Critical illness in children with influenza A/pH1N1 2009 infection in Canada.

OBJECTIVE: To describe characteristics, treatment, and outcomes of critically ill children with influenza A/pandemic influenza A virus (pH1N1) infection in Canada. DESIGN: An observational study of critically ill children with influenza A/pH1N1 infection in pediatric intensive care units (PICUs). SETTING: Nine Canadian PICUs. PATIENTS: A total of 57 patients admitted to PICUs between April 16, 2009 and August 15, 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics of critically ill children with influenza A/pH1N1 infection were recorded. Confirmed intensive care unit cases were compared with a national surveillance database containing all hospitalized pediatric patients with influenza A/pH1N1 infection. Risk factors were assessed with a Cox proportional hazard model. The PICU cohort and national surveillance data were compared, using chi-square tests. Fifty-seven children were admitted to the PICU for community-acquired influenza A/pH1N1 infection. One or more chronic comorbid illnesses were observed in 70.2% of patients, and 24.6% of patients were aboriginal. Mechanical ventilation was used in 68% of children, 20 children (35.1%) had acute lung injury on the first day of admission, and the median duration of ventilation was 6 days (range, 0-67 days). The PICU mortality rate was 7% (4 of 57 patients). When compared with nonintensive care unit hospitalized children, PICU children were more likely to have a chronic medical condition (relative risk, 1.73); aboriginal ethnicity was not a risk factor of intensive care unit admission. CONCLUSIONS: During the first outbreak of influenza A/pH1N1 infection, when the population was naïve to this novel virus, severe illness was common among children with underlying chronic conditions and aboriginal children. Influenza A/pH1N1-related critical illness in children was associated with severe hypoxemic respiratory failure and prolonged mechanical ventilation. However, this higher rate and severity of respiratory illness did not result in an increased mortality when compared with seasonal influenza.

Telehealth Ontario detection of gastrointestinal illness outbreaks.

OBJECTIVE: Prompt detection of infectious disease outbreaks and rapid introduction of mitigation strategies is a primary concern for public health, emergency and security management organizations. Traditional surveillance methods rely on astute clinical detection and reporting of disease or laboratory confirmation. Although effective, these methods are slow, dependent on physician compliance and delay timely, effective intervention. To address these issues, syndromic surveillance programs have been integrated into the health care system at the earliest points of access; in Ontario, these points are primary care providers, emergency departments (ED), and Telehealth Ontario. This study explores the role of Telehealth Ontario, a telephone helpline, as an early warning system for detection of gastrointestinal (GI) illness. METHODS: Retrospective time-series analysis of the National Ambulatory Care Reporting System (NACRS) ED discharges and Telehealth Ontario data for GI illness from June 1, 2004 to March 31, 2006. RESULTS: Telehealth Ontario recorded 184,904 calls and the NACRS registered 34,499 ED visits for GI illness. The Spearman rank correlation coefficient was calculated to be 0.90 (p < 0.0001). Time-series analysis resulted in significant correlation at lag (weekly) 0 indicating that increases in Telehealth Ontario call volume correlate with increases in NACRS data for GI illness. CONCLUSION: Telehealth Ontario call volume fluctuation reflects directly on ED GI visit data on a provincial basis. Telehealth Ontario GI call complaints are a timely, novel and representative data stream that shows promise for integration into a real-time syndromic surveillance system for detection of unexpected events.

Can Telehealth Ontario respiratory call volume be used as a proxy for emergency department respiratory visit surveillance by public health?

OBJECTIVE: There is a paucity of information regarding the usefulness of non-traditional data streams for real-time syndromic surveillance systems. The objective of this paper is to examine the temporal relation between Ontario's emergency department (ED) visits and telephone health line (Telehealth) call volume for respiratory illnesses to test the feasibility of using Ontario's Telehealth system for real-time surveillance. METHODS: Retrospective time-series data from the National Ambulatory Care Reporting System (NACRS) and the Telehealth Ontario program from June 1, 2004, to March 31, 2006, were analyzed. The added value of Telehealth Ontario data was determined by comparing it temporally with NACRS data, which uses the International Classification of Diseases (ICD) 10-Canadian Enhancement coding system for discharge diagnoses. RESULTS: Telehealth Ontario had 216,105 calls for respiratory complaints, while 819,832 ICD-coded complaints from NACRS were identified with a comparable diagnosis of respiratory illness. Telehealth Ontario call volume was heavily weighted for the 0-4 years age group (49%), while the NACRS visits were mainly from those 18-64 years old (44%). The Spearman rank correlation coefficient was calculated to be 0.97, with the time-series analysis also resulting in significant correlations at lags (semi-monthly) 0 and 1, indicating that increases in Telehealth Ontario call volume correlate with increases in NACRS discharge diagnosis data for respiratory illnesses. CONCLUSION: Telehealth Ontario call volume fluctuation reflects directly on ED respiratory visit data on a provincial basis. These call complaints are a timely, useful and representative data stream that shows promise for integration into a real-time syndromic surveillance system.

Using Ontario's "Telehealth" health telephone helpline as an early-warning system: a study protocol.

BACKGROUND: The science of syndromic surveillance is still very much in its infancy. While a number of syndromic surveillance systems are being evaluated in the US, very few have had success thus far in predicting an infectious disease event. Furthermore, to date, the majority of syndromic surveillance systems have been based primarily in emergency department settings, with varying levels of enhancement from other data sources. While research has been done on the value of telephone helplines on health care use and patient satisfaction, very few projects have looked at using a telephone helpline as a source of data for syndromic surveillance, and none have been attempted in Canada. The notable exception to this statement has been in the UK where research using the national NHS Direct system as a syndromic surveillance tool has been conducted. METHODS/DESIGN: The purpose of our proposed study is to evaluate the effectiveness of Ontario's telephone nursing helpline system as a real-time syndromic surveillance system, and how its implementation, if successful, would have an impact on outbreak event detection in Ontario. Using data collected retrospectively, all "reasons for call" and assigned algorithms will be linked to a syndrome category. Using different analytic methods, normal thresholds for the different syndromes will be ascertained. This will allow for the evaluation of the system's sensitivity, specificity and positive predictive value. The next step will include the prospective monitoring of syndromic activity, both temporally and spatially. DISCUSSION: As this is a study protocol, there are currently no results to report. However, this study has been granted ethical approval, and is now being implemented. It is our hope that this syndromic surveillance system will display high sensitivity and specificity in detecting true outbreaks within Ontario, before they are detected by conventional surveillance systems. Future results will be published in peer-reviewed journals so as to contribute to the growing body of evidence on syndromic surveillance, while also providing an non US-centric perspective.

Should dental hygienists replace dental directors in screening high-needs children?

PURPOSE: The purpose of this research was to determine whether dental hygienists are as effective as dental directors in screening high-needs children who require emergency care. METHODS: In 2000, the Community Dentistry Health Services Research Unit (CDHSRU) at the University of Toronto completed a prospective cohort study to determine whether care proposed by dental directors exposed to evidence-based practices was significantly different from the care provided by dental hygienists who screened children enrolled in the provincially mandated Children in Need of Treatment (CINOT) program. RESULTS: The dental directors and dental hygienists each prepared a treatment plan for the 71 children enrolled in this study. These plans were analyzed using a paired t-test model after being translated into relative value units (RVU). It was determined that there was no statistically significant difference between the overall dental treatment proposed by the dental hygienists and the treatment proposed by the dental directors (p=.749). A similar analysis stratified by subject site and by service type also showed no significant differences. CONCLUSIONS: The results suggest that dental hygienists are equally as effective as dental directors in screening high-needs children and may be capable of assuming the role of first point of contact for children within high-need dental programs.