Examining the effects of voluntary avoidance behaviour and policy-mediated behaviour change on the dynamics of SARS-CoV-2: A mathematical model.

Background: Throughout the SARS-CoV-2 pandemic, policymakers have had to navigate between recommending voluntary behaviour change and policy-driven behaviour change to mitigate the impact of the virus. While individuals will voluntarily engage in self-protective behaviour when there is an increasing infectious disease risk, the extent to which this occurs and its impact on an epidemic is not known. Methods: This paper describes a deterministic disease transmission model exploring the impact of individual avoidance behaviour and policy-mediated avoidance behaviour on epidemic outcomes during the second wave of SARS-CoV-2 infections in Ontario, Canada (September 1, 2020 to February 28, 2021). The model incorporates an information feedback function based on empirically derived behaviour data describing the degree to which avoidance behaviour changed in response to the number of new daily cases COVID-19. Results: Voluntary avoidance behaviour alone was estimated to reduce the final attack rate by 23.1%, the total number of hospitalizations by 26.2%, and cumulative deaths by 27.5% over 6 months compared to a counterfactual scenario in which there were no interventions or avoidance behaviour. A provincial shutdown order issued on December 26, 2020 was estimated to reduce the final attack rate by 66.7%, the total number of hospitalizations by 66.8%, and the total number of deaths by 67.2% compared to the counterfactual scenario. Conclusion: Given the dynamics of SARS-CoV-2 in a pre-vaccine era, individual avoidance behaviour in the absence of government action would have resulted in a moderate reduction in disease however, it would not have been sufficient to entirely mitigate transmission and the associated risk to the population in Ontario. Government action during the second wave of the COVID-19 pandemic in Ontario reduced infections, protected hospital capacity, and saved lives.

An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel.

An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.

Pandemic fatigue or enduring precautionary behaviours? Canadians' long-term response to COVID-19 public health measures.

The long-term dynamics of COVID-19 disease incidence and public health measures may impact individuals' precautionary behaviours as well as support for measures. The objectives of this study were to assess longitudinal changes in precautionary behaviours and support for public health measures. Survey data were collected online from 1030 Canadians in each of 5 cycles in 2020: June 15-July 13; July 22-Aug 8; Sept 7-15; Oct 14-21; and Nov 12-17. Precautionary behaviour increased over the study period in the context of increasing disease incidence. When controlling for the stringency of public health measures and disease incidence, mixed effects logistic regression models showed these behaviours did not significantly change over time. Odds ratios for avoiding contact with family and friends ranged from 0.84 (95% CI 0.59-1.20) in September to 1.25 (95% CI 0.66-2.37) in November compared with July 2020. Odds ratios for attending an indoor gathering ranged from 0.86 (95% CI 0.62-1.20) in August to 1.71 (95% CI 0.95-3.09) in October compared with July 2020. Support for non-essential business closures increased over time with 2.33 (95% CI 1.14-4.75) times higher odds of support in November compared to July 2020. Support for school closures declined over time with lower odds of support in September (OR 0.66 [95% CI 0.45-0.96]), October (OR 0.48 [95% CI 0.26-0.87]), and November (OR 0.39 [95% CI 0.19-0.81]) compared with July 2020. In summary, respondents' behaviour mirrored government guidance between July and November 2020 and supported individual precautionary behaviour and limitations on non-essential businesses over school closures.

Spatio-Temporal Variation in the Prevalence of Major Mastitis Pathogens Isolated From Bovine Milk Samples Between 2008 and 2017 in Ontario, Canada.

An understanding of the spatio-temporal distribution of several groups of mastitis pathogens can help to inform programs for the successful control and management of mastitis. However, in the absence of an active surveillance program such information is not readily available. In this retrospective study we analyzed passive surveillance data from a diagnostic laboratory with an aim to describe the spatio-temporal trend of major mastitis pathogens between 2008 and 2017 in Ontario dairy cattle. Data for all milk culture samples submitted to the Animal Health Laboratory (AHL) at the University of Guelph between 2008 and 2017 was accessed. Descriptive analyses were conducted to identify the major pathogens and Chi-square goodness-of-fit tests were used to compare between multiple proportions. Likewise, univariable logistic regression analysis was performed to determine if there was a change in the probability of isolating the major mastitis pathogens depending on geography or time. Seasonality was assessed by calculating the seasonal relative risk (RR). Of a total of 85,979 milk samples examined, more than half of the samples (61.07%) showed no growth and the proportion of samples that showed no growth almost halved during the study period. Of the samples (36.21%, n = 31,133) that showed any growth, the major bacterial pathogens were Staphylococcus aureus (15.60%), Non-aureus Staphylococci (NAS) (5.04%), Corynebacterium spp. (2.96%), and Escherichia coli (2.00%). Of the NAS, the major species reported were Staphylococcus chromogenes (69.02%), Staphylococcus simulans (14.45%), Staphylococcus epidermidis (12.99%), and Staphylococcus hyicus (2.13%). A temporal change in the prevalence of contagious pathogens like S. aureus and Corynebacterium spp. was observed with an increasing odds of 1.06 and 1.62, respectively. Likewise, except for Trueperella pyogenes, the prevalence of all the major environmental mastitis pathogens increased during the study period. The isolation of most of the pathogens peaked in summer, except for S. aureus, T. pyogenes, and Streptococcus dysgalactiae which peaked in spring months. Interestingly, a regional pattern of isolation of some bacterial pathogens within Ontario was also observed. This study showed a marked spatio-temporal change in the prevalence of major mastitis pathogens and suggests that a regional and seasonal approach to mastitis control could be of value.

Quantifying contact patterns in response to COVID-19 public health measures in Canada.

BACKGROUND: A variety of public health measures have been implemented during the COVID-19 pandemic in Canada to reduce contact between individuals. The objective of this study was to provide empirical contact pattern data to evaluate the impact of public health measures, the degree to which social contacts rebounded to normal levels, as well as direct public health efforts toward age- and location-specific settings. METHODS: Four population-based cross-sectional surveys were administered to members of a paid panel representative of Canadian adults by age, gender, official language, and region of residence during May (Survey 1), July (Survey 2), September (Survey 3), and December (Survey 4) 2020. A total of 4981 (Survey 1), 2493 (Survey 2), 2495 (Survey 3), and 2491 (Survey 4) respondents provided information about the age and setting for each direct contact made in a 24-h period. Contact matrices were constructed and contacts for those under the age of 18 years imputed. The next generation matrix approach was used to estimate the reproduction number (Rt) for each survey. Respondents with children under 18 years estimated the number of contacts their children made in school and extracurricular settings. RESULTS: Estimated Rt values were 0.49 (95% CI: 0.29-0.69) for May, 0.48 (95% CI: 0.29-0.68) for July, 1.06 (95% CI: 0.63-1.52) for September, and 0.81 (0.47-1.17) for December. The highest proportion of reported contacts occurred within the home (51.3% in May), in 'other' locations (49.2% in July) and at work (66.3 and 65.4% in September and December). Respondents with children reported an average of 22.7 (95% CI: 21.1-24.3) (September) and 19.0 (95% CI 17.7-20.4) (December) contacts at school per day per child in attendance. CONCLUSION: The skewed distribution of reported contacts toward workplace settings in September and December combined with the number of reported school-related contacts suggest that these settings represent important opportunities for transmission emphasizing the need to support and ensure infection control procedures in both workplaces and schools.

COVID-19 Case Age Distribution: Correction for Differential Testing by Age.

BACKGROUND: Despite expected initial universal susceptibility to a novel pandemic pathogen like SARS-CoV-2, the pandemic has been characterized by higher observed incidence in older persons and lower incidence in children and adolescents. OBJECTIVE: To determine whether differential testing by age group explains observed variation in incidence. DESIGN: Population-based cohort study. SETTING: Ontario, Canada. PARTICIPANTS: Persons diagnosed with SARS-CoV-2 and those tested for SARS-CoV-2. MEASUREMENTS: Test volumes from the Ontario Laboratories Information System, number of laboratory-confirmed SARS-CoV-2 cases from the Integrated Public Health Information System, and population figures from Statistics Canada. Demographic and temporal patterns in incidence, testing rates, and test positivity were explored using negative binomial regression models and standardization. Sources of variation in standardized ratios were identified and test-adjusted standardized infection ratios (SIRs) were estimated by metaregression. RESULTS: Observed disease incidence and testing rates were highest in the oldest age group and markedly lower in those younger than 20 years; no differences in incidence were seen by sex. After adjustment for testing frequency, SIRs were lowest in children and in adults aged 70 years or older and markedly higher in adolescents and in males aged 20 to 49 years compared with the overall population. Test-adjusted SIRs were highly correlated with standardized positivity ratios (Pearson correlation coefficient, 0.87 [95% CI, 0.68 to 0.95]; P < 0.001) and provided a case identification fraction similar to that estimated with serologic testing (26.7% vs. 17.2%). LIMITATIONS: The novel methodology requires external validation. Case and testing data were not linkable at the individual level. CONCLUSION: Adjustment for testing frequency provides a different picture of SARS-CoV-2 infection risk by age, suggesting that younger males are an underrecognized group at high risk for SARS-CoV-2 infection. PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research.

A sub-national real-time epidemiological and vaccination database for the COVID-19 pandemic in Canada.

The COVID-19 pandemic has demonstrated the need for real-time, open-access epidemiological information to inform public health decision-making and outbreak control efforts. In Canada, authority for healthcare delivery primarily lies at the provincial and territorial level; however, at the outset of the pandemic no definitive pan-Canadian COVID-19 datasets were available. The COVID-19 Canada Open Data Working Group was created to fill this crucial data gap. As a team of volunteer contributors, we collect daily COVID-19 data from a variety of governmental and non-governmental sources and curate a line-list of cases and mortality for all provinces and territories of Canada, including information on location, age, sex, travel history, and exposure, where available. We also curate time series of COVID-19 recoveries, testing, and vaccine doses administered and distributed. Data are recorded systematically at a fine sub-national scale, which can be used to support robust understanding of COVID-19 hotspots. We continue to maintain this dataset, and an accompanying online dashboard, to provide a reliable pan-Canadian COVID-19 resource to researchers, journalists, and the general public.

Diagnostic testing patterns for Streptococcus equi subsp. equi in Ontario horses during the years 2008 to 2018.

This retrospective study describes testing patterns and the incidence of Streptococcus equi subsp. equi in Ontario to assess the utility of laboratory data for surveillance purposes. Laboratory records for equine infectious disease test submissions were extracted from the Animal Health Laboratory (AHL) at the University of Guelph for the years 2008 to 2018. Yearly and seasonal trends in S. equi testing and the proportion of tests that returned positive results were assessed. The number of samples submitted for S. equi testing decreased over the 11-year period (odds ratio = 0.96, 95% confidence interval: 0.92 to 0.999; P = 0.04). A generalized linear model identified a significant seasonal effect for animals recognized as clinically ill, with the highest test positivity noted in the winter. Although this study identified important trends in the incidence of S. equi in Ontario, the variability in information accompanying test submissions made the data challenging to interpret, highlighting the need for more complete diagnostic submission data for S. equi.

Tendance des tests diagnostiques pour Streptococcus equi subsp. equi chez les chevaux de l'Ontario au cours des années 2008 à 2018. Cette étude rétrospective décrit les tendances des test et l'incidence de Streptococcus equi subsp. equi en Ontario pour évaluer l'utilité des données de laboratoire à des fins de surveillance. Les dossiers de laboratoire pour les soumissions de tests de maladies infectieuses équines ont été extraits des données du Animal Health Laboratory (AHL), University of Guelph pour les années 2008 à 2018. Les tendances annuelles et saisonnières des tests de S. equi et la proportion de tests qui ont donné des résultats positifs ont été évaluées. Le nombre d'échantillons soumis pour la recherche de S. equi a diminué au cours de la période de 11 ans (rapport de cotes = 0,96, intervalle de confiance à 95% : 0,92 à 0,999; P = 0,04). Un modèle linéaire généralisé a identifié un effet saisonnier significatif pour les animaux reconnus comme cliniquement malades, la positivité de test la plus élevée étant notée en hiver. Bien que cette étude ait identifié des tendances importantes dans l'incidence de S. equi en Ontario, la variabilité des informations accompagnant les soumissions a rendu les données difficiles à interpréter, soulignant le besoin de données plus complètes lors de soumission pour le diagnostic S. equi.(Traduit par Dr Serge Messier).

Socio-demographic disparities in knowledge, practices, and ability to comply with COVID-19 public health measures in Canada.

OBJECTIVES: The effectiveness of public health interventions for mitigation of the COVID-19 pandemic depends on individual attitudes, compliance, and the level of support available to allow for compliance with these measures. The aim of this study was to describe attitudes and behaviours towards the Canadian COVID-19 public health response, and identify risk-modifying behaviours based on socio-demographic characteristics. METHODS: A cross-sectional online survey was administered in May 2020 to members of a paid panel representative of the Canadian population by age, gender, official language, and region of residence. A total of 4981 respondents provided responses for indicators of self-reported risk perceptions, attitudes, and behaviours towards COVID-19 public health measures. RESULTS: More than 90% of respondents reported confidence in the ability to comply with a variety of public health measures. However, only 51% reported preparedness for illness in terms of expectation to work if sick or access to paid sick days. Risk perceptions, attitudes, and behaviours varied by demographic variables. Men, younger age groups, and those in the paid workforce were less likely to consider public health measures to be effective, and had less confidence in their ability to comply. Approximately 80% of respondents reported that parents provided childcare and 52% reported that parents in the workforce provided childcare while schools were closed. CONCLUSION: Policies to help address issues of public adherence include targeted messaging for men and younger age groups, social supports for those who need to self-isolate, changes in workplace policies to discourage presenteeism, and provincially co-ordinated masking and safe school policies.

RéSUMé: OBJECTIFS: L'efficacité des mesures d'intervention en santé publique pour atténuer la pandémie de COVID-19 dépend des attitudes individuelles, de la conformité, ainsi que du niveau d'aide disponible pour que les mesures soient respectées. Notre étude visait à décrire les attitudes et les comportements à l'égard de la riposte de la santé publique canadienne à la COVID-19 et à cerner les comportements modificateurs du risque d'après les caractéristiques sociodémographiques. MéTHODE: Un sondage en ligne transversal a été administré en mai 2020 aux membres d'un comité rémunéré représentatif de l'âge, du sexe, des langues officielles et des régions de résidence de la population canadienne. En tout, 4 981 personnes ont fourni des réponses à des questions indicatrices de leurs perceptions du risque, de leurs attitudes et de leurs comportements autodéclarés à l'égard des mesures de santé publique liées à la COVID-19. RéSULTATS: Plus de 90 % des répondants se sont dits certains de leur capacité de respecter de nombreuses mesures de santé publique. Par contre, 51 % seulement ont dit être préparés à respecter ces mesures s'ils attrapaient la maladie, c'est-à-dire pouvoir s'absenter du travail ou avoir droit à des congés de maladie payés. Les perceptions du risque, les attitudes et les comportements variaient selon les caractéristiques démographiques. Les hommes, les jeunes et les personnes ayant un emploi rémunéré étaient moins susceptibles de trouver les mesures de santé publique efficaces et moins sûrs de leur capacité de les respecter. Environ 80 % des répondants ont indiqué que la garde des enfants était assurée par les parents, et 52 % ont indiqué que la garde des enfants quand les écoles étaient fermées était assurée par des parents ayant un emploi. CONCLUSION: Des messages ciblant les hommes et les jeunes, des soutiens sociaux aux personnes ayant besoin de s'isoler, des changements dans les politiques en milieu de travail pour dissuader le présentéisme, ainsi que des politiques de port du masque et de sécurité à l'école coordonnées à l'échelle provinciale sont des mesures susceptibles d'atténuer les problèmes d'adhésion du public.

Evaluation of an OPEN Stewardship generated feedback intervention to improve antibiotic prescribing among primary care veterinarians in Ontario, Canada and Israel: protocol for evaluating usability and an interrupted time-series analysis.

INTRODUCTION: Antimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing. METHODS AND ANALYSIS: Approximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention. ETHICS AND DISSEMINATION: Research ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.

Increased Weekly Mean PM2.5, and NO2 Are Associated With Increased Proportions of Lower Airway Granulocytes in Ontario Horses.

Ambient pollution is associated with the development and exacerbation of human asthma, but whether air pollution exposure is associated with lower airway inflammation in horses has not been fully evaluated. The Air Quality Health Index (AQHI) is an online tool used by asthmatic Ontarians to modify their outdoor activity when ambient pollution is high. A single AQHI value, falling on a scale from 1 to 10+, is calculated from measurements of fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3). Increased AQHI values predict an increased risk for presenting to a health care provider for assessment of asthma exacerbation, with a time lag of 0-9 days after an increase. Whether ambient air pollution is a risk factor for identifying increased lower airway inflammatory cells on cytologic evaluation of bronchoalveolar lavage fluid (BALF) of horses has not yet been explored. To investigate this relationship, case data including BALF cytology preparations from horses across southern Ontario, Canada, were retrieved from the Guelph Animal Health Laboratory's archives. Spanning the years 2007-2017, 154 cases were identified within a 41- by 30-km area surrounding the cities of Guelph and Kitchener. In 78 of 154 cases, cytologic reevaluation identified increased proportions of one or a combination of BALF neutrophils (mean 5%, range 0-15%), eosinophils (mean 2%, range 0-31%), and mast cells (mean 4%, range 0-10%). To assess the effect of lagged pollutant and temperature exposures in these 78 cases, weekly mean values of AQHI, PM2.5, NO2, O3, and temperature were recorded for the 4 weeks prior to the date of the horse's presentation for respiratory tract evaluation. The relationship between ambient exposures and increased proportions of lower airway granulocytes was evaluated using a case-crossover design. Single unit increases in 2-, and 3-week lagged weekly mean PM2.5 and NO2, were associated, respectively, with an 11% (p = 0.04, 95% confidence interval, CI = 1.01-1.22), and 24% (p = 0.03, 95% CI = 1.08-1.43) greater risk of identifying increased lower airway granulocytes. These findings suggest that exposure to increased ambient pollutants is associated with lower airway inflammation in Guelph and Kitchener area horses.

Assessing the impact of environmental exposures and Cryptosporidium infection in cattle on human incidence of cryptosporidiosis in Southwestern Ontario, Canada.

Cryptosporidium is a waterborne parasite that causes diarrheal disease in humans and in cattle. Risk factors for human illness include contact with surface water such as lakes and rivers, exposure to contaminated municipal drinking water, as well as zoonotic transmission from livestock and agriculture. The objectives of this study are twofold: 1) to describe the temporal distribution of cryptosporidiosis in Southwestern Ontario; and 2) to determine the distribution of human cryptosporidiosis, in relation to exposures such as cryptosporidium positive cattle farms, weather events, and hydrological factors. Seasonal trends in 214 bovine and 87 human cases were assessed using regression models that predicted monthly case counts in relation to observed monthly case counts. A case-crossover approach was used to evaluate acute associations between daily environmental exposures, such as weather, hydrology, the presence of Cryptosporidium positive cattle farms within the region, and the risk of human Cryptosporidium infection. Annual seasonality was found for both human cases and bovine cases with human cases peaking in mid-summer and bovine cases peaking in late winter to early spring. Bovine cases that occurred 21 days prior to human cases were associated with a three-fold increase in the odds of human case occurrence. At both 9 and 14 days prior to human case onset, the odds of a human case increased twofold per 10-degree Celsius increase in air temperature. These results provide a preliminary hypothesis for the zoonotic transmission of cryptosporidiosis from cattle to humans via the environment and suggest that the timing of environmental conditions in relation to case occurrence is biologically plausible.

Actionable nuggets: knowledge translation tool for the needs of patients with spinal cord injury.

OBJECTIVE: To present the results of a pilot study of an innovative methodology for translating best evidence about spinal cord injury (SCI) for family practice. DESIGN: Review of Canadian and international peer-reviewed literature to develop SCI Actionable Nuggets, and a mixed qualitative-quantitative evaluation to determine Nuggets' effect on physician knowledge of and attitudes toward patients with SCI, as well as practice accessibility. SETTING: Ontario, Newfoundland, and Australia. PARTICIPANTS: Forty-nine primary care physicians. METHODS: Twenty Actionable Nuggets (pertaining to key health issues associated with long-term SCI) were developed. Nugget postcards were mailed weekly for 20 weeks to participating physicians. Prior knowledge of SCI was self-rated by participants; they also completed an online posttest to assess the information they gained from the Nugget postcards. Participants' opinions about practice accessibility and accommodations for patients with SCI, as well as the acceptability and usefulness of Nuggets, were assessed in interviews. MAIN FINDINGS: With Actionable Nuggets, participants' knowledge of the health needs of patients with SCI improved, as knowledge increased from a self-rating of fair (58%) to very good (75%) based on posttest quiz results. The mean overall score for accessibility and accommodations in physicians' practices was 72%. Participants' awareness of the need for screening and disease prevention among this population also increased. The usefulness and acceptability of SCI Nugget postcards were rated as excellent. CONCLUSION: Actionable Nuggets are a knowledge translation tool designed to provide family physicians with concise, practical information about the most prevalent and pressing primary care needs of patients with SCI. This evidence-based resource has been shown to be an excellent fit with information consumption processes in primary care. They were updated and adapted for distribution by the Canadian Medical Association to approximately 50,000 primary care physicians in Canada, in both English and French.

Transmission of influenza A in human beings.

Planning for the next influenza pandemic is occurring at many levels throughout the world, spurred on by the recent spread of H5N1 avian influenza in Asia, Europe, and Africa. Central to these planning efforts in the health-care sector are strategies to minimise the transmission of influenza to health-care workers and patients. The infection control precautions necessary to prevent airborne, droplet, and contact transmission are quite different and will need to be decided on and planned before a pandemic occurs. Despite vast clinical experience in human beings, there continues to be much debate about how influenza is transmitted. We have done a systematic review of the English language experimental and epidemiological literature on this subject to better inform infection control planning efforts. We have found that the existing data are limited with respect to the identification of specific modes of transmission in the natural setting. However, we are able to conclude that transmission occurs at close range rather than over long distances, suggesting that airborne transmission, as traditionally defined, is unlikely to be of significance in most clinical settings. Further research is required to better define conditions under which the influenza virus may transmit via the airborne route.

Resistance exercise decreases the need for insulin in overweight women with gestational diabetes mellitus.

OBJECTIVE: This study examines the effects of circuit-type resistance training on the need for insulin in women with gestational diabetes mellitus. STUDY DESIGN: Thirty-two patients with gestational diabetes mellitus were randomly assigned either to a group that was treated with diet alone or to a group that was treated with diet plus resistance exercise. RESULTS: The number of women whose condition required insulin therapy was the same, regardless of treatment. However, a subgroup analysis that examined only overweight women (prepregnant body mass index, >25 kg/m(2)) showed a lower incidence of insulin use in the diet-plus-exercise group (P<.05). Women in the diet-plus-exercise group were prescribed less insulin (P<.05) and showed a longer delay from diagnosis to the initiation of insulin therapy (P<.05), compared with the diet-alone group. CONCLUSION: Resistance exercise training may help to avoid insulin therapy for overweight women with gestational diabetes mellitus.