Combating ecosystem collapse from the tropics to the Antarctic.

Globally, collapse of ecosystems-potentially irreversible change to ecosystem structure, composition and function-imperils biodiversity, human health and well-being. We examine the current state and recent trajectories of 19 ecosystems, spanning 58° of latitude across 7.7 M km2 , from Australia's coral reefs to terrestrial Antarctica. Pressures from global climate change and regional human impacts, occurring as chronic 'presses' and/or acute 'pulses', drive ecosystem collapse. Ecosystem responses to 5-17 pressures were categorised as four collapse profiles-abrupt, smooth, stepped and fluctuating. The manifestation of widespread ecosystem collapse is a stark warning of the necessity to take action. We present a three-step assessment and management framework (3As Pathway Awareness, Anticipation and Action) to aid strategic and effective mitigation to alleviate further degradation to help secure our future.

The antibiotic management of gonorrhoea in Ontario, Canada following multiple changes in guidelines: an interrupted time-series analysis.

OBJECTIVE: This study assessed adherence with first-line gonorrhoea treatment recommendations in Ontario, Canada, following recent guideline changes due to antibiotic resistance. METHODS: We used interrupted times-series analyses to analyse treatment data for cases of uncomplicated gonorrhoea reported in Ontario, Canada, between January 2006 and May 2014. We assessed adherence with first-line treatment according to the guidelines in place at the time and the use of specific antibiotics over time. We used the introduction of new recommendations in the Canadian Guidelines for Sexually Transmitted Infections in 2008 and 2011 and the release of the province of Ontario's Guidelines for the Treatment and Management of Gonococcal Infections in Ontario in 2013 as interruptions in the time-series analysis. RESULTS: Overall, 34 287 gonorrhoea cases were reported between 1 January 2006 and 31 May 2014. Treatment data were available for 32 312 (94.2%). Our analysis included 32 272 (94.1%) cases without either a conjunctival or disseminated infection. Following the release of the 2011 recommendations, adherence with first-line recommendations immediately decreased to below 30%. Adherence slowly increased but did not reach baseline levels before the 2013 guidelines were released. Following release of the 2013 guidelines, adherence again decreased; adherence is slowly recovering but by May 2014, was only approximately 60%. CONCLUSIONS: Due to concerns about antibiotic resistance, gonorrhoea treatment guidelines need to be updated regularly and rapidly adopted in practice. Our study showed poor adherence following dissemination of updated guidelines. Over a year after the latest Ontario guidelines were released, 40% of patients did not receive first-line treatment, putting them at risk of treatment failure and potentially promoting further drug resistance. Greater attention should be devoted to dissemination and implementation of new guidelines.

A systematic review and appraisal of the quality of practice guidelines for the management of Neisseria gonorrhoeae infections.

BACKGROUND: Clinical guidelines help ensure consistent care informed by current evidence. As shifts in antimicrobial resistance continue to influence first-line treatment, up-to-date guidelines are important for preventing treatment failure. A guideline's development process will influence its recommendations and users' trust. OBJECTIVE: To assess the quality of current gonorrhoea guidelines' development processes. DATA SOURCES: Multiple databases. STUDY ELIGIBILITY CRITERIA: Original and current English-language guidelines targeting health professionals and containing treatment recommendations for uncomplicated gonorrhoea in the general adult population. STUDY APPRAISAL AND SYNTHESIS METHODS: Two appraisers assessed the guidelines independently using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Scores were combined as per the AGREE II users' manual. RESULTS: We identified 10 guidelines meeting the inclusion criteria. The quality of the gonorrhoea treatment guidelines varied. Most scored poorly on Rigour of Development; information on the evidence review process and methods for formulating recommendations was often missing. The WHO Guidelines for the Treatment of Neisseria gonorrhoeae and UK National Guideline for the Management of Gonorrhoea in Adults scored the highest on Rigour of Development. Methods to address conflicts of interest were often not described in the materials reviewed. Implementation of recommendations was often not addressed. LIMITATIONS: By limiting our study to English-language guidelines, a small number of guidelines we identified were excluded. Our analysis was limited to either published or online materials that were readily available to users. We could not differentiate between items addressed in the development process but not documented from items that were not addressed. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Gonorrhoea treatment guidelines may slow antimicrobial resistance. Many current guidelines are not in line with the current guideline development best practices; this might undermine the perceived trustworthiness of guidelines. By identifying current limitations, this study can help improve the quality of future guidelines.

Effectiveness and Safety of Antibiotic Prophylaxis for Persons Exposed to Cases of Invasive Group A Streptococcal Disease: A Systematic Review.

Among close contacts of patients with invasive group A streptococcal (iGAS) infection, the benefits and harms of chemoprophylaxis are uncertain. We conducted a systematic review of studies that reported on persons who, after being exposed to a case of laboratory-confirmed or probable iGAS, received any antibiotic prophylaxis for the prevention of GAS infection or carriage. Thirty-seven studies including 26 outbreak investigations and 11 case series or reports were included with predominantly descriptive information that suggested that antibiotic prophylaxis may be effective in preventing GAS infection or GAS carriage, with very few serious adverse events. However, current available evidence is scant (with limited information on contacts of iGAS cases) and largely based on studies with weak design and small sample size. Therefore, definitive conclusions on effectiveness of antibiotic prophylaxis cannot be drawn. Well designed prospective studies are required to establish the benefit-harm profile of antibiotic prophylaxis for secondary prevention of GAS disease among close contacts of iGAS cases.

Describing the burden of diphtheria in Canada from 2006 to 2017, using hospital administrative data and reportable disease data.

BACKGROUND: Canada has maintained a low incidence of toxigenic diphtheria since the 1990s, supported by continued commitment to publicly funded vaccination programs. OBJECTIVE: To determine whether hospitalization data, complemented with notifiable disease data, can describe the toxigenic respiratory and cutaneous diphtheria burden in Canada, and to assess if Canada is meeting its diphtheria vaccine-preventable disease-reduction target of zero annual cases of locally transmitted respiratory diphtheria. METHODS: Diphtheria-related hospital discharge data from 2006 to 2017 were extracted from the Discharge Abstract Database (DAD), and diphtheria case counts for the same period were retrieved from the Canadian Notifiable Disease Surveillance System (CNDSS), for descriptive analyses. As data from the province of Québec are not included in the DAD, CNDSS cases from Québec were excluded. RESULTS: A total of 233 diphtheria-related hospitalizations were recorded in the DAD. Of these, diphtheria was the most responsible diagnosis in 23. Half the patients were male (52%), and 57% were 60 years and older. Central region (Ontario) accounted for the most discharge records (61%), followed by Prairie region (Alberta, Manitoba and Saskatchewan; 23%). Cutaneous diphtheria accounted for 43% of records, and respiratory diphtheria accounted for 3%, with the remainder being other diphtheria complications or site unspecified. Two records with diphtheria as the most responsible diagnosis resulted in inpatient deaths. Eighteen cases of diphtheria were reported through CNDSS. Cases occurred in all age groups, with the largest proportions among those aged 20 to 59 years (39%) and those aged 19 years and younger (33%). Cases were only reported in the Prairie (89%) and West Coast (British Columbia; 11%) regions. CONCLUSION: Hospital administrative data are consistent with the low incidence of diphtheria reported in CNDSS, and a low burden of respiratory diphtheria in Canada. Although Canada appears to be on track to meet its disease-reduction target, information on endemic transmission is not available.

Invasive bacterial diseases in northern Canada, 1999 to 2018.

BACKGROUND: The International Circumpolar Surveillance (ICS) program conducts surveillance on five invasive bacterial diseases: pneumococcal disease (IPD), group A streptococcus (iGAS), Haemophilus influenzae (Hi), meningococcal disease (IMD) and group B streptococcus (GBS). Invasive bacterial diseases have a higher burden of disease in northern populations than the rest of Canada. METHODS: To describe the epidemiology of invasive bacterial diseases in northern Canada from 1999 to 2018, data for IPD, iGAS, Hi, IMD and GBS were extracted from the ICS program and the Canadian Notifiable Diseases Surveillance System (CNDSS) and analyzed. RESULTS: The annualized incidence rates for IPD, iGAS, Hi, GBS and IMD were 23.3, 10.5, 8.9, 1.9 and 1.1 per 100,000 population, respectively. The incidence of IPD, iGAS and Hi serotype b were 2.8, 3.2 and 8.8 times higher, respectively, in northern Canada than in the rest of Canada. Rates of disease decreased statistically significantly for IPD (ß=-0.02) and increased statistically for iGAS (ß=0.08) and Hi serotype a (ß=0.04) during the study period. In Northern Canada, the annualized incidence rates for IPD, iGAS and Hi were statistically higher for Indigenous residents than for non-Indigenous residents. The highest incidence rates were among the very young and older age groups. CONCLUSION: Invasive bacterial diseases represent a high burden of disease in Canada's northern populations. Indigenous peoples, children and seniors are particularly at risk.

Acute flaccid myelitis in Canada, 2018 to 2019.

Starting in 2014, biennial clusters of acute flaccid myelitis (AFM), frequently described as "polio-like" illness, have been reported across the United States and elsewhere, often linked to enteroviruses. To assess AFM trends in Canada, we reviewed the Canadian Acute Flaccid Paralysis Surveillance System (CAFPSS) for cases reported during the 2018 and 2019 calendar years that meet the Centers for Disease Control and Prevention case definitions for AFM. A total of 10 cases (8 in 2018 and 2 in 2019) met the confirmed AFM case definition and 30 (26 in 2018 and 4 in 2019) met the probable AFM case definition. Sixty percent of confirmed and probable cases were younger than five years old, and all cases had symptom onset between the months of July and October. Enteroviruses were detected in 50% of confirmed cases. At the time of writing this report, 2020 AFM data were not yet available; it is unknown if a spike in AFM cases will be seen in 2020.