Postpartum Emergency Department Use Following Midwifery-Model vs Obstetrics-Model Care

Importance

Emergency department (ED) use postpartum is a common and often-preventable event. Unlike traditional obstetrics models, the Ontario midwifery model offers early care postpartum.

Objective

To assess whether postpartum ED use differs between women who received perinatal care in midwifery-model care vs in traditional obstetrics-model care.

Design, Setting, and Participants

This retrospective population-based cohort study took place in Ontario, Canada, where public health care is universally funded. Participants included women who were low risk and primiparous and gave birth to a live baby in an Ontario hospital between 2012 and 2018. Data were collected from April 2012 to March 2018 and analyzed from June 2022 to April 2023.

Exposures

Perinatal care clinician, namely, a midwife or obstetrician.

Main Outcome and Measures

: Any unscheduled ED visit 42 days postpartum or less. Poisson regression models compared ED use between women with midwifery-model care vs obstetrics-model care, weighting by propensity score-based overlap weights.

Results

Among 104 995 primiparous women aged 11 to 50 years, those in midwifery-model care received a median (IQR) of 7 (6-8) postpartum visits, compared with 0 (0-1) visits among those receiving obstetrics-model care. Unscheduled ED visits 42 days or less postpartum occurred for 1549 of 23 124 women (6.7%) with midwifery-model care compared with 6902 of 81 871 women (8.4%) with traditional obstetrics-model care (adjusted relative risks [aRR], 0.78; 95% CI, 0.73-0.83). Similar aRRs were seen in women with a spontaneous vaginal birth (aRR, 0.71; 95% CI, 0.65-0.78) or assisted vaginal birth (aRR, 0.70; 95% CI, 0.59-0.82) but not those with a cesarean birth (aRR, 0.94; 95% CI, 0.86-1.03) or those with intrapartum transfer of care between a midwife and obstetrician (aRR, 0.94; 95% CI, 0.87-1.04). ED use 7 days or less postpartum was also lower among women receiving midwifery model care (aRR, 0.70; 95% CI, 0.65-0.77).

Conclusions and Relevance

In this cohort study, midwifery-model care was associated with less postpartum ED use than traditional obstetrics-model care among women who had low risk and were primiparous, which may be due to early access to postpartum care provided by Ontario midwives.

Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada

IMPORTANCE

Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown.

OBJECTIVE

Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic.

DESIGN, SETTING AND PARTICIPANTS

Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic.

EXPOSURE

Annual service volume of a person's attending physician in the preceding year.

MAIN OUTCOMES AND MEASURES

Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians.

RESULTS

Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic.

CONCLUSIONS AND RELEVANCE

Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.

Measuring waning protection from seasonal influenza vaccination during nine influenza seasons, Ontario, Canada, 2010/11 to 2018/19

BackgroundWaning immunity from seasonal influenza vaccination can cause suboptimal protection during peak influenza activity. However, vaccine effectiveness studies assessing waning immunity using vaccinated and unvaccinated individuals are subject to biases.AimWe examined the association between time since vaccination and laboratory-confirmed influenza to assess the change in influenza vaccine protection over time.MethodsUsing linked laboratory and health administrative databases in Ontario, Canada, we identified community-dwelling individuals aged ≥ 6 months who received an influenza vaccine before being tested for influenza by RT-PCR during the 2010/11 to 2018/19 influenza seasons. We estimated the adjusted odds ratio (aOR) for laboratory-confirmed influenza by time since vaccination (categorised into intervals) and for every 28 days.ResultsThere were 53,065 individuals who were vaccinated before testing for influenza, with 10,264 (19%) influenza-positive cases. The odds of influenza increased from 1.05 (95% CI: 0.91-1.22) at 42-69 days after vaccination and peaked at 1.27 (95% CI: 1.04-1.55) at 126-153 days when compared with the reference interval (14-41 days). This corresponded to 1.09-times increased odds of influenza every 28 days (aOR = 1.09; 95% CI: 1.04-1.15). Individuals aged 18-64 years showed the greatest decline in protection against influenza A(H1N1) (aORper 28 days = 1.26; 95% CI: 0.97-1.64), whereas for individuals aged ≥ 65 years, it was against influenza A(H3N2) (aORper 28 days = 1.20; 95% CI: 1.08-1.33). We did not observe evidence of waning vaccine protection for individuals aged < 18 years.ConclusionsInfluenza vaccine protection wanes during an influenza season. Understanding the optimal timing of vaccination could ensure robust protection during seasonal influenza activity.

Adult-born granule cells facilitate remapping of spatial and non-spatial representations in the dentate gyrus

Adult-born granule cells (abGCs) have been implicated in memory discrimination through a neural computation known as pattern separation. Here, using in vivo Ca2+ imaging, we examined how chronic ablation or acute chemogenetic silencing of abGCs affects the activity of mature granule cells (mGCs). In both cases, we observed altered remapping of mGCs. Rather than broadly modulating the activity of all mGCs, abGCs promote the remapping of place cells' firing fields while increasing rate remapping of mGCs that represent sensory cues. In turn, these remapping deficits are associated with behavioral impairments in animals' ability to correctly identify new goal locations. Thus, abGCs facilitate pattern separation through the formation of non-overlapping representations for identical sensory cues encountered in different locations. In the absence of abGCs, the dentate gyrus shifts to a state that is dominated by cue information, a situation that is consistent with the overgeneralization often observed in anxiety or age-related disorders.

Nesting chinstrap penguins accrue large quantities of sleep through seconds-long microsleeps

Microsleeps, the seconds-long interruptions of wakefulness by eye closure and sleep-related brain activity, are dangerous when driving and might be too short to provide the restorative functions of sleep. If microsleeps do fulfill sleep functions, then animals faced with a continuous need for vigilance might resort to this sleep strategy. We investigated electroencephalographically defined sleep in wild chinstrap penguins, at sea and while nesting in Antarctica, constantly exposed to an egg predator and aggression from other penguins. The penguins nodded off >10,000 times per day, engaging in bouts of bihemispheric and unihemispheric slow-wave sleep lasting on average only 4 seconds, but resulting in the accumulation of >11 hours of sleep for each hemisphere. The investment in microsleeps by successfully breeding penguins suggests that the benefits of sleep can accrue incrementally.

Effectiveness of maternal influenza vaccination during pregnancy against laboratory-confirmed seasonal influenza among infants under 6 months of age in Ontario, Canada

BACKGROUND

Randomized trials conducted in low- and middle-income settings demonstrated efficacy of influenza vaccination during pregnancy against influenza infection among infants <6 months of age. However, vaccine effectiveness (VE) estimates from settings with different population characteristics and influenza seasonality remain limited.

METHODS

We conducted a test-negative study in Ontario, Canada. All influenza virus tests among infants <6 months from 2010-2019 were identified and linked with health databases to ascertain information on maternal-infant dyads. VE was estimated from the odds ratio for influenza vaccination during pregnancy among cases versus controls, computed using logistic regression with adjustment for potential confounders.

RESULTS

Among 23,806 infants tested for influenza, 1,783 (7.5%) were positive and 1,708 (7.2%) were born to mothers vaccinated against influenza during pregnancy. VE against laboratory-confirmed infant influenza infection was 64% (95% confidence interval [CI]: 50%-74%). VE was similar by trimester of vaccination (1st/2nd: 66%, 40%-80%; 3rd: 63%, 46%-74%), infant age at testing (0-<2 months: 63%, 46%-75%; 2-<6 months: 64%, 36%-79%), and gestational age at birth (≥37 weeks: 64%, 50%-75%;  < 37 weeks: 61%, 4%-86%). VE against influenza hospitalization was 67% (95%CI: 50%-78%).

CONCLUSIONS

Influenza vaccination during pregnancy offers effective protection to infants <6 months, for whom vaccines are not currently available.

Enhanced production of difficult-to-express proteins through knocking down rnpA gene expression

Escherichia coli has been employed as a workhorse for the efficient production of recombinant proteins. However, some proteins were found to be difficult to produce in E. coli. The stability of mRNA has been considered as one of the important factors affecting recombinant protein production. Here we report a generally applicable and simple strategy for enhancing mRNA stability, and consequently improving recombinant protein production in E. coli. RNase P, a ribozyme comprising an RNA subunit (RnpB) and a protein subunit (RnpA), is involved in tRNA maturation. Based on the finding that purified RnpA can digest rRNA and mRNA in vitro, it was reasoned that knocking down the level of RnpA might enhance recombinant protein production. For this, the synthetic small regulatory RNA-based knockdown system was applied to reduce the expression level of RnpA. The developed RnpA knockdown system allowed successful overexpression of 23 different recombinant proteins of various origins and sizes, including Cas9 protein, antibody fragment, and spider silk protein. Notably, a 284.9-kDa ultra-high molecular weight, highly repetitive glycine-rich spider silk protein, which is one of the most difficult proteins to produce, could be produced to 1.38 g L-1 , about two-fold higher than the highest value previously achieved, by a fed-batch culture of recombinant E. coli strain employing the RnpA knockdown system. The RnpA-knockdown strategy reported here will be generally useful for the production of recombinant proteins including those that have been difficult to produce.

Self-harm among youth during the first 28 months of the COVID-19 pandemic in Ontario, Canada: a population-based study

BACKGROUND

Youth have reported worsening mental health during the COVID-19 pandemic. We sought to evaluate rates of pediatric acute care visits for self-harm during the pandemic according to age, sex and mental health service use.

METHODS

We conducted a population-based, repeated cross-sectional study using linked health administrative data sets to measure monthly rates of emergency department visits and hospital admissions for self-harm among youth aged 10-17 years between Jan. 1, 2017, and June 30, 2022, in Ontario, Canada. We modelled expected rates of acute care visits for self-harm after the pandemic onset based on prepandemic rates. We reported relative differences between observed and expected monthly rates overall and by age group (10-13 yr and 14-17 yr), sex and mental health service use (new and continuing).

RESULTS

In this population of about 1.3 million children and adolescents, rates of acute care visits for self-harm during the pandemic were higher than expected for emergency department visits (0.27/1000 population v. 0.21/1000 population; adjusted rate ratio [RR] 1.29, 95% confidence interval [CI] 1.19-1.39) and hospital admissions (0.74/10 000 population v. 0.43/10 000 population, adjusted RR 1.72, 95% CI 1.46-2.03). This increase was primarily observed among females. Rates of emergency department visits and hospital admissions for self-harm were higher than expected for both those aged 10-13 years and those aged 14-17 years, as well as for both those new to the mental health system and those already engaged in care.

INTERPRETATION

Rates of acute care visits for self-harm among children and adolescents were higher than expected during the first 2 and a half years of the COVID-19 pandemic, particularly among females. These findings support the need for accessible and intensive prevention efforts and mental health supports in this population.

Estimating the incidence of first RSV hospitalization in children born in Ontario, Canada

BACKGROUND

Respiratory syncytial virus (RSV) contributes significantly to morbidity in children, placing substantial burdens on health systems, thus RSV vaccine development and program implementation are a public health priority. More data on burden are needed by policymakers to identify priority populations and formulate prevention strategies as vaccines are developed and licensed.

MATERIALS/METHODS

Using health administrative data, we calculated incidence rates of RSV hospitalization in a population-based birth cohort of all children born over a six-year period (May 2009 - June 2015) in Ontario, Canada. Children were followed until their first RSV hospitalization, death, 5 th birthday, or the end of the study period (June 2016). RSV hospitalizations were identified using a validated algorithm based on International Classification of Diseases, 10 th Revision, and/or laboratory-confirmed outcomes. We calculated hospitalization rates by various characteristics of interest, including calendar month, age groups, sex, comorbidities, and gestational age.

RESULTS

The overall RSV hospitalization rate for children <5 years was 4.2 per 1,000 person-years (PY) with a wide range across age groups (from 29.6 to 0.52 per 1000PY in children aged 1 month and 36-59 months, respectively). Rates were higher in children born at a younger gestational age (23.2 per 1000PY for those born at <28 weeks versus 3.9 per 1000PY born at ≥37 weeks); this increased risk persisted as age increased. While the majority of children in our study had no comorbidities, rates were higher in children with comorbidities. For all age groups, rates were highest between December and March.

CONCLUSIONS

Our results confirm the high burden of RSV hospitalization and highlight young infants are at additional risk, namely premature infants. These results can inform prevention efforts.

The Association Between Opioid Prescribing and Opioid-Related Mortality Within Neighborhoods in Ontario, Canada: A Case-Control Study

OBJECTIVE

Recent Canadian data show that the prescribing of opioids has declined while the number of opioid deaths continues to rise. This study aimed to assess the relationship between neighborhood-level opioid prescription rates and opioid-related mortality among individuals without an opioid prescription.

METHOD

This was a nested case-control study using data in Ontario from 2013 to 2019. Neighborhood-level data were analyzed by using dissemination areas that consist of 400-700 people. Cases were defined as individuals who had an opioid-related death without an opioid prescription filled in the year prior. Cases and controls were matched using a disease risk score. After matching, there were 2,401 cases and 8,813 controls. The primary exposure was the total volume of opioids dispensed within the individual's dissemination area in the 90 days before the index date. Conditional logistic regression was used to examine the association between opioid prescriptions and the risk of overdose.

RESULTS

There was no significant association between the total volume of opioid prescriptions dispensed in a dissemination area and opioid-related mortality. In subgroup analyses stratifying the cohort into prescription and nonprescription opioid-related mortality, the number of prescriptions dispensed was positively associated with prescription opioid-related mortality. There was also a significant inverse association between the increased total volume of opioids dispensed and nonprescription opioid mortality.

CONCLUSIONS

Our results suggest that prescription opioids dispensed within a neighborhood can have both potential benefits and harms. The opioid epidemic requires a nuanced approach that ensures appropriate pain care for patients while also creating a safer environment for opioid use through harm-reduction strategies.

Evaluating the impact of statin use on influenza vaccine effectiveness and influenza infection in older adults

BACKGROUND

Older adults are recommended to receive influenza vaccination annually and many use statins. Statins have immunomodulatory properties that might modify influenza vaccine effectiveness (VE) and alter influenza infection risk.

METHODS

Using the test-negative design and linked laboratory and health administrative databases in Ontario, Canada, we estimated VE against laboratory-confirmed influenza among community-dwelling statin users and non-users aged ≥66 years during the 2010-2011 to 2018-2019 influenza seasons. We also estimated the odds ratio (OR) for influenza infection between statin users and non-users by vaccination status.

RESULTS

Among subjects tested for influenza across the 9 seasons, 54,243 had continuous statin exposure prior to testing and 48,469 were deemed unexposed. VE against laboratory-confirmed influenza was similar between statin users and non-users (17% [95%CI, 13-20%] and 17% [95%CI, 13-21%] respectively; test for interaction, p=0.87). In both vaccinated and unvaccinated subjects, statin users had higher odds of laboratory-confirmed influenza than non-users (OR for vaccinated =1.15; 95%CI, 1.10-1.21; OR for unvaccinated=1.15; 95%CI, 1.10-1.20). These findings were consistent by mean daily dose and statin type. VE did not differ between users and non-users of other cardiovascular drugs, except for beta-blockers. We did not observe that vaccinated and unvaccinated users of these drugs had increased odds of influenza, except for unvaccinated beta-blocker users.

CONCLUSIONS

Influenza VE did not differ between statin users and non-users. Statin use was associated with increased odds of laboratory-confirmed influenza in vaccinated and unvaccinated subjects, but these associations might be impacted by residual confounding.

An Open-Source Virtual Reality System for the Measurement of Spatial Learning in Head-Restrained Mice

Head-restrained behavioral experiments in mice allow neuroscientists to observe neural circuit activity with high-resolution electrophysiological and optical imaging tools while delivering precise sensory stimuli to a behaving animal. Recently, human and rodent studies using virtual reality (VR) environments have shown VR to be an important tool for uncovering the neural mechanisms underlying spatial learning in the hippocampus and cortex, due to the extremely precise control over parameters such as spatial and contextual cues. Setting up virtual environments for rodent spatial behaviors can, however, be costly and require an extensive background in engineering and computer programming. Here, we present a simple yet powerful system based upon inexpensive, modular, open-source hardware and software that enables researchers to study spatial learning in head-restrained mice using a VR environment. This system uses coupled microcontrollers to measure locomotion and deliver behavioral stimuli while head-restrained mice run on a wheel in concert with a virtual linear track environment rendered by a graphical software package running on a single-board computer. The emphasis on distributed processing allows researchers to design flexible, modular systems to elicit and measure complex spatial behaviors in mice in order to determine the connection between neural circuit activity and spatial learning in the mammalian brain.

Health conditions and service use of autistic women and men: A retrospective population-based case-control study

LAY ABSTRACT

This study used administrative data from Ontario, Canada to compare the health conditions and service use of autistic women and men with adults with other developmental disabilities and with adults without developmental disabilities. Autistic women and men were more likely to have physical and mental health conditions compared to adults without developmental disabilities. Rates of health conditions were similar or lower among autistic adults compared to adults with other developmental disabilities, except more autistic adults had psychiatric conditions. Autistic women and men used higher rates of psychiatric services compared to all other groups. When comparing autistic women with same aged autistic men, sex differences were found for specific physical (Crohn's disease/colitis, rheumatoid arthritis) and psychiatric conditions (psychotic disorders, non-psychotic disorders), as well differences in service use (emergency department visits, hospitalizations, family doctor and neurologist visits). These results further highlight the high health needs and service use of autistic women and men, as well as adults with other developmental disabilities. It is critical for future research to focus on mental health support for autistic adults and to better understand how to tailor supports to best serve autistic women.

Coronavirus disease 2019 vaccine effectiveness among a population-based cohort of people living with HIV

OBJECTIVE

People with HIV were underrepresented in coronavirus disease 2019 (COVID-19) vaccine clinical trials. We estimated vaccine effectiveness (VE) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for the BNT162b2, mRNA-1273, and ChAdOx1 vaccines among a population-based cohort of people with HIV in Ontario, Canada.

DESIGN

Test-negative design.

METHODS

We identified people with HIV aged ≥19 years who were tested for SARS-CoV-2 by RT-PCR between December 14, 2020 (first availability of COVID-19 vaccines) and November 21, 2021 (pre-Omicron circulation). Outcomes included any infection, symptomatic infection, and COVID-19-related hospitalization/death. We compared the odds of vaccination between test-positive cases and test-negative controls using multivariable logistic regression with adjustment for age, sex, region, calendar time, SARS-CoV-2 test histories, influenza vaccination, comorbidities, and neighborhood-level socio-economic status. VE was derived as (1 - adjusted odds ratio) × 100%.

RESULTS

Among 21 023 adults living with HIV, there were 801 (8.3%) test-positive cases and 8,879 (91.7%) test-negative controls. 20.1% cases and 47.8% of controls received ≥1 COVID-19 vaccine dose; among two-dose recipients, 93.4% received ≥1 mRNA dose. Two-dose VE ≥7 days before specimen collection was 82% (95% confidence interval [CI] = 74-87%) against any infection, 94% (95% CI = 82-98%) against symptomatic infection, and 97% (95% CI = 85-100%) against hospitalization/death. Against any infection, VE declined from 86% (95% CI = 77-92%) within 7-59 days after the second dose to 66% (95% CI = -15-90%) after ≥180 days; we did not observe evidence of waning protection for other outcomes.

CONCLUSION

Two doses of COVID-19 vaccine offered substantial protection against symptomatic illness and hospitalization/death in people with HIV prior to the emergence of the Omicron variant. Our findings do not support a broad conclusion that COVID-19 VE is lower among people with HIV in populations that, for the most part, are attending HIV care, taking antiretroviral medication, and are virally suppressed.

Cluster Analysis of DSC MRI, Dynamic Contrast-Enhanced MRI, and DWI Parameters Associated with Prognosis in Patients with Glioblastoma after Removal of the Contrast-Enhancing Component: A Preliminary Study

BACKGROUND AND PURPOSE

No report has been published on the use of DSC MR imaging, DCE MR imaging, and DWI parameters in combination to create a prognostic prediction model in glioblastoma patients. The aim of this study was to develop a machine learning-based model to find preoperative multiparametric MR imaging parameters associated with prognosis in patients with glioblastoma. Normalized CBV, volume transfer constant, and ADC of the nonenhancing T2 high-signal-intensity lesions were evaluated using K-means clustering.

MATERIALS AND METHODS

A total of 142 patients with glioblastoma who underwent preoperative MR imaging and total resection were included in this retrospective study. From the normalized CBV, volume transfer constant, and ADC maps, the parametric data were sorted using the K-means clustering method. Patients were divided into training and test sets (ratio, 1:1), and the optimal number of clusters was determined using receiver operating characteristic analysis. Kaplan-Meier survival analysis and log-rank tests were performed to identify potential parametric predictors. A multivariate Cox proportional hazard model was conducted to adjust for clinical predictors.

RESULTS

The nonenhancing T2 high-signal-intensity lesions were divided into 6 clusters. The cluster (class 4) with the relatively low normalized CBV and volume transfer constant value and the lowest ADC values was most associated with predicting glioblastoma prognosis. The optimal cutoff of the class 4 volume fraction of nonenhancing T2 high-signal-intensity lesions predicting 1-year progression-free survival was 9.70%, below which the cutoff was associated with longer progression-free survival. Two Kaplan-Meier curves based on the cutoff value showed a statistically significant difference (P = .037). When we adjusted for all clinical predictors, the cluster with the relatively low normalized CBV and volume transfer constant values and the lowest ADC value was an independent prognostic marker (hazard ratio, 3.04; P = .048). The multivariate Cox proportional hazard model showed a concordance index of 0.699 for progression-free survival.

CONCLUSIONS

Our model showed that nonenhancing T2 high-signal-intensity lesions with the relatively low normalized CBV, low volume transfer constant values, and the lowest ADC values could serve as useful prognostic imaging markers for predicting survival outcomes in patients with glioblastoma.

Paid Sick Leave and Sickness Benefits for employees’ economic and job security: A Scoping Review

 

In health emergencies, such as in the COVID-19 pandemic, the need to expand or introduce the Paid sick leave(PSL) and Sickness benefits(SB) increases. They are key components of the universal health coverage(UHC) and active labor market policies(ALMPs) that enable workers to take care of their health and guarantee return-to-work after recovery. This study examines effects those policies in achieving economic stability and job security of covered workers through a scoping review. Studies were selected using the search terms ‘paid sick leave', ‘sickness benefits', ‘paid sick day', and ‘earned sick leave’ in PubMed and Web of Science. Our search conducted on 6th April 2021 yielded 1,030 articles, of which 22 articles were included in the review. All articles were analyzed by the 4 sub-groups(employees, families, employers, and government) and we investigated indicators of socio-economic impacts on their lives. Articles are largely PSL(90.9%)-focused. PSL guarantees not only workers’ job security by securing employment agreement, but also their income security by promising part of wages enough to afford healthcare and living expenses during the medical treatment and recovery. Additionally, PSL attenuates employers’ financial risk, as it reduces presenteeism while increasing the return-to-work rate. Moreover, PSL and SB reduce the total healthcare and social security expenditures of the government. To sum up, PSL and SB guarantee health and labor rights by ensuring income and job security to employees while assuring financial stability to both employers, and the government. However, as the previous studies paid less attention on the equity of these impacts at the system levels, future research should more focus on the dimension.

Key messages

• PSL and SB guarantee health and labour rights by ensuring income and job security for employees, while assuring financial stability for both employers and the government.

• The previous studies that examined the effects of PSL and SB paid less attention on the equity of ensuring income and employment security, therefore future studies should focus more on this dimension.

The paid sick leave and sickness benefits for universal health coverage: a scoping review

Background

The countries with paid sick leave (PSL) and sickness benefits (SB) mostly provide the benefit coverage to specific categories of workers, which results in health inequalities among employees in COVID-19. The PSL and SB are key factors to achieve universal health coverage (UHC) in that they protect access to healthcare and improve population health. This study attempted to investigate whether the policies helped achieve the UHC when they were expanded.

Methods

This review followed the scoping review protocol of PRISMA-ScR. On April 6, 2021, we extracted the literature using the keywords ‘paid sick leave', ‘sickness benefits', ‘paid sick day', and ‘earned sick leave’ from PubMed and Web of Science and added two studies through hand-search. All articles were written in English. We did not limit the publication date.

Results

Forty-four selected studies were based in four single countries and the European Union. Most of the studies were published after 2010 (84.1%) and were conducted as cross-sectional (72.7%) studies. Not only workers who use PSL and SB but also children whose parents use PSL and SB increased their use of healthcare services and getting flu shots. Also, using PSL and SB decreased their unmet healthcare needs and emergency use. The various health status factors, such as infectious disease incidence, mortality, and presenteeism, also decreased.

Conclusions

The provisions of PSL and SB offer individual and public health benefits by allowing employees and their families to use healthcare services. Group of employees, we can expect similar public health impacts on newly covered groups, thus contributing to achieving the UHC. Since more than 90% of articles are published from the United States, future studies need to evaluate the outcomes of health effects in various European or Asian countries.

Key messages

• The provision of PSL and SB positively affects employees and their families by allowing them to use healthcare services.

• The expansion of PSL and SB contributes to the UHC by guaranteeing indirect medical costs that enable universal access to essential healthcare services.

A Sick Benefit Scheme Reduces Unmet Healthcare Needs: An Natural Experiment in Seoul

 

South Korea experiences four times more unmet healthcare needs than OECD countries (11.6% and 2.6% respectively). Unmet healthcare needs are caused by the double burden of direct and indirect costs including income loss, and OECD countries operate a sickness benefit scheme to resolve sudden loss of pay. Seoul introduced the first sickness benefit system, Seoul-Type Paid Sick Leave Support (hereinafter Seoul Sick Leave), for self-employed national healthcare insurance subscribers to reduce the rate of unmet healthcare needs. By comparing the amount of increasing medical expenses between the beneficiary and non-beneficiary before (2018) and after (2019-2020) the introduction of the system, the study was intended to confirm the reduced unmet healthcare needs. This study used data from the National Health Information Database (NHID) and the difference in differences (DID) analytic framework. 96 and 121 patients were included in benefit and non-benefit cohorts, respectively. As a result, the beneficiary group’s expenses were smaller than those of the non-beneficiary group (coef.=-1.24, p = 0.026). However, the beneficiary group had a greater amount of increase in hospitalization expenses before and after the introduction than the non-beneficiary group did (coef.=1.66, p = 0.005). Our finding showed that the Seoul Sick Leave helped the precarious workers as they were able to use inpatient services when they needed. If it is to be scaled up to the national level, it should be applied all people to enhance universal health insurance in Korea.

Key messages

• Identified the effectiveness of the first sickness benefit system as it helped the precarious workers as they were able to use inpatient services when they needed.

• By financially supporting them, the Seoul Sick Leave support can achieve health promotion through early detection and treatment.

Inequalities in adverse birth outcomes and survival in early childhood: birth cohort in South Korea

Background

Adverse birth outcomes (ABOs) are considered the most common factor of deaths in early childhood. Inequalities in child mortality occur due to interactions between intrinsic and socio-environmental factors related to socioeconomic disadvantage. There are, however, few studies investigating the impact of ABOs on mortality in terms of parental SEP.

Methods

Using the Under-5 Infant Birth-Death Cohort Data in Korea, a pooled retrospective birth cohort of all children born in 2012-2014 was built (N = 1,356,584). We analyzed neonatal, post-neonatal, and childhood mortality by ABOs and with the interaction of parental SEP using the Cox proportional hazard regression model for survival analyses. We further stratified the analysis both by parental SEP and child age. Multiple logistic regression was performed to confirm the social inequalities in ABO itself.

Results

After adjusting for covariates, children born with ABOs presented higher risk of mortality for all periods. For post-neonatal period, lower maternal education showed significant interaction effect with LBW (HR = 0.57; 95% CI = [0.39-0.85]), PTB (HR = 0.53; 95% CI = [0.33-0.86]), LBW & PTB ([HR = 0.67; 95% CI = [0.54-0.83]) while lower paternal education (HR = 0.67; 95% CI = [0.54-0.82]) and maternal unemployment (HR = 0.80; 95% CI = [0.63-0.99]) showed significance for babies with LBW & PTB. However, stratification analyses suggested that the impact of ABOs on mortality was greater for children born to lower parental SEP in neonatal period. Meanwhile apparent social inequalities in ABOs were suggested from regression analyses.

Conclusions

We confirmed social inequalities in the incidence of ABOs as well as mortalities from ABOs. However, the difference in mortality between babies with and without ABOs was greater for advantaged children. Policies to reduce the mortality of children with ABOs as well as those of healthy children among socioeconomically disadvantaged families are required.

Key messages

• Social inequalities in mortality from ABOs were apparent especially in the neonatal period while the incidence of ABOs itself was greater among children from disadvantaged families.

• Disadvantaged children are more likely to die not only from ABOs but also from other socio-environmental determinants, especially in the post-neonatal period than their counterparts.

Effectiveness of COVID-19 vaccines over time prior to Omicron emergence in Ontario, Canada: test-negative design study

Background

Waning protection from two doses of COVID-19 vaccines led to third dose availability in multiple countries even prior to emergence of the Omicron variant.

Methods

We used the test-negative study design to estimate vaccine effectiveness (VE) against any SARS-CoV-2 infection, symptomatic infection, and severe outcomes (COVID-19-related hospitalizations or death) by time since second dose of any combination of BNT162b2, mRNA-1273, and ChAdOx1 between 11 January and 21 November 2021 for subgroups based on patient and vaccine characteristics.

Results

We included 261,360 test-positive cases (of any SARS-CoV-2 lineage) and 2,783,699 individuals as test-negative controls. VE of two mRNA vaccine doses decreased from 90% (95%CI, 90-90%) 7-59 days after the second dose to 75% (95%CI, 72-78%) after ≥240 days against infection, from 94% (95%CI, 84-95%) to 87% (95%CI, 85-89%) against symptomatic infection, and remained stable (98% [95%CI, 97-98%] to 98% [95%CI, 96-99%])against severe outcomes. Similar trends were seen with heterologous ChAdOx1 and mRNA vaccine schedules. VE estimates for dosing intervals &lt;35 days were lower than for longer intervals (e.g., VE of two mRNA vaccines against symptomatic infection at 120-179 days was 86% [95%CI, 85-88%] for dosing intervals &lt;35 days, 92% [95%CI, 91-93%] for 35-55 days, and 91% [95%CI, 90-92%] for ≥56 days), but when stratified by age group and subperiod, there were no differences between dosing intervals.

Conclusions

Prior to Omicron emergence, VE of any two-dose primary series, including heterologous schedules and varying dosing intervals, decreased over time against any infection and symptomatic infection but remained high against severe outcomes.

Estimated Effectiveness of COVID-19 Vaccines Against Omicron or Delta Symptomatic Infection and Severe Outcomes

Importance

The incidence of SARS-CoV-2 infection, including among individuals who have received 2 doses of COVID-19 vaccine, increased substantially following the emergence of the Omicron variant in Ontario, Canada. Understanding the estimated effectiveness of 2 or 3 doses of COVID-19 vaccine against outcomes associated with Omicron and Delta infections may aid decision-making at the individual and population levels.

Objective

To estimate vaccine effectiveness (VE) against symptomatic infections due to the Omicron and Delta variants and severe outcomes (hospitalization or death) associated with these infections.

Design, Setting, and Participants

This test-negative case-control study used linked provincial databases for SARS-CoV-2 laboratory testing, reportable disease, COVID-19 vaccination, and health administration in Ontario, Canada. Participants were individuals aged 18 years or older who had COVID-19 symptoms or severe outcomes (hospitalization or death) and were tested for SARS-CoV-2 between December 6 and 26, 2021.

Exposures

Receipt of 2 or 3 doses of the COVID-19 vaccine and time since last dose.

Main Outcomes and Measures

The main outcomes were symptomatic Omicron or Delta infection and severe outcomes (hospitalization or death) associated with infection. Multivariable logistic regression was used to estimate the effectiveness of 2 or 3 COVID-19 vaccine doses by time since the latest dose compared with no vaccination. Estimated VE was calculated using the formula VE = (1 - [adjusted odds ratio]) × 100%.

Results

Of 134 435 total participants, 16 087 were Omicron-positive cases (mean [SD] age, 36.0 [14.1] years; 8249 [51.3%] female), 4261 were Delta-positive cases (mean [SD] age, 44.2 [16.8] years; 2199 [51.6%] female), and 114 087 were test-negative controls (mean [SD] age, 42.0 [16.5] years; 67 884 [59.5%] female). Estimated VE against symptomatic Delta infection decreased from 89% (95% CI, 86%-92%) 7 to 59 days after a second dose to 80% (95% CI, 74%-84%) after 240 or more days but increased to 97% (95% CI, 96%-98%) 7 or more days after a third dose. Estimated VE against symptomatic Omicron infection was 36% (95% CI, 24%-45%) 7 to 59 days after a second dose and 1% (95% CI, -8% to 10%) after 180 days or longer, but 7 or more days after a third dose, it increased to 61% (95% CI, 56%-65%). Estimated VE against severe outcomes was high 7 or more days after a third dose for both Delta (99%; 95% CI, 98%-99%) and Omicron (95%; 95% CI, 87%-98%).

Conclusions and Relevance

In this study, in contrast to high estimated VE against symptomatic Delta infection and severe outcomes after 2 doses of COVID-19 vaccine, estimated VE was modest and short term against symptomatic Omicron infection but better maintained against severe outcomes. A third dose was associated with improved estimated VE against symptomatic infection and with high estimated VE against severe outcomes for both variants. Preventing infection due to Omicron and potential future variants may require tools beyond the currently available vaccines.

Vaccine effectiveness against SARS-CoV-2 infection and severe outcomes among individuals with immune-mediated inflammatory diseases tested between March 1 and Nov 22, 2021, in Ontario, Canada: a population-based analysis

Background

We estimated COVID-19 vaccine effectiveness against SARS-CoV-2 infection and severe COVID-19 outcomes among individuals with immune-mediated inflammatory diseases in Ontario, Canada.

Methods

In this population-based analysis, we used a test-negative design across four immune-mediated inflammatory disease population-based cohorts, comprising individuals with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease. We identified all SARS-CoV-2 tests done in these populations between March 1 and Nov 22, 2021 (a period in which there was rapid uptake of vaccines, and the alpha [B.1.1.7] and delta [B.1.617.2] SARS-CoV-2 variants were predominantly circulating in Canada) and separately assessed outcomes of SARS-CoV-2 infection and severe COVID-19 outcomes (hospitalisation due to COVID-19 and death due to COVID-19) for each disease group. We used multivariable logistic regression to estimate the effectiveness of one, two, and three doses of mRNA-based COVID-19 vaccine (BNT162b2 [Pfizer–BioNTech], or mRNA-1273 [Moderna]) among individuals at the time of SARS-CoV-2 testing.

Findings

Between March 1 and Nov 22, 2021, we identified 2127 (5·9%) test-positive cases among 36 145 individuals (26 476 [73·2%] were female and 9669 [26·8%] were male) with rheumatoid arthritis tested, 476 (6·1%) test-positive cases among 7863 individuals (4130 [52·5%] were female and 3733 [47·5%] were male) with ankylosing spondylitis tested, 3089 (6·5%) test-positive cases among 47 199 individuals (26 062 [55·2%] were female and 21 137 [44·8%] were male) with psoriasis tested, and 1702 (5·4%) test-positive cases among 31 311 individuals (17 716 [56·6%] were female and 13 595 [43·4%] were male) with inflammatory bowel disease tested. Adjusted vaccine effectiveness of two doses against infection was 83% (95% CI 80–86) in those with rheumatoid arthritis, 89% (83–93) among those with ankylosing spondylitis, 84% (81–86) among those with psoriasis, and 79% (74–82) among those with inflammatory bowel disease. After two vaccine doses, effectiveness against infection generally peaked 31–60 days after vaccination and waned gradually with each additional month. Vaccine effectiveness against severe outcomes after two doses was 92% (95% CI 88–95) in those with rheumatoid arthritis, 97% (83–99) among those with ankylosing spondylitis, 92% (86–95) among those with psoriasis, and 94% (88–97) among those with inflammatory bowel disease. Vaccine effectiveness after a third dose against infection was similar to or higher than after the second dose (ranging from 76% [47–89] to 96% [72–99]), although due to a paucity of events, estimates could not be calculated for some subgroups for severe outcomes.

Interpretation

Two vaccine doses were found to be highly effective against both SARS-CoV-2 infection and severe COVID-19 outcomes in patients with rheumatoid arthritis, ankylosing spondylitis, psoriasis, and inflammatory bowel disease during the study period. Research is needed to determine the durability of effectiveness of three doses over time, particularly against emerging variants.

Funding

Public Health Agency of Canada

Premature mortality in a population-based cohort of autistic adults in Canada

Research from different countries suggests that autistic adults are more likely to die prematurely than non-autistic adults, but these studies do not always investigate male and female individuals separately and do not consider whether this pattern is unique to autistic people or is also an issue for people with other developmental disabilities. We examined premature mortality in autistic males and females (assigned at birth) in a population-based cohort, compared to males and females with and without other developmental disabilities. Using linked administrative health and social services population data from Ontario, Canada, age-matched males and females aged 19-65 years were followed between 2010 and 2016, and causes of death were determined. Over the 6-year observation period, 330 of 42,607 persons (0.77%) in the group without developmental disabilities had died compared to 259 of 10,646 persons (2.43%) in the autism group and 419 of 10,615 persons (3.95%) in the other developmental disabilities group. Autistic males and females were more likely to die than non-autistic males (adjusted risk ratio, RR 3.13, 95%CI 2.58-3.79) and non-autistic females (adjusted RR 3.12, 95%CI 2.35-4.13) without developmental disabilities, but were less likely to die than adults with other developmental disabilities (males: adjusted RR 0.66, 95%CI 0.55-0.79; females: adjusted RR 0.55, 95%CI 0.43-0.71). Most common causes of death varied depending on a person's sex and diagnosis. Given the greater likelihood of premature mortality in adults with developmental disabilities including autism, greater attention and resources directed toward their health and social care are needed, tailored to their sex and diagnosis-informed needs. LAY SUMMARY: This study looked at how many autistic men and women died over 6 years (2010-2016), along with how they died, and compared this to adults who did not have autism living in Ontario, Canada. It found that autistic men and women were more than three times as likely to die as people of the same age who did not have a developmental disability. However, adults with other developmental disabilities besides autism were even more likely to die than autistic adults. This means that we have to pay more attention and invest in better social and health care for autistic people, along with people who have other types of developmental disabilities.

Screening Large Population Health Databases for Potential COVID-19 Therapeutics: A Pharmacopeia-Wide Association Study (PWAS) of Commonly Prescribed Medications

Background

For both the current and future pandemics, there is a need for high-throughput drug screening methods to identify existing drugs with potential preventative and/or therapeutic activity. Epidemiologic studies could complement lab-focused efforts to identify possible therapeutic agents.

Methods

We performed a pharmacopeia-wide association study (PWAS) to identify commonly prescribed medications and medication classes that are associated with the detection of SARS-CoV-2 in older individuals (&gt;65 years) in long-term care homes (LTCH) and the community, between January 15 th, 2020 and December 31 st, 2020, across the province of Ontario, Canada.

Results

26,121 cases and 2,369,020 controls from LTCH and the community were included in this analysis. Many of the drugs and drug classes evaluated did not yield significant associations with SARS-CoV-2 detection. However, some drugs and drug classes appeared significantly associated with reduced SARS-CoV-2 detection, including cardioprotective drug classes such as statins (weighted OR 0.91, standard p-value &lt;0.01, adjusted p-value &lt;0.01) and beta-blockers (weighted OR 0.87, standard p-value &lt;0.01, adjusted p-value 0.01), along with individual agents ranging from levetiracetam (weighted OR 0.70, standard p-value &lt;0.01, adjusted p-value &lt;0.01) to fluoxetine (weighted OR 0.86, standard p-value 0.013, adjusted p-value 0.198) to digoxin (weighted OR 0.89, standard p-value &lt;0.01, adjusted p-value 0.02).

Conclusions

Using this epidemiologic approach which can be applied to current and future pandemics we have identified a variety of target drugs and drug classes that could offer therapeutic benefit in COVID-19 and may warrant further validation. Some of these agents (e.g. fluoxetine) have already been identified for their therapeutic potential.

Development of a minimum dataset for subacute rehabilitation: a three-round e-Delphi consensus study

OBJECTIVES

To develop a minimum dataset to be routinely collected across a heterogenous population within a subacute rehabilitation service to guide best care and outcomes for patients, and value for the health service.

DESIGN

Three-round e-Delphi exercise, followed by consensus meetings.

SETTING

Multicentre study in Brisbane, Australia.

PARTICIPANTS

Rehabilitation decision-makers, researchers and clinicians were invited to participate in the e-Delphi exercise. A multidisciplinary project steering committee (rehabilitation decision makers, researchers, clinicians and consumers) participated in consensus meetings.

METHODS

In round 1 of the e-Delphi, participants responded to an open-ended question, generating data and outcomes that should be routinely collected in rehabilitation. In rounds 2 and 3, participants rated the importance of collecting each item on a nine-point scale. Consensus was defined a priori, as items rated as 'essential' by at least 70%, and of 'limited importance' by less than 15%, of respondents. Consensus meetings were held to further refine and define the dataset for implementation.

RESULTS

In total, 38 participants completed round 1 of the e-Delphi. Qualitative content analysis of their responses generated 1072 codes, which were condensed into 39 categories and 209 subcategories. Following two rounds of rating (round 2: n=32 participants; round 3: n=28 participants), consensus was reached for 124 items. Four consensus meetings (n=14 participants) resulted in the final dataset which included 42 items across six domains: (1) patient demographics, (2) premorbid health and psychosocial information, (3) admission information, (4) service delivery and interventions, (5) outcomes and (6) caregiver information and outcomes.

CONCLUSIONS

We identified 42 items that reflect the values and experiences of rehabilitation stakeholders. Items unique to this dataset include caregiver information and outcomes, and detailed service delivery and intervention data. Future research will establish the feasibility of collection in practice.

Effectiveness of COVID-19 vaccines against symptomatic SARS-CoV-2 infection and severe outcomes with variants of concern in Ontario

SARS-CoV-2 variants of concern (VOC) are more transmissible and may have the potential for increased disease severity and decreased vaccine effectiveness. We estimated the effectiveness of BNT162b2 (Pfizer-BioNTech Comirnaty), mRNA-1273 (Moderna Spikevax) and ChAdOx1 (AstraZeneca Vaxzevria) vaccines against symptomatic SARS-CoV-2 infection and COVID-19 hospitalization or death caused by the Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1) and Delta (B.1.617.2) VOC in Ontario, Canada, using a test-negative design study. We identified 682,071 symptomatic community-dwelling individuals who were tested for SARS-CoV-2, and 15,269 individuals with a COVID-19 hospitalization or death. Effectiveness against symptomatic infection ≥7 d after two doses was 89-92% against Alpha, 87% against Beta, 88% against Gamma, 82-89% against Beta/Gamma and 87-95% against Delta across vaccine products. The corresponding estimates ≥14 d after one dose were lower. Effectiveness estimates against hospitalization or death were similar to or higher than against symptomatic infection. Effectiveness against symptomatic infection was generally lower for older adults (≥60 years) than for younger adults (<60 years) for most of the VOC-vaccine combinations. Our findings suggest that jurisdictions facing vaccine supply constraints may benefit from delaying the second dose in younger individuals to more rapidly achieve greater overall population protection; however, older adults would likely benefit most from minimizing the delay in receiving the second dose to achieve adequate protection against VOC.

Pivoting data and analytic capacity to support Ontario's COVID-19 response

Introduction

Health care systems have faced unprecedented challenges due to the COVID-19 pandemic. Access to timely population-based data has been vital to informing public health policy and practice.

Methods

We describe how ICES, an independent not-for-profit research and analytic institute in Ontario, Canada, pivoted existing research infrastructure and engaged health system stakeholders to provide near real-time population-based data and analytics to support Ontario's COVID-19 pandemic response.

Results

Since April 2020, ICES provided the Ontario COVID-19 Provincial Command Table and public health partners with regular and ad hoc reports on SARS-CoV-2 testing and COVID-19 vaccine coverage. These reports: 1) helped identify congregate care/shared living settings that needed testing and prevention efforts early in the pandemic; 2) provided early indications of inequities in testing and infection in marginalized neighbourhoods, including areas with higher proportions of immigrants and visible minorities; 3) identified areas with high test positivity, which helped Public Health Units target and evaluate prevention efforts; and 4) contributed to altering the province's COVID-19 vaccine roll-out strategy to target high-risk neighbourhoods and helping Public Health Units and community organizations plan local vaccination programs. In addition, ICES is a key component of the Ontario Health Data Platform, which provides scientists with data access to conduct COVID-19 research and analyses.

Discussion and Conclusion

ICES was well-positioned to provide rapid analyses for decision-makers to respond to the evolving public health emergency, and continues to contribute to Ontario's pandemic response by providing timely, relevant reports to health system stakeholders and facilitating data access for externally-funded COVID-19 research.

A multi-country investigation of influenza vaccine coverage in pregnant individuals, 2010-2016

BACKGROUND

Many countries recommend influenza vaccination during pregnancy. Despite this recommendation, influenza vaccine among pregnant individuals remains under-utilized and uptake varies by country. Factors associated with influenza vaccine uptake during pregnancy may also vary across countries.

METHODS

As members of the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT), five sites from four countries (Australia, Canada, Israel, and the United States) retrospectively identified cohorts of individuals aged 18-50 years who were pregnant during pre-defined influenza seasons. Influenza vaccine coverage estimates were calculated for the 2010-11 through 2015-16 northern hemisphere and the 2012 through 2015 southern hemisphere influenza seasons, by site. Sites used electronic health records, administrative data, and immunization registries to collect information on pregnancy, health history, demographics, and vaccination status. Each season, vaccination coverage was calculated as the percentage of individuals who received influenza vaccine among the individuals in the cohort that season. Characteristics were compared between those vaccinated and unvaccinated, by site.

RESULTS

More than two million pregnancies were identified over the study period. Influenza vaccination coverage ranged from 5% to 58% across sites and seasons. Coverage increased consistently over the study period at three of the five sites (Western Australia, Alberta, and Israel), and was highest in all seasons at the United States study site (39-58%). Associations with vaccination varied by country and across seasons; where available, parity >0, presence of a high-risk medical condition, and urban residence were consistently associated with increased likelihood of vaccination.

CONCLUSIONS

Though increasing, uptake of influenza vaccine among pregnant individuals remains lower than recommended. Coverage varied substantially by country, suggesting an ongoing need for targeted strategies to improve influenza vaccine uptake in this population.

The receipt of information by family physicians about their patient's emergency department visits: a record linkage study of electronic medical records to health administrative data

Background

Canadians are known to be frequent users of emergency department (ED) care. However, the exchange of information from ED visits to family physicians (FPs) is not well known. Our objectives were to determine whether Canadian FPs received information about their patient’s ED visit and the patient characteristics related to the receipt of ED information.

Methods

This study was a descriptive record linkage study of FP Electronic Medical Record (EMR) data linked to health administrative data. Our study cohort included patients who had at least one ED visit in 2010 or 2015 in Ontario, Canada. An ED visit could include a transfer to or from another ED. The receipt of information from an ED note was examined in relation to patient age, sex, neighbourhood income quintiles, rurality and comorbidity.

Results

There were 26,609 patients in 2010 and 50,541 patients in 2015 with at least one ED visit. In 2010, 53.3% of FPs received an ED note for patients having a single ED visit compared to 41.0% in 2015. For patients with multiple ED visits, 58.2% of FPs received an ED note in 2010 compared to 45.7% in 2015. FPs were more likely to receive an ED note for patients not living in low income neighbourhoods, older patients, patients living in small urban areas and for patients having moderate comorbidity. FPs were less likely to receive a note for patients living in rural areas.

Conclusions

Community-based FPs are more likely to get information after an ED visit for their older and sicker patients. However, FPs do not receive any information from EDs for over half their patients. Electronic health record technologies and their adoption by ED providers need to improve the seamless transfer of information about the care provided in EDs to FPs in the community.

Effectiveness of BNT162b2 and mRNA-1273 covid-19 vaccines against symptomatic SARS-CoV-2 infection and severe covid-19 outcomes in Ontario, Canada: test negative design study

OBJECTIVE

To estimate the effectiveness of mRNA covid-19 vaccines against symptomatic infection and severe outcomes (hospital admission or death).

DESIGN

Test negative design study.

SETTING

Ontario, Canada between 14 December 2020 and 19 April 2021.

PARTICIPANTS

324 033 community dwelling people aged ≥16 years who had symptoms of covid-19 and were tested for SARS-CoV-2.

INTERVENTIONS

BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna) vaccine.

MAIN OUTCOME MEASURES

Laboratory confirmed SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) and hospital admissions and deaths associated with SARS-CoV-2 infection. Multivariable logistic regression was adjusted for personal and clinical characteristics associated with SARS-CoV-2 and vaccine receipt to estimate vaccine effectiveness against symptomatic infection and severe outcomes.

RESULTS

Of 324 033 people with symptoms, 53 270 (16.4%) were positive for SARS-CoV-2 and 21 272 (6.6%) received at least one dose of vaccine. Among participants who tested positive, 2479 (4.7%) were admitted to hospital or died. Vaccine effectiveness against symptomatic infection observed ≥14 days after one dose was 60% (95% confidence interval 57% to 64%), increasing from 48% (41% to 54%) at 14-20 days after one dose to 71% (63% to 78%) at 35-41 days. Vaccine effectiveness observed ≥7 days after two doses was 91% (89% to 93%). Vaccine effectiveness against hospital admission or death observed ≥14 days after one dose was 70% (60% to 77%), increasing from 62% (44% to 75%) at 14-20 days to 91% (73% to 97%) at ≥35 days, whereas vaccine effectiveness observed ≥7 days after two doses was 98% (88% to 100%). For adults aged ≥70 years, vaccine effectiveness estimates were observed to be lower for intervals shortly after one dose but were comparable to those for younger people for all intervals after 28 days. After two doses, high vaccine effectiveness was observed against variants with the E484K mutation.

CONCLUSIONS

Two doses of mRNA covid-19 vaccines were observed to be highly effective against symptomatic infection and severe outcomes. Vaccine effectiveness of one dose was observed to be lower, particularly for older adults shortly after the first dose.

SARS-CoV-2 Infection Among Maternal-Infant Dyads in Ontario, Canada

This cohort study uses population-based health data to assess SARS-CoV-2 testing outcomes among infants born in Ontario, Canada, during 9 months of the 2020 COVID-19 pandemic to mothers with confirmed infection at delivery.

Data Architecture to Support Real-Time Data Analytics for the Population-Based HIV Impact Assessments

BACKGROUND AND SETTING

Electronic data capture facilitates timely use of data. Population-based HIV impact assessments (PHIAs) were led by host governments, with funding from the President's Emergency Plan for AIDS Relief, technical assistance from the Centers for Disease Control, and implementation support from ICAP at Columbia University. We described data architectures, code-based processes, and resulting data volume and quality for 14 national PHIA surveys with concurrent timelines and varied country-level data governance (2015-2020).

METHODS

PHIA project data were collected through tablets, point-of-care and laboratory testing instruments, and inventory management systems, using open-source software, vendor solutions, and custom-built software. Data were securely uploaded to the PHIA data warehouse daily or weekly and then used to populate survey-monitoring dashboards and return timely laboratory-based test results on an ongoing basis. Automated data processing allowed timely reporting of survey results.

RESULTS

Fourteen data architectures were successfully established, and data from more than 450,000 participants in 30,000 files across 13 countries with completed PHIAs, and blood draws producing approximately 6000 aliquots each week per country, were securely collected, transmitted, and processed by 17 full-time equivalent staff. More than 25,600 viral load results were returned to clinics of participants' choice. Data cleaning was not needed for 98.5% of household and 99.2% of individual questionnaires.

CONCLUSION

The PHIA data architecture permitted secure, simultaneous collection and transmission of high-quality interview and biomarker data across multiple countries, quick turnaround time of laboratory-based biomarker results, and rapid dissemination of survey outcomes to guide President's Emergency Plan for AIDS Relief epidemic control.

The Role of a Resilient Information Infrastructure in COVID-19 Vaccine Uptake in Ontario

The COVID-19 pandemic has highlighted the need for a robust and nimble public health data infrastructure. ICES - a government-sponsored, independent, non-profit research institute in Ontario, Canada - functions as a key component of a resilient information infrastructure and an enabler of data co-production, contributing to Ontario's response to the COVID-19 pandemic as part of a learning health system. Linked data on the cumulative incidence of infection and vaccination at the neighbourhood level revealed disparate uptake between areas with low versus high risk of COVID-19. These data were leveraged by the government, service providers, media and the public to inform a more efficient and equitable vaccination strategy.

Background rates of all-cause mortality, hospitalizations, and emergency department visits among nursing home residents in Ontario, Canada to inform COVID-19 vaccine safety assessments

Background

Nursing home (NH) residents are prioritized for COVID-19 vaccination. We report monthly mortality, hospitalizations, and emergency department (ED) visit incidence rates (IRs) during 2010–2020 to provide context for COVID-19 vaccine safety assessments.

Methods

We observed outcomes among all NH residents in Ontario using administrative databases. IRs were calculated by month, sex, and age group. Comparisons between months were assessed using one-sample t-tests; comparisons by age and sex were assessed using chi-squared tests.

Results

From 2010 to 2019, there were 83,453 (SD: 652.4) NH residents per month, with an average of 2.3 (SD: 0.28) deaths, 3.1 (SD: 0.16) hospitalizations, and 3.6 (SD: 0.17) ED visits per 100 residents per month. From March to December 2020, mortality IRs were increased, but hospitalization and ED visit IRs were reduced (p < 0.05).

Conclusion

We identified consistent monthly mortality, hospitalization, and ED visit IRs during 2010–2019. Marked differences in these rates were observed during 2020, coinciding with the COVID-19 pandemic.

Diagnosis of Chronic Hepatitis B Pericomplication: Risk factors and Trends Over Time

BACKGROUND AND AIMS

Hepatitis B virus (HBV) is a major cause of chronic liver disease, which can progress to cirrhosis, hepatocellular carcinoma, and death. A timely diagnosis allows for antiviral treatment, which can prevent liver-related complications. Conversely, a late diagnosis signals a missed opportunity for earlier care and treatment. Our objective was to measure the proportion of chronic HBV diagnoses that are made within 6 months of presentation with a liver disease-related complication and examine associated factors and trends over time.

APPROACH AND RESULTS

We used provincial laboratory data to identify patients with chronic HBV diagnosed from 2003 to 2014. We measured the proportion who experienced a liver disease complication (decompensated cirrhosis, hepatocellular carcinoma, or liver transplant) within ±6 months of their HBV diagnosis date. A multivariable logistic regression model was used to identify factors associated with HBV diagnosis pericomplication. Of 18,434 patients with chronic HBV, 1,279 (6.9%) developed an HBV-related complication during the follow-up period. Among these, 570 (44.6%) had a first diagnosis pericomplication. HBV diagnosis pericomplication did not decrease over time and was independently associated with older age at HBV diagnosis, rural residence, alcohol use, and moderate to high levels of comorbidity. Female patients, immigrants, and those with more outpatient physician visits were less likely to have an HBV diagnosis pericomplication.

CONCLUSIONS

A high proportion of patients with HBV-related complications are first diagnosed with HBV pericomplication. These signal missed opportunities for earlier detection and treatment. Our findings support expansion of HBV screening.

Validating viral hepatitis B and C diagnosis codes: a retrospective analysis using Ontario's health administrative data

OBJECTIVE

We aimed to determine the criterion validity of using diagnosis codes for hepatitis B virus (HBV) and hepatitis C virus (HCV) to identify infections.

METHODS

Using linked laboratory and administrative data in Ontario, Canada, from January 2004 to December 2014, we validated HBV/HCV diagnosis codes against laboratory-confirmed infections. Performance measures (sensitivity, specificity, and positive predictive value) were estimated via cross-validated logistic regression and we explored variations by varying time windows from 1 to 5 years before (i.e., prognostic prediction) and after (i.e., diagnostic prediction) the date of laboratory confirmation. Subgroup analyses were performed among immigrants, males, baby boomers, and females to examine the robustness of these measures.

RESULTS

A total of 1,599,023 individuals were tested for HBV and 840,924 for HCV, with a resulting 41,714 (2.7%) and 58,563 (7.0%) infections identified, respectively. HBV/HCV diagnosis codes ± 3 years of laboratory confirmation showed high specificity (99.9% HBV; 99.8% HCV), moderate positive predictive value (70.3% HBV; 85.8% HCV), and low sensitivity (12.8% HBV; 30.8% HCV). Varying the time window resulted in limited changes to performance measures. Diagnostic models consistently outperformed prognostic models. No major differences were observed among subgroups.

CONCLUSION

HBV/HCV codes should not be the only source used for monitoring the population burden of these infections, due to low sensitivity and moderate positive predictive values. These results underscore the importance of ongoing laboratory and reportable disease surveillance systems for monitoring viral hepatitis in Ontario.