Perceptions of frontline staff regarding data collection methodologies used during the 2009 A H1N1 influenza immunization campaign in Canada

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.

Time and motion study to compare electronic and hybrid data collection systems during the pandemic (H1N1) 2009 influenza vaccination campaign

During the pandemic (H1N1) 2009 vaccination campaign, vaccine providers collected immunization data using hybrid (paper-based and electronic methods) and electronic data systems. We measured staff time in seconds spent on data collection tasks to compare system efficiencies. The sample consisted of 38 organizations across nine Canadian provinces/territories. The total mean data collection times per client were 104 s (electronic system), 143 s (hybrid system with electronic registration) and 172 s (hybrid system with paper registration). Electronic registration and record keeping were faster than paper-based methods; these findings should be used to improve data collection for future influenza seasons.

Perceptions of immunization information systems for collecting pandemic H1N1 immunization data within Canada's public health community: a qualitative study

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.

An evaluation of the Australian National Serosurveillance Program

The Australian National Serosurveillance Program (ANSP) was established in 1997 to provide national estimates of population immunity to vaccine preventable diseases and inform immunisation policy in Australia. The 1st round tested opportunistically collected sera from pathology laboratories across Australia, a 2nd round was carried out in 2002, and a 3rd round of testing is currently ongoing using sera from 2007-08. This is the 1st systematic evaluation of the ANSP since its inception. Existing information and outputs from the ANSP were reviewed and used in conjunction with data collected from a survey of the program operators to evaluate the overall utility of the ANSP and the following system attributes; acceptability, stability, simplicity, flexibility, data quality, sensitivity, representativeness and timeliness. So far the ANSP has generated 26 peer-reviewed publications and provided useful data that have influenced and provided an evidence base for immunisation policy in Australia; for example informing mathematical models, which identified the need for the young adult measles-mumps-rubella immunisation campaign. However, difficulties have been encountered with obtaining enough samples for testing in the 3rd round currently being undertaken. This is a concern that has the potential to undermine the representativeness and stability of the system, and other methods of sample collection must be investigated. Serological surveillance is an important component of any comprehensive system for monitoring population immunity to vaccine preventable diseases and evaluating the effectiveness of immunisation programs. However, an effective ongoing program requires strong support to ensure it remains sustainable in an era when laboratory based population health research for the public good is becoming increasingly challenging.

The Australian Childhood Immunisation Register-A model for universal immunisation registers?

The Australian Childhood Immunisation Register (ACIR) was established in 1996 as an opt-out register built on the platform of Medicare, the universal national health insurance scheme. Introduction of financial incentives for providers and parents, linked to the ACIR, followed from 1998. Over the subsequent decade, national levels for receipt of all vaccines by 12, 24 and 72 months of age have risen to 91%, 93%, and 88%, respectively. Conscientious objection to immunisation can be registered, with retention of eligibility for incentives. The ACIR has been important in implementation of a range of measures to improve childhood immunisation coverage in Australia. Linkage of a universal childhood immunisation register to national health insurance schemes has potential applicability in a variety of settings internationally.

Interim estimates of human papillomavirus vaccination coverage in the school-based program in Australia

In November 2006, the Australian Government announced the National HPV Vaccination Program, consisting of a course of prophylactic human papillomavirus (HPV) vaccine for all Australian females aged 12-26 years. Females aged 12-18 years are vaccinated through school-based programs. The school-based component commenced in April 2007, with the school years targeted varying across jurisdictions. Each jurisdiction maintains comprehensive records of HPV doses delivered in the school-based programs although how this is captured varies. This report presents interim coverage estimates for Year 1 (2007) of the program. Both New South Wales and Victoria achieved coverage of 70% or more among almost all school cohorts vaccinated in the program. Some of the variation in coverage achieved may reflect different levels of experience with school-based programs, and varying methods for school-based vaccine delivery and recording of doses administered. Except for some doses in South Australia, these interim coverage estimates do not include catch-up doses delivered by general practitioners or persons who were vaccinated prior to the onset of the program. Therefore, these data should be considered minimum estimates of coverage. The 1st year of the school-based HPV vaccination program should be considered a success, given time and resource constraints. Public sector immunisation providers across Australia should be commended for planning and implementing a new national immunisation program in approximately 4 months.

Invasive bacterial diseases in northern Canada

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.

Epidemiology of Haemophilus influenzae serotype a, North American Arctic, 2000-2005

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.

International Circumpolar Surveillance System for invasive pneumococcal disease, 1999-2005

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.

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.

Serious adverse events associated with bacille Calmette-Guérin vaccine in Canada

BACKGROUND

Targeted Bacille Calmette-Guérin (BCG) vaccination is offered to neonates in some First Nations and Inuit (FNI) communities in Canada. Serious adverse events associated with BCG vaccine prompted a review to assess causality.

METHODS

The Immunization Monitoring Program Active (IMPACT), a pediatric hospital-based active surveillance network, reported admissions for BCG-related adverse events between 1993 and April 2002. The Canadian Advisory Committee on Causality Assessment (ACCA) reviewed the reports to assess causality. Data between 1987 and September 2002 from the Vaccine-Associated Adverse Event Surveillance (VAAES) Program, a passive national reporting system, were also reviewed.

RESULTS

IMPACT identified 21 pediatric cases; 19 were Canadian-born, and 18 were FNI. Six disseminated BCG cases were identified; 5 were FNI infants who subsequently died. All had immunodeficiencies and concurrent infections. Other adverse events included 2 cases of osteomyelitis, BCG abscesses and lymphadenitis. ACCA reviewed the 21 cases and determined that 14 were very likely associated with the vaccine, including the 6 disseminated BCGs; 5 were probably associated and 1 was possibly associated with the vaccine; 1 was unclassifiable. The VAAES program identified 157 adverse events. No additional serious systemic adverse events (disseminated BCG or osteomyelitis) were identified.

CONCLUSIONS

Serious BCG vaccine-associated complications continue to occur in Canada. The numbers of FNI children with disseminated disease was greater than expected from reported rates in the literature.

A fresh look at an old vaccine: does BCG have a role in 21st century Canada?

INTRODUCTION

In Canada, bacille Calmette-Guerin (BCG) vaccine is now primarily given to First Nations and Inuit (FNI) neonates living in tuberculosis (TB) endemic areas. With declining TB rates, attention has shifted from the protective effects of BCG to reports of serious vaccine-associated adverse events (VAAE).

METHODS

Surveillance data were reviewed to assess TB burden and trends, BCG coverage, and VAAE among FNI people in the 1990s.

RESULTS

TB among FNI people living on reserve was 25 times higher than the Canadian-born, non-Aboriginal rate between 1997 and 2000. Paediatric TB rates declined from 149 per 100,000 in 1990 to 23 per 100,000 in 2000, with one case of TB meningitis and one TB fatality (due to congenital TB) reported in the 0-4 age group. Nine cases of disseminated BCG infection occurred in a 21-year period among children with congenital or acquired immunodeficiencies. The estimated rate of disseminated BCG infection was 205 per 1,000,000 (95% CI 62-678).

DISCUSSION

BCG provides protection against severe forms of childhood TB. However, in a country with publicly funded health care and declining TB rates, it is important to consider VAAE. Disseminated BCG infection increases mortality among children with immunodeficiency disorders, which now have successful therapies. Although TB remains a threat in FNI communities, early detection and treatment of TB infection may be a more appropriate intervention.

Annualized incidence and spectrum of illness from an outbreak investigation of Bell's palsy

BACKGROUND

There are limited clinical and epidemiological data on patients diagnosed with Bell's palsy. While investigating an apparent clustering of Bell's palsy, we sought to characterize the spectrum of illness in patients with this diagnosis.

METHODS

A telephone survey of persons with idiopathic facial (Bell's) palsy in the Greater Toronto Area (GTA, population = 4.99 million) and Nova Scotia (population = 0.93 million) from August 1 to November 15, 1997 collected information on subject demographics, neurological symptoms, constitutional symptoms, medical investigation and management. Information regarding potential risks for exposure to infectious agents, past medical history, and family history of Bell's palsy was also collected. Subjects with other secondary causes of facial palsy were excluded.

RESULTS

In the GTA and Nova Scotia, 222 and 36 patients were diagnosed with idiopathic facial (Bell's) palsy, respectively. The crude annualized incidence of Bell's palsy was 15.2 and 13.1 per 100,000 population in the GTA and Nova Scotia, respectively. There was no temporal or geographical clustering, and symptomatology did not differ significantly between the two samples. The mean age was 45 years, with 55% of subjects being female. The most common symptoms accompanying Bell's palsy were increased tearing (63%), pain in or around the ear (63%), and taste abnormalities (52%). A significant number of patients reported neurological symptoms not attributable to the facial nerve.

CONCLUSION

No clustering of cases of Bell's palsy was observed to support an infectious etiology for the condition. Misdiagnosis of the etiology of facial weakness is common. Patients diagnosed with Bell's palsy have a variety of neurological symptoms, many of which cannot be attributed to a facial nerve disorder.

The spectrum of electrophysiological abnormalities in Bell's palsy

BACKGROUND

As part of an investigation of a suspected "outbreak" of Bell's palsy in the Greater Toronto Area, a population-based sample of patients with Bell's palsy was investigated electrophysiologically to help understand the spectrum of abnormalities that can be seen in this setting.

METHODS

Two hundred and twenty-four patients were surveyed, of whom 91 underwent formal neurological assessment. Of the latter, 44 were studied electrophysiologically using standard techniques. Thirty-two of the 44 patients fulfilled clinical criteria for Bell's palsy.

RESULTS

A wide range of electrophysiological changes was observed. Blink responses were the most useful test showing diagnostic sensitivity of 81% and specificity of 94% compared to the contralateral control side. Needle electromyography was additionally helpful in only one patient of six with normal conduction studies.

CONCLUSIONS

There is a wide spectrum of electrophysiological abnormalities in Bell's palsy. Blink reflex latencies may be under-utilized in the assessment of the facial nerve in Bell's palsy. Facial EMG is not generally useful in routine assessment.

Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae. The Streptococcus pneumoniae Working Group

OBJECTIVES

To assess differences in risk factors, clinical presentation, and course of illness between children infected with penicillin-sensitive and drug-resistant Streptococcus pneumoniae (DRSP).

DESIGN

A retrospective cohort study conducted in Uruguay and Argentina using information from a hospital-based surveillance system. Hospitalized children 5 years of age and younger who had S pneumoniae isolated from a normally sterile site between June 1993 and October 1996 were eligible. Hospital records were linked with surveillance data. Both stratified univariate analysis and logistic regression was completed.

RESULTS

Of the 380 children eligible for the study, 274 records (72%) were available for review. Ninety-nine children (36%) had DRSP; 46 showed intermediate susceptibility (minimum inhibitory concentration, 0.12-1.0 microg/mL) and 53 showed high-level resistance (minimum inhibitory concentration >/=2.0 microg/mL). Children with meningitis were less likely to have DRSP than those with other forms of invasive disease (relative risk = 0. 5; 95% confidence interval [CI], 0.2-0.9). Risk factors associated with DRSP were use of penicillin or ampicillin in the 3 months before illness (odds ratio = 2.9; 95% CI, 1.5-5.7) and possession of private medical coverage (odds ratio = 2.4; 95% CI, 1.2-5.0). Response to therapy, including response to penicillin or ampicillin among children with nonmeningeal invasive disease, course of illness, and clinical outcome did not differ significantly between children infected with penicillin-susceptible or penicillin-resistant isolates.

CONCLUSION

In this study, previous use of penicillin or ampicillin and private medical coverage were associated with having DRSP. Children with nonmeningeal invasive disease responded equally well to penicillin regardless of the penicillin susceptibility of their pneumococcal isolate.

Vaccine coverage during a school-based hepatitis B immunization program

Ontario initiated a universal hepatitis B immunization program for grade seven students in the fall of 1994. An ecological study was conducted within seven health units of the Greater Toronto Area to assess vaccine coverage. The study population consisted of all grade seven students enrolled within schools in the participating health units, on October 1, 1994. There were 39,935 students enrolled in 604 schools eligible for inclusion in the study. Consent to receive the vaccine series was obtained for 88% (range across health units from 81.5% to 96.3%) of the students. Among students for whom consent was obtained, an average of 95% (range 88.1% to 99.5%) completed the series. Therefore, the total vaccine coverage for the study population was 84% (range 77.5% to 89.5%). Series completion varied by school board, education provider and the use of Ministry of Health educational material. A limiting factor in achieving high vaccination coverage among grade seven students was obtaining consent to receive the vaccine series.