Swish and gargle saliva sampling is a patient-friendly and comparable alternative to nasopharyngeal swabs to detect SARS-CoV-2 in outpatient settings for adults and children.

IMPORTANCE: Widespread and frequent testing for COVID-19 was an important strategy to identify infected patients to isolate and control the spread of the disease during the pandemic. The nasopharyngeal swab (NPS) global supply chain and access to trained healthcare professionals for standard NPS collection were often compromised. Patient discomfort and limited access challenged health systems to reach large numbers for testing in adult and pediatric populations. Our study revealed that swish and gargle saliva (SGS) was comparable to NPS in detecting SARS-CoV-2 and more patient-friendly than NPS. Patients were more likely to repeat the test with SGS. SGS was amenable to self-collection instead of relying on skilled professionals. This comprehensive evaluation highlights the challenges of comparing the accuracy of new methods to imperfect gold standards and identifies additional patient-centric factors that should be considered when defining such standards. Thus, SGS is an advantageous alternative specimen collection for outpatient en masse testing.

Pediatric School Outreach: Clinical Needs of an Urban Student Population.

Pediatric School Outreach (PSO) is a school-based health center (SBHC) in an urban elementary school in Toronto, Canada. PSO focuses on developmental, behavioral, mental health, and educational concerns. A retrospective chart review aimed to characterize demographics, diagnoses, and referrals of patients attending PSO. Of 137 children, ages 2 to 15 years, 73.7% were male; 58.1% had a household annual income of <$30 000 CAD. Possible or confirmed diagnoses included attention deficit hyperactivity disorder (48.5%), learning disability (35.6%), anxiety (22.0%), autism spectrum disorder (16.7%), oppositional defiant disorder (14.4%), and expressive language delay (11.4%). Involvement of community mental health and other agencies was advised in 37.9% of cases. Psychoeducational testing was recommended for 25.0% of patients. Results suggest the need for timely developmental testing, particularly for autism spectrum disorder, and accessible learning disability diagnostic support. There is potential for expansion of interprofessional care at PSO, including psychology, psychiatry, social work, and behavior therapy.

Herpes zoster in older adults in Ontario, 2002-2016: Investigating incidence and exploring equity.

Older adults are at increased risk of herpes zoster (HZ) and post-herpetic neuralgia (PHN) and HZ vaccines are available to help prevent infection. The objective of our study was to provide updated data on incidence of HZ and PHN related to clinical and demographic factors in older adults to inform immunization practices. We conducted a population-based, retrospective cohort study and included all cases of HZ seen in outpatient, emergency department, and hospital settings for adults aged 65 years and over between April 1, 2002 to August 31, 2016 in Ontario, Canada. We calculated the incidence of HZ and PHN, and estimated the proportion within each subgroup that developed PHN. We also assessed incidence by neighbourhood-level income quintile before and after the availability of vaccine for private purchase. The average annual incidence of HZ in any setting was 59.0 per 10,000 older adults, with higher incidence in outpatient as opposed to hospital settings. Incidence was higher in the oldest age groups, females, and those classified as immunocompromised or frail. Relative to the pre-vaccine era, the disparities in incidence of HZ by neighbourhood-level income increased, with higher rates of HZ and PHN seen in those residing in lower income quintiles. Additional prevention efforts should be targeted toward adults who are immunocompromised, frail, and those living in lower socioeconomic quintiles. Future work should assess the impact of the zoster vaccine program with a particular focus on equity in the publicly-funded era.

Incidence of Hospitalizations and Emergency Department Visits for Herpes Zoster in Immunocompromised and Immunocompetent Adults in Ontario, Canada, 2002-2016.

BACKGROUND: Immunocompromised adults are at .increased risk of herpes zoster (HZ) infection and related complications. We aimed to assess the incidence of hospital-attended HZ (ie, seen in hospital or emergency department) in immunocompromised populations and compare it to immunocompetent populations. METHODS: We calculated incidence rates (IRs) of hospital-attended HZ in Ontario, Canada, between 1 April 2002 and 31 August 2016 in adults ≥18 years of age categorized as immunocompromised or immunocompetent. We repeated these analyses by type of immunocompromising condition and provided incidence rate ratios (IRRs) comparing to immunocompetent adults. We also calculated IRs and IRRs of HZ complications by immunocompromised status. RESULTS: There were 135 206 incident cases of hospital-attended HZ during the study period. Immunocompromised adults accounted for 13% of these cases despite representing 3% of the population. The risk of hospital-attended HZ was higher for immunocompromised adults compared with immunocompetent adults (IRR, 2.9 [95% confidence interval {CI}, 2.9-3.0]) and ranged across type of immunocompromising conditions, from 2.6 (95% CI, 2.6-2.7) in those with a solid tumor malignancy to 12.3 (95% CI, 11.3-13.2) in those who had undergone hematopoietic stem cell transplant. The risk of any HZ complication was higher in immunocompromised adults (IRR, 3.6 [95% CI, 3.5-3.7]) and highest for disseminated zoster (IRR, 32.8 [95% CI, 27.8-38.6]). CONCLUSIONS: The risk of hospital-attended HZ and related complications was higher in immunocompromised populations compared with immunocompetent populations. Our findings underscore the high-risk nature of this population and the potential benefits that may be realized through HZ vaccination.

Demonstration of background rates of three conditions of interest for vaccine safety surveillance.

INTRODUCTION: Adverse events following immunization (AEFIs) are unwanted or unexpected health outcomes following vaccination, which may or may not be causally-linked to vaccines. AEFI reporting is important to post-marketing vaccine safety surveillance and has the potential to identify new or rare AEFIs, show increases in known AEFIs, and help to maintain public confidence in vaccine programs. Knowledge of the expected incidence (i.e. background rate) of a possible AEFI is essential to the investigation of vaccine safety signals. We selected three rarely reported AEFIs representing the spectrum of causal association with vaccines, from proven (immune thrombocytopenia [ITP]) to questioned (Kawasaki disease [KD]) to unsubstantiated (multiple sclerosis [MS]) and determined their background rates. METHODS: We extracted data on hospitalizations (CIHI Discharge Abstract Database) for ITP, KD, and MS among Ontario children for the period 2005 to 2014 from IntelliHEALTH. As ITP can be managed without hospitalization, we also extracted emergency department (ED) visits from the CIHI National Ambulatory Care Reporting System. For all conditions, we only counted the first visit and if the same child had both an ED visit and a hospitalization for ITP, only the hospitalization was included. We calculated rates by year, age group and sex using population estimates from 2005-2014, focusing on age groups within the Ontario immunization schedule around vaccine(s) of interest. RESULTS: Per 100,000 population, annual age-specific incidence of ITP in children age 1 to 7 years ranged from 8.9 to 12.2 and annual incidence of KD in children less than 5 years ranged from 19.1 to 32.1. Average annualized incidence of adolescent (11-17 years) MS across the study period was 0.8 per 100,000. DISCUSSION: Despite limitations, including lack of clinical validation, this study provides an example of how health administrative data can be used to determine background rates which may assist with interpretation of passive vaccine safety surveillance.

HIV Prophylaxis in High Risk Newborns: An Examination of Sociodemographic Factors in an Inner City Context.

Background. Perinatal HIV transmission is less than 1% with antiretroviral (ARV) prophylaxis. Transmission risk appears higher in "high risk" dyads, yet this is not well defined, possibly exposing more infants to combination ARV compared with standard care. Objective. To describe characteristics of mother-infant dyads where infants received ARVs and how these characteristics relate to specific ARV regimens. Methods. Retrospective chart review of ARV-receiving newborns at St. Michael's Hospital from 2007 to 2012 (and their mothers). Numerical and categorical variables were analyzed using t-tests/ANOVA F-tests and Fisher's exact tests, respectively. Results. Maternal HIV status at delivery was as follows: 69% positive and 24% unknown. Maternal factors significantly associated with newborn-triple therapy are Canadian origin, substance abuse, unstable housing, lost custody of previous children, and sex work. Neonatal factors are child protective services involvement, NICU, and lengthier admission. Maternal factors associated with monotherapy are African origin, HIV-positive, employment, and education. Further analysis based on maternal presentation at delivery demonstrated unequal distribution of many aforementioned factors. Discussion. This cohort revealed associations between particular factors and newborn-monotherapy or triple therapy that exist, suggesting that sociodemographic factors may influence the choice of ARV regimen. Canadian perinatal HIV transmission guidelines should qualify how to risk stratify newborns and consider use of rapid HIV antibody testing.

Twenty Years of Medically-Attended Pediatric Varicella and Herpes Zoster in Ontario, Canada: A Population-Based Study.

OBJECTIVE: To determine if reductions in medically-attended pediatric varicella and herpes zoster occurred in Ontario, Canada, after publicly-funded varicella immunization was implemented in 2004. METHODS: For fiscal years (FY) 1992-2011, we examined data on varicella and herpes zoster physician office visits, emergency department (ED) visits, hospitalizations (including for varicella-associated skin and soft tissue infections [SSTI]), and intensive care unit (ICU) admissions, among those aged <18 years. The pre-vaccine, privately-available, and vaccine program eras were FY1992-1998, FY1999-2003, and FY2004-2011, respectively. We used Poisson regressionand Kruskal-Wallis tests (all at the p<0.05 level of significance), and compared rates using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: Incidence of varicella office visits declined over the study period from a high of 25.1/1,000 in FY1994 to a low of 3.2/1,000 in FY2011. ED visits and hospitalizations followed similar patterns of decreasing rates later in the study period. IRRs comparing the vaccine program versus pre-vaccine eras were 0.29 (95%CI: 0.26-0.32) for office visits, 0.29 (95%CI: 0.21-0.40) for ED visits, and 0.41 (95%CI: 0.10-1.69) for hospitalizations. Annual declines in varicella office visits were 7.7%, 9.1%, 8.4%, and 8.4% per year among children aged <1 year, 1-4 years, 5-11 years, and ≥12 years, respectively (all p<0.001). Age-specific rates of varicella-associated SSTI declined significantly among children <12 years (p<0.001) and rates of ICU admissions decreased significantly for children <1 year (p = 0.02). (p<0.001) over the study period. For children aged 5-17 years, herpes zoster office visits decreased whereas ED visits increased (both p<0.001) and there was a small, non-significant (p = 0.07), decrease in hospitalizations. CONCLUSION: Medically-attended varicella decreased during the study period, particularly since varicella vaccine was publicly-funded. Results suggest immunization program-related changes in varicella epidemiology, including herd effects, demonstrated by reductions in varicella in program-ineligible age groups. We did not observe a consistent impact on herpes zoster.

Parental perceptions of school-based influenza immunisation in Ontario, Canada: a qualitative study.

OBJECTIVE: To understand the perspectives of Ontario parents regarding the advantages and disadvantages of adding influenza immunisation to the currently existing Ontario school-based immunisation programmes. DESIGN: Descriptive qualitative study. PARTICIPANTS: Parents of school-age children in Ontario, Canada, who were recruited using a variety of electronic strategies (social media, emails and media releases), and identified as eligible (Ontario resident, parent of one or more school-age children, able to read/write English) on the basis of a screening questionnaire. We used stratified purposeful sampling to obtain maximum variation in two groups: parents who had ever immunised at least one child against influenza or who had never done so. We conducted focus groups (teleconference or internet forum) and individual interviews to collect data. Thematic analysis was used to analyse the data. SETTING: Ontario, Canada. RESULTS: Of the 55 participants, 16 took part in four teleconference focus groups, 35 in 6 internet forum focus groups and four in individual interviews conducted between October 2012 and February 2013. Participants who stated that a school-based influenza immunisation programme would be worthwhile for their child valued its convenience and its potential to reduce influenza transmission without interfering with the family routine. However, most thought that for a programme to be acceptable, it would need to be well designed and voluntary, with adequate parental control and transparent communication between the key stakeholder groups of public health, schools and parents. CONCLUSIONS: These results will benefit decision-makers in the public health and education sectors as they consider the advantages and disadvantages of immunising children in schools as part of a system-wide influenza prevention approach. Further research is needed to assess the perceptions of school board and public health stakeholders.

The good, bad, and ugly of online recruitment of parents for health-related focus groups: lessons learned.

BACKGROUND: We describe our experiences with identifying and recruiting Ontario parents through the Internet, primarily, as well as other modes, for participation in focus groups about adding the influenza vaccine to school-based immunization programs. OBJECTIVE: Our objectives were to assess participation rates with and without incentives and software restrictions. We also plan to examine study response patterns of unique and multiple submissions and assess efficiency of each online advertising mode. METHODS: We used social media, deal forum websites, online classified ads, conventional mass media, and email lists to invite parents of school-aged children from Ontario, Canada to complete an online questionnaire to determine eligibility for focus groups. We compared responses and paradata when an incentive was provided and there were no software restrictions to the questionnaire (Period 1) to a period when only a single submission per Internet protocol (IP) address (ie, software restrictions invoked) was permitted and no incentive was provided (Period 2). We also compared the median time to complete a questionnaire, response patterns, and percentage of missing data between questionnaires classified as multiple submissions from the same Internet protocol (IP) address or email versus unique submissions. Efficiency was calculated as the total number of hours study personnel devoted to an advertising mode divided by the resultant number of unique eligible completed questionnaires . RESULTS: Of 1346 submitted questionnaires, 223 (16.6%) were incomplete and 34 (2.52%) did not meet the initial eligibility criteria. Of the remaining 1089 questionnaires, 246 (22.6%) were not from Ontario based on IP address and postal code, and 469 (43.1%) were submitted from the same IP address or email address (multiple submissions). In Period 2 vs Period 1, a larger proportion of questionnaires were submitted from Ontario (92.8%, 141/152 vs 75.1%, 702/937, P<.001), and a smaller proportion of same IP addresses (7.9%, 12/152 vs 47.1%, 441/937, P<.001) were received. Compared to those who made unique submissions, those who made multiple submissions spent less time per questionnaire (166 vs 215 seconds, P<.001), and had a higher percentage of missing data among their responses (15.0% vs 7.6%, P=.004). Advertisements posted on RedFlagDeals were the most efficient for recruitment (0.03 hours of staff time per questionnaire), whereas those placed on Twitter were the least efficient (3.64 hours of staff time per questionnaire). CONCLUSIONS: Using multiple online advertising strategies was effective for recruiting a large sample of participants in a relatively short period time with minimal resources. However, risks such as multiple submissions and potentially fraudulent information need to be considered. In our study, these problems were associated with providing an incentive for responding, and could have been partially avoided by activating restrictive software features for online questionnaires.

Have changing pneumococcal vaccination programmes impacted disease in Ontario?

BACKGROUND: Publicly funded infant 7-valent pneumococcal conjugate vaccine (PCV7) was introduced in Ontario, Canada in 2005 and was replaced by 10- and 13-valent vaccines (PCV10, PCV13) in October 2009 and November 2010, respectively. Among adults ≥ 65 years, a 23-valent polysaccharide vaccine (PPV23) has been universally available since 1996. In January 2012, PCV13 was approved for adults ≥ 50 years. This study examines the impact of publicly funded vaccination programmes on invasive pneumococcal disease (IPD). METHODS: Laboratory data from population-based surveillance for IPD conducted at the Toronto Invasive Bacterial Disease Network and from Public Health Ontario Laboratories between January 1, 2008 and December 31, 2010 were analyzed. RESULTS: Between 2008 and 2010 there were 3259 cases of IPD; overall incidence was 7.4/9.3/8.3 per 100,000 in 2008/9/10, respectively. Incidence increased significantly among adults 65+ years during the period; this group had the highest incidence (21.5-25.6/100,000). The second highest incidence in 2008 and 2009 was in infants <1 year, whereas in 2010 it was in children 1-4 years. Among children <5 years, 68% and 19% of serotypes were covered by PCV13 and PCV10, respectively, between 2008 and 2010. In 2009, 6 cases with the 3 additional PCV10 serotypes were reported in infants compared with 2 in 2010. Among persons eligible for PCV7 (born≥2004), there was a 77% decrease in the rate of IPD due to PCV7 serotypes between 2008 and 2010 and a 60% decrease in PCV7 serotypes among persons not vaccine-eligible (born<2004). There was a 15% difference in serotype coverage between PCV13 and the 23-valent polysaccharide vaccine in adults≥50 years. CONCLUSIONS: During Ontario's PCV7 programme, serotype-specific decreases in IPD were observed, suggesting vaccine programme success, including herd immunity. Our results also suggest some early impact among infants from PCV10 introduction. A substantial burden of disease was also observed among older adults.

Feasibility study on the Model Schools Paediatric Health Initiative pilot project.

OBJECTIVES: To assess the feasibility and efficacy of a school-based health centre (SBHC) established at an inner-city elementary school to help alleviate barriers to accessing health care. METHODS: A retrospective chart review of the first year of the SBHC was conducted. Feasibility metrics included the number of children who enrolled at the SBHC. Efficacy metrics included the proportion of enrolled children who attended and received new diagnoses and treatment plans. RESULTS: A total of 379 children enrolled at the SBHC and 127 children attended. Of the SBHC users, 74.0% received a new diagnosis and 90.6% received a treatment plan; 79.6% were from families with an annual income <$30,000, and 91.6% were from families whose first language was not English. CONCLUSION: The SBHC represents a feasible and efficacious way to enhance the delivery of health care to inner-city children.

OBJECTIF: Évaluer la faisabilité et l'efficacité d'un centre de santé en milieu scolaire (CSMS) installé dans l'école primaire d'un quartier pauvre pour contribuer à réduire les obstacles liés à l'accès aux soins. MÉTHODOLOGIE: Les chercheurs ont mené une analyse rétrospective des dossiers de la première année du CSMS. Comme mesures de faisabilité, ils ont inclus le nombre d'enfants inscrits au CSMC, tandis que les mesures d'efficacité incluaient la proportion d'enfants inscrits qui ont utilisé le service et reçu de nouveaux diagnostics et plans thérapeutiques. RÉSULTATS: Au total, 379 enfants se sont inscrits au CSMS et 127 ont utilisé le service. Parmi les utilisateurs du CSMS, 74,0 % ont reçu un nouveau diagnostic et 90,6 %, un plan thérapeutique. De plus, 79,6 % provenaient d'une famille dont le revenu annuel était inférieur à 30 000 $, et la langue maternelle de 91,6 % d'entre eux n'était pas l'anglais. CONCLUSION: Le CSMS est un moyen faisable et efficace d'améliorer la prestation des soins aux enfants des quartiers pauvres.