A multi-function public health surveillance system and the lessons learned in its development: the Alberta Real Time Syndromic Surveillance Net.

OBJECTIVE: We describe a centralized automated multi-function detection and reporting system for public health surveillance--the Alberta Real Time Syndromic Surveillance Net (ARTSSN). This improves upon traditional paper-based systems which are often fragmented, limited by incomplete data collection and inadequate analytical capacity, and incapable of providing timely information for public health action. METHODS: ARTSSN concurrently analyzes multiple electronic data sources in real time to describe results in tables, charts and maps. Detected anomalies are immediately disseminated via alerts to decision-makers for action. RESULTS: ARTSSN provides richly integrated information on a variety of health conditions for early detection of and prompt action on abnormal events such as clusters, outbreaks and trends. Examples of such health conditions include chronic and communicable disease, injury and environment-mediated adverse incidents. DISCUSSION: Key advantages of ARTSSN over traditional paper-based methods are its timeliness, comprehensiveness and automation. Public health surveillance of communicable disease, injury, environmental hazard exposure and chronic disease now occurs in a single system in real time year round. Examples are given to demonstrate the public health value of this system, particularly during Pandemic (H1N1) 2009.

The feasibility of using an 'opt-out' approach to achieve universal HIV testing of tuberculosis patients in Alberta.

OBJECTIVE: Universal HIV testing of tuberculosis (TB) patients, defined as testing greater than 80% of incident cases, has been recommended but not achieved in Canada. The objectives of this study were: i) to assess the success of an 'opt-out' approach, whereby HIV testing is routine unless the patient specifically chooses otherwise, and ii) to determine the risk factors for HIV in patients tested before and after this approach was implemented. METHODS: TB and HIV databases in the province of Alberta were cross-matched before HAART (highly active anti-retroviral therapy) was available (1991-1997), after HAART but before 'opt-out' testing was implemented (1998-2002), and after 'opt-out' testing was implemented (2003-2006), and the HIV status of TB patients in each time period was described. The demographic and clinical characteristics of HIV-positive and -negative TB patients aged 15-64 years were compared. RESULTS: HIV testing of TB patients increased from 11.5% before HAART, to 44.9% after HAART but before 'opt-out' testing, to 81.9% after 'opt-out' testing was implemented. Between 1991 and 2006, 50 TB patients were diagnosed with HIV co-infection, all in the age group 15-64 years. Among TB patients aged 15-64 years who were HIV tested, those testing positive were significantly less likely to be female and to have respiratory TB and significantly more likely to have both respiratory and non-respiratory TB. The prevalence of HIV positivity in HIV-tested TB patients aged 15-64 years was 7.4% in 2003-2006. CONCLUSION: Universal HIV testing of TB patients is achievable through 'opt-out' HIV testing.

A framework for addressing the global obesity epidemic locally: the Child Health Ecological Surveillance System (CHESS).

Childhood obesity has reached epidemic levels in the developed world. Recent research and commentary suggest that an ecological approach is required to address childhood obesity, given the multidimensional nature of the problem. We propose a Canadian prototype, the Child Health Ecological Surveillance System, for a regional health authority to address the growing obesity epidemic. This prototype could potentially be used in other jurisdictions to address other child health issues. We present 8 guiding principles for the development and implementation of a regional framework for action.

Development and introduction of a comprehensive tobacco control policy in a Canadian regional health authority.

BACKGROUND: Tobacco control policies in health care settings are necessary to protect patients, employees, physicians, visitors, and volunteers from the dangers of secondhand smoke. This report documents the process of developing and introducing a comprehensive tobacco control policy in one Canadian regional health authority. CONTEXT: Capital Health (CH), a health authority that has 30,000 employees and serves 1.6 million people, is responsible for 18 hospitals and primary care facilities, 33 continuing care facilities, 29 public health locations, and 9 community care facilities. CH recently determined that it needed to revise its tobacco control policy because its facilities had different directives regarding tobacco use, some of which did not reflect the best current knowledge about the health risks associated with exposure to secondhand smoke. METHODS: The new smoke-free policy needed to be developed and executed within a narrow time frame, which required careful planning as well as the support of patients and CH staff members. An essential part of the new policy was the prevention of nicotine withdrawal among people required to undergo involuntary tobacco abstinence. The plan also included an integrated screening, intervention, and referral process designed to optimize health benefits for patients and staff members who smoked, as well as for those who did not. CONSEQUENCES: CH decided to close all smoking rooms (including those in psychiatry, palliative care, geriatrics, eating disorder, and tuberculosis units), to ban smoking in outdoor areas, to stop all sales of tobacco products in CH facilities, to require smoke-free environments during home visitations, and to reject funding from the tobacco industry. INTERPRETATION: By implementing a consistent ban on indoor and outdoor smoking, CH is contributing to a comprehensive tobacco control policy that is arguably a regional health authority's most profound opportunity for health promotion.

Taking care of the sick and scared: a local response in pandemic preparedness.

Virtually all health care operations, including public health, are undertaken only at a local or regional level. Large-scale infectious disease emergencies, such as SARS or pandemic influenza, will be recognized and managed at a local level. The creation of the Public Health Agency of Canada (PHAC) was an important step in strengthening public health capacity. However, we need adequate operational capacity in local public health departments to have a strong public health system. Local public health takes an integral role in the preparation for and management of infectious disease emergencies. Local public health departments and regional public health infrastructures must be positioned to both maintain core functions and to lead and support health sector response to emergencies. The local establishment of a flexible and sustainable emergency management system must address the need to: integrate health care and first responders; provide all-hazards tools for managing a crisis at the frontline; rank service priorities and provide surge resources; and provide accurate information on a timely basis. Only the leaders within the local or regional health care facilities and organizations can develop workable plans to deliver health care. PHAC must ensure and support the local public health infrastructure and local emergency preparedness. Without this support, there will be consequences for local response to major public health emergencies.

Clinical, microbiological, and epidemiological findings of an outbreak of Mycobacterium abscessus hand-and-foot disease.

In 2003, we identified an outbreak of clinically distinct lesions involving the hands and feet associated with a public wading pool in Edmonton, Alberta, Canada. A total of 85 cases were identified. The management and follow-up of 41 children and 1 adult patients is presented. Skin lesions occurred within a median incubation period of 29 days and approximately 88 days for the adult patient. Lesions resolved within a median of 58 days and approximately 150 days for the adult patient. Patients were treated with clarithromycin, topical antibiotic dressings, and/or incision and drainage of pustules or followed without treatment. All resolved without complication. The pool was closed and cleaned. The M. abscessus hand-and-foot disease is characterized by the onset, mainly in children, of tender, erythematous papules, pustules, and abscesses with a self-limited course. This is the first documented M. abscessus outbreak associated with wading pool exposure.

An outbreak of E. coli O157:H7 hemorrhagic colitis associated with unpasteurized gouda cheese.

BACKGROUND: A cluster of E. coli O157:H7 hemorrhagic colitis was identified in metro Edmonton, Alberta through notifiable disease surveillance in late 2002. METHODS: Environmental health officers collected food histories and clinical information from cases in the cluster. The provincial public health laboratory conducted pulsed field gel electrophoresis (PFGE) analysis on E. coli O157:H7 isolates from cluster cases. Public health and food regulatory agencies conducted an investigation when a food source (unpasteurized gouda cheese) was implicated. RESULTS: PFGE analysis revealed an "outbreak" profile in 13 cases. Onset dates for the outbreak cases ranged between October 2002 and February 2003. Two cases, aged 22 months and 4 years, developed hemolytic uremic syndrome as a result of their infection. Consumption of unpasteurized gouda cheese produced at a local dairy farm was reported by 12 of 13 outbreak cases in the 2 to 8 days prior to illness. E. coli O157:H7 was isolated from 2 of 26 cheese samples manufactured by the implicated producer. The cheese isolates had indistinguishable PFGE profiles as compared with outbreak case isolates. Implicated cheese was found to be contaminated with E. coli O157:H7 104 days after production, despite having met regulated microbiological and aging requirements. CONCLUSION: To our knowledge, this is the first confirmed outbreak of E. coli O157:H7 infection in Canada associated with raw milk hard cheese. A review of federal legislation vis-à-vis raw milk hard cheese may be in order.

Prevalence and correlates of Chlamydia infection in Canadian street youth.

PURPOSE: To determine the prevalence and correlates of Chlamydia trachomatis in Canadian street youth. METHODS: A cross-sectional study of street youth between the ages of 15-24 years was conducted over a 9-month period in seven large urban centers across Canada. Youth were recruited through "drop-in" centers, outreach work, and mobile vans in each city. Information was collected through a nurse-administered questionnaire. Youth were asked to provide urine to test for chlamydia trachomatis by polymerase chain reaction. Separate logistic regression models were run for males and females controlling for age. RESULTS: The prevalence rate of chlamydia was 8.6% in 1355 youth (95% CI = (7.1%, 10.1%)). Higher prevalence rates were found in females than in males (10.9% vs. 7.3%, respectively) and in Aboriginal youth than in non-Aboriginal youth (13.7% vs. 6.6%, respectively). Four variables were associated with increased risk of chlamydia infection in females: Aboriginal status; self-perceived risk; having no permanent home; and having been in foster care. One predictor of chlamydia for males was having had a social worker. CONCLUSIONS: A high prevalence of chlamydia was found in this vulnerable population in comparison to other Canadian youth. Having been in foster care and having had a social worker were found to have a strong association with chlamydia.

Outcomes and costs among seniors requiring hospitalization for community-acquired pneumonia in Alberta.

OBJECTIVES: To determine the age-specific rates of hospital discharge, cost per day, and overall in-hospital 1- and 4-year mortality for seniors who required hospitalization for the treatment of community-acquired pneumonia (CAP). DESIGN: Retrospective analysis of two administrative health service databases. SETTING: Province of Alberta, Canada. PARTICIPANTS: Residents of Alberta aged 18 and older. MEASUREMENTS: Hospital abstracts and vital statistics from April 1, 1994, to March 31, 1999, were analyzed, and mortality and cost outcomes statistically modeled by regression. RESULTS: There were 8,500 annual hospital discharges for CAP costing more than $40 million per year. The overall in-hospital all-cause mortality rate was 12%, and the 1-year mortality rate was 26%. The mean age of pneumonia cases increased (P<.000) from 62.8 in 1994/1995 to 67.2 in 1998/1999. The proportion of hospital discharges in those aged 85 and older was 13% in 1994/1995, increasing to 18% in 1998/1999 (P<.000). The age-specific hospital discharge rate and length of hospitalization increased with age. After adjustment for other factors using modeling, it was found that the relative risk (RR) of in-hospital and 1-year mortality increased with age, the RR of using special medical care and higher-than-average daily hospital cost decreased with age, and the RR of greater-than-average daily hospital cost was not associated with an increase in comorbidity. Total costs per hospital stay were similar in patients aged 85 and older to those in patients aged 65 to 74, despite a one-third longer length of stay, which was consistent with reduced use of special medical care in those aged 85 and older. CONCLUSION: The increased use of hospital resources for CAP in the setting of an aging population may have been partially avoided because of limitations in care provided for seniors aged 85 and older.

Myiasis in an urban setting: A case report.

Myiasis is considered to be a condition only found in tropical, developing countries. However, this paper reports a case identified in an urban, North American setting. The clinical presentation is discussed along with the underlying comorbidities and social determinants.

The association between influenza immunization coverage rates and hospitalization for community-acquired pneumonia in Alberta.

BACKGROUND: We compared regional coverage rates of influenza vaccination (composition in 1999/00 was A/Sydney-like A/Beijing-like B/Yamanashi-like and in 2000/01 was A/Moscow A/New Caledonia B/Beijing) to the rates, cost, and mortality for community-acquired pneumonia. METHODS: We used the Pearson's correlation coefficient to establish linear associations between variables derived from Alberta administrative data during the period April 1, 1999 to March 31, 2001. RESULTS: The influenza vaccination coverage rate for the 17 health regions varied between 30% to 80% (mean 70%) in Alberta seniors (n=298,473). The annual hospitalization and ambulatory community-acquired pneumonia attack rates were 2% and 6.5% per year respectively. There were strongly negative correlations between vaccination coverage rates and pneumonia rates requiring hospitalization (r1999=-0.59 and r2000=-0.79 with both p<0.05), total per capita physician and hospital costs for pneumonia (r1999=-0.57 and r2000=-0.79 with both p<0.01), community-diagnosed pneumonia rate (r1999=-0.39, p=0.12 and r2000=-0.70, p<0.01) and per capita in-hospital mortality for pneumonia (r1999=-0.30, p=0.24 and r2000=-0.57, p<0.05). Per capita costs, rates, and mortality were highest and influenza vaccinations rate lowest in the northern, remote health regions. The per capita vaccination cost (about 10 dollars) was small in relationship to the per capita cost of hospital care for pneumonia (about 100 dollars). CONCLUSION: Regional under-utilization of preventive influenza vaccination in Alberta seniors is associated with increased utilization of health services for community-acquired pneumonia.

Hospitalization for community-acquired pneumonia in Alberta patients with human immunodeficiency virus infections: a case control study.

BACKGROUND: To determine whether outcomes of pneumonia among human immunodeficiency virus (HIV)-positive persons differed from those among HIV-negative persons. METHODS: Alberta hospital patient abstracts for HIV-positive per-sons requiring hospitalization for pneumonia from April 1, 1994,until March 31, 1999, were matched by age and sex with four HIV-negative counterparts. RESULTS: Hospitalizations for community-acquired pneumonia decreased for those with HIV (acquired immunodeficiency syndrome[AIDS]) and increased for those with HIV (non-AIDS) during the study period. HIV (AIDS) patients admitted for community-acquired pneumonia (n=130) manifested three times higher odds for a longer length of hospital stay and had three and 10 times higher odds for excess in-hospital and one-year mortality, respectively, than their matched controls. Similarly, HIV (non-AIDS) patients admitted for community-acquired pneumonia (n=46) manifested two times high-er odds for a longer length of hospital stay and had four times higher odds for excess one-year mortality than their matched controls. The in-hospital and one-year mortality rates for the HIV (AIDS) patients were 21.2% and 64.3%, respectively, during the first three years, and decreased to 8.7% and 40.7%, respectively, in the last two years of the study. CONCLUSIONS: The outcomes for community-acquired pneumonia were worse for those with HIV (non-AIDS) and HIV (AIDS)compared with non-HIV hospitalized patients matched for age and sex, and controlling for severity of illness and comorbidity. In-hospital and one-year mortality rates for patients with HIV (AIDS)showed a marked decline over the study period.

The effects of community-acquired pneumonia during pregnancy ending with a live birth.

OBJECTIVE: The incidence and outcomes for community-acquired pneumonia during a pregnancy ending with a live birth in the province of Alberta, Canada, were analyzed. STUDY DESIGN: Hospital abstracts and vital statistics data between April 1, 1994, to March 31, 1999, were used. RESULTS: The incidence of hospitalization for community-acquired pneumonia was 1.51 (95% CI 1.35-1.67) per 1000 pregnancies in mothers 18 years and older compared with 1.47 (95% CI 1.42-1.51) per 1000 women (18 to 49 years) in the general population. The relative risk of staying longer at hospital for pneumonia was 0.44 during pregnancy compared with nonpregnant mothers with pneumonia. The relative risk of staying longer at hospital during delivery was 1.88, higher in those with a past hospitalization for community-acquired pneumonia. The relative risk of a small-for-gestational-age newborn infant was 1.86 for those with a past hospitalization for community-acquired pneumonia compared with those without a past hospitalization. CONCLUSION: Community-acquired pneumonia during most pregnancies ending with a live birth appears to be well tolerated by mothers and newborn infants.

Was it something she ate? Case report and discussion of scombroid poisoning.

We report the case of a 51-year old woman who developed headache, nausea, palpitations, tachycardia and hypertension 30 minutes after eating a tuna fish salad. Elevated histamine levels in the salad helped to confirm a suspected diagnosis of scombroid poisoning. The signs, symptoms, pathophysiology and management of poisoning from spoiled scombroid fish are discussed.