Ministère de la Santé et des Services Sociaux (Québec)

Administrative databases in the Canadian health sector do not contain socio-economic information. To facilitate the monitoring of social inequalities for health planning, this study proposes a material and social deprivation index for Canada. After explaining the concept of deprivation, we describe the methodological aspects of the index and apply it to the example of premature mortality (i.e. death before the age of 75). We illustrate variations in deprivation and the links between deprivation and mortality nationwide and in different geographic areas including the census metropolitan areas (CMAs) of Toronto, Montréal and Vancouver; other CMAs; average-size cities, referred to as census agglomerations (CAs); small towns and rural communities; and five regions of Canada, namely Atlantic, Quebec, Ontario, the Prairies and British Columbia. Material and social deprivation and their links to mortality vary considerably by geographic area. We comment on the results as well as the limitations of the index and its advantages for health planning.

Given that the synthesis of cumulated knowledge is an essential condition for any field to grow and develop, we believe that the enhanced role of IS reviews requires that this expository form be given careful scrutiny. Over the past decade, several senior scholars have made calls for more review papers in our field. While the number of IS review papers has substantially increased in recent years, no prior research has attempted to develop a general framework to conduct and evaluate the rigor of standalone reviews. In this paper, we fill this gap. More precisely, we present a set of guidelines for guiding and evaluating IS literature reviews and specify to which review types they apply. To do so, we first distinguish between four broad categories of review papers and then propose a set of guidelines that are grouped according to the generic phases and steps of the review process. We hope our work will serve as a valuable source for those conducting, evaluating, and/or interpreting reviews in our field.

The effect of age on the clinical presentation of pertussis was assessed in 664 adolescent and adult cases. Complications were more frequent in adults than in adolescents (28% vs. 16%). Pneumonia occurred in 2% of patients <30 years old but in 5%-9% of older patients. Urinary incontinence occurred in 34% of women >/=50 years old. Duration of cough, risk of sinusitis, and number of nights with disturbed sleep increased with smoking and asthma. The secondary attack rate in other household members >/=12 years was 11%. Pertussis in secondary case patients was less severe than in index case patients but presented with classic symptoms. The main source of infection in adolescents was schoolmates or friends; in adults it was workplace or their children. Teachers and health care workers had a greater risk of pertussis than did the general population. The burden of disease appears to increase with age, with smoking, and with asthma.

BACKGROUND: Developing and updating high-quality guidelines requires substantial time and resources. To reduce duplication of effort and enhance efficiency, we developed a process for guideline adaptation and assessed initial perceptions of its feasibility and usefulness. METHODS: Based on preliminary developments and empirical studies, a series of meetings with guideline experts were organised to define a process for guideline adaptation (ADAPTE) and to develop a manual and a toolkit made available on a website (http://www.adapte.org). Potential users, guideline developers and implementers, were invited to register and to complete a questionnaire evaluating their perception about the proposed process. RESULTS: The ADAPTE process consists of three phases (set-up, adaptation, finalisation), 9 modules and 24 steps. The adaptation phase involves identifying specific clinical questions, searching for, retrieving and assessing available guidelines, and preparing the draft adapted guideline. Among 330 registered individuals (46 countries), 144 completed the questionnaire. A majority found the ADAPTE process clear (78%), comprehensive (69%) and feasible (60%), and the manual useful (79%). However, 21% found the ADAPTE process complex. 44% feared that they will not find appropriate and high-quality source guidelines. DISCUSSION: A comprehensive framework for guideline adaptation has been developed to meet the challenges of timely guideline development and implementation. The ADAPTE process generated important interest among guideline developers and implementers. The majority perceived the ADAPTE process to be feasible, useful and leading to improved methodological rigour and guideline quality. However, some de novo development might be needed if no high quality guideline exists for a given topic.

In the World Health Organization/United Nations Children's Fund document Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, neonatal care is mentioned as 1 area that would benefit from expansion of the original Ten Steps to Successful Breastfeeding. The different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers, necessitate a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care. Facilitation of early, continuous, and prolonged skin-to-skin contact (kangaroo mother care), early initiation of breastfeeding, and mothers' access to breastfeeding support during the infants' whole hospital stay are important. Mother's own milk or donor milk (when available) is the optimal nutrition. Efforts should be made to minimize parent-infant separation and facilitate parents' unrestricted presence with their infants. The initiation and continuation of breastfeeding should be guided only by infant competence and stability, using a semi-demand feeding regimen during the transition to exclusive breastfeeding. Pacifiers are appropriate during tube-feeding, for pain relief, and for calming infants. Nipple shields can be used for facilitating establishment of breastfeeding, but only after qualified support and attempts at the breast. Alternatives to bottles should be used until breastfeeding is well established. The discharge program should include adequate preparation of parents, information about access to lactation and breastfeeding support, both professional and peer support, and a plan for continued follow-up.

PURPOSE: On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS: Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS: One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS: The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

Background. The role of patient and public involvement programs (PPIPs) in developing and implementing clinical practice guidelines (CPGs) has generated great interest. Purpose. The authors sought to identify key components of PPIPs used in developing and implementing CPGs. Data sources. The authors searched bibliographic databases and contacted relevant organizations. Study selection. In total, 2161 articles and reports were retrieved on PPIPs in the development and implementation of CPGs. Of these, 71 qualified for inclusion in the review. Data extraction. Reviewers independently extracted data on key components of PPIPs and barriers and facilitators to their operation. Data synthesis. Over half of the studies were published after 2002, and more than half originated from the United States, the United Kingdom, Australia, and Germany. CPGs that involved patients and the public addressed a variety of health problems, especially mental health and cancer. The most frequently cited objective for using PPIPs in developing CPGs was to incorporate patients’ values or perspectives in CPG recommendations. Patients and their families and caregivers were the parties most often involved. Methods used to recruit PPIP participants included soliciting through patient/public organizations, sending invitations, and receiving referrals and recruits from clinicians. Patients and the public most often participated by taking part in a CPG working group, workshop, meeting, seminar, literature review, or consultation such as a focus group, individual interview, or survey. Patients and the public principally helped formulate recommendations and revise drafts. Limitations. The authors did not contact the authors of the studies. Conclusion. This literature review provides an extensive knowledge base for making PPIPs more effective when developing and implementing CPGs. More research is needed to assess the impact of PPIPs and resources they require.

OBJECTIVES: This review assessed the confounding effect of one traffic-related exposure (noise or air pollutants) on the association between the other exposure and cardiovascular outcomes. METHODS: A systematic review was conducted with the databases Medline and Embase. The confounding effects in studies were assessed by using change in the estimate with a 10 % cutoff point. The influence on the change in the estimate of the quality of the studies, the exposure assessment methods and the correlation between road noise and air pollutions were also assessed. RESULTS: Nine publications were identified. For most studies, the specified confounders produced changes in estimates <10 %. The correlation between noise and pollutants, the quality of the study and of the exposure assessment do not seem to influence the confounding effects. CONCLUSIONS: Results from this review suggest that confounding of cardiovascular effects by noise or air pollutants is low, though with further improvements in exposure assessment, the situation may change. More studies using pollution indicators specific to road traffic are needed to properly assess if noise and air pollution are subjected to confounding.

OBJECTIVE: Housing First (HF) programs for people who are chronically or episodically homeless, combining rapid access to permanent housing with community-based, integrated treatment, rehabilitation and support services, are rapidly expanding in North America and Europe. Overall costs of services use by homeless people can be considerable, suggesting the potential for significant cost offsets with HF programs. Our purpose was to provide an updated literature review, from 2007 to the present, focusing specifically on the cost offsets of HF programs. METHOD: A systematic review was performed on MEDLINE and PsycINFO as well as Google and the Homeless Hub for grey literature. Study characteristics and key findings were extracted from identified studies. Where available, impact on service cost associated with HF (increase or decrease) and net impact on overall costs, taking into account the cost of HF intervention, were noted. RESULTS: Twelve published studies (4 randomized studies and 8 quasi-experimental) and 22 unpublished studies were retained. Shelter and emergency department costs decreased with HF, while impacts on hospitalization and justice costs are more ambiguous. Studies using a pre-post design reported a net decrease in overall costs with HF. In contrast, experimental studies reported a net increase in overall costs with HF. CONCLUSIONS: While our review casts doubt on whether HF programs can be expected to pay for themselves, the certainty of significant cost offsets, combined with their benefits for participants, means that they represent a more efficient allocation of resources than traditional services.

BACKGROUND: The largest measles epidemic in North America in the last decade, occurred in 2011 in Quebec, Canada, where rates of 1- and 2-dose vaccine coverage among children 3 years of age were 95%-97% and 90%, respectively, with 3%-5% unvaccinated. METHODS: Case patients identified through passive surveillance and outbreak investigation were contacted to determine clinical course, vaccination status, and possible source of infection. RESULTS: There were 21 measles importations and 725 cases. A superspreading event triggered by 1 importation resulted in sustained transmission and 678 cases. The overall incidence was 9.1 per 100,000; the highest incidence was in adolescents 12-17 years old (75.6 per 100,000), who comprised 56% of case patients. Among adolescents, 22% had received 2 vaccine doses. Outbreak investigation showed this proportion to have been an underestimate; active case finding identified 130% more cases among 2-dose recipients. Two-dose recipients had milder illness and a significantly lower risk of hospitalization than those who were unvaccinated or single-dose recipients. CONCLUSIONS: A chance superspreading event revealed an overall level of immunity barely above the elimination threshold when unexpected vulnerability in 2-dose recipients was taken into account. Unvaccinated individuals remain the immunization priority, but a better understanding of susceptibility in 2-dose recipients is needed to define effective interventions if elimination is to be achieved.

Early detection of breast cancer through screening reduces breast cancer mortality. The benefits of screening must also be considered within the context of potential harms (e.g., false positives, overdiagnosis). Furthermore, while breast cancer risk is highly variable within the population, most screening programs use age to determine eligibility. A risk-based approach is expected to improve the benefit-harm ratio of breast cancer screening programs. The PERSPECTIVE I&I (Personalized Risk Assessment for Prevention and Early Detection of Breast Cancer: Integration and Implementation) project seeks to improve personalized risk assessment to allow for a cost-effective, population-based approach to risk-based screening and determine best practices for implementation in Canada. This commentary describes the four inter-related activities that comprise the PERSPECTIVE I&I project. 1: Identification and validation of novel moderate to high-risk susceptibility genes. 2: Improvement, validation, and adaptation of a risk prediction web-tool for the Canadian context. 3: Development and piloting of a socio-ethical framework to support implementation of risk-based breast cancer screening. 4: Economic analysis to optimize the implementation of risk-based screening. Risk-based screening and prevention is expected to benefit all women, empowering them to work with their healthcare provider to make informed decisions about screening and prevention.

OBJECTIVES: This study evaluated the impact of a 4-year, community-based cardiovascular disease prevention program among adults aged 18 to 65 years living in St-Henri, a low-income, innercity neighborhood in Montreal, Quebec. METHODS: Awareness of and participation in the program were monitored in 3 independent sample telephone surveys. Self-reported behaviors were compared in St-Henri and a nearby comparison community before and after program implementation in both a 3-year repeat independent sample survey and a 5-year longitudinal cohort telephone survey. RESULTS: Awareness of the program reached 37.4%, but participation was low (2%-3%). There were no secular declines in smoking or high-fat diet; physical inactivity increased in both communities. There were no statistically significant program effects detected in the independent sample surveys, although physical inactivity increased more in the comparison community than in St-Henri. In the longitudinal cohort sample, there was a small, statistically significant increase favoring St-Henri in frequency of cholesterol checkups. CONCLUSIONS: Despite careful adaptation of the program to the local social context, there were few community-wide program effects. However, several component interventions showed promise in terms of community penetration and impact.

Longitudinal studies are needed to increase understanding of the causes of childhood obesity. To identify 1- and 2-year predictors of excess weight gain among preadolescents, the authors conducted a prospective cohort study of fourth- and fifth-grade students in 16 elementary schools located in multiethnic, low-income neighborhoods in Montreal, Quebec, Canada, that were participating in the evaluation of a school-based heart health promotion program. Subjects included 2,318 children aged 9-12 years with baseline and 1-year follow-up data and 633 children aged 9-11 years with baseline and 2-year follow-up data. One-year predictors of highest decile of change in body mass index (BMI) identified in logistic regression analyses included baseline BMI of 90th percentile or more (odds ratio (OR) = 2.66, 95% confidence interval: 1.80, 3.94) in boys and baseline BMI of 90th percentile or more (OR = 2.34, 95% confidence interval: 1.46, 3.76), no sports outside school (OR = 1.90, 95% confidence interval: 1.18, 3.06), and playing video games everyday (OR = 2.48, 95% confidence interval: 1.04, 5.92) in girls. Two-year predictors included baseline BMI of 90th percentile or more (OR = 3.26, 95% confidence interval: 1.52, 7.01), no sports outside school (OR = 2.14, 95% confidence interval: 0.96, 4.77), and least active (OR = 2.18, 95% confidence interval: 1.01, 4.71) in boys; only baseline BMI of 90th percentile or more (OR = 2.22, 95% confidence interval: 1.02, 4.81) was significant in girls. Results suggest the need for interventions to promote increased physical activity in children.

Methodology for evaluation of impact of health technology assessments (HTAs) is outlined and its use illustrated by applying it to 21 HTAs produced by CETS. Impact on policies and technology diffusion was identified in documents, through interviews, questionnaires, and use of data banks. There was evidence that all but three reports influenced policy and that cost-minimization studies caused savings of between $16 million and $27 million annually. Precise estimates of impact will seldom be possible, but systematic documentation of effects is feasible.

OBJECTIVE: To summarize seven years of surveillance data for Lyme disease cases reported in Canada from 2009 to 2015. METHODS: We describe the incidence over time, seasonal and geographic distribution, demographic and clinical characteristics of reported Lyme disease cases. Logistic regression was used to explore differences between age groups, sex and year to better understand potential demographic risk factors for the occurrence of Lyme disease. RESULTS: The number of reported Lyme disease cases increased more than six-fold, from 144 in 2009 to 917 in 2015, mainly due to an increase in infections acquired in Canada. Most locally acquired cases were reported between May and November. An increase in incidence of Lyme disease was observed in provinces from Manitoba eastwards. This is consistent with our knowledge of range expansion of the tick vectors in this region. In the western provinces the incidence has remained low and stable. All cases reported by Alberta, Saskatchewan and Newfoundland and Labrador were acquired outside of the province, either elsewhere in Canada or abroad. There was a bimodal distribution for Lyme disease by age with peaks at 5-9 and 45-74 years of age. The most common presenting symptom was a single erythema migrans rash (74.2%) and arthritis (35.7%). Variations in the frequency of reported clinical manifestations were observed among age groups and years of study. CONCLUSION: Lyme disease incidence continues to increase in Canada as does the geographic range of ticks that carry the Lyme disease bacteria. Ongoing surveillance, preventive strategies as well as early disease recognition and treatment will continue to minimize the impact of Lyme disease in Canada.

Objective: To summarize seven years of surveillance data for Lyme disease cases reported in Canada from 2009 to 2015. Methods: We describe the incidence over time, seasonal and geographic distribution, demographic and clinical characteristics of reported Lyme disease cases. Logistic regression was used to explore differences between age groups, sex and year to better understand potential demographic risk factors for the occurrence of Lyme disease.

A case-control study was conducted from 1 January to 31 May 2003 to identify risk factors for S . Heidelberg infection in Canada. Controls were pair-matched by age group and telephone exchange to 95 cases. Exposures in the 7 days before illness/interview were assessed using multivariate conditional logistic regression. Consumption of home-prepared chicken nuggets and/or strips [matched odds ratio (mOR) 4.0, 95% confidence interval (CI) 1.4-13.8], and undercooked eggs (mOR 7.5, 95% CI 1.5-75.5) increased the risk of illness. Exposure to a farm setting lowered the risk (mOR 0.22, 95% CI 0.03-1.00). The population-attributable fraction associated with chicken nuggets/strips was 34% and with undercooked eggs was 16%. One-third of study participants did not perceive, handle or prepare chicken nuggets and strips as high-risk products, although the majority of the products on the Canadian market are raw. These findings have prompted changes in product-labelling policy and consumer education.

The World Health Organization/United Nations Children's Fund Baby-Friendly Hospital Initiative: Revised, Updated, and Expanded for Integrated Care (2009) identifies the need for expanding the guidelines originally developed for maternity units to include neonatal intensive care. For this purpose, an expert group from the Nordic countries and Quebec, Canada, prepared a draft proposal, which was discussed at an international workshop in Uppsala, Sweden, in September 2011. The expert group suggests the addition of 3 "Guiding Principles" to the Ten Steps to support this vulnerable population of mothers and infants: 1. The staff attitude to the mother must focus on the individual mother and her situation. 2. The facility must provide family-centered care, supported by the environment. 3. The health care system must ensure continuity of care, that is, continuity of pre-, peri-, and postnatal care and post-discharge care. The goal of the expert group is to create a final document, the Baby Friendly Hospital Initiative for Neonatal Units, including standards and criteria for each of the 3 Guiding Principles, Ten Steps, and the Code; to develop tools for self-appraisal and monitoring compliance with the guidelines; and for external assessment to decide whether neonatal intensive/intermediate care units meet the conditions required to be designated as Baby-Friendly. The documents will be finalized after consultation with the World Health Organization/United Nations Children's Fund, and the goal is to offer these documents to international health care, professional, and other nongovernmental organizations involved in lactation and breastfeeding support for mothers of infants who require special neonatal care.

Salmonella enterica serovar Heidelberg is the second most frequently occurring serovar in Quebec and the third-most prevalent in Canada. Given that conventional pulsed-field gel electrophoresis (PFGE) subtyping for common Salmonella serovars, such as S. Heidelberg, yields identical subtypes for the majority of isolates recovered, public health laboratories are desperate for new subtyping tools to resolve highly clonal S. Heidelberg strains involved in outbreak events. As PFGE was unable to discriminate isolates from three epidemiologically distinct outbreaks in Quebec, this study was conducted to evaluate whole-genome sequencing (WGS) and phylogenetic analysis as an alternative to conventional subtyping tools. Genomes of 46 isolates from 3 Quebec outbreaks (2012, 2013, and 2014) supported by strong epidemiological evidence were sequenced and analyzed using a high-quality core genome single-nucleotide variant (hqSNV) bioinformatics approach (SNV phylogenomics [SNVphyl] pipeline). Outbreaks were indistinguishable by conventional PFGE subtyping, exhibiting the same PFGE pattern (SHEXAI.0001/SHEBNI.0001). Phylogenetic analysis based on hqSNVs extracted from WGS separated the outbreak isolates into three distinct groups, 100% concordant with the epidemiological data. The minimum and maximum number of hqSNVs between isolates from the same outbreak was 0 and 4, respectively, while >59 hqSNVs were measured between 2 previously indistinguishable outbreaks having the same PFGE and phage type, thus corroborating their distinction as separate unrelated outbreaks. This study demonstrates that despite the previously reported high clonality of this serovar, the WGS-based hqSNV approach is a superior typing method, capable of resolving events that were previously indistinguishable using classic subtyping tools.

A multi-province outbreak of listeriosis occurred in Canada from June to November 2008. Fifty-seven persons were infected with 1 of 3 similar outbreak strains defined by pulsed-field gel electrophoresis, and 24 (42%) individuals died. Forty-one (72%) of 57 individuals were residents of long-term care facilities or hospital inpatients during their exposure period. Descriptive epidemiology, product traceback, and detection of the outbreak strains of Listeria monocytogenes in food samples and the plant environment confirmed delicatessen meat manufactured by one establishment and purchased primarily by institutions was the source of the outbreak. The food safety investigation identified a plant environment conducive to the introduction and proliferation of L. monocytogenes and persistently contaminated with Listeria spp. This outbreak demonstrated the need for improved listeriosis surveillance, strict control of L. monocytogenes in establishments producing ready-to-eat foods, and advice to vulnerable populations and institutions serving these populations regarding which high-risk foods to avoid.