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Hossain MM, Saha N, Rodela TT, Tasnim S, Nuzhath T, Roy TJ, Burdine JN, Ahmed HU, McKyer ELJ, Basu BK, Ma P. Global research on syndemics: a meta-knowledge analysis (2001-2020). F1000Res 2022; 11:253. [PMID: 36936050 PMCID: PMC10015119 DOI: 10.12688/f1000research.74190.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years. METHODS We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship. RESULTS We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science. CONCLUSIONS The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.
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Affiliation(s)
- Md Mahbub Hossain
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Nobonita Saha
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka, Bangladesh
| | - Tahmina Tasnim Rodela
- Department of Economics, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh
| | - Samia Tasnim
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Tasmiah Nuzhath
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Tamal Joyti Roy
- Institute of Information and Communication Technology, Khulna, Bangladesh
| | - James N. Burdine
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | | | - E. Lisako J. McKyer
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | | | - Ping Ma
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
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Hossain MM, Saha N, Rodela TT, Tasnim S, Nuzhath T, Roy TJ, Burdine JN, Ahmed HU, McKyer ELJ, Basu BK, Ma P. Global research on syndemics: a meta-knowledge analysis (2001-2020). F1000Res 2022; 11:253. [PMID: 36936050 PMCID: PMC10015119 DOI: 10.12688/f1000research.74190.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Syndemics or synergies of cooccurring epidemics are widely studied across health and social sciences in recent years. METHODS We conducted a meta-knowledge analysis of articles published between 2001 to 2020 in this growing field of academic scholarship. RESULTS We found a total of 830 articles authored by 3025 authors, mostly from high-income countries. Publications on syndemics are gradually increasing since 2003, with rapid development in 2013. Each article was cited more than 15 times on average, and most (n = 604) articles were original studies. Syndemics research focused on several areas, including HIV/AIDS, substance abuse, mental health, gender minority stressors, racism, violence, chronic physical and mental disorders, food insecurity, social determinants of health, and coronavirus disease 2019. Moreover, biopsychosocial interactions between multiple health problems were studied across medical, anthropological, public health, and other disciplines of science. CONCLUSIONS The limited yet rapidly evolving literature on syndemics informs transdisciplinary interests to understand complex coexisting health challenges in the context of systematic exclusion and structural violence in vulnerable populations. The findings also suggest applications of syndemic theory to evaluate clinical and public health problems, examine the socioecological dynamics of factors influencing health and wellbeing, and use the insights to alleviate health inequities in the intersections of synergistic epidemics and persistent contextual challenges for population health.
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Affiliation(s)
- Md Mahbub Hossain
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Nobonita Saha
- Institute of Nutrition and Food Science, University of Dhaka, Dhaka, Bangladesh
| | - Tahmina Tasnim Rodela
- Department of Economics, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh
| | - Samia Tasnim
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Tasmiah Nuzhath
- EviSyn Health, Khulna, Bangladesh
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | - Tamal Joyti Roy
- Institute of Information and Communication Technology, Khulna, Bangladesh
| | - James N. Burdine
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | | | - E. Lisako J. McKyer
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
| | | | - Ping Ma
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center, College Stataion, Texas, 77840, USA
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Sentís A, Montoro-Fernandez M, Lopez-Corbeto E, Egea-Cortés L, Nomah DK, Díaz Y, Garcia de Olalla P, Mercuriali L, Borrell N, Reyes-Urueña J, Casabona J. STI epidemic re-emergence, socio-epidemiological clusters characterisation and HIV coinfection in Catalonia, Spain, during 2017-2019: a retrospective population-based cohort study. BMJ Open 2021; 11:e052817. [PMID: 34903544 PMCID: PMC8672020 DOI: 10.1136/bmjopen-2021-052817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe the epidemiology of sexually transmitted infections (STIs), identify and characterise socio-epidemiological clusters and determine factors associated with HIV coinfection. DESIGN Retrospective population-based cohort. SETTING Catalonia, Spain. PARTICIPANTS 42 283 confirmed syphilis, gonorrhoea, chlamydia and lymphogranuloma venereum cases, among 34 600 individuals, reported to the Catalan HIV/STI Registry in 2017-2019. PRIMARY AND SECONDARY OUTCOMES Descriptive analysis of confirmed STI cases and incidence rates. Factors associated with HIV coinfection were determined using logistic regression. We identified and characterized socio-epidemiological STI clusters by Basic Health Area (BHA) using K-means clustering. RESULTS The incidence rate of STIs increased by 91.3% from 128.2 to 248.9 cases per 100 000 population between 2017 and 2019 (p<0.001), primarily driven by increase among women (132%) and individuals below 30 years old (125%). During 2017-2019, 50.1% of STIs were chlamydia and 31.6% gonorrhoea. Reinfections accounted for 10.8% of all cases and 6% of cases affected HIV-positive individuals. Factors associated with the greatest likelihood of HIV coinfection were male sex (adjusted OR (aOR) 23.69; 95% CI 16.67 to 35.13), age 30-39 years (versus <20 years, aOR 18.58; 95% CI 8.56 to 52.13), having 5-7 STI episodes (vs 1 episode, aOR 5.96; 95% CI 4.26 to 8.24) and living in urban areas (aOR 1.32; 95% CI 1.04 to 1.69). Living in the most deprived BHAs (aOR 0.60; 95% CI 0.50 to 0.72) was associated with the least likelihood of HIV coinfection. K-means clustering identified three distinct clusters, showing that young women in rural and more deprived areas were more affected by chlamydia, while men who have sex with men in urban and less deprived areas showed higher rates of STI incidence, multiple STI episodes and HIV coinfection. CONCLUSIONS We recommend socio-epidemiological identification and characterisation of STI clusters and factors associated with HIV coinfection to identify at-risk populations at a small health area level to design effective interventions.
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Affiliation(s)
- Alexis Sentís
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Pompeu Fabra University (UPF), Barcelona, Spain
- Epidemiology Department, Epiconcept, Paris, France
| | - Marcos Montoro-Fernandez
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Evelin Lopez-Corbeto
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Laia Egea-Cortés
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Daniel K Nomah
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Department of Paediatrics, Obstetrics and Gynecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yesika Díaz
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Patricia Garcia de Olalla
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Lilas Mercuriali
- Epidemiology Service, Public Health Agency of Barcelona, Barcelona, Spain
| | - Núria Borrell
- Epidemiological Surveillance and Response to Public Health Emergencies Service in Tarragona, Agency of Public Health of Catalonia, Generalitat of Catalonia, Tarragona, Spain
| | - Juliana Reyes-Urueña
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Casabona
- Centre of Epidemiological Studies of Sexually Transmitted Disease and AIDS in Catalonia (CEEISCAT), Department of Health, Generalitat of Catalonia, Badalona, Spain
- Fundació Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
- Department of Paediatrics, Obstetrics and Gynecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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Caught between HIV exceptionalism and health service integration: Making visible the role of public health policy in the scale-up of novel sexual health services. Health Place 2021; 72:102696. [PMID: 34736155 DOI: 10.1016/j.healthplace.2021.102696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/13/2021] [Accepted: 10/07/2021] [Indexed: 11/21/2022]
Abstract
The role of contextual factors for program implementation is well-documented; however, their changing function throughout implementation phases is less established. We conducted an institutional ethnography to understand how structural conditions for scaling up initiatives are shaped by public health policy. We conducted 25 interviews with implementers of a comprehensive sexual health testing service in Canada, 21 meeting observations, and textual analyses of key policies and reports. Our analysis revealed a disjuncture between implementers' task of scaling up programming and the actualities of working within the discursive and material confines of policies premised on HIV exceptionalism and underfunded integrated health services.
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Li J, Casey JL, Greenwald ZR, Yasseen III AS, Dickie M, Feld JJ, Cooper CL, Crawley AM. The 9th Canadian Symposium on Hepatitis C Virus: Advances in HCV research and treatment towards elimination. CANADIAN LIVER JOURNAL 2021; 4:59-71. [DOI: 10.3138/canlivj-2020-0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Hepatitis C virus (HCV) elimination has evolved into a coordinated global effort. Canada, with more than 250,000 chronically infected individuals, is among the countries leading this effort. The 9th Canadian Symposium on HCV, held in February 2020, thus established and addressed its theme, ‘advances in HCV research and treatment towards elimination’, by gathering together basic scientists, clinicians, epidemiologists, social scientists, and community members interested in HCV research in Canada. Plenary sessions showcased topical research from prominent international and national researchers, complemented by select abstract presentations. This event was hosted by the Canadian Network on Hepatitis C (CanHepC), with support from the Public Health Agency of Canada and the Canadian Institutes of Health Research and in partnership with the Canadian Liver Meeting. CanHepC has an established record in HCV research by its members and in its advocacy activities to address the care, treatment, diagnosis, and immediate and long-term needs of those affected by HCV infection. Many challenges remain in tackling chronic HCV infection, such as the need for a vaccine; difficult-to-treat populations and unknown aspects of patient subgroups, including pregnant women and children; vulnerable people; and issues distinct to Indigenous peoples. There is also increasing concern about long-term clinical outcomes after successful treatment, with the rise in comorbidities such as diabetes, cardiovascular disease, and fatty liver disease and the remaining risk for hepatocellular carcinoma in cirrhotic individuals. The symposium addressed these topics in highlighting research advances that will collectively play an important role in eliminating HCV and minimizing subsequent health challenges.
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Affiliation(s)
- Jiafeng Li
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Centre for Infection, Immunity and Inflammation, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia L Casey
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Zoë R Greenwald
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Abdool S Yasseen III
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Melisa Dickie
- Knowledge Exchange Division, Community AIDS Treatment Information Exchange, Toronto, Ontario, Canada
| | - Jordan J Feld
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Curtis L Cooper
- Centre for Infection, Immunity and Inflammation, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Angela M Crawley
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
- Chronic Disease Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Centre for Infection, Immunity and Inflammation, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Biology, Carleton University, Ottawa, Ontario, Canada
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Haddad N, Weeks A, Robert A, Totten S. HIV in Canada-surveillance report, 2019. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2021; 47:77-86. [PMID: 33679250 PMCID: PMC7927910 DOI: 10.14745/ccdr.v47i01a11] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Human immunodeficiency virus (HIV) is a global public health issue. HIV has been nationally notifiable in Canada since 1985. The Public Health Agency of Canada (PHAC) monitors trends in new HIV diagnoses. OBJECTIVES The objective of this surveillance report is to provide an overview of the epidemiology of reported HIV cases in 2019 in Canada. The report highlights 10-year trends (2010-2019). Data on HIV diagnosed through Immigration Medical Exams (IME) and trends in perinatal transmission of HIV are also presented. METHODS PHAC monitors HIV through the HIV/AIDS Surveillance System, a passive, case-based system that collates non-nominal data submitted voluntarily by all Canadian provinces and territories. Descriptive analyses were conducted on national data. IME data were obtained from Immigration, Refugees and Citizenship Canada (IRCC), and data on HIV-exposed pregnancies were obtained through the Canadian Perinatal HIV Surveillance Program. RESULTS In 2019, a total of 2,122 HIV diagnoses were reported in Canada (5.6 per 100,000 population). Saskatchewan reported the highest provincial diagnosis rate at 16.9 per 100,000 population. The 30 to 39-year age group had the highest HIV diagnosis rate at 12.7 per 100,000 population. While the rates for both males and females fluctuated in the past decade, since 2010 the rates among males decreased overall, while the rate among females increased slightly. As in previous years, the diagnosis rate for males in 2019 was higher than that for females (7.9 versus 3.4 per 100,000 population, respectively). The highest proportion of all reported adult cases with known exposure were gay, bisexual and other men who have sex with men (gbMSM, 39.7%), followed by cases attributed to heterosexual contact (28.3%) and among people who inject drugs (PWID, 21.5%). The number of migrants who tested positive for HIV during an IME conducted in Canada was 626. The one documented perinatal HIV transmission related to a mother who had not received antepartum or intrapartum antiretroviral therapy prophylaxis. CONCLUSION The number and rate of reported HIV cases in Canada has remained relatively stable over the last decade, with minor year-to-year variations. As in previous years, the gbMSM and PWID populations represent a high proportion of HIV diagnoses, although a sizable number of cases were attributed to heterosexual contact. It is important to routinely monitor trends in HIV in light of pan-Canadian commitments to reduce the health impact of sexually transmitted and blood-borne infections by 2030.
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Affiliation(s)
- Nisrine Haddad
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
| | - Ashley Weeks
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
| | - Anita Robert
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
| | - Stephanie Totten
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON
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Whelan M, Renda C, Hohenadel K, Buchan S, Murti M. All together now: aggregating multiple records to develop a person-based dataset to integrate and enhance infectious disease surveillance in Ontario, Canada. Canadian Journal of Public Health 2020; 111:752-760. [PMID: 32096013 PMCID: PMC7501341 DOI: 10.17269/s41997-020-00295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 02/03/2020] [Indexed: 11/22/2022]
Abstract
Setting Syndemics occur when two or more health conditions interact to increase morbidity and mortality and are exacerbated by social, economic, environmental, and political factors. Routine provincial surveillance in Ontario assesses and reports on the epidemiology of single infectious diseases separately. Therefore, we aimed to develop a method that allows disease overlaps to be examined routinely as a path to better understanding and addressing syndemics in Ontario. Intervention We extracted data for individuals with a record of chlamydia, gonorrhea, infectious syphilis, hepatitis B and C, HIV/AIDS, invasive group A streptococcal disease (iGAS), or tuberculosis in Ontario’s reportable disease database from 1990 to 2018. We transformed the data into a person-based integrated surveillance dataset retaining individuals (clients) with at least one record between 2006 and 2018. Outcomes The resulting dataset had 659,136 unique disease records among 470,673 unique clients. Of those clients, 23.1% had multiple disease records with 50 being the most for one client. We described the frequency of disease overlaps; for example, 34.7% of clients with a syphilis record had a gonorrhea record. We quantified known overlaps, finding 1274 clients had gonorrhea, infectious syphilis, and HIV/AIDS records, and potentially emerging overlaps, finding 59 clients had HIV/AIDS, hepatitis C, and iGAS records. Implications Our novel person-based integrated surveillance dataset represents a platform for ongoing in-depth assessment of disease overlaps such as the relative timing of disease records. It enables a more client-focused approach, is a step towards improved characterization of syndemics in Ontario, and could inform other jurisdictions interested in adopting similar approaches.
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Affiliation(s)
- Michael Whelan
- Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario, 661 University Avenue, 17th Floor, Toronto, ON, M5G 1M1, Canada.
| | - Christina Renda
- Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario, 661 University Avenue, 17th Floor, Toronto, ON, M5G 1M1, Canada
| | - Karin Hohenadel
- Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario, 661 University Avenue, 17th Floor, Toronto, ON, M5G 1M1, Canada
| | - Sarah Buchan
- Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario, 661 University Avenue, 17th Floor, Toronto, ON, M5G 1M1, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Michelle Murti
- Communicable Diseases, Emergency Preparedness and Response, Public Health Ontario, 661 University Avenue, 17th Floor, Toronto, ON, M5G 1M1, Canada.,Dalla Lana School of Public Health, University of Toronto, Health Sciences Building 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
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