Exploring medical and veterinary student perceptions and communication preferences related to antimicrobial resistance in Ontario, Canada using qualitative methods

BACKGROUND

Antimicrobial resistance (AMR) threatens our ability to treat and prevent infectious diseases worldwide. A significant driver of AMR is antimicrobial use (AMU) in human and veterinary medicine. Therefore, education and awareness of AMR among antimicrobial prescribers is critical. Human and animal health professionals play important roles in the AMR issue, both as contributors to the emergence of AMR, and as potential developers and implementers of effective solutions. Studies have shown that engaging stakeholders prior to developing communication materials can increase relevance, awareness, and dissemination of research findings and communication materials. As future antimicrobial prescribers, medical and veterinary students' perspectives on AMR, as well as their preferences for future communication materials, are important. The first objective of this study was to explore medical and veterinary student perceptions and understanding of factors associated with emergence and spread of AMR. The second objective was to identify key messages, knowledge translation and transfer (KTT) methods, and dissemination strategies for communication of AMR information to these groups.

METHODS

Beginning in November 2018, focus groups were conducted with medical and veterinary students in Ontario, Canada. A semi-structured format, using standardized open-ended questions and follow-up probing questions was followed. Thematic analysis was used to identify and analyze patterns within the data.

RESULTS

Analyses showed that students believed AMR to be an important global issue and identified AMU in food-producing animals and human medicine as the main drivers of AMR. Students also highlighted the need to address society's reliance on antimicrobials and the importance of collaboration between different sectors to effectively reduce the emergence and transmission of AMR. When assessing different communication materials, students felt that although infographics provide easily digestible information, other KTT materials such as fact sheets are better at providing more information without overwhelming the target audiences (e.g., professional or general public).

CONCLUSION

Overall, the study participants felt that AMR is an important issue and emphasized the need to develop different KTT tools for different audiences. This research will help inform the development of future communication materials, and support development of AMR-KTT tools tailored to the needs of different student and professional groups.

"I Think There Should Be Photos": Female Indoor Tanners' Perceptions of Health Warning Labels for Tanning Beds

This study explores female indoor tanners' perceptions of the current, text-only Canadian health warning label (HWL) for tanning equipment, as well as pictorial, evidence-based alternative HWLs. We created 10 test HWLs that depicted skin health effects, eye damage, premature aging, and death. Young women who had tanned indoors in the past year discussed these and the current federal HWL in focus groups. Although the current Canadian HWL was seen as informative, several participants did not recognize it, and many said that they would not read it due to the small text, wordiness, and lack of an image. Graphic images, particularly those depicting permanent conditions affecting the face, eyes, or appearance, were seen as effective. Common criticisms of the images were lack of believability, relatability, and comprehensibility. Although concise text was important for encouraging reading, many participants expressed a desire for more information in the test HWLs. Premature aging was of great concern to many participants, but the images selected for these HWLs were not perceived as effective. Although the text was seen as effective in the death HWLs, most participants dismissed the images. This research has implications for IT HWLs in Canada and globally. These results suggest that graphic images may be impactful in IT HWLs. Images must be supplemented with informative text that increases believability, relatability, and comprehensibility. These modifications would create HWLs that are engaging, informative, and that form part of a wider effort to spread awareness about the harmful effects of IT.

Antimicrobial use in lactating sows, piglets, nursery, and grower-finisher pigs on swine farms in Ontario, Canada during 2017 and 2018

Background

Data on antimicrobial use (AMU) in pig production are needed for the development of good antimicrobial stewardship practices to reduce the risk of antimicrobial resistance in bacteria that can cause illness in animals and humans. In Canada, there is a lack of quantitative data on AMU in the farrowing and nursery stages of pig production. This study aimed to determine which antimicrobial active ingredients are currently used in farrowing, nursery, and grower-finisher herds in the province of Ontario, Canada, and to quantify AMU using various metrics. We collected data on herd demographics, biosecurity, health status, and AMU during one production cycle from 25 farrowing and 25 nursery herds in Ontario, between May 2017 and April 2018, and obtained data from 23 Ontario grower-finisher herds during the same time frame from the Public Health Agency’s Canadian Integrated Program for Antimicrobial Resistance Surveillance. We applied frequency measures, and weight-, and dose-based metrics to the data.

Results

In all pigs, the highest quantity of AMU was administered in-feed. By all routes of administration and compared to other production stages, nursery pigs used more antimicrobials in mg/kg biomass and the number of Canadian defined daily doses per 1000 pig-days (dose_CA rate), while grower-finisher pigs used more antimicrobials in total kilograms and the number of Canadian defined daily doses per pig. In suckling pigs in some herds, there was routine disease prevention use of ceftiofur, an antimicrobial active ingredient categorized as very highly important in human medicine by Health Canada. The top antimicrobial used in each stage of pig production often varied by the metric used. There was producer-reported growth promotion use of antimicrobials in suckling and grower-finisher feed.

Conclusions

The results of this study provide a current picture of AMU in pigs in Ontario and can be used as a basis for further research on AMU in farrowing and nursery herds in Canada. Our findings confirm that it would be useful to include farrowing and nursery herds in routine AMU surveillance in Canada. A future analysis using data from this project will examine factors that affect the quantity of AMU.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40813-022-00259-w.

Increasing incidence and antimicrobial resistance in Escherichia coli bloodstream infections: a multinational population-based cohort study

BACKGROUND

Escherichia coli is an important pathogen in humans and is the most common cause of bacterial bloodstream infections (BSIs). The objectives of our study were to determine factors associated with E. coli BSI incidence rate and third-generation cephalosporin resistance in a multinational population-based cohort.

METHODS

We included all incident E. coli BSIs (2014-2018) from national (Finland) and regional (Australia [Canberra], Sweden [Skaraborg], and Canada [Calgary, Sherbrooke, and western interior]) surveillance. Incidence rates were directly age and sex standardized to the European Union 28-country 2018 population. Multivariable negative binomial and logistic regression models estimated factors significantly associated with E. coli BSI incidence rate and third-generation cephalosporin resistance, respectively. The explanatory variables considered for inclusion in both models were year (2014-2018), region (six areas), age (< 70-years-old and ≥ 70-years-old), and sex (female and male).

RESULTS

We identified 31,889 E. coli BSIs from 40.7 million person-years of surveillance. Overall and third-generation cephalosporin-resistant standardized rates were 87.1 and 6.6 cases/100,000 person-years, respectively, and increased 14.0% and 40.1% over the five-year study. Overall, 7.8% (2483/31889) of E. coli BSIs were third-generation cephalosporin-resistant. Calgary, Canberra, Sherbrooke, and western interior had significantly lower E. coli BSI rates compared to Finland. The significant association between age and E. coli BSI rate varied with sex. Calgary, Canberra, and western interior had significantly greater odds of third-generation cephalosporin-resistant E. coli BSIs compared to Finland. Compared to 2014, the odds of third-generation cephalosporin-resistant E. coli BSIs were significantly increased in 2016, 2017, and 2018. The significant association between age and the odds of having a third-generation cephalosporin-resistant E. coli BSI varied with sex.

CONCLUSIONS

Increases in overall and third-generation cephalosporin-resistant standardized E. coli BSI rates were clinically important. Overall, E. coli BSI incidence rates were 40-104% greater than previous investigations from the same study areas. Region, sex, and age are important variables when analyzing E. coli BSI rates and third-generation cephalosporin resistance in E. coli BSIs. Considering E. coli is the most common cause of BSIs, this increasing burden and evolving third-generation cephalosporin resistance will have an important impact on human health, especially in aging populations.

Mortality in Escherichia coli bloodstream infections: a multinational population-based cohort study

Background

Escherichia coli is the most common cause of bloodstream infections (BSIs) and mortality is an important aspect of burden of disease. Using a multinational population-based cohort of E. coli BSIs, our objectives were to evaluate 30-day case fatality risk and mortality rate, and determine factors associated with each.

Methods

During 2014–2018, we identified 30-day deaths from all incident E. coli BSIs from surveillance nationally in Finland, and regionally in Sweden (Skaraborg) and Canada (Calgary, Sherbrooke, western interior). We used a multivariable logistic regression model to estimate factors associated with 30-day case fatality risk. The explanatory variables considered for inclusion were year (2014–2018), region (five areas), age (< 70-years-old, ≥70-years-old), sex (female, male), third-generation cephalosporin (3GC) resistance (susceptible, resistant), and location of onset (community-onset, hospital-onset). The European Union 28-country 2018 population was used to directly age and sex standardize mortality rates. We used a multivariable Poisson model to estimate factors associated with mortality rate, and year, region, age and sex were considered for inclusion.

Results

From 38.7 million person-years of surveillance, we identified 2961 30-day deaths in 30,923 incident E. coli BSIs. The overall 30-day case fatality risk was 9.6% (2961/30923). Calgary, Skaraborg, and western interior had significantly increased odds of 30-day mortality compared to Finland. Hospital-onset and 3GC-resistant E. coli BSIs had significantly increased odds of mortality compared to community-onset and 3GC-susceptible. The significant association between age and odds of mortality varied with sex, and contrasts were used to interpret this interaction relationship. The overall standardized 30-day mortality rate was 8.5 deaths/100,000 person-years. Sherbrooke had a significantly lower 30-day mortality rate compared to Finland. Patients that were either ≥70-years-old or male both experienced significantly higher mortality rates than those < 70-years-old or female.

Conclusions

In our study populations, region, age, and sex were significantly associated with both 30-day case fatality risk and mortality rate. Additionally, 3GC resistance and location of onset were significantly associated with 30-day case fatality risk. Escherichia coli BSIs caused a considerable burden of disease from 30-day mortality. When analyzing population-based mortality data, it is important to explore mortality through two lenses, mortality rate and case fatality risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06326-x.

Detection of spatial and spatio-temporal Salmonella Heidelberg and Salmonella Typhimurium human case clusters focused around licensed abattoirs in Ontario in 2015, and their potential relation to known outbreaks

Salmonellosis is one of several zoonotic diseases for which individuals with occupational animal contact, including abattoir workers, are at an increased risk. If meat is contaminated during slaughter, this can increase the risk of enteric illness for consumers. In this study, we investigated whether reported cases of Salmonella Heidelberg and Typhimurium were clustered around abattoirs in Ontario in 2015 and whether there was any evidence (laboratory/exposure) to suggest an abattoir at the centre of a cluster might be the source of exposure. Data for each reported case of S. Heidelberg and S. Typhimurium in Ontario in 2015 were collected. Multi-focused and non-focused spatial and space-time cluster detection tests were performed for each serotype, with and without cases linked to known outbreaks, using Poisson and space-time permutation models. Focused tests included the location of abattoirs operational in all or part of 2015. Laboratory data and exposure information were used to explore the relatedness of cases within identified clusters. Focused spatial tests identified clusters of S. Heidelberg and S. Typhimurium around abattoirs. Focused space-time permutation tests identified 2 significant space-time clusters of S. Heidelberg; one cluster (n = 11 cases) included 8 of 9 cases associated with a known outbreak and the other cluster (n = 18 cases) was not part of a previously identified outbreak. Review of laboratory and risk factor information suggested that cases within each cluster shared a common exposure. Cases were not asked about goat or sheep meat consumption. The focused cluster test, particularly with the space-time permutation model, could assist in identifying outbreaks associated with a particular physical location, such as an abattoir. Improvements to the current case investigation process, such as consistent collection and reporting of high-risk occupation information and more detailed food consumption history, could assist in outbreak identification when coupled with this statistic.

Choosing which metrics to use when reporting antimicrobial use information to veterinarians in the Canadian swine industry

The objective of this study was to evaluate preferences for various metrics and denominators among Canadian swine veterinarians, in order to improve reporting of antimicrobial use (AMU) information to these stakeholders and to facilitate enhanced stewardship decisions. An online survey was made available to swine veterinarians across Canada; 12 responses (estimated response rate 17.6%) were submitted and analyzed. Responses represented veterinarians from every major pig-producing province and from a range of year of graduation from veterinary college. Participants self-evaluated their understanding of dose-based metrics as higher than weight- and frequency-based metrics and interpreted most results of AMU analyses correctly. Participants preferred dose-based metrics over others, and had various objectives for AMU information, including improving AMU on their clients' farms and enabling comparisons with other farms. The results are useful to those making decisions about which AMU metrics to use in reports targeted to swine veterinarians.

Non-antibiotic Approaches for Disease Prevention and Control in Nursery Pigs: A Scoping Review

Swine producers are encouraged to practice antibiotic stewardship by reducing their use of antibiotics belonging to classes of medical importance to humans. We conducted a scoping review of non-antibiotic approaches in the form of products or management practices that might prevent or control disease and thus reduce the need for antibiotics in nursery pigs. Our objectives were to systematically describe the research on this broad topic for the North American context, identify specific topics that could feasibly support systematic reviews, and identify knowledge gaps. A search of multiple databases identified 11,316 articles and proceedings for relevance screening. From these, 441 eligible clinical trials and observational studies were charted. The majority were clinical trials (94%). Study results from EU countries were mostly communicated through journal articles, whereas study results from the USA were mostly communicated through conference proceedings. Interventions and health outcomes were diverse. The two most frequent intervention categories were feed additives and piglet vaccines. The three most frequent outcomes reported were diarrhea, mortality, and indices of vaccine immunity. There were 13 specific topics comprising various feed additives and vaccines that might feasibly support systematic reviews. There were relatively few studies in which interventions were compared with antibiotic comparison groups and relatively few studies evaluating management practices.

Readability and content of online pet obesity information

OBJECTIVE

To assess the readability of pet obesity information, document the presence and absence of types of pet obesity information, and perform comparisons between dog and cat obesity information content on websites.

SAMPLE

68 websites containing pet obesity content.

PROCEDURES

Websites were systematically retrieved with a search engine and predefined search terms and phrases. For each website, pet obesity information was scored by use of 2 established readability tools: the simple measure of gobbledygook (SMOG) index and Flesch-Kincaid (FK) readability test. A directed content analysis was conducted with a codebook that assessed the presence or absence of 103 variables across 5 main topics related to pet obesity on each website.

RESULTS

The mean reading grade levels determined with the SMOG index and FK readability test were 16.61 and 9.07, respectively. Instructions for weight measurement and body condition scoring were found infrequently, as were nonmodifiable risk factors. There was a greater focus on addressing obesity through dietary changes than through increasing physical activity. Few websites recommended regular follow-up appointments with veterinarians. Weight management information and the emphasis on owners' commitment to achieve their pet's weight loss targets differed among dog- and cat-focused websites.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that pet obesity information on the studied websites was largely inaccessible to pet owners owing to the associated high reading grade levels. Readers of that information would benefit from clarification of information gaps along with provision of guidance regarding navigating online information and counseling on the importance of nutritional and dietary reassessments for individual pets performed by veterinarians.

Evaluation of the health and healthcare system burden due to antimicrobial-resistant Escherichia coli infections in humans: a systematic review and meta-analysis

BACKGROUND

Assessment of the burden of disease due to antimicrobial-resistant Escherichia coli infections facilitates understanding the scale of the problem and potential impacts, and comparison to other diseases, which allows prioritization of research, surveillance, and funding. Using systematic review and meta-analysis methodology, the objectives were to evaluate whether humans with antimicrobial-resistant E. coli infections experience increases in measures of health or healthcare system burden when compared to susceptible E. coli infections.

METHODS

Comprehensive literature searches were performed in four primary and seven grey literature databases. Analytic observational studies of human E. coli infections that assessed the impact of resistance to third/fourth/fifth-generation cephalosporins, resistance to quinolones, and/or multidrug resistance on mortality, treatment failure, length of hospital stay and/or healthcare costs were included. Two researchers independently performed screening, data extraction, and risk of bias assessment. When possible, random effect meta-analyses followed by assessment of the confidence in the cumulative evidence were performed for mortality and length of hospital stay outcomes, and narrative syntheses were performed for treatment failure and healthcare costs.

RESULTS

Literature searches identified 14,759 de-duplicated records and 76 articles were included. Based on 30-day and all-cause mortality meta-analyses, regardless of the type of resistance, there was a significant increase in the odds of dying with resistant E. coli infections compared to susceptible infections. A summary mean difference was not presented for total length of hospital stay meta-analyses due to substantial to considerable heterogeneity. Since small numbers of studies contributed to meta-analyses for bacterium-attributable mortality and post-infection length of hospital stay, the summary results should be considered with caution. Studies contributing results for treatment failure and healthcare costs had considerable variability in definitions and reporting.

CONCLUSIONS

Overall, resistant E. coli infections were associated with significant 30-day and all-cause mortality burden. More research and/or improved reporting are necessary to facilitate quantitative syntheses of bacterium-attributable mortality, length of hospital stay, and hospital costs. Protocol Registration PROSPERO CRD42018111197.

Detection of spatial, temporal and space-time Salmonella Heidelberg and Salmonella Typhimurium clusters in Ontario in 2015, and comparisons to known outbreaks

PURPOSE

Salmonellosis is one of several reportable diseases in Ontario (ON). Two or more cases of the same serotype that are linked to a common exposure or related to one another in time and/or space are considered a potential outbreak. While laboratory data can help to determine the molecular relatedness of cases, results may take up to several weeks. This study aimed to assess the utility of the retrospective spatial scan statistic in detecting clusters of Salmonella Heidelberg and Salmonella Typhimurium cases using data from ON in 2015. Identified clusters were validated by laboratory data (where available) to determine whether identified clusters were likely outbreaks.

METHODS

Data representing the location of each reported S. Heidelberg or S. Typhimurium case in 2015, responsible serotype and symptom onset date were exported to SaTScan for retrospective spatial, temporal, and space-time analyses using the spatial scan statistic with Bernoulli models and a space-time permutation model. Analyses were performed with and without those cases linked to known outbreaks. Laboratory subtyping data (i.e. pulsed field gel electrophoresis (PFGE) and/or phage type) and food and environmental exposure information (e.g. travel, animal contact, poultry and other food item consumption) were used to explore the relatedness of cases within identified clusters.

RESULTS

Spatial, temporal and space-time analyses identified a known outbreak of S. Heidelberg in 2015 (n = 9 cases) and a previously unidentified cluster of S. Heidelberg cases. Most cases (94%) within a cluster detected via a space-time permutation model of S. Heidelberg cases shared an identical PFGE pattern and appeared to represent a true outbreak.

CONCLUSIONS

The spatial scan statistic, and particularly the space-time permutation model, could assist in outbreak identification before laboratory data are available, allowing for faster cluster identification and implementation of control measures.

A case-case study comparing the individual risk factors and symptomatology of Salmonella Heidelberg and Salmonella Typhimurium in Ontario in 2015, following implementation of the Ontario Investigation Tools

Salmonella Heidelberg and Salmonella Typhimurium are among the most common serotypes responsible for human salmonellosis in Ontario. Introduction of the Ontario Investigation Tools (OIT) in 2014 allowed for standardized case investigation and reporting. This study compared the risk factors and symptomatology for sporadic S. Heidelberg and S. Typhimurium cases reported in Ontario in 2015, following implementation of the OIT. Multilevel logistic regression models were applied to assess associations between serotype and individual-level demographic characteristics, exposures and symptoms for sporadic confirmed cases of S. Heidelberg and S. Typhimurium in Ontario in 2015. There were 476 sporadic cases of S. Typhimurium (n = 278) and S. Heidelberg (n = 198) reported in Ontario in 2015. There were significant associations between the odds of the isolate from a case being one of these serotypes, and travel, consumption of sprouts (any type), contact with reptiles and development of malaise, fever or bloody diarrhoea. The S. Typhimurium and S. Heidelberg cases differed in both symptom presentation and risk factors for illness. Case-case comparisons of Salmonella serotypes have some advantages over case-control studies in that these are less susceptible to selection and recall bias while allowing for rapid comparison of cases to identify potential high-risk exposures that are unique to one of the serotypes when compared to the other. Comparing cases of two different Salmonella serotypes can help to highlight risk factors that may be uniquely associated with one serotype, or more strongly associated with one serotype compared to another. This information may be useful for understanding relative source attribution between common serotypes of Salmonella.

Validation of the LacTek Test Applied to Spiked Extracts of Tissue Samples: Determination of Performance Characteristics

LacTekTM tests are competitive enzyme-linked immunosorbent assays intended for rapid detection of antimicrobial residues in bovine milk. In this study, the LacTek test protocol was modified for use with extracts of bovine tissue to detect β-lac-tam, tetracycline, and sulfamethazine residues. Testperformance characteristics—precision, accuracy, ruggedness, practicability, and analytical specificity and sensitivity—were investigated. Results suggest that LacTek tests can be easily adapted to detect antimicrobial residues in extracts of lean ground beef. However, positive samples may not contain residues at violative concentrations (i.e., Canadian maximum residue limits), and therefore, additional analysis would be required for final confirmation and quantitation (e.g., chromatography).

The Effect of Food Handler Certification on Food Premises in Ontario, Canada

Although health units have implemented food handler certification to operators of food premises, evidence on its effectiveness to improve premise food safety remains inconclusive. Regression models were constructed using inspection data from a health unit in Ontario, Canada, to measure the effect of certification on premise inspection results. We found that premises without certified food handlers at the time of inspection were significantly more likely to fail inspections. The odds of inspection failure were significantly different depending on the premise's cultural cuisine classification. Independently owned establishments had lower odds of inspection failure versus chain operations. Inspector was a significant random effect explaining a small percentage of data variations. These results support the use of food handler certification to improve food safety outcomes at establishments. Further efforts should ensure training programs are accessible and relatable to premise operators, particularly those serving all types of cultural cuisines.

Antimicrobial Resistance of Human Campylobacter Species Infections in Saskatchewan, Canada (1999-2006): A Historical Provincial Collection of All Reported Cases

To describe a historical baseline of antimicrobial resistance (AMR) profiles for human clinical Campylobacter species isolates obtained by laboratory surveillance in the province of Saskatchewan from 1999 to 2006; to determine if there were differences in resistance between Campylobacter jejuni and Campylobacter coli; and to determine if there were changes in the annual resistance levels in the two species. One thousand three hundred seventy-eight Campylobacter isolates were subjected to antimicrobial susceptibility testing using the E-test method. Annual resistance levels in C. jejuni and C. coli were compared using logistic regression models. One thousand two hundred (87.1%) isolates were C. jejuni and 129 (9.4%) were C. coli. Resistance in C. jejuni isolates included ciprofloxacin (CIP: 9.4%), erythromycin (ERY: 0.5%), and tetracycline (33.3%). CIP resistance in C. jejuni was higher in 1999 (15.5%, odds ratio [OR] = 3.96, p = 0.01), 2000 (12.7%, OR = 3.10, p = 0.01), 2005 (10.2%, OR = 2.47, p = 0.05), and 2006 (13.0%, OR = 3.22, p = 0.01) compared with 2004 (4.4%). C. coli had significantly higher CIP resistance (15.5%, OR = 1.78, p = 0.03), ERY resistance (13.2%, OR = 60.12, p < 0.01), multidrug resistance (2.3%, OR = 36.29, p < 0.01), and CIP-ERY resistance (3.1%, OR = 50.23, p < 0.01) compared with C. jejuni. This represents the first and most current report of AMR of the collective human Campylobacter isolates from a province in Canada and provides a baseline against which current and future resistance patterns can be compared. Fluoroquinolone resistance in C. jejuni isolates fluctuated from 1999 to 2006, including an increased prevalence in 2005-2006, while macrolide/lincosamide resistance remained very low. Human clinical C. jejuni isolates from Saskatchewan demonstrated resistance to multiple antimicrobials but had significantly less fluoroquinolone and macrolide resistance than C. coli isolates.

Resistance to antimicrobials used at hatchery level among clinical Escherichia coli isolates from Ontario broilers

Antimicrobials are used for prophylactic purposes in some flocks because chicks are susceptible to pathogenic bacterial infection at the hatchery stage. The objectives of this study were to assess temporal changes in resistance to ceftiofur, gentamicin, and spectinomycin in Escherichia coli clinical isolates from Ontario broiler chickens between 2008 and 2015, to determine whether stage of production, year and season are predictors of resistance, and whether published data on antimicrobial use help to interpret the temporal patterns in resistance. Logistic regression revealed that stage of production, year, and season were significant predictors of resistance to all 3 antimicrobials. Resistance to ceftiofur fluctuated over time, with a trend towards decreasing resistance between 2013 to 2015; resistance to gentamicin and spectinomycin increased over the study period, with significantly high resistance clusters identified from 2013 to 2015. Comparisons with published hatchery-level antimicrobial use data suggest that these trends may reflect changes in use of ceftiofur and spectinomycin in Ontario.

Extended-Spectrum β-Lactamase and AmpC β-Lactamase-Producing Escherichia coli Isolates from Chickens Raised in Small Flocks in Ontario, Canada

Food-producing animals are recognized to play a role in the epidemiology of antimicrobial resistance in Canada. However, the presence of resistant organisms in particular groups of animals, such as chickens raised in small-holder flocks, has not been studied. The purpose of this study was, therefore, to identify and characterize Escherichia coli possessing broad-spectrum β-lactamase genes among a collection of third-generation cephalosporin-resistant isolates recovered from 205 small flocks in southern Ontario. Extended-spectrum β-lactamase (ESBL; CTX-M-1) positive strains were isolated from 26 out of 205 flocks (12.7%), whereas 39 strains possessing AmpC (CMY-2) were grown from 31 out of 205 flocks (15.1%). Pulsed-field gel electrophoresis (PFGE) revealed that the isolates were genetically heterogeneous. Further testing by multi-locus sequence typing confirmed that none of the PFGE-defined clusters belonged to ST131. Our results suggest that the dissemination of this resistance in bacteria isolated from chickens in small-holder flocks may be associated with the spread of plasmids rather than particular E. coli clones and that these isolates do not possess the ESBL types most commonly associated with human infections (CTX-M-15).

Integrating Whole-Genome Sequencing Data Into Quantitative Risk Assessment of Foodborne Antimicrobial Resistance: A Review of Opportunities and Challenges

Whole-genome sequencing (WGS) will soon replace traditional phenotypic methods for routine testing of foodborne antimicrobial resistance (AMR). WGS is expected to improve AMR surveillance by providing a greater understanding of the transmission of resistant bacteria and AMR genes throughout the food chain, and therefore support risk assessment activities. At this stage, it is unclear how WGS data can be integrated into quantitative microbial risk assessment (QMRA) models and whether their integration will impact final risk estimates or the assessment of risk mitigation measures. This review explores opportunities and challenges of integrating WGS data into QMRA models that follow the Codex Alimentarius Guidelines for Risk Analysis of Foodborne AMR. We describe how WGS offers an opportunity to enhance the next-generation of foodborne AMR QMRA modeling. Instead of considering all hazard strains as equally likely to cause disease, WGS data can improve hazard identification by focusing on those strains of highest public health relevance. WGS results can be used to stratify hazards into strains with similar genetic profiles that are expected to behave similarly, e.g., in terms of growth, survival, virulence or response to antimicrobial treatment. The QMRA input distributions can be tailored to each strain accordingly, making it possible to capture the variability in the strains of interest while decreasing the uncertainty in the model. WGS also allows for a more meaningful approach to explore genetic similarity among bacterial populations found at successive stages of the food chain, improving the estimation of the probability and magnitude of exposure to AMR hazards at point of consumption. WGS therefore has the potential to substantially improve the utility of foodborne AMR QMRA models. However, some degree of uncertainty remains in relation to the thresholds of genetic similarity to be used, as well as the degree of correlation between genotypic and phenotypic profiles. The latter could be improved using a functional approach based on prediction of microbial behavior from a combination of 'omics' techniques (e.g., transcriptomics, proteomics and metabolomics). We strongly recommend that methodologies to incorporate WGS data in risk assessment be included in any future revision of the Codex Alimentarius Guidelines for Risk Analysis of Foodborne AMR.

One Health-Its Importance in Helping to Better Control Antimicrobial Resistance

Approaching any issue from a One Health perspective necessitates looking at the interactions of people, domestic animals, wildlife, plants, and our environment. For antimicrobial resistance this includes antimicrobial use (and abuse) in the human, animal and environmental sectors. More importantly, the spread of resistant bacteria and resistance determinants within and between these sectors and globally must be addressed. Better managing this problem includes taking steps to preserve the continued effectiveness of existing antimicrobials such as trying to eliminate their inappropriate use, particularly where they are used in high volumes. Examples are the mass medication of animals with critically important antimicrobials for humans, such as third generation cephalosporins and fluoroquinolones, and the long term, in-feed use of antimicrobials, such colistin, tetracyclines and macrolides, for growth promotion. In people it is essential to better prevent infections, reduce over-prescribing and over-use of antimicrobials and stop resistant bacteria from spreading by improving hygiene and infection control, drinking water and sanitation. Pollution from inadequate treatment of industrial, residential and farm waste is expanding the resistome in the environment. Numerous countries and several international agencies have now included a One Health Approach within their action plans to address antimicrobial resistance. Necessary actions include improvements in antimicrobial use, better regulation and policy, as well as improved surveillance, stewardship, infection control, sanitation, animal husbandry, and finding alternatives to antimicrobials.

Changes in antimicrobial resistance levels among Escherichia coli, Salmonella, and Campylobacter in Ontario broiler chickens between 2003 and 2015

Poultry has been identified as a reservoir of foodborne enteric pathogens and antimicrobial resistant bacteria. The objective of this study was to describe and compare antimicrobial resistant isolates from an Ontario broiler chicken farm-level baseline project (2003 to 2004) to the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) Ontario abattoir and retail surveillance data from 2003, and to the most recent (2015) CIPARS Ontario chicken surveillance data in order to assess the impact of an industry-wide policy change in antimicrobial use. Ceftiofur resistance (TIO-R) prevalence in Salmonella decreased by 7% on farm between 2003 and 2004 and 2015. During the same timeframe, TIO-R E. coli prevalence decreased significantly by 16%, 11%, and 8% in farm, abattoir, and retail samples, respectively. Gentamicin resistant (GEN-R) E. coli, however, increased by 10% in farm and 15% in retail-derived isolates, and trimethoprim-sulfamethoxazole resistant (TMSm-R) E. coli increased significantly by 20%, 18%, and 5% in farm, abattoir, and retail isolates, respectively. Similarly, ciprofloxacin-resistant (CIP-R) Campylobacter spp. significantly increased in retail isolates by 11% and increased in farm (33%) and abattoir isolates (7%). The decrease in TIO-R Salmonella/E. coli in recent years is consistent with the timing of an industry-led intervention eliminating the preventive use of ceftiofur, a third generation cephalosporin and class of antimicrobials deemed critically important to human medicine. The rise in GEN-R and TMSm-R prevalence is indicative of recent shifts in antimicrobial use. Our study highlights the importance of integrated surveillance in detecting emerging trends and determining the efficacy of interventions to improve food safety.

World Health Organization (WHO) guidelines on use of medically important antimicrobials in food-producing animals

Background

Antimicrobial use in food-producing animals selects for antimicrobial resistance that can be transmitted to humans via food or other transmission routes. The World Health Organization (WHO) in 2005 ranked the medical importance of antimicrobials used in humans. In late 2017, to preserve the effectiveness of medically important antimicrobials for humans, WHO released guidelines on use of antimicrobials in food-producing animals that incorporated the latest WHO rankings.

Methods

WHO commissioned systematic reviews and literature reviews, and convened a Guideline Development Group (GDG) of external experts free of unacceptable conflicts-of-interest. The GDG assessed the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and formulated recommendations using a structured evidence-to-decision approach that considered the balance of benefits and harms, feasibility, resource implications, and impact on equity. The resulting guidelines were peer-reviewed by an independent External Review Group and approved by the WHO Guidelines Review Committee.

Results

These guidelines recommend reductions in the overall use of medically important antimicrobials in food-producing animals, including complete restriction of use of antimicrobials for growth promotion and for disease prevention (i.e., in healthy animals considered at risk of infection). These guidelines also recommend that antimicrobials identified as critically important for humans not be used in food-producing animals for treatment or disease control unless susceptibility testing demonstrates the drug to be the only treatment option.

Conclusions

To preserve the effectiveness of medically important antimicrobials, veterinarians, farmers, regulatory agencies, and all other stakeholders are urged to adopt these recommendations and work towards implementation of these guidelines.

Prevalence of antimicrobial resistance in fecal Escherichia coli and Salmonella enterica in Canadian commercial meat, companion, laboratory, and shelter rabbits (Oryctolagus cuniculus) and its association with routine antimicrobial use in commercial meat rabbits

Antimicrobial resistance (AMR) in zoonotic (e.g. Salmonella spp.), pathogenic, and opportunistic (e.g. E. coli) bacteria in animals represents a potential reservoir of antimicrobial resistant bacteria and resistance genes to bacteria infecting humans and other animals. This study evaluated the prevalence of E. coli and Salmonella enterica, and the presence of associated AMR in commercial meat, companion, research, and shelter rabbits in Canada. Associations between antimicrobial usage and prevalence of AMR in bacterial isolates were also examined in commercial meat rabbits. Culture and susceptibility testing was conducted on pooled fecal samples from weanling and adult commercial meat rabbits taken during both summer and winter months (n=100, 27 farms), and from pooled laboratory (n=14, 8 laboratory facilities), companion (n=53), and shelter (n=15, 4 shelters) rabbit fecal samples. At the facility level, E. coli was identified in samples from each commercial rabbit farm, laboratory facility, and 3 of 4 shelters, and in 6 of 53 companion rabbit fecal samples. Seventy-nine of 314 (25.2%; CI: 20.7-30.2%) E. coli isolates demonstrated resistance to >1 antimicrobial agent. At least one E. coli isolate resistant to at least one antimicrobial agent was present in samples from 55.6% of commercial farms, and from 25% of each laboratory and shelter facilities, with resistance to tetracycline being most common; no resistance was identified in companion animal samples. Salmonella enterica subsp. was identified exclusively in pooled fecal samples from commercial rabbit farms; Salmonella enterica serovar London from one farm and Salmonella enterica serovar Kentucky from another. The S. Kentucky isolate was resistant to amoxicillin/clavulanic acid, ampicillin, cefoxitin, ceftiofur, ceftriaxone, streptomycin, and tetracycline, whereas the S. London isolate was pansusceptible. Routine use of antimicrobials on commercial meat rabbit farms was not significantly associated with the presence of antimicrobial resistant E. coli or S. enterica on farms; trends towards resistance were present when resistance to specific antimicrobial classes was examined. E. coli was widely prevalent in many Canadian domestic rabbit populations, while S. enterica was rare. The prevalence of AMR in isolated bacteria was variable and most common in isolates from commercial meat rabbits (96% of the AMR isolates were from commercial meat rabbit fecal samples). Our results highlight that domestic rabbits, and particularly meat rabbits, may be carriers of phenotypically antimicrobial-resistant bacteria and AMR genes, possibly contributing to transmission of these bacteria and their genes to bacteria in humans through food or direct contact, as well as to other co-housed animal species.

Prevalence and antimicrobial resistance among Escherichia coli and Salmonella in Ontario smallholder chicken flocks

Surveillance is an important component of an overall strategy to address antimicrobial resistant bacteria in food animals and the food chain. The poultry market has many points of entry into the Canadian food chain, and some production practices are underrepresented in terms of surveillance. For example, pathogen carriage and antimicrobial resistance surveillance data are limited in smallholder chicken flocks raised for slaughter at provincially inspected abattoirs. In Canada, antimicrobial resistance in Escherichia coli and Salmonella isolated from commercial broiler chicken flocks, slaughtered at federally inspected abattoirs, is monitored by the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS). The objective of this study was to establish baseline information of antimicrobial resistance presence in E. coli and Salmonella isolated from smallholder flocks in Ontario, utilizing CIPARS collection and isolation methodologies, and to compare findings with CIPARS federally inspected abattoir data from Ontario, Canada. Five chickens per flock were sampled from 205 smallholder flocks. Of 1,025 samples, the E. coli prevalence was 99% (1,022/1,025), and 47% (483/1,022) of positive E. coli isolates were resistant to one or more of the 14 antimicrobials. Furthermore, as compared to results reported for the CIPARS commercial flocks, E. coli isolates from smallholder flocks had significantly lower resistance prevalence to six of 14 individual antimicrobials. Recovery of E. coli did not differ between federally inspected and provincially inspected flocks. Salmonella prevalence at the bird level in smallholder flocks was 0.3% (3/1,025), significantly lower (p ≪ 0.0001, 95% CI 0.080%-0.86%) than federally inspected commercial flocks. The overall differences found between the commercial and smallholder flocks may be explained by differences in poultry husbandry practices and hatchery sources.

Prevalence and risk factors for Coxiella burnetii seropositivity in small ruminant veterinarians and veterinary students in Ontario, Canada

Coxiella burnetii is a zoonotic pathogen that causes Q fever in humans. Serological and questionnaire data on C. burnetii were obtained from 32 small ruminant veterinarians and veterinary students in Ontario, Canada, in February 2012. Overall, 59% of participants were seropositive; advanced stage of career and increased age were associated with seropositivity.

Exploring the relationships between small non-community drinking water system characteristics and water system performance in Ontario, Canada

The objectives of this work were to investigate the relationships between characteristics of small non-community drinking water systems (SDWSs) and the performance of these systems with respect to Escherichia coli testing and risk ratings. Ontario-wide SDWS data were analysed using regression models with outcomes of (1) having an adverse E. coli test result in the 12 months prior to the last inspection and (2) the SDWS risk rating (high/medium vs. low risk) that is assigned by public health inspectors. Almost 34% (2,364/7,003) of SDWSs did not utilize treatment, more commonly for ground water than surface supplies (P < 0.001). The odds of having a positive E. coli test result were greater in systems using ground water with treatment (OR = 2.00; 95% CI 1.23-3.24) and surface water with treatment (OR = 1.97; 95% CI 1.05-3.71) compared to ground water with no treatment. The odds of having a water system rated high or medium compared to low risk was greater if the water system operated seasonally (OR = 1.36; 95% CI 1.17-1.59), had an adverse E. coli test result (OR = 1.66; 95% CI 1.09-2.53), and in specific facility types. This research helps to inform existing training opportunities available to SDWS operators in Ontario, and to better standardize the SDWS risk assessment process.

On-farm starling populations and other environmental and management factors associated with the presence of cefotaxime and ciprofloxacin resistant E. coli among dairy cattle in Ohio

Wild birds that forage around livestock facilities have been implicated as vectors of antimicrobial resistant organisms. Although antimicrobial resistant bacteria have been isolated from European starlings (Sturnus vulgaris), their role in the dissemination of antimicrobial resistant elements in livestock facilities needs further investigation. To determine whether on-farm starling density and other factors were associated with the presence of cefotaxime and ciprofloxacin resistant E. coli among dairy cows in Ohio, bovine fecal pats from 150 farms were tested for the presence of cefotaxime and ciprofloxacin resistant E. coli. Each farm was visited twice (during the summer and fall of 2007-2009). Multi-level logistic regression models with a random intercept to account for fecal pats collected within a specific visit to a farm were used to assess the associations. The percentage of samples with cefotaxime and ciprofloxacin resistant E. coli was 13.4% and 13.6%, respectively. The percentage of farms having at least one sample testing positive for cefotaxime and ciprofloxacin resistant E. coli was 56.7% and 48.7%, respectively. The odds of detecting cefotaxime and ciprofloxacin resistant E. coli in the samples was significantly higher in 2007 compared to 2008 and 2009, in fall compared to summer, and from farms closer than 60km to starling night roost sites compared to the farms further than 60km. The presence of starlings during the day had a negative association with the likelihood of detecting cefotaxime resistant E. coli. Presence of calves also had a negative association with the likelihood of detecting both cefotaxime and ciprofloxacin resistant E. coli. European starlings might play a role in the dissemination of antimicrobial resistant agents in livestock facilities related to their daily population movements rather than the specific density of birds on farm during the day.

Risk Profile of Hepatitis E Virus from Pigs or Pork in Canada

The role and importance of pigs and pork as sources of zoonotic hepatitis E virus (HEV) has been debated in Canada and abroad for over 20 years. To further investigate this question, we compiled data to populate a risk profile for HEV in pigs or pork in Canada. We organized the risk profile (RP) using the headings prescribed for a foodborne microbial risk assessment and used research synthesis methods and inputs wherever possible in populating the fields of this RP. A scoping review of potential public health risks of HEV, and two Canadian field surveys sampling finisher pigs, and retail pork chops and pork livers, provided inputs to inform this RP. We calculated summary estimates of prevalence using the Comprehensive Meta-analysis 3 software, employing the method of moments. Overall, we found the incidence of sporadic locally acquired hepatitis E in Canada, compiled from peer-reviewed literature or from diagnosis at the National Microbiology Laboratory to be low relative to other non-endemic countries. In contrast, we found the prevalence of detection of HEV RNA in pigs and retail pork livers, to be comparable to that reported in the USA and Europe. We drafted risk categories (high/medium/low) for acquiring clinical hepatitis E from exposure to pigs or pork in Canada and hypothesize that the proportion of the Canadian population at high risk from either exposure is relatively small.

World Health Organization Ranking of Antimicrobials According to Their Importance in Human Medicine: A Critical Step for Developing Risk Management Strategies to Control Antimicrobial Resistance From Food Animal Production

Antimicrobial use in food animals selects for antimicrobial resistance in bacteria, which can spread to people. Reducing use of antimicrobials-particularly those deemed to be critically important for human medicine-in food production animals continues to be an important step for preserving the benefits of these antimicrobials for people. The World Health Organization ranking of antimicrobials according to their relative importance in human medicine was recently updated. Antimicrobials considered the highest priority among the critically important antimicrobials were quinolones, third- and fourth-generation cephalosporins, macrolides and ketolides, and glycopeptides. The updated ranking allows stakeholders in the agriculture sector and regulatory agencies to focus risk management efforts on drugs used in food animals that are the most important to human medicine. In particular, the current large-scale use of fluoroquinolones, macrolides, and third-generation cephalosporins and any potential use of glycopeptides and carbapenems need to be addressed urgently.

Implications of applying methodological shortcuts to expedite systematic reviews: three case studies using systematic reviews from agri-food public health

Background

The rapid review is an approach to synthesizing research evidence when a shorter timeframe is required. The implications of what is lost in terms of rigour, increased bias and accuracy when conducting a rapid review have not yet been elucidated.

Methods

We assessed the potential implications of methodological shortcuts on the outcomes of three completed systematic reviews addressing agri‐food public health topics. For each review, shortcuts were applied individually to assess the impact on the number of relevant studies included and whether omitted studies affected the direction, magnitude or precision of summary estimates from meta‐analyses.

Results

In most instances, the shortcuts resulted in at least one relevant study being omitted from the review. The omission of studies affected 39 of 143 possible meta‐analyses, of which 14 were no longer possible because of insufficient studies (<2). When meta‐analysis was possible, the omission of studies generally resulted in less precise pooled estimates (i.e. wider confidence intervals) that did not differ in direction from the original estimate.

Conclusions

The three case studies demonstrated the risk of missing relevant literature and its impact on summary estimates when methodological shortcuts are applied in rapid reviews. © 2016 The Authors. Research Synthesis Methods Published by John Wiley & Sons Ltd.

Development of a tiered framework for public health capacity in Canada

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Select SARS reports were qualitatively analyzed for usage of “capacity”/“capacities”.

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Public health capacity can be sub-divided into 17 individual capacity components.

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These components can be organized into five tiers to build a capacity framework.

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This framework can be used to guide capacity assessment and building efforts.

Area-level global and local clustering of human Salmonella Enteritidis infection rates in the city of Toronto, Canada, 2007-2009

BACKGROUND

Salmonella enterica serotype Enteritidis (S. Enteritidis) remains a major foodborne pathogen in North America yet studies examining the spatial epidemiology of salmonellosis in urban environments are lacking. Our ecological study combined a number of spatial statistical methods with a geographic information system to assess area-level heterogeneity of S. Enteritidis infection rates in the city of Toronto.

METHODS

Data on S. Enteritidis infections between January 1, 2007 and December 31, 2009 were obtained from Ontario's surveillance system, and were grouped and analyzed at the forward sortation area (FSA)-level (an area signified by the first three characters of the postal code). Incidence rates were directly standardized using the FSA-level age- and sex-based standard population. A spatial empirical Bayes method was used to smooth the standardized incidence rates (SIRs). Global clustering of FSAs with high or low non-smoothed SIRs was evaluated using the Getis-Ord G method. Local clustering of FSAs with high, low, or dissimilar non-smoothed SIRs was assessed using the Getis-Ord Gi* and the Local Moran's I methods.

RESULTS

Spatial heterogeneity of S. Enteritidis infection rates was detected across the city of Toronto. The non-smoothed FSA-level SIRs ranged from 0 to 16.9 infections per 100,000 person-years (mean = 6.6), whereas the smoothed SIRs ranged from 2.9 to 11.1 (mean = 6.3). The global Getis-Ord G method showed significant (p ≤ 0.05) maximum spatial clustering of FSAs with high SIRs at 3.3 km. The local Getis-Ord Gi* method identified eight FSAs with significantly high SIRs and one FSA with a significantly low SIR. The Local Moran's I method detected five FSAs with significantly high-high SIRs, one FSA with a significantly low-low SIR, and four significant outlier FSAs (one high-low, and three low-high).

CONCLUSIONS

Salmonella Enteritidis infection rates clustered globally at a small distance band, suggesting clustering of high SIRs in small distinct areas. This finding was supported by the local cluster analyses, where distinct FSAs with high SIRs, mainly in downtown Toronto, were detected. These areas should be evaluated by future studies to identify risk factors of disease in order to implement targeted prevention and control programs. We demonstrated the usefulness of combining several spatial statistical techniques with a geographic information system to detect geographical areas of interest for further study, and to evaluate spatial processes that influenced S. Enteritidis infection rates. Our study methodology could be applied to other foodborne disease surveillance data.

The potential Public Health Impact of Mycobacterium avium ssp. paratuberculosis: Global Opinion Survey of Topic Specialists

Global research knowledge has accumulated over the past few decades, and there is reasonable evidence for a positive association between Mycobacterium avium spp. paratuberculosis and Crohn's disease in humans, although its role as a human pathogen has not been entirely accepted. For this reason, management of public health risk due to M. paratuberculosis remains an important policy issue in agri-food public health arenas in many countries. Responsible authorities must decide whether existing mitigation strategies are sufficient to prevent or reduce human exposure to M. paratuberculosis. A Web-based questionnaire was administered to topic specialists to elicit empirical knowledge and opinion on the overall public health impact of M. paratuberculosis, the importance of various routes of human exposure to the pathogen, existing mitigation strategies and the need for future strategies. The questionnaire had four sections and consisted of 20 closed and five open questions. Topic specialists believed that M. paratuberculosis is likely a risk to human health (44.8%) and, given the paucity of available evidence, most frequently ranked it as a moderate public health issue (40.1%). A significant correlation was detected between topic specialists' commitment to M. paratuberculosis in terms of the number of years or proportion of work dedicated to this topic, and the likelihood of an extreme answer (high or low) to the above questions. Topic specialists identified contact with ruminants and dairy products as the most likely routes of exposure for humans. There was consensus on exposure routes for ruminants and what commodities to target in mitigation efforts. Described mandatory programmes mainly focused on culling diseased animals and voluntary on-farm prevention programmes. Despite ongoing difficulties in the identification of subclinical infections in animals, the topic specialists largely agreed that further enhancement of on-farm programmes in affected commodities by the agri-food industry (68.4%) and allocation of resources by governments to monitor the issue (92%) are most appropriate given the current state of evidence.

Factors Affecting Detection of Hepatitis E Virus on Canadian Retail Pork Chops and Pork Livers Assayed Using Real-Time RT-PCR

We collected 599 Canadian retail pork chops and 283 pork livers routinely (usually weekly) from April 2011 to March 2012 using the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) retail sampling platform. Samples were assayed using validated real-time (q) reverse transcriptase polymerase chain reaction (RT-PCR) and nested classical RT-PCR for the detection of hepatitis E virus (HEV), porcine enteric calicivirus (PEC) and rotavirus (RV). The presence of Escherichia coli, Salmonella spp. and Campylobacter spp. was measured on a subset of our samples. Exact logistic regression models were fitted for predictors for HEV detection, for each assay. For both assays, sample type (pork chop versus liver) was a significant predictor for HEV RNA detection. For nested classical RT-PCR but not qRT-PCR, region of sample collection was a significant predictor (P = 0.008) of HEV detection. Odds of HEV detection were greatest in spring relative to other seasons. E. coli was a significant predictor for HEV RNA detection using the qRT-PCR (P = 0.03). Overall, the prevalence of E. coli, Salmonella spp. and Campylobacter spp. was significantly greater than HEV, PEC or RV on our retail pork samples. Our sparse data set for the detection of PEC and RV precluded modelling of risk factors for the detection of these viruses.

A guide for developing plain-language and contextual summaries of systematic reviews in agri-food public health

The application of systematic reviews is increasing in the agri-food public health sector to investigate the efficacy of policy-relevant interventions. In order to enhance the uptake and utility of these reviews for decision-making, there is a need to develop summary formats that are written in plain language and incorporate supporting contextual information. The objectives of this study were (1) to develop a guideline for summarizing systematic reviews in one- and three-page formats, and (2) to apply the guideline on two published systematic reviews that investigated the efficacy of vaccination and targeted feed and water additives to reduce Salmonella colonization in broiler chickens. Both summary formats highlight the key systematic review results and implications in plain language. Three-page summaries also incorporated four categories of contextual information (cost, availability, practicality, and other stakeholder considerations) to complement the systematic review findings. We collected contextual information through structured rapid reviews of the peer-reviewed and gray literature and by conducting interviews with 12 topic specialists. The overall utility of the literature searches and interviews depended on the specific intervention topic and contextual category. In general, interviews with topic specialists were the most useful and efficient method of gathering contextual information. Preliminary evaluation with five end-users indicated positive feedback on the summary formats. We estimate that one-page summaries could be developed by trained science-to-policy professionals in 3-5 days, while three-page summaries would require additional resources and time (e.g., 2-4 weeks). Therefore, one-page summaries are more suited for routine development, while three-page summaries could be developed for a more limited number of high-priority reviews. The summary guideline offers a structured and transparent approach to support the utilization of systematic reviews in decision-making in this sector. Future research is necessary to evaluate the utility of these summary formats for a variety of end-users in different contexts.

Climate-sensitive health priorities in Nunatsiavut, Canada

BACKGROUND

This exploratory study used participatory methods to identify, characterize, and rank climate-sensitive health priorities in Nunatsiavut, Labrador, Canada.

METHODS

A mixed method study design was used and involved collecting both qualitative and quantitative data at regional, community, and individual levels. In-depth interviews with regional health representatives were conducted throughout Nunatsiavut (n = 11). In addition, three PhotoVoice workshops were held with Rigolet community members (n = 11), where participants took photos of areas, items, or concepts that expressed how climate change is impacting their health. The workshop groups shared their photographs, discussed the stories and messages behind them, and then grouped photos into re-occurring themes. Two community surveys were administered in Rigolet to capture data on observed climatic and environmental changes in the area, and perceived impacts on health, wellbeing, and lifestyles (n = 187).

RESULTS

Climate-sensitive health pathways were described in terms of inter-relationships between environmental and social determinants of Inuit health. The climate-sensitive health priorities for the region included food security, water security, mental health and wellbeing, new hazards and safety concerns, and health services and delivery.

CONCLUSIONS

The results highlight several climate-sensitive health priorities that are specific to the Nunatsiavut region, and suggest approaching health research and adaptation planning from an EcoHealth perspective.

Healthcare use for acute gastrointestinal illness in two Inuit communities: Rigolet and Iqaluit, Canada

Background

The incidence of self-reported acute gastrointestinal illness (AGI) in Rigolet, Nunatsiavut, and Iqaluit, Nunavut, is higher than reported elsewhere in Canada; as such, understanding AGI-related healthcare use is important for healthcare provision, public health practice and surveillance of AGI.

Objectives

This study described symptoms, severity and duration of self-reported AGI in the general population and examined the incidence and factors associated with healthcare utilization for AGI in these 2 Inuit communities.

Design

Cross-sectional survey data were analysed using multivariable exact logistic regression to examine factors associated with individuals’ self-reported healthcare and over-the-counter (OTC) medication utilization related to AGI symptoms.

Results

In Rigolet, few AGI cases used healthcare services [4.8% (95% CI=1.5–14.4%)]; in Iqaluit, some cases used healthcare services [16.9% (95% CI=11.2–24.7%)]. Missing traditional activities due to AGI (OR=3.8; 95% CI=1.18–12.4) and taking OTC medication for AGI symptoms (OR=3.8; 95% CI=1.2–15.1) were associated with increased odds of using healthcare services in Iqaluit. In both communities, AGI severity and secondary symptoms (extreme tiredness, headache, muscle pains, chills) were significantly associated with increased odds of taking OTC medication.

Conclusions

While rates of self-reported AGI were higher in Inuit communities compared to non-Inuit communities in Canada, there were lower rates of AGI-related healthcare use in Inuit communities compared to other regions in Canada. As such, the rates of healthcare use for a given disease can differ between Inuit and non-Inuit communities, and caution should be exercised in making comparisons between Inuit and non-Inuit health outcomes based solely on clinic records and healthcare use.

Dairy cattle management factors that influence on-farm density of European starlings in Ohio, 2007-2009

Potential dairy farm management and environmental factors that attract European starlings (Sturnus vulgaris) to dairy farms were explored. During the period from 2007 to 2009, 150 dairy farms were each visited twice (once during the summer and again in the fall) and the number of starlings was recorded. Risk factors were assessed for possible association with the number of starlings per milking cow (starling density), using a zero-inflated negative binomial model. Starling density was higher on farms visited in 2007 compared to those visited in 2008 or 2009. The interaction term between feeding method and feeding site was significantly associated with starling density on farm; generally, feeding outdoors was associated with increased starling density. The odds of a zero starling count (compared to a count greater than zero) was higher on farms that removed manure from barns weekly or less frequently than weekly compared to those that removed manure daily or after every milking. The odds of a zero starling count decreased with increasing distance of a farm from the closest night roost. Identifying on farm risk factors that expose farms to starlings will help farmers develop strategies that minimize the number of birds on their farms and thereby reduce physical damage to the farms as well as the potential for pathogen transmission from birds to cattle and humans.

A scoping review of the evidence for public health risks of three emerging potentially zoonotic viruses: hepatitis E virus, norovirus, and rotavirus

Emerging zoonoses are defined as those newly recognized, or increasing in incidence or geographic range. Hepatitis E virus (HEV), norovirus (NoV), and rotavirus (RV), while well known to be transmitted person-person, have also been hypothesized to be emerging zoonoses. Our objective was to investigate their potential public health risks from animal reservoirs. Given the diversity of evidence sources, a scoping review incorporating a mixed methods synthesis approach was used. A broad search was conducted in five electronic databases. Each citation was appraised independently by two reviewers using screening tools designed and tested a priori. Level 1 relevance screening excluded irrelevant citations; level 2 confirmed relevance and categorized. At level 3 screening, data were extracted to support a risk profile. A stakeholder group provided input on study tools and knowledge translation and transfer. Level 1 screening captured 2471 citations, with 1270 advancing to level 2 screening, and 1094 to level 3. We defined criteria for case attribution to zoonosis for each virus. Using these criteria, we identified a small number of zoonotic cases (HEV n=3, NoV=0, RV=40 (zoonoses=3; human-animal re-assortants=37)) categorized as 'likely'. The available evidence suggests the following potential HEV human exposure sources: swine, other domestic animals, wildlife, surface waters, and asymptomatic human shedders. Possible at-risk groups include the immunocompromised and the elderly. Reports of NoV intergenogroup recombinants suggest potential for human-animal recombination. Greatest public health impact for RV zoonoses may be the potential effect of human-animal reassortants on vaccination efficacy.

Lived experience of acute gastrointestinal illness in Rigolet, Nunatsiavut: "just suffer through it"

Enteric illness associated with foodborne and waterborne disease is thought to be common in some Canadian Indigenous communities. This study aimed to understand the lived experience of acute gastrointestinal illness (AGI), including symptoms and severity, perceived causes, and healthcare seeking behaviors of AGI in the small Inuit community of Rigolet, Canada. A concurrent mixed quantitative and qualitative methods design was used. Two cross-sectional retrospective surveys provided quantitative data to examine self-reported AGI symptoms and the distribution of potential risk factors in the community. Qualitative data from in-depth interviews with one-third of AGI cases were analyzed using a constant-comparative method to describe symptoms and severity, identify perceived risk factors, and explore health seeking behavior of AGI in Rigolet. Of the survey respondents reporting AGI, most reported symptoms of diarrhea without vomiting, followed by diarrhea with vomiting, and vomiting without diarrhea. The most common secondary symptoms included stomach cramps and abdominal pain, nausea, and extreme tiredness. Community members identified potential risk factors for AGI that reflect the epidemiology triad (host, agent, and environmental factors), including hygiene, retail food, tap water, boil water advisories, and personal stress. Risk aversion and healthcare seeking behaviors reflected the core constructs of the Health Belief Model (perceived susceptibility, severity, and benefits and barriers to action). Understanding community experience, perspectives, and beliefs related to AGI is useful for public health practitioners and health care providers. This information is important especially considering the relatively high estimated burden of AGI and the relatively low healthcare seeking behaviors in some Indigenous communities compared to national estimates. Moreover, the mixed-methods approach used to understand the burden of AGI could be extended to other health research in Indigenous contexts.

Experience, training and confidence among small, non-community drinking water system operators in Ontario, Canada

The water operator plays an important role in water safety; however, little published research exists that has examined this role. The purpose of this study was to develop a greater understanding of the experience, existing knowledge, confidence and future training needs of the small, non-community drinking water operator in Ontario in order to help guide future outreach and training opportunities. A cross-sectional telephone survey of 332 small, non-community drinking water operators in Ontario was conducted in July and August 2011. Survey questions pertained to respondents' experience as operators, formal training, perceived importance of water safety issues, confidence in handling water safety issues, and future training needs. Approximately 16% (54/330) of respondents had one year or less experience as a water operator, and 60% (199/332) reported that being a water operator was not a chosen profession. Only 37% (124/332) of operators reported completing operator training. Respondents reported a preference for online training courses or on-site training (compared with a classroom setting). Low training rates, inexperience, and in certain situations, low confidence, among many small water system operators highlight a need to provide continued support to the development of ongoing training opportunities in this population.

Surveillance of antimicrobial resistance in clinical isolates of Pasteurella multocida and Streptococcus suis from Ontario swine

Susceptibility results for Pasteurella multocida and Streptococcus suis isolated from swine clinical samples were obtained from January 1998 to October 2010 from the Animal Health Laboratory at the University of Guelph, Guelph, Ontario, and used to describe variation in antimicrobial resistance (AMR) to 4 drugs of importance in the Ontario swine industry: ampicillin, tetracycline, tiamulin, and trimethoprim-sulfamethoxazole. Four temporal data-analysis options were used: visualization of trends in 12-month rolling averages, logistic-regression modeling, temporal-scan statistics, and a scan with the "What's strange about recent events?" (WSARE) algorithm. The AMR trends varied among the antimicrobial drugs for a single pathogen and between pathogens for a single antimicrobial, suggesting that pathogen-specific AMR surveillance may be preferable to indicator data. The 4 methods provided complementary and, at times, redundant results. The most appropriate combination of analysis methods for surveillance using these data included temporal-scan statistics with a visualization method (rolling-average or predicted-probability plots following logistic-regression models). The WSARE algorithm provided interesting results for quality control and has the potential to detect new resistance patterns; however, missing data created problems for displaying the results in a way that would be meaningful to all surveillance stakeholders.

Using core competencies to build an evaluative framework: outcome assessment of the University of Guelph Master of Public Health program

BACKGROUND

Master of Public Health programs have been developed across Canada in response to the need for graduate-level trained professionals to work in the public health sector. The University of Guelph recently conducted a five-year outcome assessment using the Core Competencies for Public Health in Canada as an evaluative framework to determine whether graduates are receiving adequate training, and identify areas for improvement.

METHODS

A curriculum map of core courses and an online survey of University of Guelph Master of Public Health graduates comprised the outcome assessment. The curriculum map was constructed by evaluating course outlines, assignments, and content to determine the extent to which the Core Competencies were covered in each course. Quantitative survey results were characterized using descriptive statistics. Qualitative survey results were analyzed to identify common themes and patterns in open-ended responses.

RESULTS

The University of Guelph Master of Public Health program provided a positive learning environment in which graduates gained proficiency across the Core Competencies through core and elective courses, meaningful practicums, and competent faculty. Practice-based learning environments, particularly in collaboration with public health organizations, were deemed to be beneficial to students' learning experiences.

CONCLUSIONS

The Core Competencies and graduate surveys can be used to conduct a meaningful and informative outcome assessment. We encourage other Master of Public Health programs to conduct their own outcome assessments using a similar framework, and disseminate these results in order to identify best practices and strengthen the Canadian graduate public health education system.

A scoping review of scoping reviews: advancing the approach and enhancing the consistency

Background

The scoping review has become an increasingly popular approach for synthesizing research evidence. It is a relatively new approach for which a universal study definition or definitive procedure has not been established. The purpose of this scoping review was to provide an overview of scoping reviews in the literature.

Methods

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in four bibliographic databases and the gray literature to identify scoping review studies. Review selection and characterization were performed by two independent reviewers using pretested forms.

Results

The search identified 344 scoping reviews published from 1999 to October 2012. The reviews varied in terms of purpose, methodology, and detail of reporting. Nearly three-quarter of reviews (74.1%) addressed a health topic. Study completion times varied from 2 weeks to 20 months, and 51% utilized a published methodological framework. Quality assessment of included studies was infrequently performed (22.38%).

Conclusions

Scoping reviews are a relatively new but increasingly common approach for mapping broad topics. Because of variability in their conduct, there is a need for their methodological standardization to ensure the utility and strength of evidence. © 2014 The Authors. Research Synthesis Methods published by John Wiley & Sons, Ltd.

A longitudinal study of feed contamination by European starling excreta in Ohio dairy farms (2007-2008)

The objectives of this study were to understand the temporal pattern of contamination of cattle feed by starling excrement on dairy farms and to evaluate the temporal pattern in recovering Escherichia coli O157:H7 or Salmonella in relation to the absolute mass of excrement recovered. A longitudinal study was conducted on 15 dairy farms in Ohio from July 2007 to October 2008. One open-topped tray filled with bird feed was placed near a cattle feeding site; bird excrement from the tray was weighed monthly for 12 consecutive months. Linear regression models with a random intercept for farm were computed to examine the association between the absolute weight of excrement recovered each month or the farm-specific standard score for weight of excrement, and month or season. Exact logistic regression was used to determine whether an association between recovering E. coli O157:H7 or Salmonella was present and the amount of excrement recovered and season. A spatial scan statistic was used to test for evidence of space-time clustering of excrement, based on the standard score for the weight of the excrement, among our study farms. A total of 5 of 179 excrement samples (2.79%) were positive for E. coli O157:H7 and 2 (1.12%) were positive for Salmonella. A significantly higher level of contamination with excrement was observed during the winter. The odds of recovering a pathogen increased with the amount of excrement recovered and decreased if the excrement was collected in the winter. A spatio-temporal cluster of contamination with excrement was detected. These findings provide basic information for future quantitative microbial risk assessments concerning the role of starlings in spreading enteric pathogens on dairy farms.