine diagram captures model agent states in a formalism that facilitates the development of system dynamics or agent-based models. These quantitative models can be applied to optimizing the allocation of resources, and to evaluate potential strategies for improved patient care and system performance. The novel approach of combining UML diagrams we present provides a general method for modelling capacity ---management strategies within complex health systems.

Routine HIV testing in acute care hospitals: Changing practice to curb a local HIV epidemic in Vancouver, BC.

Early treatment of HIV infection increases life expectancy and reduces infectivity; however, delayed HIV diagnosis remains common. Implementation and sustainability of hospital-based routine HIV testing in Vancouver, British Columbia, was evaluated to address a local HIV epidemic by facilitating earlier diagnosis and treatment. Public health issued a recommendation in 2011 to offer HIV testing to all patients presenting to three Vancouver hospitals as part of routine care, including all patients admitted to medical/surgical units with expansion to emergency departments (ED). We evaluated acceptability, feasibility, and effectiveness from 2011 to 2014 and continued monitoring through 2016 for sustainability. Between October 2011-December 2016, 114,803 HIV tests were administered at the three hospitals; an 11-fold increase following implementation of routine testing. The rate of testing was sustained and remained high through 2018. Of those tested, 151 patients were diagnosed with HIV for a testing yield of 0.13%. Review of 12,996 charts demonstrated 4935/5876 (96·9%) of admitted patients agreed to have an HIV test when offered. People diagnosed in hospital were significantly more likely to be diagnosed with acute stage (aOR 1·96, 95% CI 1·19, 3·23) infection, particularly those diagnosed in the ED. This study provides practice-based evidence of the feasibility, acceptability, and effectiveness of implementing a recommendation for routine HIV testing among inpatient and emergency department admissions, as well as the ability to normalize and sustain this change. Routine hospital-based HIV testing can increase diagnoses of acute HIV infection and facilitate earlier initiation of antiretroviral treatment.

Reconciling randomized trial evidence on proximal versus distal outcomes, with application to trials of influenza vaccination for healthcare workers.

When synthesizing the body of evidence concerning a clinical intervention, impacts on both proximal and distal outcome variables may be relevant. Assessments will be more defensible if results concerning a proximal outcome align with those concerning a corresponding distal outcome. We present a method to assess the coherence of empirical clinical trial results with biologic and mathematical first principles in situations where the intervention can only plausibly impact the distal outcome indirectly via the proximal outcome. The method comprises a probabilistic sensitivity analysis, where plausible ranges for key parameters are specified, resulting in a constellation of plausible pairs of estimated intervention effects, for the proximal and distal outcomes, respectively. Both outcome misclassification and sampling variability are reflected in the method. We apply our methodology in the context of cluster randomized trials to evaluate the impacts of vaccinating healthcare workers on the health of elderly patients, where the proximal outcome is suspected influenza and the distal outcome is death. However, there is scope to apply the method for other interventions in other disease areas.

Safety of a Modified Community Trailer to Manage Patients with Presumed Fentanyl Overdose.

Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.

Stability of hepatitis B viral load during pregnancy and implications for antepartum prophylaxis: A prospective cohort study.

BACKGROUND: We examined changes in hepatitis B virus (HBV) viral loads (VLs) in pregnancy, their association with hepatitis B e antigen (HBeAg), and the associated infant outcomes. METHODS: We prospectively followed 132 mothers positive for hepatitis B surface antigen (HBsAg) and their 135 infants from 2011 to 2015 in Vancouver, British Columbia. Outcome measures included association between maternal HBeAg and high (>200,000 IU/mL) or low (≤200,000 IU/mL) HBV VL, changes in HBV VL through pregnancy, infant HBsAg status, and infant completion of the HBV vaccination series. RESULTS: f the 91 participants with an available HBV VL, 13 (14.3%) had an HBV VL of more than 200,000 IU/mL. Of 59 participants with paired HBeAg and HBV VL in pregnancy, 6 had an HBV VL of more than 200,000 IU/mL; of interest, 2 of the 6 (33.3%) were HBeAg-negative. Thirty-eight participants had HBV VL results at both mid-trimester and delivery. For these 38 participants, Wilcoxon signed-ranks test for paired data found that an HBV VL remained stable (p = .58). We observed no perinatal transmissions. However, 20.7% of infants did not have a documented complete HBV vaccination series, 20.0% did not have post-vaccination HBsAg testing completed, and 18% did not have anti-HBs titres measured by age 12 months. CONCLUSIONS: Our study demonstrates that HBeAg and HBV VL are not reliably predictive of each other. This supports the improved predictive value of VL measurement in pregnancy to risk stratify pregnant patients to offer antiviral treatment when indicated and further minimize the risk of perinatal transmission.

Outbreak of Vibrio parahaemolyticus Associated with Consumption of Raw Oysters in Canada, 2015.

There has been a steady increase in illness incidence of Vibrio parahaemolyticus (Vp). The majority of illnesses are associated with consumption of raw oysters. In the summer of 2015, Canada experienced the largest outbreak associated with the consumption of raw oysters harvested from British Columbia (BC) coastal waters. Case investigation of laboratory-confirmed cases was conducted to collect information on exposures and to assist traceback. Investigations at processors and oyster sampling were conducted. Eighty-two laboratory-confirmed cases of Vp infection were reported between January 1 and October 26, 2015. The majority of the cases were reported in BC, associated with consumption of raw BC oysters in restaurants. Sea surface temperatures were above the historical levels in 2015. This outbreak identified the need to improve surveillance and response to increases in human cases of Vp. This is of particular importance due to the potential for increasing water temperatures and the likelihood of additional outbreaks of Vibrio.

Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling study.

BACKGROUND: Illicit use of high-potency synthetic opioids has become a global issue over the past decade. This misuse is particularly pronounced in British Columbia, Canada, where a rapid increase in availability of fentanyl and other synthetic opioids in the local illicit drug supply during 2016 led to a substantial increase in overdoses and deaths. In response, distribution of take-home naloxone (THN) overdose prevention kits was scaled up (6·4-fold increase) throughout the province. The aim of this study was to estimate the impact of the THN programme in terms of the number of deaths averted over the study period. METHODS: We estimated the impact of THN kits on the ongoing epidemic among people who use illicit opioids in British Columbia and explored counterfactual scenarios for the provincial response. A Markov chain model was constructed explicitly including opioid-related deaths, fentanyl-related deaths, ambulance-attended overdoses, and uses of THN kits. The model was calibrated in a Bayesian framework incorporating population data between Jan 1, 2012, and Oct 31, 2016. FINDINGS: 22 499 ambulance-attended overdoses and 2121 illicit drug-related deaths (677 [32%] deaths related to fentanyl) were recorded in the study period, mostly since January, 2016. In the same period, 19 074 THN kits were distributed. We estimate that 298 deaths (95% credible interval [CrI] 91-474) were averted by the THN programme. Of these deaths, 226 (95% CrI 125-340) were averted in 2016, following a rapid scale-up in distribution of kits. We infer a rapid increase in fentanyl adulterant at the beginning of 2016, with an estimated 2·3 times (95% CrI 2·0-2·9) increase from 2015 to 2016. Counterfactual modelling indicated that an earlier scale-up of the programme would have averted an additional 118 deaths (95% CrI 64-207). Our model also indicated that the increase in deaths could parsimoniously be explained through a change in the fentanyl-related overdose rate alone. INTERPRETATION: The THN programme substantially reduced the number of overdose deaths during a period of rapid increase in the number of illicit drug overdoses due to fentanyl in British Columbia. However, earlier adoption and distribution of the THN intervention might have had an even greater impact on overdose deaths. Our findings show the value of a fast and effective response at the start of a synthetic opioid epidemic. We also believe that multiple interventions are needed to achieve an optimal impact. FUNDING: Canadian Institutes of Health Research Partnerships for Health Systems Improvement programme (grant 318068) and Natural Science and Engineering Research Council of Canada (grant 04611).

The Cost-Effectiveness of Human Immunodeficiency Virus Testing and Treatment Engagement Initiatives in British Columbia, Canada: 2011-2013.

Background: Recognition of the secondary preventive benefits of antiretroviral therapy (ART) has mobilized global efforts to "seek, test, treat, and retain" people living with human immunodeficiency virus [HIV]/AIDS (PLHIV) in HIV care. We aimed to determine the cost-effectiveness of a set of HIV testing and treatment engagement interventions initiated in British Columbia, Canada, in 2011-2013. Methods: Using a previously validated dynamic HIV transmission model, linked individual-level health administrative data for PLHIV, and aggregate-level HIV testing data, we estimated the cost-effectiveness of primary care testing (hospital, emergency department [ED], outpatient), ART initiation, and ART retention initiatives vs a counterfactual scenario that approximated the status quo. HIV incidence, mortality, costs (in 2015$CDN), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios were estimated. Analyses were executed over 5- to 25-year time horizons from a government-payer perspective. Results: ED testing was the best value at $30216 per QALY gained and had the greatest impact on incidence and mortality among PLHIV, while ART initiation provided the greatest QALY gains. The ART retention initiative was not cost-effective. Delivered in combination at the observed scale and sustained throughout the study period, we estimated a 12.8% reduction in cumulative HIV incidence and a 4.7% reduction in deaths among PLHIV at $55258 per QALY gained. Results were most sensitive to uncertainty in the number of undiagnosed PLHIV. Conclusions: HIV testing and ART initiation interventions were cost-effective, while the ART retention intervention was not. Developing strategies to reengage PLHIV lost to care is a priority moving forward.

Prevalence of HIV infection and acceptability of point-of-care testing in a Canadian inner-city emergency department.

OBJECTIVES: The objective of this study was to estimate the seroprevalence of HIV infection and the acceptability of point-of-care HIV testing in an innercity Canadian emergency department. METHODS: We conducted a prospective cohort study in an urban tertiary care emergency department between August 2009 and January 2011. Randomly selected patients were enrolled using probabilistic sampling based on patient volumes. Inclusion criteria were age 19-75 years and ability to provide informed consent. Patients who were intoxicated or in extremis were excluded. After informed consent and brief pre-test counselling, participants' HIV status was obtained using the INSTI HIV-1/HIV-2 Antibody Test. Participants completed a questionnaire on HIV risk behaviours and satisfaction with emergency department HIV testing. Participants with a positive result or those having other blood tests received confirmatory Western blot testing. HIV-positive participants were offered immediate referral to an HIV specialty clinic. RESULTS: A total of 2,077 patients were approached, and 1,402 (67.5%) agreed to participate. Participants' mean age was 43.3 years, and 58.4% of participants were male. The HIV antibody seroprevalence based on the point-of-care test was 65/1,402 (4.6%; 95% confidence interval: 3.5%-5.8%). No new diagnoses of HIV were identified in our cohort. Patient satisfaction with point-of-care HIV testing was high (mean satisfaction score 9.6/10). CONCLUSION: On the basis of a rapid, point-of-care HIV antibody test, the seroprevalence rate of HIV in an inner city emergency department was 4.6%. Point-of-care testing in the emergency department is acceptable, and patients' satisfaction with the testing procedure was high.

Near real-time monitoring of HIV transmission hotspots from routine HIV genotyping: an implementation case study.

BACKGROUND: HIV evolves rapidly and therefore infections with similar genetic sequences are likely linked by recent transmission events. Clusters of related infections can represent subpopulations with high rates of transmission. We describe the implementation of an automated near real-time system to monitor and characterise HIV transmission hotspots in British Columbia, Canada. METHODS: In this implementation case study, we applied a monitoring system to the British Columbia drug treatment database, which holds more than 32 000 anonymised HIV genotypes for nearly 9000 residents of British Columbia living with HIV. On average, five to six new HIV genotypes are deposited in the database every day, which triggers an automated reanalysis of the entire database. We extracted clusters of five or more individuals with short phylogenetic distances between their respective HIV sequences. The system generated monthly reports of the growth and characteristics of clusters that were distributed to public health officers. FINDINGS: In June, 2014, the monitoring system detected the expansion of a cluster by 11 new cases during 3 months, including eight cases with transmitted drug resistance. This cluster generally comprised young men who have sex with men. The subsequent report precipitated an enhanced public health follow-up to ensure linkage to care and treatment initiation in the affected subpopulation. Of the nine cases associated with this follow-up, all had already been linked to care and five cases had started treatment. Subsequent to the follow-up, three additional cases started treatment and most cases achieved suppressed viral loads. During the next 12 months, we detected 12 new cases in this cluster with reduction in the onward transmission of drug resistance. INTERPRETATION: Our findings show the first application of an automated phylogenetic system monitoring a clinical database to detect a recent HIV outbreak and support the ensuing public health response. By making secondary use of routinely collected HIV genotypes, this approach is cost-effective, attains near real-time monitoring of new cases, and can be implemented in all settings in which HIV genotyping is the standard of care. FUNDING: BC Centre for Excellence in HIV/AIDS, the Canadian Institutes for Health Research, the Genome Canada-CIHR Partnership in Genomics and Personalized Health, and the US National Institute on Drug Abuse.

HIV testing behaviour and use of risk reduction strategies by HIV risk category among MSM in Vancouver.

We carried out an analysis of a serobehavioural study of men who have sex with men >19 years of age in Vancouver, Canada to examine HIV testing behaviour and use of risk reduction strategies by HIV risk category, as defined by routinely gathered clinical data. We restricted our analysis to those who self-identified as HIV-negative, completed a questionnaire, and provided a dried blood spot sample. Of 842 participants, 365 (43.3%) were categorised as lower-risk, 245 (29.1%) as medium-risk and 232 (27.6%) as higher-risk. The prevalence of undiagnosed HIV infection was low (lower 0.8%, medium 3.3%, higher 3.9%; p = 0.032). Participants differed by risk category in terms of having had an HIV test in the previous year (lower 46.5%, medium 54.6%, higher 67.0%; p < 0.001) and in their use of serosorting (lower 23.3%, medium 48.3%, higher 43.1%; p < 0.001) and only having sex with HIV-positive men if those men had low viral loads or were taking HIV medication (lower 5.1%, medium 4.8%, higher 10.9%; p = 0.021) as risk reduction strategies. These findings speak to the need to consider segmented health promotion services for men who have sex with men with differing risk profiles. Risk stratification could be used to determine who might benefit from tailored multiple health promotion interventions, including HIV pre-exposure prophylaxis.

Avian Influenza A(H7N9) Virus Infection in 2 Travelers Returning from China to Canada, January 2015.

In January 2015, British Columbia, Canada, reported avian influenza A(H7N9) virus infection in 2 travelers returning from China who sought outpatient care for typical influenza-like illness. There was no further spread, but serosurvey findings showed broad population susceptibility to H7N9 virus. Travel history and timely notification are critical to emerging pathogen detection and response.

Whole-Genome Sequencing of Measles Virus Genotypes H1 and D8 During Outbreaks of Infection Following the 2010 Olympic Winter Games Reveals Viral Transmission Routes.

We used whole-genome sequencing to investigate a dual-genotype outbreak of measles occurring after the XXI Olympic Winter Games in Vancouver, Canada. By sequencing 27 complete genomes from H1 and D8 genotype measles viruses isolated from outbreak cases, we estimated the virus mutation rate, determined that person-to-person transmission is typically associated with 0 mutations between isolates, and established that a single introduction of H1 virus led to the expansion of the outbreak beyond Vancouver. This is the largest measles genomics project to date, revealing novel aspects of measles virus genetics and providing new insights into transmission of this reemerging viral pathogen.

Seroprevalence of hepatitis C and correlates of seropositivity among men who have sex with men in Vancouver, Canada: a cross-sectional survey.

OBJECTIVES: We sought to determine the prevalence of hepatitis C virus (HCV) infection among men who have sex with men (MSM) in Vancouver, Canada, and associations of risk behaviours with HCV serostatus. METHODS: We used data from the ManCount Study, a cross-sectional survey of MSM selected through a venue-based, time-location sampling method. Bivariate analyses and multivariate logistic regression modelling were used to determine correlates of HCV seropositivity. Bivariate analyses of participants who reported no history of injection drug use (IDU) were used to explore sexual behaviours associated with HCV seropositivity. RESULTS: HCV seroprevalence was 4.9% (56/1132). Among HCV-seropositive participants who responded to the question, 22.4% (11/49) were unaware of their HCV-seropositive status, 84.9% (45/53) reported a history of IDU and 60.7% (34/56) were HIV positive by dried blood spot. Multivariate modelling found previous IDU (adjusted OR (AOR): 26.30, 95% CI 11.15 to 62.03), receiving goods, drugs or money for sex (AOR 4.98, 95% CI 2.43 to 10.20) and current smoking (AOR 3.46, 95% CI 1.47 to 8.16) were associated with HCV seropositivity. Among MSM who reported no history of IDU, HCV seropositivity was associated with bleeding after receptive anal sex (p=0.001) and a previous diagnosis of gonorrhoea (p=0.007). CONCLUSIONS: HCV seroprevalence among a sample of MSM is higher than the general population and associated with a history of IDU. Among those who did not report IDU, we found evidence that suggests sexual exposure could be the route of transmission.

Optimizing an HIV testing program using a system dynamics model of the continuum of care.

Realizing the full individual and population-wide benefits of antiretroviral therapy for human immunodeficiency virus (HIV) infection requires an efficient mechanism of HIV-related health service delivery. We developed a system dynamics model of the continuum of HIV care in Vancouver, Canada, which reflects key activities and decisions in the delivery of antiretroviral therapy, including HIV testing, linkage to care, and long-term retention in care and treatment. To measure the influence of operational interventions on population health outcomes, we incorporated an HIV transmission component into the model. We determined optimal resource allocations among targeted and routine testing programs to minimize new HIV infections over five years in Vancouver. Simulation scenarios assumed various constraints informed by the local health policy. The project was conducted in close collaboration with the local health care providers, Vancouver Coastal Health Authority and Providence Health Care.

Systematic community- and hospital-based surveillance for enterovirus-D68 in three Canadian provinces, August to December 2014.

Respiratory specimens collected from outpatients with influenza-like illness in three Canadian provinces (British Columbia (BC), Alberta and Quebec) participating in a community-based sentinel surveillance network were prospectively screened for enterovirus-D68 (EV-D68) from 1 August to 31 December 2014 and compared to specimens collected from 1 October 2013 to 31 July 2014. Eighteen (1%) of 1,894 specimens were EV-D68-positive: 1/348 (0.3%) collected from October to December 2013 and 11/460 (2.4%) from October to December 2014, an eight-fold increase in detection rates (p=0.01), consistent with epidemic circulation in autumn 2014. The remaining EV-D68 detections were in September 2014 (6/37). Enhanced passive surveillance was also conducted on all inpatient and outpatient EV-D68 cases (n=211) detected at the BC provincial reference laboratory from 28 August to 31 December 2014. Incidence of hospitalisations was 3/100,000 overall and 21, 17, 4 and 1/100,000 among those<5, 5-9, 10-19 and ≥20-years-old with male-to-female ratios>1 among paediatric but not adult cases. Three cases in BC with comorbidity or co-infection died and five exhibited neurological features persisting >9 months. Active surveillance in outpatient and inpatient settings is needed from more areas and additional seasons to better understand EV-D68 epidemiology and potential at-risk groups for severe or unusual manifestations.