Paediatric tuberculosis among the foreign-born: utility of the Canadian TB immigration medical surveillance programme.

BACKGROUND: There are few data on the utility of screening paediatric immigrants for tuberculosis (TB) in low TB burden countries. OBJECTIVE: To evaluate the utility of the Canadian immigration medical examination and TB Medical Surveillance (TBMS) for detecting paediatric TB disease. DESIGN: A 10-year population-based retrospective cohort study of foreign-born children (ages 0-10 years) and adolescents (ages 11-17 years) immigrating to Ontario, Canada, using linked immigration and public health databases. RESULTS: Among 232 169 individuals (median follow-up of 5.7 years), active TB was diagnosed at or after immigration in 125 cases (20 children and 105 adolescents), at an overall rate of 54/100 000 (14/100 000 children, 116/100 000 adolescents). All cases originated from 34 countries. Active TB was diagnosed in 0/419 children and 10/418 adolescents referred for medical surveillance, representing only 8.0% of all cases. TBMS referrals were correlated with a previous diagnosis of TB (κ = 0.8) and were driven by country of origin (e.g., hazard ratio 31.2 for the Philippines). Rates of pre-immigration TB diagnosis varied considerably among high TB burden countries. CONCLUSIONS: The current Canadian system detects little TB disease, and reveals very different rates of pre-immigration paediatric TB diagnosis in different high TB burden countries. These data provide a basis for improving TB screening strategies for immigrants to low TB burden countries.

Antiviral medication use in a cohort of pregnant women during the 2009-2010 influenza pandemic.

Preventing influenza-like illness (ILI) during pregnancy with antiviral medication use (AVMU) can mitigate serious health risks to mother and foetus. We report on AVMU in pregnant women in Ontario, Canada, and describe characteristics of AVMU during the 2009-2010 H1N1 pandemic. Rates and risk estimates of AVMU were compared across multiple categories and stratified across ILI infection status. Increased AVMU was observed in women with influenza infections, active smokers, those vaccinated against influenza, and those with pre-existing co-morbidities. Decreased AVMU was observed in women with multiple gestations, and those in neighbourhoods of high immigrant concentrations. Our stratified analysis indicated that the observed patterns differed by ILI infection status. We demonstrated that once infected, women across multiple groups were equally likely to use antiviral medications. In this report we also propose possible clinical explanations for the observed differences in AVMU, which will be useful in planning prevention initiatives for future pandemics.

Influence of skin colour on diagnostic accuracy of the jaundice meter JM 103 in newborns.

AIM: To assess the diagnostic accuracy of the JM 103 as a screening tool for neonatal jaundice and explore differential effects based on skin colour. METHODS: We prospectively compared the transcutaneous bilirubin (TcB) and serum bilirubin (TSB) measurements of newborns over a 3 month-period. Skin colour was assigned via reference colour swatches. Diagnostic measures of the TcB/TSB comparison were made and clinically relevant TcB cut-off values were determined for each skin colour group. RESULTS: 451 infants (51 light, 326 medium and 74 dark skin colour) were recruited. The association between TcB and TSB was high for all skin colours (rs>0.9). The Bland-Altman analysis showed an absolute mean difference between the two measures of 13.3±26.4 µmol/L with broad limits of agreement (-39.4-66.0 µmol/L), with TcB underestimating TSB in light and medium skin colours and overestimating in dark skin colour. Diagnostic measures were also consistently high across skin colours, with no clinically significant differences observed. CONCLUSIONS: The JM 103 is a useful screening tool to identify infants in need of serum bilirubin, regardless of skin colour. The effect of skin colour on the accuracy of this device at high levels of serum bilirubin could not be assessed fully due to small numbers in the light and dark groups.

Evaluation of the impact of fetal fibronectin test implementation on hospital admissions for preterm labour in Ontario: a multiple baseline time-series design.

OBJECTIVE: To determine the impact of a health system-wide fetal fibronectin (fFN) testing programme on the rates of hospital admission for preterm labour (PTL). DESIGN: Multiple baseline time-series design. SETTING: Canadian province of Ontario. POPULATION: A retrospective population-based cohort of antepartum and delivered obstetrical admissions in all Ontario hospitals between 1 April 2002 and 31 March 2010. METHODS: International Classification of Diseases codes in a health system-wide hospital administrative database were used to identify the study population and define the outcome measure. An aggregate time series of monthly rates of hospital admissions for PTL was analysed using segmented regression models after aligning the fFN test implementation date for each institution. MAIN OUTCOME MEASURE: Rate of obstetrical hospital admission for PTL. RESULTS: Estimated rates of hospital admission for PTL following fFN implementation were lower than predicted had pre-implementation trends prevailed. The reduction in the rate was modest, but statistically significant, when estimated at 12 months following fFN implementation (-0.96 hospital admissions for PTL per 100 preterm births; 95% confidence interval [CI], -1.02 to -0.90, P = 0.04). The statistically significant reduction was sustained at 24 and 36 months following implementation. CONCLUSIONS: Using a robust quasi-experimental study design to overcome confounding as a result of underlying secular trends or concurrent interventions, we found evidence of a small but statistically significant reduction in the health system-level rate of hospital admissions for PTL following implementation of fFN testing in a large Canadian province.

Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study.

AIMS: To explore intention to breastfeed and breastfeeding rates in hospital and on discharge across women with pre-gestational or gestational diabetes mellitus, or no diabetes. METHODS: A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study. Unadjusted and adjusted odds ratios were calculated for each outcome measure and were used to compare the breastfeeding rates among women with and without diabetes. RESULTS: After controlling for potential confounders, women with insulin-treated diabetes were less likely to intend to breastfeed, when compared with women without diabetes (adjusted odds ratio 0.49, 95% CI 0.27-0.89). In hospital, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.42, 95% CI 0.26-0.67), followed by women with non-insulin-treated diabetes (odds ratio 0.50, 95% CI 0.26-0.96) and women with gestational diabetes (odds ratio 0.77, 95% CI 0.68-0.87) when compared with women without diabetes. On discharge, women with insulin-treated diabetes were least likely to breastfeed (odds ratio 0.38, 95% CI 0.24-0.60), followed by women with gestational diabetes (odds ratio 0.75, 95% CI 0.66-0.85); rates of breastfeeding among women with non-insulin-treated diabetes were comparable on discharge with those of women without diabetes. Women seeking care from an antenatal provider other than a physician were 2-3 times more likely to breastfeed in hospital and on discharge. CONCLUSIONS: Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.