Continuity of pediatric ambulatory care in a universally insured population.

OBJECTIVE: To describe the prevalence of continuity of care over a 5-year period in a complete cohort of urban children universally insured for medical care provided under fee-for-service reimbursement. METHOD: All children enrolled in the study were born to women living in metropolitan Winnipeg between July 1, 1987 and December 31, 1988 (N = 12,590). All ambulatory physician services for this group were enumerated from computerized administrative databases for the period from birth through 60 months. Continuity of care, defined as the proportion of total care provided by the most frequently seen physician or physician practice over time, was calculated for each child. Descriptive analyses include an examination of maternal and household characteristics associated with children receiving 80% or more of total ambulatory care from a single provider source. RESULTS: From birth to 24 months, 51% of children received at least 80% of ambulatory visits from a single provider practice. This proportion of the children declined to 28% at 25 through 60 months. Children living in low-income neighborhoods had poorer continuity profiles. Other household factors associated with poor continuity included young maternal age, single maternal marital status, residential mobility, and inadequate maternal use of prenatal medical care. Households affiliated with pediatric practices had better continuity profiles than households affiliated with general medical practices. CONCLUSION: Despite universal medical insurance, barriers to a longitudinally continuous relationship with a primary care provider remain in this setting. Although this study has emphasized the description of those barriers associated with household characteristics, there is evidence that factors related to the organization and delivery of medical care are also relevant.

Excess prevalence of non diabetic renal disease in native American children in Manitoba.

We undertook a 1-year prospective point prevalence study to test the hypothesis that there is an excess of non-diabetic renal disease in native American children; 29.6% (73/247) of the population attending the only regional pediatric nephrology clinic in 1993 were native compared with 8.2% of the Manitoba population in this age group (odds ratio = 4.4, P < 0.001). Patients were classified as low risk (normal renal function, no deterioration expected), high risk (normal renal function, deterioration probable), or established chronic renal failure (creatinine clearance chronically low or post renal transplant). Patients were further classified as suffering from congenital renal anomalies, genetic or metabolic disease, or acquired renal disease. Odds ratios were calculated based on data from the Aboriginal Peoples' Population Survey and Statistics Canada census data. The odds ratios for low-risk renal disease, high-risk renal disease, and chronic renal failure were 3.8, 5.6, and 6.3, respectively (P < 0.001 in all categories). The odds ratios for congenital, genetic, or acquired disease were 4.5 (P < 0.001), 0.9 (P = ns), and 6.1 (P < 0.001), respectively. Native American children in Manitoba demonstrate increased prevalence of serious congenital and acquired renal disease. These children are also more likely to live in medically underserviced communities, long distances from tertiary care centers. This study emphasizes the importance of considering factors other than diabetes mellitus when considering the problem of renal disease in native Americans.

Epidemiology of juvenile rheumatoid arthritis in Manitoba, Canada, 1975-92: cycles in incidence.

OBJECTIVE: To determine the yearly incidence of juvenile rheumatoid arthritis (JRA) and to seek correlations between this and cyclic infections occurring in the province of Manitoba, Canada, during the same period. METHODS: An estimate of the incidence of JRA in Manitoba was determined from a disease registry of the Pediatric Rheumatology Clinic, Children's Hospital, Winnipeg. The numbers of confirmed Mycoplasma pneumoniae and viral respiratory infections were determined from annual reports of Cadham Provincial Laboratory. Both facilities provide centralized services for the province. RESULTS: Between 1975 and 1992 the onset of JRA occurred in 261 patients (136 with pauciarticular, 91 polyarticular, and 34 systemic onset). The average annual incidence of JRA for this period was 5.34/100,000. However, a cyclic incidence was apparent with peaks in 1979, 1982, 1986, and 1990-91. Increases in confirmed M. pneumoniae infections were concurrent with peaks in the incidence of JRA. A significant correlation was found between the incidence of JRA and the number of M. pneumoniae infections detected in the province between 1985 and 1992 (R = 0.76, p = 0.044). In contrast, there was no consistent variation in the incidence of seronegative spondyloarthropathies in children (n = 103 patients). CONCLUSION: These data suggest the need for further study of a possible infectious etiology for JRA.

Vitamin D deficiency in a Manitoba community.

OBJECTIVE: Using a cross-sectional survey, to investigate the vitamin D status of a random sample of 80 mother-child pairs (child age 3-24 months) in a Manitoba community with a high incidence of rickets. METHOD: A questionnaire on feeding habits, gestational history, maternal diet and vitamin supplements was administered to mothers in their homes with the assistance of a local interpreter. Venous blood was collected from both mother and child for serum 25-hydroxyvitamin D levels. RESULTS: Of 91% babies initially breastfed, 36% received no formula or milk after weaning and 40% received no vitamin supplements. 24% of mothers took no vitamin supplements during pregnancy and lactation. Knowledge about rickets was poor. In 43% of children and 76% of mothers, serum 25-hydroxyvitamin D levels were below normal range. CONCLUSIONS: Vitamin D levels are low in this population due to lack of fortified dairy products and vitamin D supplements. A public health program should include counseling on rickets and vitamin D supplementation for all infants and pregnant or lactating women.

PIP: In the isolated Island Lake area of northern Manitoba, which has a high incidence of rickets, interviews were conducted with 80 mothers, each with a child at least 2 years old, living in St. Theresa Point and Garden Hill in their homes during June-July 1987 to determine their knowledge and attitudes towards rickets. Nurses obtained blood samples from the women and their young children so the researchers could determine the vitamin D status of both. The mother-child pairs were native Canadians from the Ojibway linguistic group that speaks its own dialect of Ojibway-Cree. Mothers initially breast fed 91% of the children. After weaning, 1/3 of infants received neither infant formula nor milk. No vitamin supplements were given to 40%. Many of the children who did receive vitamin supplements did not receive them regularly. 70% of the mothers did not drink any milk. 24% were milk-intolerant. 24% took no vitamin supplements during pregnancy and lactation. Mothers who did take supplements did not do so regularly. 17% claimed that their skin was sensitive to sunlight. 84% of mothers in one community had never heard of rickets. Most did not know its cause. Neither mothers nor the children were exposed to the sunlight in the summer. When outside, almost all small infants were completely covered to protect them from the elements. The mean 25-hydroxy-vitamin D level was 26.2 nmol/l for the children and 19.8 nmol/l for the mothers. 43% of children and 76% of mothers had a 25-hydroxy-vitamin D level below the normal range. These high levels of vitamin D insufficiency were even more troublesome given that the blood was taken in late June and July when vitamin D levels would be likely to be at their highest. The dearth of vitamin D fortified dairy products and vitamin supplements greatly contributed to the low level of vitamin D status in this area. The findings show a need for public health officials to include education on rickets and vitamin D supplementation for all infants and pregnant or lactating women.

Group A streptococcal pharyngeal carriage, pharyngitis, and impetigo in two northern Canadian native communities.

The prevalence of pharyngeal carriage of group A streptococci, streptococcal pharyngitis, and impetigo was determined in schoolchildren in two northern communities, one Inuit (mean number of schoolchildren surveyed, 233) and one native Indian (mean number of schoolchildren surveyed, 349). At three surveys from November 1984 to May 1985, pharyngeal group A streptococcal carriage was 5.3%, 22%, and 34% in the Inuit community and 5.3%, 5.1% and 10% in the native Indian, with impetigo prevalence 1.6%, 3.8% and 1.0%, and 2.4%, 4.2% and 0.6%, respectively. Increased pharyngeal carriage correlated with the increasing number of household residents and the lower school grade. In 12 months of observation the incidence of group A streptococcal pharyngitis was 49/100 schoolchildren for the Inuit and 9.4/100 for the native Indian community, with impetigo 13/100 and 11/100 respectively. The maximal incidence of pharyngitis was late winter in the Inuit community and midsummer in the native Indian. The incidence of impetigo peaked in January for both communities. M and T typing showed consecutive outbreaks of different serotypes in the Inuit community, but a persistent low level of endemic infection in the Indian community. These observations suggest a seasonal prevalence of group A streptococcal pharyngeal carriage consistent with other North American populations, but marked inter-community variation in pharyngeal carriage and disease. The midwinter peak of impetigo appears unique to these populations.

Erythromycin-resistant group G streptococci in an isolated northern Canadian community.

The susceptibility of groups A, C, and G streptococci isolated from pharynx or skin in two northern Canadian native communities during a one year study of the epidemiology of streptococcal infection was determined for penicillin, erythromycin and clindamycin using an agar dilution method. Organisms studied included 725 group A, 82 group C, and 184 group G streptococci. All organisms were susceptible to penicillin (minimum inhibitory concentration [MIC] range less than 0.004 to 0.015 µg/mL; MIC(90) 0.015 µg/mL) and clindamycin (range 0.007 to 0.06 µg/mL; MIC(90) 0.06 µg/mL) with no differences observed between streptococcal groups. For erythromycin, groups A and C were generally susceptible (range less than 0.007 to 0.030 µg/mL; MIC(90) 0.03 µg/mL; and range 0.007 to 1.0 µg/mL; MIC(90) 0.06 µg/mL, respectively). Group G was less susceptible (range 0.007 to greater than 2.0 µg/mL; MIC(90) greater than 2.0 µg/mL) with 38% of all isolates having an MIC greater than or equal to 1 µg/mL. On review of group G isolates, 100 of 100 from one community were susceptible (MIC less than 0.007 to 0.03 µg/mL) and 73 (87%) of 84 from the second community were resistant. All resistant strains tested were type T16. These data suggest that erythromycin-resistant group G streptococci may occur with high prevalence in certain populations and that patterns of antimicrobial susceptibility in isolated communities may be highly community-specific.

Haemophilus influenzae meningitis in Manitoba and the Keewatin District, NWT: potential for mass vaccination.

A community-based surveillance study of all central nervous system infections was carried out in Manitoba and the Keewatin District, NWT, between Apr. 1, 1981, and Mar. 31, 1984. There were 201 cases of bacterial meningitis in Manitoba over the study period, 81 (40%) caused by Haemophilus influenzae; all but one isolate tested were type b (Hib). There were nine cases of H. influenzae meningitis in the Keewatin District. The overall annual incidence rate of H. influenzae meningitis in Manitoba was 2.5/100,000; for children under 5 years the rate was 32.1/100,000. For the Keewatin District the corresponding rates were 69.6/100,000 and 530/100,000. A total of 85% and 100% of the cases of H. influenzae meningitis occurred by 24 months of age in Manitoba and the Keewatin District respectively. The age at onset was earlier in native Indian children (22 cases) and Inuit children (9 cases) than in non-native children (59 cases) (p less than 0.005); thus, vaccine prevention of Hib meningitis will likely be more difficult in native Indian and Métis children. Without evaluating the increased potential of H. influenzae vaccines to prevent nonmeningitic forms of disease, we concluded that mass childhood vaccination with polyribosylribitolphosphate (PRP) vaccine is not warranted in Manitoba or the Keewatin District. Immunogenicity studies suggest that administration of conjugated Hib vaccines such as PRP-D in infancy may prevent approximately one-third to two-thirds of cases of H. influenzae meningitis; these vaccines warrant consideration for use in mass childhood vaccination programs.