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1.  Simulation Study of the Effect of Influenza and Influenza Vaccination on Risk of Acquiring Guillain-Barré Syndrome 
Emerging Infectious Diseases  2015;21(2):224-231.
Under typical conditions, such as influenza incidence rates of >5% and vaccine effectiveness >60%, vaccination reduced risk.
It is unclear whether seasonal influenza vaccination results in a net increase or decrease in the risk for Guillain-Barré syndrome (GBS). To assess the effect of seasonal influenza vaccination on the absolute risk of acquiring GBS, we used simulation models and published estimates of age- and sex-specific risks for GBS, influenza incidence, and vaccine effectiveness. For a hypothetical 45-year-old woman and 75-year-old man, excess GBS risk for influenza vaccination versus no vaccination was −0.36/1 million vaccinations (95% credible interval −1.22 to 0.28) and −0.42/1 million vaccinations (95% credible interval, –3.68 to 2.44), respectively. These numbers represent a small absolute reduction in GBS risk with vaccination. Under typical conditions (e.g. influenza incidence rates >5% and vaccine effectiveness >60%), vaccination reduced GBS risk. These findings should strengthen confidence in the safety of influenza vaccine and allow health professionals to better put GBS risk in context when discussing influenza vaccination with patients.
doi:10.3201/eid2102.131879
PMCID: PMC4313628  PMID: 25625590
seasonal influenza; influenza vaccination; Guillain-Barré syndrome; risk modeling; decision tree modeling; viruses; vaccination; influenza; modeling
2.  An assessment of mumps vaccine effectiveness by dose during an outbreak in Canada 
Background
This investigation was done to assess vaccine effectiveness of one and two doses of the measles, mumps and rubella (MMR) vaccine during an outbreak of mumps in Ontario. The level of coverage required to reach herd immunity and interrupt community transmission of mumps was also estimated.
Methods
Information on confirmed cases of mumps was retrieved from Ontario’s integrated Public Health Information System. Cases that occurred between Sept. 1, 2009, and June 10, 2010, were included. Selected health units supplied coverage data from the Ontario Immunization Record Information System. Vaccine effectiveness by dose was calculated using the screening method. The basic reproductive number (R0) represents the average number of new infections per case in a fully susceptile population, and R0 values of between 4 and 10 were considered for varying levels of vaccine effectiveness.
Results
A total of 134 confirmed cases of mumps were identified. Information on receipt of MMR vaccine was available for 114 (85.1%) cases, of whom 63 (55.3%) reported having received only one dose of vaccine; 32 (28.1%) reported having received two doses. Vaccine effectiveness of one dose of the MMR vaccine ranged from 49.2% to 81.6%, whereas vaccine effectiveness of two doses ranged from 66.3% to 88.0%. If we assume vaccine effectiveness of 85% for two doses of the vaccine, vaccine coverage of 88.2% and 98.0% would be needed to interrupt community transmission of mumps if the corresponding reproductive values were four and six.
Interpretation
Our estimates of vaccine effectiveness of one and two doses of mumps-containing vaccine were consistent with the estimates that have been reported in other outbreaks. Outbreaks occurring in Ontario and elsewhere serve as a warning against complacency over vaccination programs.
doi:10.1503/cmaj.101371
PMCID: PMC3114893  PMID: 21576295
3.  Invasive Bacterial Diseases in Northern Canada 
Emerging Infectious Diseases  2008;14(1):34-40.
Data collected by International Circumpolar Surveillance contribute to understanding the epidemiology of these diseases.
International Circumpolar Surveillance (ICS) is a population-based invasive bacterial disease surveillance network. Participating Canadian regions include Yukon, Northwest Territories, Nunavut, and northern regions of Québec and Labrador (total population 132,956, 59% aboriginal). Clinical and demographic information were collected by using standardized surveillance forms. Bacterial isolates were forwarded to reference laboratories for confirmation and serotyping. After pneumococcal conjugate vaccine introduction, crude annual incidence rates of invasive Streptococcus pneumoniae decreased from 34.0/100,000 population (1999–2002) to 23.6/100,000 population (2003–2005); substantial reductions were shown among aboriginals. However, incidence rates of S. pneumoniae, Haemophilus influenzae, and group A streptococci were higher in aboriginal populations than in non-aboriginal populations. H. influenzae type b was rare; 52% of all H. influenzae cases were caused by type a. Data collected by ICS contribute to the understanding of the epidemiology of invasive bacterial diseases among northern populations, which assists in formulation of prevention and control strategies, including immunization recommendations.
doi:10.3201/eid1401.061522
PMCID: PMC2600163  PMID: 18258074
Pneumococcal infections; Arctic regions; pneumococcal vaccines; Streptococcus pneumoniae; Haemophilus influenzae; streptococcal infections; Canada; surveillance; research
4.  Electronic immunization data collection systems: application of an evaluation framework 
Background
Evaluating the features and performance of health information systems can serve to strengthen the systems themselves as well as to guide other organizations in the process of designing and implementing surveillance tools. We adapted an evaluation framework in order to assess electronic immunization data collection systems, and applied it in two Ontario public health units.
Methods
The Centers for Disease Control and Prevention’s Guidelines for Evaluating Public Health Surveillance Systems are broad in nature and serve as an organizational tool to guide the development of comprehensive evaluation materials. Based on these Guidelines, and informed by other evaluation resources and input from stakeholders in the public health community, we applied an evaluation framework to two examples of immunization data collection and examined several system attributes: simplicity, flexibility, data quality, timeliness, and acceptability. Data collection approaches included key informant interviews, logic and completeness assessments, client surveys, and on-site observations.
Results
Both evaluated systems allow high-quality immunization data to be collected, analyzed, and applied in a rapid fashion. However, neither system is currently able to link to other providers’ immunization data or provincial data sources, limiting the comprehensiveness of coverage assessments. We recommended that both organizations explore possibilities for external data linkage and collaborate with other jurisdictions to promote a provincial immunization repository or data sharing platform.
Conclusions
Electronic systems such as the ones described in this paper allow immunization data to be collected, analyzed, and applied in a rapid fashion, and represent the infostructure required to establish a population-based immunization registry, critical for comprehensively assessing vaccine coverage.
doi:10.1186/1472-6947-14-5
PMCID: PMC3898919  PMID: 24423014
Immunization; Information systems; Data collection; Program evaluation
5.  Association between Birth Order and Emergency Room Visits and Acute Hospital Admissions following Pediatric Vaccination: A Self-Controlled Study 
PLoS ONE  2013;8(12):e81070.
Objective
We investigated the association between a child's birth order and emergency room (ER) visits and hospital admissions following 2-,4-,6- and 12-month pediatric vaccinations.
Methods
We included all children born in Ontario between April 1st, 2006 and March 31st, 2009 who received a qualifying vaccination. We identified vaccinations, ER visits and admissions using health administrative data housed at the Institute for Clinical Evaluative Sciences. We used the self-controlled case series design to compare the relative incidence (RI) of events among 1st-born and later-born children using relative incidence ratios (RIR).
Results
For the 2-month vaccination, the RIR for 1st-borns versus later-born children was 1.37 (95% CI: 1.19–1.57), which translates to 112 additional events/100,000 vaccinated. For the 4-month vaccination, the RIR for 1st-borns vs. later-borns was 1.70 (95% CI: 1.45–1.99), representing 157 additional events/100,000 vaccinated. At 6 months, the RIR for 1st vs. later-borns was 1.27 (95% CI: 1.09–1.48), or 77 excess events/100,000 vaccinated. At the 12-month vaccination, the RIR was 1.11 (95% CI: 1.02–1.21), or 249 excess events/100,000 vaccinated.
Conclusions
Birth order is associated with increased incidence of ER visits and hospitalizations following vaccination in infancy. 1st-born children had significantly higher relative incidence of events compared to later-born children.
doi:10.1371/journal.pone.0081070
PMCID: PMC3852020  PMID: 24324662
6.  Rubella immunity among prenatal women in Ontario, 2006–2010 
BMC Infectious Diseases  2013;13:362.
Background
Countries of the Americas have been working towards rubella elimination since 2003 and endemic rubella virus transmission appears to have been interrupted since 2009. To contribute towards monitoring of rubella elimination, we assessed rubella seroprevalence among prenatal screening tests performed in Ontario.
Methods
Specimens received for prenatal rubella serologic testing at the Public Health Ontario Laboratory, the provincial reference laboratory, between 2006 and 2010 were analyzed. A patient-based dataset was created using all tests occurring among 15–49 year-old females, where prenatal screening was indicated. Multiple tests were assigned to the same patient on the basis of health card number, name and date of birth. Only unique tests performed at least nine months apart were included. SAS version 9.2 was used for analysis.
Results
Between 2006 and 2010, we identified 459,963 women who underwent 551,160 unique prenatal screening tests for rubella. Of these, 81.6%, 17.1% and 1.4% had one, two and three or more tests respectively.
Rubella immunity remained stable at approximately 90% overall; the proportion of susceptible women was 4.4%. Additionally, 0.6% of women were initially susceptible and subsequently developed immunity. Across the province, susceptibility was highest in the north and declined with increasing age (p < 0.0001). Among women with multiple tests, the proportion who remained susceptible declined as the number of years between tests increased (p < .0001). Based on age at first test, younger women had the highest susceptibility (4.2% among 15–19 year-olds) and were significantly more likely to develop immunity if previously susceptible (p < .0001).
Conclusion
Rubella susceptibility among prenatal women in Ontario supports elimination goals as population immunity in this group is relatively high. Higher susceptibility among young women and women living in the north highlights an opportunity for greater focus on identification and immunization of susceptible women in these groups.
doi:10.1186/1471-2334-13-362
PMCID: PMC3735453  PMID: 23914729
Rubella; Seroprevalence study; Prenatal screening; Rubella elimination goals; Ontario; Canada
7.  Contagious Comments: What Was the Online Buzz About the 2011 Quebec Measles Outbreak? 
PLoS ONE  2013;8(5):e64072.
Background
Although interruption of endemic measles was achieved in the Americas in 2002, Quebec experienced an outbreak in 2011 of 776 reported cases; 80% of these individuals had not been fully vaccinated. We analyzed readers’ online responses to Canadian news articles regarding the outbreak to better understand public perceptions of measles and vaccination.
Methods
We searched Canadian online English and French news sites for articles posted between April 2011 and March 2012 containing the words “measles” and “Quebec”. We included articles that i) concerned the outbreak or related vaccination strategies; and ii) generated at least ten comments. Two English and two bilingual researchers coded the unedited comments, categorizing codes to allow themes to emerge.
Results
We analyzed 448 comments from 188 individuals, in response to three French articles and six English articles; 112 individuals expressed positive perceptions of measles vaccination (2.2 comments/person), 38 were negative (4.2 comments/person), 11 had mixed feelings (1.5 comments/person), and 27 expressed no opinion (1.1 comments/person). Vaccine-supportive themes involved the success of vaccination in preventing disease spread, societal responsibility to vaccinate for herd immunity, and refutation of the autism link. Those against measles vaccination felt it was a personal rather than societal choice, and conveyed a distrust of vaccine manufacturers, believing that measles infection is not only safe but safer than vaccination. Commenters with mixed feelings expressed uncertainty of the infection’s severity, and varied in support of all vaccines based on perceived risk/benefit ratios.
Conclusion
The anti-vaccine minority’s volume of comments translates to a disproportionately high representation on online boards. Public health messages should address concerns by emphasizing that immunization is always a personal choice in Canada, and that the pharmaceutical industry is strictly controlled. Illustrating the dangers of measles through personal stories, rather than scientific data only, may also serve to strengthen messaging.
doi:10.1371/journal.pone.0064072
PMCID: PMC3654905  PMID: 23691152
8.  Local public health response to vaccine-associated measles: case report 
BMC Public Health  2013;13:269.
Background
The most appropriate public health approach to vaccine-associated measles in immunocompromised patients is unknown, mainly because these cases are rare and transmission of vaccine-associated measles has not been previously documented. In this case report, we describe Peel Public Health’s response to a vaccine-associated measles case in an immunocompromised child in Ontario, Canada.
Case presentation
A five-year-old Canadian-born boy with a history of a hematopoetic stem cell transplant three years previously received live attenuated measles, mumps, and rubella (MMR) vaccine. Over the subsequent 7 to 14 days, he developed an illness clinically consistent with measles. There was no travel history or other measles exposure. Serology and polymerase chain reaction (PCR) testing confirmed acute measles infection. Following discussion with pediatric infectious diseases specialists, but prior to the availability of virus sequencing, it was felt that this case was most likely due to vaccine strain. Although no microbiologically confirmed secondary cases of vaccine-associated measles have been previously described, we sent notification letters to advise all contacts of measles symptoms since the likelihood of transmission from an immunocompromised patient was low, but theoretically possible. We decided to stratify contacts into immune competent and compromised and to deal with the latter group conservatively by excluding them as if they were exposed to wild-type measles because the risk of transmission of disease in this population, while presumably very low, is unknown. However, no contacts self-identified as immunocompromised and there were no secondary cases. Subsequent genotyping confirmed that this case was caused by vaccine strain measles virus.
Conclusion
The public health approach to contact tracing and exclusions for vaccine-associated measles in immunocompromised patients is unclear. The rarity of secondary cases provides further evidence that the risk to the general public is likely extremely low. Although the risk appears negligible, exclusion and administration of immune globulin may be considered for susceptible, immunocompromised contacts of cases of vaccine-associated measles in immunocompromised patients.
doi:10.1186/1471-2458-13-269
PMCID: PMC3623646  PMID: 23531102
(3–10): measles; Immunization; Vaccine associated; Vaccine strain; Contact tracing; Adverse event
10.  Human papilloma virus vaccination programs reduce health inequity in most scenarios: a simulation study 
BMC Public Health  2012;12:935.
Background
The global and within-country epidemiology of cervical cancer exemplifies health inequity. Public health programs may reduce absolute risk but increase inequity; inequity may be further compounded by screening programs. In this context, we aimed to explore what the impact of human papillomavirus (HPV) vaccine might have on health equity allowing for uncertainty surrounding the long-term effect of HPV vaccination programs.
Methods
A simple static multi-way sensitivity analysis was carried out to compare the relative risk, comparing after to before implementation of a vaccination program, of infections which would cause invasive cervical cancer if neither prevented nor detected, using plausible ranges of vaccine effectiveness, vaccination coverage, screening sensitivity, screening uptake and changes in uptake.
Results
We considered a total number of 3,793,902 scenarios. In 63.9% of scenarios considered, vaccination would lead to a better outcome for a population or subgroup with that combination of parameters. Regardless of vaccine effectiveness and coverage, most simulations led to lower rates of disease.
Conclusions
If vaccination coverage and screening uptake are high, then communities are always better off with a vaccination program. The findings highlight the importance of achieving and maintaining high immunization coverage and screening uptake in high risk groups in the interest of health equity.
doi:10.1186/1471-2458-12-935
PMCID: PMC3529110  PMID: 23113881
11.  Influenza vaccination coverage across ethnic groups in Canada 
Background:
The success of influenza vaccination campaigns may be suboptimal if subgroups of the population face unique barriers or have misconceptions about vaccination. We conducted a national study to estimate influenza vaccine coverage across 12 ethnic groups in Canada to assess the presence of ethnic disparities.
Methods:
We pooled responses to the Canadian Community Health Survey between 2003 and 2009 (n = 437 488). We estimated ethnicity-specific self-reported influenza vaccine coverage for the overall population, for people aged 65 years and older, and for people aged 12–64 years with and without chronic conditions. We used weighted logistic regression models to examine the association between ethnicity and influenza vaccination, adjusting for sociodemographic factors and health status.
Results:
Influenza vaccination coverage ranged from 25% to 41% across ethnic groups. After adjusting for sociodemographic factors and health status for people aged 12 years and older, all ethnic groups were more likely to have received a vaccination against influenza than people who self-identified as white, with the exception of those who self-identified as black (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.88–1.15). Compared with white Canadians, Canadians of Filipino (OR 2.00, 95% CI 1.67–2.40) and Southeast Asian (OR 1.66, 95% CI 1.36–2.03) descent had the greatest likelihood of having received vaccination against influenza.
Interpretation:
Influenza vaccine coverage in Canada varies by ethnicity. Black and white Canadians have the lowest uptake of influenza vaccine of the ethnic groups represented in our study. Further research is needed to understand the facilitators, barriers and misconceptions relating to vaccination that exist across ethnic groups, and to identify promotional strategies that may improve uptake among black and white Canadians.
doi:10.1503/cmaj.111628
PMCID: PMC3478352  PMID: 22966054
12.  The Impact of Infection on Population Health: Results of the Ontario Burden of Infectious Diseases Study 
PLoS ONE  2012;7(9):e44103.
Background
Evidence-based priority setting is increasingly important for rationally distributing scarce health resources and for guiding future health research. We sought to quantify the contribution of a wide range of infectious diseases to the overall infectious disease burden in a high-income setting.
Methodology/Principal Findings
We used health-adjusted life years (HALYs), a composite measure comprising premature mortality and reduced functioning due to disease, to estimate the burden of 51 infectious diseases and associated syndromes in Ontario using 2005–2007 data. Deaths were estimated from vital statistics data and disease incidence was estimated from reportable disease, healthcare utilization, and cancer registry data, supplemented by local modeling studies and national and international epidemiologic studies. The 51 infectious agents and associated syndromes accounted for 729 lost HALYs, 44.2 deaths, and 58,987 incident cases per 100,000 population annually. The most burdensome infectious agents were: hepatitis C virus, Streptococcus pneumoniae, Escherichia coli, human papillomavirus, hepatitis B virus, human immunodeficiency virus, Staphylococcus aureus, influenza virus, Clostridium difficile, and rhinovirus. The top five, ten, and 20 pathogens accounted for 46%, 67%, and 75% of the total infectious disease burden, respectively. Marked sex-specific differences in disease burden were observed for some pathogens. The main limitations of this study were the exclusion of certain infectious diseases due to data availability issues, not considering the impact of co-infections and co-morbidity, and the inability to assess the burden of milder infections that do not result in healthcare utilization.
Conclusions/Significance
Infectious diseases continue to cause a substantial health burden in high-income settings such as Ontario. Most of this burden is attributable to a relatively small number of infectious agents, for which many effective interventions have been previously identified. Therefore, these findings should be used to guide public health policy, planning, and research.
doi:10.1371/journal.pone.0044103
PMCID: PMC3433488  PMID: 22962601
13.  Epidemiology of serogroup B invasive meningococcal disease in Ontario, Canada, 2000 to 2010 
BMC Infectious Diseases  2012;12:202.
Background
Invasive meningococcal disease (IMD) caused by serogroup B is the last major serogroup in Canada to become vaccine-preventable. The anticipated availability of vaccines targeting this serogroup prompted an assessment of the epidemiology of serogroup B disease in Ontario, Canada.
Methods
We retrieved information on confirmed IMD cases reported to Ontario’s reportable disease database between January 1, 2000 and December 31, 2010 and probabilistically-linked these cases to Public Health Ontario Laboratory records. Rates were calculated with denominator data obtained from Statistics Canada. We calculated a crude number needed to vaccinate using the inverse of the infant (<1 year) age-specific incidence multiplied by expected vaccine efficacies between 70% and 80%, and assuming only direct protection (no herd effects).
Results
A total of 259 serogroup B IMD cases were identified in Ontario over the 11-year period. Serogroup B was the most common cause of IMD. Incidence ranged from 0.11 to 0.27/100,000/year, and fluctuated over time. Cases ranged in age from 13 days to 101 years; 21.4% occurred in infants, of which 72.7% were <6 months. Infants had the highest incidence (3.70/100,000). Case-fatality ratio was 10.7% overall. If we assume that all infant cases would be preventable by vaccination, we would need to vaccinate between 33,784 and 38,610 infants to prevent one case of disease.
Conclusions
Although rare, the proportion of IMD caused by serogroup B has increased and currently causes most IMD in Ontario, with infants having the highest risk of disease. Although serogroup B meningococcal vaccines are highly anticipated, our findings suggest that decisions regarding publicly funding serogroup B meningococcal vaccines will be difficult and may not be based on disease burden alone.
doi:10.1186/1471-2334-12-202
PMCID: PMC3472197  PMID: 22928839
Invasive meningococcal disease; Neisseria meningitidis; Serogroup B; Epidemiology; Surveillance; Ontario; Canada
14.  Factors associated with initiation and completion of the quadrivalent human papillomavirus vaccine series in an ontario cohort of grade 8 girls 
BMC Public Health  2011;11:645.
Background
Although over a hundred million dollars have been invested in offering free quadrivalent human papillomavirus (HPV) vaccination to young girls in Ontario, there continues to be very little information about its usage. In order to successfully guide future HPV vaccine programming, it is important to monitor HPV vaccine use and determine factors associated with use in this population.
Methods
Linking administrative health and immunization databases, we conducted a population-based, retrospective cohort study of girls eligible for Ontario's Grade 8 HPV vaccination program in Kingston, Frontenac, Lennox, and Addington. We determined the proportion of girls who initiated (at least one dose) and completed (all three doses) the vaccination series overall and according to socio-demographics, vaccination history, health services utilization, medical history, and program year. Multivariable logistic regression was used to estimate the strength of association between individual factors and initiation and completion, adjusted for all other factors.
Results
We identified a cohort of 2519 girls, 56.6% of whom received at least one dose of the HPV vaccine. Among vaccinated girls, 85.3% received all three doses. Vaccination history was the strongest predictor of initiation in that girls who received the measles-mumps-rubella, meningococcal C, and hepatitis B vaccines were considerably more likely to also receive the HPV vaccine (odds ratio 4.89; 95% confidence interval 4.04-5.92). Nevertheless, HPV vaccine uptake was more than 20% lower than that of these other vaccines. In addition, while series initiation was not influenced by income, series completion was. In particular, girls of low income were the least likely to receive all three indicated doses of the HPV vaccine (odds ratio 0.45; 95% confidence interval 0.28-0.72).
Conclusions
The current low level of HPV vaccine acceptance in Kingston, Frontenac, Lennox, and Addington will likely have important implications in terms of the health benefits and cost-effectiveness of its publicly funded program. We identified important factors associated with series initiation and completion that should be considered in efforts to improve HPV vaccine use in this population.
doi:10.1186/1471-2458-11-645
PMCID: PMC3224094  PMID: 21838921
human papillomavirus vaccine; cohort studies; vaccine acceptability; vaccination; immunization
15.  Estimating background rates of Guillain-Barré Syndrome in Ontario in order to respond to safety concerns during pandemic H1N1/09 immunization campaign 
BMC Public Health  2011;11:329.
Background
The province of Ontario, Canada initiated mass immunization clinics with adjuvanted pandemic H1N1 influenza vaccine in October 2009. Due to the scale of the campaign, temporal associations with Guillain-Barré syndrome (GBS) and vaccination were expected. The objectives of this analysis were to estimate the number of background GBS cases expected to occur in the projected vaccinated population and to estimate the number of additional GBS cases which would be expected if an association with vaccination existed. The number of influenza-associated GBS cases was also determined.
Methods
Baseline incidence rates of GBS were determined from published Canadian studies and applied to projected vaccine coverage data to estimate the expected number of GBS cases in the vaccinated population. Assuming an association with vaccine existed, the number of additional cases of GBS expected was determined by applying the rates observed during the 1976 Swine Flu and 1992/1994 seasonal influenza campaigns in the United States. The number of influenza-associated GBS cases expected to occur during the vaccination campaign was determined based on risk estimates of GBS after influenza infection and provincial influenza infection rates using a combination of laboratory-confirmed cases and data from a seroprevalence study.
Results
The overall provincial vaccine coverage was estimated to be between 32% and 38%. Assuming 38% coverage, between 6 and 13 background cases of GBS were expected within this projected vaccinated cohort (assuming 32% coverage yielded between 5-11 background cases). An additional 6 or 42 cases would be expected if an association between GBS and influenza vaccine was observed (assuming 32% coverage yielded 5 or 35 additional cases); while up to 31 influenza-associated GBS cases could be expected to occur. In comparison, during the same period, only 7 cases of GBS were reported among vaccinated persons.
Conclusions
Our analyses do not suggest an increased number of GBS cases due to the vaccine. Awareness of expected rates of GBS is crucial when assessing adverse events following influenza immunization. Furthermore, since individuals with influenza infection are also at risk of developing GBS, they must be considered in such analyses, particularly if the vaccine campaign and disease are occurring concurrently.
doi:10.1186/1471-2458-11-329
PMCID: PMC3112136  PMID: 21586163
16.  Perceptions of frontline staff regarding data collection methodologies used during the 2009 A H1N1 influenza immunization campaign in Canada 
BMC Public Health  2010;10:796.
Background
During the 2009 H1N1 immunization campaign, electronic and hybrid (comprising both electronic and paper components) systems were employed to collect client-level vaccination data in clinics across Canada. Because different systems were used across the country, the 2009 immunization campaign offered an opportunity to study the usability of the various data collection methods.
Methods
A convenience sample of clinic staff working in public health agencies and hospitals in 9 provinces/territories across Canada completed a questionnaire in which they indicated their level of agreement with seven statements regarding the usability of the data collection system employed at their vaccination clinic. Questions included overall ease of use, effectiveness of the method utilized, efficiency at completing tasks, comfort using the method, ability to recover from mistakes, ease of learning the method and overall satisfaction with the method. A 5-point Likert-type scale was used to measure responses.
Results
Most respondents (96%) were employed in sites run by public health. Respondents included 186 nurses and 114 administrative staff, among whom 90% and 47%, respectively, used a paper-based method for data collection. Approximately half the respondents had a year or less of experience with immunization-related tasks during seasonal influenza campaigns. Over 90% of all frontline staff found their data collection method easy to use, perceived it to be effective in helping them complete their tasks, felt quick and comfortable using the method, and found the method easy to learn, regardless of whether a hybrid or electronic system was used.
Conclusions
This study demonstrates that there may be a greater willingness of frontline immunization staff to adapt to new technologies than previously perceived by decision-makers. The public health community should recognize that usability may not be a barrier to implementing electronic methods for collecting individual-level immunization data.
doi:10.1186/1471-2458-10-796
PMCID: PMC3024979  PMID: 21831331
17.  Perceptions of immunization information systems for collecting pandemic H1N1 immunization data within Canada's public health community: A qualitative study 
BMC Public Health  2010;10:523.
Background
Immunization information systems (IISs) are electronic registries used to monitor individual vaccination status and assess vaccine coverage. IISs are currently not widely used across Canada, where health jurisdictions employ a range of approaches to capture influenza immunization information. Conducted in advance of the 2009 H1N1 vaccination campaign, the objectives of this study were to understand the perceived value of individual-level data and IISs for influenza control, identify ideal system functions, and explore barriers to implementation.
Methods
In July and August 2009, semi-structured interviews were conducted with key informants engaged in vaccine delivery and/or pandemic planning at regional, provincial/territorial and federal levels across Canada. Key informants were recruited using a combination of convenience and snowball sampling methodologies. Qualitative analysis was used to extract themes from interview content.
Results
Patient management, assessment of vaccine coverage, and evaluation of safety and effectiveness were identified as public health priorities that would be achieved in a more timely manner, and with greater accuracy, through the use of an IIS. Features described as ideal included system flexibility, rapid data entry, and universality. Financial and human resource constraints as well as coordination between immunization providers were expressed as barriers to implementation.
Conclusions
IISs were perceived as valuable by key informants for strengthening management capacity and improving evaluation of both seasonal and pandemic influenza vaccination campaigns. However, certain implementation restrictions may need to be overcome for these benefits to be achieved.
doi:10.1186/1471-2458-10-523
PMCID: PMC2941494  PMID: 20807421
18.  International Circumpolar Surveillance System for Invasive Pneumococcal Disease, 1999–2005 
Emerging Infectious Diseases  2008;14(1):25-33.
Disease rates are high among indigenous persons in Arctic countries, and PCV7 has resulted in decreased rates in North American children.
The International Circumpolar Surveillance System is a population-based surveillance network for invasive bacterial disease in the Arctic. The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced for routine infant vaccination in Alaska (2001), northern Canada (2002–2006), and Norway (2006). Data for invasive pneumococcal disease (IPD) were analyzed to identify clinical findings, disease rates, serotype distribution, and antimicrobial drug susceptibility; 11,244 IPD cases were reported. Pneumonia and bacteremia were common clinical findings. Rates of IPD among indigenous persons in Alaska and northern Canada were 43 and 38 cases per 100,000 population, respectively. Rates in children <2 years of age ranged from 21 to 153 cases per 100,000 population. In Alaska and northern Canada, IPD rates in children <2 years of age caused by PCV7 serotypes decreased by >80% after routine vaccination. IPD rates are high among indigenous persons and children in Arctic countries. After vaccine introduction, IPD caused by non-PCV7 serotypes increased in Alaska.
doi:10.3201/eid1401.071315
PMCID: PMC2600171  PMID: 18258073
Streptococcus pneumoniae; invasive pneumococcal disease; IPD; surveillance; PCV7; serotype replacement; indigenous; Alaska Native; circumpolar; arctic; research
19.  Epidemiology of Haemophilus influenzae Serotype a, North American Arctic, 2000–2005 
Emerging Infectious Diseases  2008;14(1):48-55.
Serotype a is now the most common seen in the North American Arctic; highest rates occur in indigenous children.
Before the introduction of Haemophilus influenzae type b (Hib) conjugate vaccines, rates of invasive H. influenzae disease among indigenous people of the North American Arctic were among the highest in the world. Routine vaccination reduced rates to low levels; however, serotype replacement with non–type b strains may result in a reemergence of invasive disease in children. We reviewed population-based data on invasive H. influenzae in Alaska and northern Canada from 2000–2005; 138 cases were reported. Among 88 typeable isolates, 42 (48%) were H. influenzae type a (Hia); 35 (83%) occurred in indigenous peoples. Among Hia patients, median age was 1.1 years; 62% were male; 1 adult died. Common clinical manifestations included meningitis, pneumonia, and septic arthritis. Overall annual incidence was 0.9 cases per 100,000 population. Incidence among indigenous children <2 years of age in Alaska and northern Canada was 21 and 102, respectively. Serotype a is now the most common H. influenzae serotype in the North American Arctic; the highest rates are among indigenous children.
doi:10.3201/eid1401.070822
PMCID: PMC2600153  PMID: 18258076
Haemophilus influenzae; Hia; Hib; emerging infections; indigenous; surveillance; Alaska; Canada; meningitis; pneumonia; septic arthritis; research
20.  Household transmission of SARS, 2003 
Background
In the 2003 outbreak in Toronto (in Ontario, Canada) of severe acute respiratory syndrome (SARS), about 20% of cases resulted from household transmission. The purpose of our study was to determine characteristics associated with the transmission of SARS within households.
Methods
A retrospective cohort of SARS-affected households was studied to determine risk factors for household transmission. Questionnaires addressed characteristics of the index case, the household and behaviours among household members. Potential risk factors for secondary transmission of infection were assessed in regression models appropriate to the outcome (secondary cases) and nonindependence of household members.
Results
The 74 households that participated included 18 secondary cases and 158 uninfected household members in addition to the 74 index cases. The household secondary attack rate was 10.2% (95% confidence interval [CI] 6.7%–23.5%). There was a linear association between the time the index patient spent at home after symptom onset and the secondary attack rate. Infected health care workers who were index cases had lower rates of household transmission.
Interpretation
SARS transmission in households is complex and increases with the length of time an ill person spends at home. Risk of transmission was lower when the index case was a health care worker. Rapid case identification is the public health measure most useful in minimizing exposure in the home.
doi:10.1503/cmaj.050876
PMCID: PMC1626520  PMID: 17098951

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