Congenital rubella syndrome, a case series.

Rubella, or German measles, is a vaccine-preventable disease. Rubella infection is usually mild; however, infection in pregnancy is associated with severe outcomes for the baby, including pregnancy loss or a combination of developmental defects called congenital rubella syndrome. Within the last ten-year period, two cases of congenital rubella syndrome in Saskatchewan were reported to the provincial ministry and the Public Health Agency of Canada of the newborns of mothers who had recently arrived from Sub-Saharan Africa. Both infants had multiple health complications at birth consistent with congenital rubella and tested positive for the rubella virus. The article discusses the challenges encountered by the healthcare system in diagnosing, investigating, monitoring and managing cases of congenital rubella syndrome to prevent further sporadic transmission. The article emphasizes the need to provide additional support for cases and their households, especially new Canadians with less support to comply with public health advice and the importance of routine immunization to eliminate rubella globally.

Efficacy, effectiveness and immunogenicity of reduced HPV vaccination schedules: A review of available evidence.

Background: Current National Advisory Committee on Immunization (NACI) guidance recommends human papillomavirus (HPV) vaccines be administered as a two or three-dose schedule. Recently, several large clinical trials have reported the clinical benefit of a single HPV vaccine dose. As a result, the World Health Organization released updated guidance on HPV vaccines in 2022, recommending a two-dose schedule for individuals aged 9-20 years, and acknowledging the use of an alternative off-label single dose schedule. Objective: The objective of this overview is to provide a detailed account of the available evidence comparing HPV vaccination schedules, which was considered by NACI when updating recommendations on HPV vaccines. Methods: To identify relevant evidence, existing systematic reviews were leveraged where possible. Individual studies were critically appraised, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence. Results: Available evidence suggests that a one, two, or three-dose HPV vaccine schedule may provide similar protection from HPV infection. While antibody levels against HPV vaccine types were statistically significantly lower with a single dose schedule compared to two or three doses, titres were sustained for up to 16 years. The clinical significance of lower antibody titres is unknown, as there is no established immunologic correlate of protection. Conclusion: While the available evidence on single-dose HPV vaccination schedules shows a one-dose schedule is highly effective, continued follow-up of single-dose cohorts will be critical to understanding the relative duration of protection for reduced dose schedules and informing future NACI guidance on HPV vaccines.

Revaccination outcomes among adolescents and adults with suspected hypersensitivity reactions following COVID-19 vaccination: A Canadian immunization research network study.

BACKGROUND: COVID-19 vaccination has been associated with anaphylaxis and hypersensitivity reactions. Infectious disease physicians and allergists in the Canadian Special Immunization Clinic (SIC) Network developed guidance for evaluating patients with adverse events following immunization (AEFI) including suspected hypersensitivity. This study evaluated management and adverse event recurrence following subsequent COVID-19 vaccinations. METHODS: Individuals aged 12 years and older enrolled at participating SICs before February 28, 2023 who were referred for suspected or diagnosed hypersensitivity reaction following COVID-19 vaccination, or for prevaccination assessment of suspected allergy to a COVID-19 vaccine component were included. De-identified clinical assessments and revaccination data, captured in a centralized database, were analyzed. The Brighton Collaboration case definition (BCCD) for anaphylaxis (2023 version) was applied. RESULTS: The analysis included 206 participants from 13 sites: 26 participants referred for pre-vaccination assessment and 180 participants referred for adverse events following COVID-19 vaccination (15/180 [8.3%] with BCCD confirmed anaphylaxis, 84 [46.7%] with immediate hypersensitivity symptoms not meeting BCCD, 33 [18.3%] with other diagnosed hypersensitivity reactions, and 48 [26.7%] participants with a final diagnosis of non-hypersensitivity AEFI). Among participants referred for AEFIs following COVID-19 vaccination, 166/180 (92.2%) were recommended for COVID-19 revaccination after risk assessment, of whom 158/166 (95.2%) were revaccinated (all with a COVID-19 mRNA vaccine). After revaccination, 1/15 (6.7%) participants with prior anaphylaxis, 1/77 (1.3%) with immediate hypersensitivity not meeting criteria for anaphylaxis and 1/24 (4.2%) with other physician diagnosed hypersensitivity developed recurrent AEFI symptoms that met the BCCD for anaphylaxis. All 26 participants referred pre-vaccination, including 9 (34.6%) with history of polyethylene glycol-asparaginase reactions, were vaccinated without occurrence of immediate hypersensitivity symptoms. CONCLUSIONS: Most individuals in this national cohort who experienced a hypersensitivity event following COVID-19 vaccination and were referred for specialist review were revaccinated without AEFI recurrence, suggesting that specialist evaluation can facilitate safe revaccination.

Post-COVID-19 Condition in Children 6 and 12 Months After Infection.

Importance: There is a need to understand the long-term outcomes among children infected with SARS-CoV-2. Objective: To quantify the prevalence of post-COVID-19 condition (PCC) among children tested for SARS-CoV-2 infection in pediatric emergency departments (EDs). Design, Setting, and Participants: Multicenter, prospective cohort study at 14 Canadian tertiary pediatric EDs that are members of the Pediatric Emergency Research Canada network with 90-day, 6-month, and 12-month follow-up. Participants were children younger than 18 years who were tested for SARS-CoV-2 infection between August 2020 and February 2022. Data were analyzed from May to November 2023. Exposure: The presence of SARS-CoV-2 infection at or within 14 days of the index ED visit. Main Outcomes and Measures: Presence of symptoms and QoL reductions that meet the PCC definition. This includes any symptom with onset within 3 months of infection that is ongoing at the time of follow-up and affects everyday functioning. The outcome was quantified at 6 and 12 months following the index ED visit. Results: Among the 5147 children at 6 months (1152 with SARS-CoV-2 positive tests and 3995 with negative tests) and 5563 children at 12 months (1192 with SARS-CoV-2 positive tests and 4371 with negative tests) who had sufficient data regarding the primary outcome to enable PCC classification, the median (IQR) age was 2.0 (0.9-5.0) years, and 2956 of 5563 (53.1%) were male. At 6-month follow-up, symptoms and QoL changes consistent with the PCC definition were present in 6 of 1152 children with positive SARS-CoV-2 tests (0.52%) and 4 of 3995 children with negative SARS-CoV-2 tests (0.10%; absolute risk difference, 0.42%; 95% CI, 0.02% to 0.94%). The PCC definition was met at 12 months by 8 of 1192 children with positive SARS-CoV-2 tests (0.67%) and 7 of 4371 children with negative SARS-CoV-2 tests (0.16%; absolute risk difference, 0.51%; 95% CI, 0.06 to 1.08%). At 12 months, the median (IQR) PedsQL Generic Core Scale scores were 98.4 (90.0-100) among children with positive SARS-CoV-2 tests and 98.8 (91.7-100) among children with negative SARS-CoV-2 tests (difference, -0.3; 95% CI, -1.5 to 0.8; P = .56). Among the 8 children with SARS-CoV-2 positive tests and PCC at 12-month follow-up, children reported respiratory (7 of 8 patients [88%]), systemic (3 of 8 patients [38%]), and neurologic (1 of 8 patients [13%]) symptoms. Conclusions and Relevance: In this cohort study of children tested for SARS-CoV-2 infection in Canadian pediatric EDs, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed PCC, and overall QoL did not differ from children with negative SARS-CoV-2 tests.

Impact of SARS-CoV-2 Infection on the Association Between Laboratory Tests and Severe Outcomes Among Hospitalized Children.

Background: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. Methods: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. Results: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 109/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 109/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. Conclusions: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative.

Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage.

BACKGROUND: Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU). METHODS: Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression. RESULTS: We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU. CONCLUSIONS: Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages. IMPACT: We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.

Comparison of Symptoms Associated With SARS-CoV-2 Variants Among Children in Canada.

Importance: Clinical manifestations of SARS-CoV-2 variants have not been systematically compared in children. Objective: To compare symptoms, emergency department (ED) chest radiography, treatments, and outcomes among children with different SARS-CoV-2 variants. Design, Setting, and Participants: This multicenter cohort study was performed at 14 Canadian pediatric EDs. Participants included children and adolescents younger than 18 years (hereinafter referred to as children) tested for SARS-CoV-2 infection in an ED between August 4, 2020, and February 22, 2022, with 14 days of follow-up. Exposure(s): SARS-CoV-2 variants detected on a specimen collected from the nasopharynx, nares, or throat. Main Outcomes and Measures: The primary outcome was presence and number of presenting symptoms. The secondary outcomes were presence of core COVID-19 symptoms, chest radiography findings, treatments, and 14-day outcomes. Results: Among 7272 participants presenting to an ED, 1440 (19.8%) had test results positive for SARS-CoV-2 infection. Of these, 801 (55.6%) were boys, with a median age of 2.0 (IQR, 0.6-7.0) years. Children with the Alpha variant reported the fewest core COVID-19 symptoms (195 of 237 [82.3%]), which were most often reported by participants with Omicron variant infection (434 of 468 [92.7%]; difference, 10.5% [95% CI, 5.1%-15.9%]). In a multivariable model with the original type as the referent, the Omicron and Delta variants were associated with fever (odds ratios [ORs], 2.00 [95% CI, 1.43-2.80] and 1.93 [95% CI, 1.33-2.78], respectively) and cough (ORs, 1.42 [95% CI, 1.06-1.91] and 1.57 [95% CI, 1.13-2.17], respectively). Upper respiratory tract symptoms were associated with Delta infection (OR, 1.96 [95% CI, 1.38-2.79]); lower respiratory tract and systemic symptoms were associated with Omicron variant infection (ORs, 1.42 [95% CI, 1.04-1.92] and 1.77 [95% CI, 1.24-2.52], respectively). Children with Omicron infection most often had chest radiography performed and received treatments; compared with those who had Delta infection, they were more likely to have chest radiography performed (difference, 9.7% [95% CI, 4.7%-14.8%]), to receive intravenous fluids (difference, 5.6% [95% CI, 1.0%-10.2%]) and corticosteroids (difference, 7.9% [95% CI, 3.2%-12.7%]), and to have an ED revisit (difference, 8.8% [95% CI, 3.5%-14.1%]). The proportions of children admitted to the hospital and intensive care unit did not differ between variants. Conclusions and Relevance: The findings of this cohort study of SARS-CoV-2 variants suggest that the Omicron and Delta variants were more strongly associated with fever and cough than the original-type virus and the Alpha variant. Children with Omicron variant infection were more likely to report lower respiratory tract symptoms and systemic manifestations, undergo chest radiography, and receive interventions. No differences were found in undesirable outcomes (ie, hospitalization, intensive care unit admission) across variants.

Pertussis epidemiology in Canada, 2005-2019.

Background: Pertussis, also known as whooping cough, is an endemic vaccine-preventable disease that affects the respiratory tract and is caused by the bacterium Bordetella pertussis. Between 1999 and 2004, the adolescent booster dose of pertussis was introduced across Canada. This report describes the epidemiology of pertussis in Canada from 2005 to 2019, the period after adolescent acellular vaccination was recommended. Methods: We analyzed pertussis incidence by year, age groups, sex and geographic region using national surveillance data from the Canadian Notifiable Disease Surveillance System. Hospitalization data from the Discharge Abstract Database was used to investigate pertussis hospitalizations by sex and age. Deaths from pertussis were explored using Statistics Canada's vital statistics data. Vaccination coverage data was gathered from the 2019 Childhood National Immunization Coverage Survey and 2018-2019 Seasonal Influenza Vaccination Coverage Survey. Results: Between 2005 and 2019, there were a total of 33,481 pertussis cases with the average annual incidence rate of 6.4 cases per 100,000 population. The highest average age-specific incidence rate was among infants under one year of age (n=68.7 cases per 100,000 population). There were a total of 1,593 pertussis hospitalizations; nearly 80% of these hospitalizations were infants under one year of age. Hospitalization rates were 8.2 times higher in infants three months or younger compared to infants four to 11 months of age. There were 17 deaths; all among infants under one year of age. Conclusion: The highest morbidity and fatality of pertussis were among infants under one year of age. It is important to take measures to reduce transmission to infants who are too young to be vaccinated. Increasing vaccine coverage in children and pregnant women are important to reduce the burden of disease.

Impact of the COVID-19 pandemic on healthcare-associated viral respiratory infections at a tertiary care pediatric hospital.

The incidence of healthcare-associated viral respiratory infections in a pediatric hospital decreased from 1.6 /1,000 patient-days in 2019 to 0.2 /1,000 patient-days in 2020 (P < .01), and this was maintained in 2021 despite an increase in community circulation of respiratory viruses. Universal masking, stricter infection control measures, and pandemic public health interventions likely accounted for this improvement.

Epidemiology of tetanus in Canada, 1995-2019.

OBJECTIVES: This report aims to use tetanus hospitalization data to describe the epidemiology in Canada from 1995 to 2019 and to assess progress on national reduction targets, including validating that Canada has eliminated maternal and neonatal tetanus (MNT). METHODS: Tetanus hospitalizations and fatalities occurring between 1995 and 2019 were retrieved from the Canadian Institute for Health Information (CIHI) and Statistics Canada. Cases coded with ICD-10 codes A33, A34, or A35 as the primary diagnosis (or ICD-9 equivalents) were included. The Canadian national case definition was used for generic tetanus and definitions from the World Health Organization were referenced for MNT. R version 4.0.2 was used for analyses. RESULTS: From 1995 to 2019, 155 non-MNT, 6 neonatal, and 0 maternal tetanus cases were retrieved from CIHI. However, all 6 neonatal cases were excluded after validating with provincial/territorial public health officials. In the same time period, there were 91 national notifications of tetanus. Cases were distributed relatively equally across the country, with the exception of the territories, where zero cases were reported. Adults 75 and over had significantly higher incidence rates compared to younger age groups (p<0.001). Ten deaths were reported during the timeframe. CONCLUSION: Tetanus incidence remains low and hospitalization data reveal that Canada has met its reduction target of maintaining 5 cases or fewer annually in recent years. For MNT, Canada has successfully met the elimination target of zero cases. Continued vaccination efforts must be practiced for all age groups, including those aged 75 years and older, to sustain targets moving forward.

RéSUMé: OBJECTIFS: Ce rapport vise à utiliser les données sur les hospitalisations dues au tétanos pour décrire l'épidémiologie au Canada de 1995 à 2019 et pour évaluer les progrès réalisés par rapport aux objectifs nationaux de réduction, notamment pour confirmer que le Canada a éliminé le tétanos maternel et néonatal (TMN). MéTHODES: Les données sur les hospitalisations et les décès attribuables au tétanos survenus entre 1995 et 2019 proviennent de l'Institut canadien d'information sur la santé (ICIS) et de Statistique Canada. Les cas pour lesquels les codes sont CIM-10 A33, A34 ou A35 comme diagnostic primaire (ou leurs équivalents CIM-9) sont inclus. La définition de cas nationale canadienne a été utilisée pour le tétanos générique et les définitions de l'Organisation mondiale de la santé ont servi de référence pour le TMN. La version 4.0.2 de R a été utilisée pour les analyses. RéSULTATS: De 1995 à 2019, il y a eu 155 cas de tétanos autres que TMN, 6 cas de tétanos néonatal et 0 cas de tétanos maternel selon l'ICIS. Cependant, les 6 cas de tétanos néonatal ont été exclus après validation auprès des responsables de la santé publique provinciaux/territoriaux. Durant la même période, il y a eu 91 notifications nationales de cas de tétanos. Ces cas étaient répartis de manière relativement égale à travers du pays, à l'exception des territoires, où aucun cas n'a été signalé. Les adultes de 75 ans et plus présentaient des taux d'incidence significativement plus élevés que les groupes d'âge plus jeune (p<0,001). Dix décès ont été rapportés pendant cette période. CONCLUSION: L'incidence du tétanos reste faible et les données sur les hospitalisations révèlent que le Canada a atteint son objectif de réduction de 5 cas ou moins par an au cours des dernières années. En ce qui concerne le TMN, le Canada a réussi à atteindre l'objectif d'élimination des cas. Il faut poursuivre les efforts de vaccination pour tous les groupes, y compris les personnes âgées de 75 ans et plus, afin de maintenir les objectifs à l'avenir.

Severe rhabdomyolysis secondary to COVID-19 mRNA vaccine in a teenager.

BACKGROUND: Rhabdomyolysis, the breakdown of skeletal muscles following an insult or injury, has been established as a possible complication of SARS-CoV-2 infection. Despite being highly effective in preventing COVID-19-related morbidity and mortality, several cases of COVID-19 mRNA vaccination-induced rhabdomyolysis have been identified. We provide the second description of a pediatric case of severe rhabdomyolysis presenting after COVID-19 mRNA vaccination. CASE: DIAGNOSIS/TREATMENT: A 16-year-old male reported to the emergency department with a 2-day history of bilateral upper extremity myalgias and dark urine 2 days after his first dose of COVID-19 vaccine (Pfizer-BioNtech). The initial blood work showed an elevated creatinine kinase (CK) of 141,300 units/L and a normal creatinine of 69 umol/L. The urinalysis was suggestive of myoglobinuria, with the microscopy revealing blood but no red blood cells. Rhabdomyolysis was diagnosed, and the patient was admitted for intravenous hydration, alkalinization of urine, and monitoring of kidney function. CK levels declined with supportive care, while his kidney function remained normal, and no electrolyte abnormalities developed. The patient was discharged 5 days after admission as his symptoms resolved. CONCLUSION: While vaccination is the safest and most effective way to prevent morbidity from COVID-19, clinicians should be aware that rhabdomyolysis could be a rare but treatable adverse event of COVID-19 mRNA vaccination. With early recognition and diagnosis and supportive management, rhabdomyolysis has an excellent prognosis.

Investigation of acute severe hepatitis in children: A review of liver transplant data, Canada, 2021-2022.

An increase in severe acute hepatitis of unknown etiology was first reported in the United Kingdom in April 2022. Following this report, the Public Health Agency of Canada connected with three paediatric liver transplant centres across Canada to determine if an increase in liver transplants was noted. Data demonstrated no observable increase in the number of transplants conducted in 2022. These data in conjunction with a federal, provincial, territorial investigation provided insight into the situation in Canada.

Acute severe hepatitis of unknown origin in children in Canada.

Background: In spring 2022, a series of reports from the United Kingdom and the United States identified an increase in the incidence of acute severe hepatitis in children. The Public Health Agency of Canada (PHAC) collaborated with provincial/territorial health partners to investigate in Canada. Clinical hepatitis, or inflammation of the liver, is not reportable in Canada, so to determine if an increase was occurring above historical levels, the baseline incidence in Canada was estimated. This article estimates the pre-existing baseline incidence of acute severe hepatitis of unknown origin in children in Canada using administrative databases. It further summarizes the outbreak investigation using information from the national case report forms. Methods: A committee with representatives from PHAC and provincial/territorial health partners was established to investigate current cases in Canada. A national probable case definition and case report form were developed, and intentionally created to be highly sensitive to capture all potential cases for etiological investigations. To estimate a nationally representative baseline incidence, hospitalization data were extracted from the Discharge Abstract Database and was combined with data from Québec from the Ministère de la Santé et des Services sociaux. Results: Twenty-eight probable cases of acute severe hepatitis of unknown origin in children were reported between October 1, 2021, to September 23, 2022, by six provinces: British Columbia=1; Alberta=5; Saskatchewan=1; Manitoba=3; Ontario=14; and Québec=4. The estimated national baseline incidence was an average of 70 cases annually, or 5.8 cases per month. Conclusion: There was no apparent increase above the estimated historical baseline levels.