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Background: Hepatitis B virus (HBV) immunization protocols are routinely followed in dialysis units. Recommendations for retesting and booster dose administration are variable and less well known. Design: Quality improvement report. Setting & Participants: Provincial dialysis cohort in all 5 regional centers in British Columbia (n 1,055). Quality Improvement Plan: (1) Describe the variations in HBV testing practice patterns between centers and modalities of dialysis, (2) propose an evidence-based protocol for HBV follow-up testing, and (3) compare the current practice for HBV follow-up testing with the protocol. Measures: (1) Number of HBV tests performed based on geographic center and dialysis modality; (2) tabulation of local, national, and international guidelines to determine concordance and develop British Columbian protocol, and (3) percentage of patients who received recommended HBV testing based on protocol. Results: (1) Significant variation noted in HBV testing frequency among the 5 regional centers and between hemodialysis and peritoneal dialysis patients (P 0.001); (2) current available guidelines generally are concordant, but vary in regard to frequency of follow-up testing; and (3) comparing recommended testing frequency with actual testing, 50% of patients were tested as recommended; 13%,less than recommended; and 37%, more than recommended. Hemodialysis patients often were tested more than recommended (hemodialysis, 47% versus peritoneal dialysis, 16%; P 0.01). Patients with current or past HBV infection were tested more than recommended (P 0.01). All variability remained significant when adjusted for age, sex, and dialysis therapy duration in a multivariate model. Limitations: The cohort was ascertained from laboratory data; therefore, information for vaccination and booster dose administration was not available. Conclusion: In a cohort of dialysis patients initially screened for hepatitis B, 50% of patients are being appropriately monitored with retesting compared with an evidence-based protocol. Patients with known HBV infection and hemodialysis patients are being tested more than recommended. Adherence to a protocol for retesting would ensure appropriate follow-up and reduce unnecessary retesting, potentially leading to significant cost savings. Am J Kidney Dis 52:939-946. © 2008 by the National Kidney Foundation, Inc.

A clear understanding of risk factors is very important to develop appropriate prevention and control strategies for infection caused by such pathogens as Salmonella (S.) Typhimurium. The objective of this study is to utilise intelligent models to identify significant risk factors for S. Typhimurium DT104 and non-DT104 illness in Canada, and compare findings to those obtained using traditional statistical methods. Previous studies have focused on analysing each risk factor separately using single variable analysis (SVA), or modelling multiple risk factors using statistical models, such as logistic regression (LR) models. In this paper, neural networks and statistical models are developed and compared to determine which method produces superior results. In general, simulation results show that the neural network yields more accurate prediction than the statistical models. The network size, number of training iterations, learning rate, and training sample size in the neural networks are discussed to improve the performance of systems.

In persons with chronic hepatitis C virus (HCV) infections, superinfection by hepatitis A virus (HAV) or hepatitis B virus (HBV) can cause serious complications, including fulminating hepatitis or increased severity of hepatitis. Therefore, it is important to adequately protect persons with chronic HCV infections by immunization. Suboptimal response to vaccines has been reported in patients with chronic liver disease. The present article reviews HAV and HBV vaccine responses reported in the literature when administered to individuals with chronic HCV infection, and reviews current national and international recommendations.RESULTS: Persons with chronic HCV respond well to HAV vaccine, but studies exploring HBV vaccine efficacy in this population have equivocal results. Vaccine schedules and participant characteristics differ among studies, and most do not adjust for confounders. Some studies found no difference in HBV vaccine response between patients with chronic HCV and controls. However, HBV vaccine response was generally reduced in those with cirrhosis and HCV genotype 1. Organizations recommend HAV and HBV vaccines for persons with chronic HCV, but do not suggest alterations in schedule or dose.RECOMMENDATIONS: Because HAV vaccine response is good and routine laboratory testing may not detect lower levels of vaccine-induced anti-HAV, the standard HAV vaccine schedule is recommended without postimmunization testing. HBV vaccine should be administered early in the course of chronic HCV infection because response may be lower in patients with cirrhosis. Reflex testing of anti-HCV reactive sera for anti-HAV and hepatitis B surface antibody can facilitate appropriate follow-up and timely immunization. Determination of postimmunization hepatitis B surface antibody, especially in patients with cirrhosis or genotype 1, will allow HBV vaccine boosters to be offered.

Background In British Columbia, Canada, methadone maintenance treatment formulation transitioned from the oral liquid compound Tang™-flavoured methadone to the ten-times more concentrated cherry-flavoured Methadose™ in February 2014. We quantitatively describe perceptions and reported consequences among a sample of patients on methadone maintenance treatment following this transition. Methods A province-wide survey was used. Bivariable analyses utilized independent samples t-tests, Phi associations, and Chi-square tests. Multivariable logistic regression analyses evaluated factors related to dependent variables – namely, increases in dose, pain, dope sickness, and the need to supplement with additional opioids. Results Four hundred five methadone maintenance treatment patients from fifty harm reduction sites across British Columbia reported transitioning to Methadose™ in February 2014. The majority (n = 258; 73.1 %) heard about the formulation change from their methadone provider or pharmacist. Adjusted models show worse taste was positively associated with reporting an increasing dose (OR = 2.46; CI:1.31–4.61), feeling more dope sick (OR = 3.39; CI:1.88–6.12), and worsening pain (OR = 4.65; CI:2.45–8.80). Feeling more dope sick was positively associated with dose increase (OR = 2.24; CI:1.37–3.66), and supplementing with opioids (OR = 8.81; CI:5.16–15.05). Conclusions Methadone maintenance treatment policy changes in British Columbia affect a structurally vulnerable population who may be less able to cope with transitions and loss of autonomy. There may be a psychosocial component contributing to the perception of Methadose™ tasting worse, and increased dope sickness, pain, and dose. Our study shows the pronounced negative impacts medication changes can have on patients without informed, coordinated efforts. We stress the need to engage all stakeholders allowing for communication about the reasons, risks and consequences of medication policy changes and provision of additional psychosocial support.

A clear understanding of risk factors is important to develop appropriate prevention and control strategies for infection caused by such pathogens as Salmonella Typhimurium. In this study, there are 91 risk factors that nonlinearly contribute to the Salmonella Typhimurium infection and many of them are not of significance. It is very important to automatically extract a factor subset with those important risk factors. This paper proposes a genetic algorithm for factor subset extraction in conjunction with neural and statistical classifiers to classify case and control status in Salmonella Typhimurium infection. The results show that the proposed approach is able to find an appropriate factor subset and the proposed neural classifiers outperform the traditional statistical classifiers. A statistical analysis is conducted by varying the parameters in the genetic algorithm based neural classifier to minimise the prediction error and determine the optimal system configuration.

BACKGROUND: Suspected transfusion-transmissible infections (TTIs) have been reported to public health (PH) in British Columbia (BC) since August 2002. The impact of PH notification of suspected transfusion-transmissible hepatitis C virus (TT-HCV) infection over the first 2.5 years and the effectiveness of HCV lookback (LB) and traceback (TB) investigations conducted by Canadian Blood Services (CBS) in BC were evaluated. STUDY DESIGN AND METHODS: Suspected TT-HCV cases reported to CBS in BC between August 28, 2002, and February 28, 2005, were analyzed. The incremental yield of plausible TTIs from PH-reported suspected TTIs was calculated. The effectiveness of LB and TB investigations was assessed with respect to the impact of improved anti-HCV donor screening, the number of newly recognized HCV infections, and the timeliness of initiating investigations. RESULTS: Nine of 553 (1.6%) investigations were initiated after PH reporting, yielding an additional 2 of 237 (i.e., 0.8%) plausible TTIs. Ninety-two percent of investigations with transfused units involved transfusions before implementing second-generation anti-HCV enzyme immunoassay (EIA) donor screening. Almost one-third of HCV-infected persons in linked investigations (i.e., LB triggered by a TB and vice versa) were newly identified. Recently tested, PH-reported cases incurred a mean delay exceeding 6 months until initiating a LB or TB investigation. CONCLUSION: PH reporting of TTIs and investigating transfusions after second-generation anti-HCV EIA donor screening identified few plausible TT-HCV infections. Many HCV-infected recipients or lapsed donors first became aware of their infection status as a result of CBS investigations. The current process of reporting suspected TTIs incurs significant time delay.

There is a growing concern surrounding crystal methamphetamine use in Canada despite surprisingly little empirical data to support such claims. We evaluated the trends in crystal methamphetamine injection and factors associated with injection of the drug among a cohort of injection drug users (IDU) in Vancouver.We conducted a prospective analysis of factors associated with crystal methamphetamine injection among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with crystal methamphetamine injection were evaluated using generalized estimating equations (GEE) with logit link for binary outcomes.Overall, 1587 IDU were enrolled into the VIDUS cohort between May 1996 and December 2004. The proportion of IDU who reported injecting crystal methamphetamine during the last 6 months increased during the study period (Cochran-Armitage trend test, p0.001). In multivariate GEE analyses, crystal methamphetamine injection was independently associated with younger age (adjusted odds ratio [AOR]: 4.77, 95% confidence interval [CI]=3.40-6.70), Caucasian ethnicity (AOR=2.21, 95% CI=1.57-3.12), syringe borrowing (AOR=1.62, 95% CI=1.22-2.13), and syringe lending (AOR=1.40, 95% CI=1.02-1.86).There was a significant trend towards increasing crystal methamphetamine injection in this setting and elevated HIV risk behavior and younger age were independently associated with crystal methamphetamine injection. Given that banning precursor chemicals has had a limited effect on reducing methamphetamine supply in other jurisdictions, pragmatic and effective interventions are needed to address the growing use of this drug.

Background Fentanyl-detected illicit drug overdose deaths in British Columbia (BC) recently increased dramatically from 13 deaths in 2012 to 90 deaths in 2014, signaling an emerging public health concern. Illicit fentanyl is sold as pills or powders, often mixed with other substances like heroin or oxycodone; reports from coroners suggested that fentanyl was frequently taken unknowingly by people who use drugs. This study aimed to assess the prevalence and characteristics of fentanyl use among clients accessing harm reduction (HR) services in BC. Methods Participants attending HR services at 17 sites across BC were invited to complete an anonymous questionnaire describing drugs they have used within the last 3 days and provide a urine sample to test for fentanyl. Data from eligible participants were analyzed using descriptive, bivariate, and multivariate statistical methods. Results Surveys from 17 HR sites were received, resulting in analysis of responses from 242 eligible participants. Most participants used multiple substances (median = 3), with crystal meth (59 %) and heroin (52 %) use most frequently reported. Seventy participants (29 %) tested positive for fentanyl, 73 % of whom did not report using fentanyl. Controlling for age, gender, and health authority, reported use of fentanyl (odds ratio (OR) = 6.13, 95 % confidence interval (CI) = [2.52, 15.78], p

Objectives. We estimated HCV incidence among individuals who repeatedly underwent anti-HCV testing. Methods. We studied HCV-negative individuals who had at least 2 tests between April 1992 and September 2012 in British Columbia, Canada. We calculated incidence as the number of new infections per 100 person-years at risk. Results. From 1992 to 2012, 323 598 individuals who persistently tested negative and 7490 HCV seroconverters contributed 1 774 262 person-years of observation time. Incidence rates ranged from 2.66 infections per 100 person-years (95% confidence interval [CI] = 2.07, 3.35) in 1993 to 0.25 infections per 100 person-years (95% CI = 0.21, 0.29) in 2011. Rates declined sharply in the 1990s and declined more gradually in the 2000s. Incidence declined with age; highest incidence rates were among those aged 15 to 24 years. Incidence among male repeat testers exceeded that of female repeat testers across all years, although the gap narrowed over time. Conclusions. Addictions treatment, harm reduction, prevention education, and novel initiatives to remove barriers in health infrastructure need to be intensified for those who inject drugs, particularly men and younger persons.

Objectives Prescription opioid (PO) use by people who inject drugs (PWID) is a growing public health concern. Non-fatal overdose remains a leading source of morbidity among PWID, however, little is known about the relationship between PO injection and non-fatal overdose in this population. In this study we sought to examine the impact of PO injection on non-fatal overdose among PWID from Vancouver, Canada. Methods Data were derived from two open prospective cohorts of PWID for the period of December, 2005 to May, 2014. Multivariable generalized estimating equations were used to examine the odds of overdose among those who injected: POs; heroin; and POs and heroin. Results In total, 1660 PWID (33.7% women) participated in this study. In multivariable analyses, in comparison to those who were injecting non-opioid drugs, exclusive PO injection was not significantly associated with non-fatal overdose (adjusted odds ratio [AOR]: 1.17, 95% confidence interval [CI]: 0.74–1.86). The odds of non-fatal overdose were elevated for heroin injection (AOR: 1.72, 95% CI: 1.31–2.27), but were greatest for those who injected both heroin and POs (AOR: 2.46, 95% CI: 1.83–3.30). Discussion Compared to injecting non-opioids, injecting POs exclusively did not increase risk of non-fatal overdose; however, injecting both POs and heroin doubled the risk. This may reflect consistencies in drug potency and composition when POs are used, as well as unique characteristics of exclusive PO injectors. Our findings call for the continued scale-up of evidence-based overdose prevention interventions for people who inject opioids, including POs.

Chronic rhinosinusitis (CRS) is becoming increasingly prevalent in adults with cystic fibrosis (CF), as the median age of survival rises for these individuals. Delayed identification of CRS may contribute to worsening health-related quality of life and increased treatment burden. Our objective was to investigate the utility of the 22-item Sino-Nasal Outcome Test (SNOT-22) as a tool to identify CRS in adults with CF.In this cross-sectional study, participants were sampled from an adult-specific CF clinic in Vancouver, Canada, between September 2013 and April 2014. CRS was determined by use of standardized diagnostic guidelines. Participants completed the SNOT-22 and medical charts were reviewed for additional predictor variables. Logistic regression was used to compare the SNOT-22 as a univariable predictor variable to a multivariable prediction model, in order to best differentiate CRS and non-CRS participants.Ninety-three of 101 adults provided written informed consent. The prevalence of CRS was 56.3% (95% confidence interval [CI], 45.9% to 66.3%). Individuals with CRS reported significantly higher SNOT-22 scores than non-CRS participants (mean difference: 13.9; 95% CI, 6.1 to 21.7). The optimal SNOT-22 score to differentiate CRS was 21 out of 110 (sensitivity: 76%, specificity: 61%, positive predictive value: 71%, likelihood ratio: 1.9).Compared to the current diagnostic gold standard, SNOT-22 scores greater than 21 sufficiently identified adults with CF presenting with concomitant CRS. The SNOT-22 is a simple instrument that can easily be implemented in adult CF clinics to assist care providers identify individuals requiring more detailed assessment or referral to a sinus clinic.

Fear of stigma and discrimination among health care workers (HCWs) in South African hospitals is thought to be a major factor in the high rates of HIV and tuberculosis infection experienced in the health care workforce. The aim of the current study is to inform the development of a stigma reduction intervention in the context of a large multicomponent trial. We analysed relevant results of four feasibility studies conducted in the lead up to the trial. Our findings suggest that a stigma reduction campaign must address community and structural level drivers of stigma, in addition to individual level concerns, through a participatory and iterative approach. Importantly, stigma reduction must not only be embedded in the institutional management of HCWs but also be attentive to the localised needs of HCWs themselves.

PurposeThe purpose of this paper is to describe the development, by incarcerated women who were members of a prison participatory health research team, of a survey tool regarding homelessness and housing, the survey findings and recommendations for policy.Design/methodology/approachA survey was developed by incarcerated women in a minimum/medium security women's prison in Canada. Associations were examined between socio‐demographic factors and reports of difficulty finding housing upon release, homelessness contributing to a return to crime, and a desire for relocation to another city upon release. Open‐ended questions were examined to look for recurrent themes and to illuminate the survey findings.FindingsIn total, 83 women completed the survey, a 72 per cent response rate. Of the 71 who were previously incarcerated, 56 per cent stated that homelessness contributed to their return to crime. Finding housing upon release was a problem for 63 per cent and 34 per cent desired relocation to another city upon release. Women indicated that a successful housing plan should incorporate flexible progressive staged housing.Research limitations/implicationsThe present study focuses only on incarcerated women but could be expanded in future to include men.Practical implicationsIncarcerated women used the findings to create a housing proposal for prison leavers and created a resource database of the limited housing resources for women prison leavers.Social implicationsLack of suitable housing is a major factor leading to recidivism. This study highlights the reality of the cycle of homelessness, poverty, crime for survival, street‐life leading to drug use and barriers to health, education and employment that incarcerated women face.Originality/valueHousing is a recognized basic determinant of health. No previous studies have used participatory research to address homelessness in a prison population.

This paper describes the development of a unique prison participatory research project, in which incarcerated women formed a research team, the research activities and the lessons learned. The participatory action research project was conducted in the main short sentence minimum/medium security women's prison located in a Western Canadian province. An ethnographic multi-method approach was used for data collection and analysis. Quantitative data was collected by surveys and analysed using descriptive statistics. Qualitative data was collected from orientation package entries, audio recordings, and written archives of research team discussions, forums and debriefings, and presentations. These data and ethnographic observations were transcribed and analysed using iterative and interpretative qualitative methods and NVivo 7 software. Up to 15 women worked each day as prison research team members; a total of 190 women participated at some time in the project between November 2005 and August 2007. Incarcerated women peer researchers developed the research processes including opportunities for them to develop leadership and technical skills. Through these processes, including data collection and analysis, nine health goals emerged. Lessons learned from the research processes were confirmed by the common themes that emerged from thematic analysis of the research activity data. Incarceration provides a unique opportunity for engagement of women as expert partners alongside academic researchers and primary care workers in participatory research processes to improve their health.

There is growing concern regarding rising rates of prescription drug-related deaths among the general North American population as well as increasing availability of illicitly obtained prescription opioids. Concurrently among people who inject drugs (IDU), illicit prescription opioid use has increased while non-fatal overdose remains a major source of morbidity.To evaluate whether the use of prescription opioids was associated with non-fatal overdose among IDU in Vancouver, Canada.Data was obtained from two open prospective cohorts of IDU between December 2005 and May 2013. We used generalized estimating equation (GEE) logistic regression to evaluate the association between prescription opioid use and non-fatal overdose, adjusting for various social, demographic, and behavioral factors.There were 1614 IDU, including 541 (33.5%) women, who were recruited and included in this analysis. At baseline, 526 (32.6%) reported using prescription opioids and 118 (7.3%) reported experiencing an overdose in the previous six months. In a multivariable analysis, prescription opioid use remained independently associated with non-fatal overdose (adjusted odds ratio: 1.61, 95% confidence interval: 1.32-1.95), after adjusting for confounders.We observed relatively high rates of prescription opioid use among IDU in this setting, and found an independent association between prescription opioid use and non-fatal overdose. Our data is likely representative of riskier substance use associated with those who use prescription opioids within our sample. Interventions to prevent and respond to overdoses should consider the higher risk profiles of IDU who use prescription opioids.

As the life expectancy for individuals with cystic fibrosis (CF) continues to improve, an emphasis on optimizing health-related quality of life (HRQoL) has become increasingly important. The Cystic Fibrosis Questionnaire-Revised (CFQ-R 14+) is the most widely accepted method to quantify HRQoL in this patient population.Our objective was to systematically review the literature to identify sociodemographic and clinical factors associated with HRQoL among adolescents and adults with CF.Five major literature databases were searched (MEDLINE, EMBASE, CENTRAL, CINAHL, psychINFO) to identify studies published from January 1989 to April 2014 (n=1,921). We included all full-text studies that: (1) focused on individuals 14 years of age or older, and (2) examined the relationship between sociodemographic (age, sex, body-mass index [BMI], socioeconomic status, and employment) and clinical (FEV1 % predicted, pulmonary exacerbation, comorbidities) factors with the CFQ-R 14+. Effect estimates and levels of statistical significance in the association between sociodemographic and clinical factors with each of the 12 CFQ-R 14+ domains were analyzed, if examined in at least two studies.Twenty-eight articles met our inclusion/exclusion criteria, but 5 studies were excluded at the data synthesis stage, leaving 23 articles for analysis. In relation to the CFQ-R 14+, 10 candidate factors were examined in at least two studies. The five most commonly studied factors were FEV1 % predicted (57.1% of 28 studies), sex (32.1%), BMI (28.6%), age (17.6%), and pulmonary exacerbations (13%). In studies incorporating multivariable methods, FEV1 % predicted was positively associated with all CFQ-R 14+ domains with the exception of Digestion, Social Functioning, and Emotional Functioning. Male subjects reported higher Physical Functioning and lower Body Image scores than female subjects, BMI was positively correlated with Body Image and Weight, and age was negatively correlated with Treatment Burden. Pulmonary exacerbations were negatively associated with multiple domains, including Respiratory Symptoms, Physical, and Role Functioning.Although several factors have been found to be associated with the CFQ-R in adolescents and adults with CF, FEV1 % predicted and pulmonary exacerbations have the broadest impact on HRQoL. Further research is required to investigate the impact of age-related comorbidities, psychosocial factors, and treatment-related factors on HRQoL in adolescents/adults with cystic fibrosis.

Sensation seeking, a personality trait, has been shown to predict engagement in high-risk behaviors. However, little is known regarding the impact of sensation seeking on substance use among street youth. We therefore sought to modify a sensation seeking scale (SSS) for use among this population. Street youth from the Vancouver-based At-Risk Youth Study (n = 226) completed the modified SSS. Exploratory and confirmatory factor analysis (EFA/CFA) were undertaken to establish the scale’s dimensionality and internal validity. The association between SSS score and injection-related behaviors was tested using generalized estimating equation (GEE) analysis. EFA results indicated scale unidimensionality. The comparative fit index (CFI) suggested acceptable fit (CFI = 0.914). In multivariate analysis, sensation seeking was independently associated with injection drug use, crystal methamphetamine use, polysubstance use, and binge drug use (all p < 0.05). Our findings provide preliminary support for the use of the modified SSS among street youth.

Crystal methamphetamine (CM) is a psychoactive form of methamphetamine whose effects include euphoria, alertness, restlessness, feelings of endless energy, sleep deprivation, depression, paranoia, acute psychosis, and malnutrition. CM use among street-involved youth is high, yet little is known about their patterns of use, the side effects they experience, and the ways in which they manage their drug use and survive on the streets. We undertook a small qualitative study among inner-city, street-involved youth to explore the social context of their CM use. Semi-structured interviews were conducted with twelve youth. Data were analyzed using thematic analysis and four key themes were identified: Patterns of Jib Use, Reasons for Using Jib, Downside of Using, and Managing Jib Use. Each theme revealed interrelationships between drug use and street-involvement. The youth used CM to stay awake to protect belongings, to enhance social interaction, to cope with negative emotions, and as an alternative to psychiatric medications. The negative consequences of CM use included deteriorating physical and mental health, exploitation, isolation, and physical harm. These youth were knowledgeable about their drug use and capable of creatively adapting to many of the related consequences. Social service agencies and health care professionals were not identified as helpful in managing their drug use and its side effects. Although the

To identify risk factors for sporadic Salmonella Typhimurium definitive phage-type 104 (DT104) and non-DT104 diarrhoeal illness in Canada, we conducted a matched case-control study between 1999 and 2000. Cases were matched 1:1 on age and province of residence. Multivariate analysis suggested that recent antibiotic use [odds ratio (OR) 5.2, 95% confidence interval (CI) 1.8-15.3], living on a livestock farm (OR 4.9, 95% CI 1.9-18.9), and recent travel outside Canada (OR 4.1, 95% CI 1.2-13.8) are independent risk factors for DT104 illness. Similar analyses suggested that recent travel outside North America is a sizable risk factor for non-DT104 illness (OR 66.8, 95% CI 6.7-665.3). No food exposure was a risk factor in either analysis. Educating health-care providers and the public about appropriate antibiotic use and antimicrobial resistance is important. Appropriate administration of antibiotics to livestock, particularly cattle, and hygienic measures such as handwashing after contact with farm animals may reduce risk. Travel represents an important and probably underestimated risk factor for sporadic illness with S. Typhimurium. Improved national surveillance and detailed investigation of travel-related illness are required.

Inconsistent reports of the prevalence of risk perception accuracy may be related to the use of different classification strategies. The purpose of this study was to compare two approaches for assessing the accuracy of women's breast cancer risk perceptions. A telephone survey was conducted with an age-stratified random sample of British Columbian women 20-79 years of age without a breast cancer diagnosis (n = 761). A comparison of two methods employed to determine perception accuracy revealed substantial differences between the methods with regard to the classification of women as under- and over-estimators. The study highlights the need for researchers to consider the method used to determine the accuracy of risk perceptions and the implications of using different strategies to assess risk perception accuracy when such information is used in research or to guide interventions.

This study investigated the burden of illness associated with 440 cases of Salmonella enterica serotype Typhimurium infection identified in Canada between December 1999 and November 2000. We categorized case subjects' infections by definitive phage type 104 (DT104) and antimicrobial-resistance patterns. These variables were then investigated as risk factors for hospitalization. Hospitalization was more likely to occur among case subjects whose infections were resistant to at least ampicillin, chloramphenicol and/or kanamycin, streptomycin, sulphamethoxazole, and tetracycline (R-type AK/CSSuT; odds ratio [OR], 2.3; P=.003), compared with case subjects with AK/CSSuT-susceptible infections, and among case subjects with non-DT104 R-type AKSSuT infections (OR, 3.6; P=.005), compared with case subjects with non-DT104 AKSSuT-susceptible infections. In contrast, hospitalization rates did not differ between case subjects with DT104 infections and case subjects with non-DT104 infections or between case subjects with DT104 R-type ACSSuT infections and case subjects with DT104 ACSSuT-susceptible infections. We estimated that 57% of the hospitalizations among AK/CSSuT case subjects and 72% of the hospitalizations among non-DT104 AKSSuT case subjects were attributable to the resistance patterns of the infections.

BACKGROUND: The objective was to compare women’s personal estimates of their risk with objective breast cancer risk estimates and to describe the risk factors for breast cancer identified by women. METHODS: Telephone survey of a random sample of 761 rural and urban women with no history of breast cancer. Survey instrument included measures of perceptions of lifetime risk for breast cancer for themselves and for the average woman, perceptions of risk factors that influenced their risk and the average woman’s risk for breast cancer. Objective estimates of breast cancer risk were calculated using the Gail et al. algorithm. Descriptive statistics and multiple linear regression were used to analyze the data. RESULTS: Women’s estimates of their own lifetime risk for breast cancer were significantly higher than their Gail model risk estimates (mean difference=19%, p

We investigated a large summertime outbreak of acute respiratory illness during May-September 1998 in Alaska and the Yukon Territory, Canada. Surveillance for acute respiratory illness (ARI), influenza-like illness (ILI), and pneumonia conducted at 31 hospital, clinic, and cruise ship infirmary sites identified 5361 cases of ARI (including 2864 cases of ILI [53%] and 171 cases of pneumonia [3.2%]) occurring primarily in tourists and tourism workers (from 18 and 37 countries, respectively). Influenza A viruses were isolated from 41 of 210 patients with ILI at 8 of 14 land sites and 8 of 17 cruise ship infirmaries. Twenty-two influenza isolates were antigenically characterized, and all were influenza A/Sydney/05/97-like (H3N2) viruses. No other predominant pathogens were identified. We estimated that >33,000 cases of ARI might have occurred during this protracted outbreak, which was attributed primarily to influenza A/Sydney/05/97-like (H3N2) viruses. Modern travel patterns may facilitate similar outbreaks, indicating the need for increased awareness about influenza by health care providers and travelers and the desirability of year-round influenza surveillance in some regions.

The purpose of this study was to compare the results of different measures of interest in genetic testing for breast cancer risk. A telephone survey of a random sample of women without breast cancer was conducted in British Columbia, Canada. Interest in genetic testing for breast cancer risk was measured in three ways: (1) an unprompted assessment of interest, (2) assessment of interest when prompted with a hypothetical offer of testing, and (3) assessment of interest when provided with supplementary information. Substantial differences in reported levels of interest in genetic testing were observed across the different assessment approaches, with the unprompted assessment of interest resulting in lowest levels of interest. The highest levels of interest were observed when the assessment of interest was prompted with a hypothetical offer of testing. Factors predicting interest in genetic testing varied depending on the assessment measure used. These findings suggest that more attention must be given to measurement issues, including complete reporting of measures used in research, development of standardized approaches to assessing interest in genetic testing, and more rigorous psychometric evaluations of measures of interest in genetic testing.

Background Leaving hospital against medical advice (AMA) is common among people who use illicit drugs (PWUD) and is associated with severe health-related harms and costs. However, little is known about the prevalence of and factors associated with leaving AMA among PWUD. Methods Data were collected through two Canadian prospective cohort studies involving PWUD between September 2005 and July 2011 and linked to a hospital admission/discharge database. Bivariable and multivariable generalized estimating equations were used to examine factors associated with leaving hospital AMA among PWUD who were hospitalized. Results Among 488 participants who experienced at least one hospitalization, 212 (43.4%) left the hospital AMA at least once during the study period. In multivariable analyses, factors positively and significantly associated with leaving hospital AMA included: unstable employment (AOR = 1.92; 95% confidence interval [CI]: 1.22–3.03); recent incarceration (AOR = 1.63; 95%CI: 1.07–2.49); ≥ daily heroin injection (AOR = 1.49; 95%CI: 1.05–2.11); and younger age per year younger (adjusted odds ratio [AOR] = 1.04; 95%CI: 1.02–1.06). Conclusions We found a substantial proportion of PWUD in this setting left hospital AMA and that various markers of risk and vulnerability were associated with this phenomenon. Our findings highlight the need to address substance abuse issues early following hospital admission. These findings further suggest a need to develop novel interventions to minimize PWUD leaving hospital prematurely.

Background Co-occurrence of social conditions and infections may affect HIV/HCV disease risk and progression. We examined the changes in relationship of these social conditions and infections on HIV and hepatitis C virus (HCV) infections over time in British Columbia during 1990–2013. Methods The BC Hepatitis Testers Cohort (BC-HTC) includes ~1.5 million individuals tested for HIV or HCV, or reported as a case of HCV, HIV, HBV, or tuberculosis linked to administrative healthcare databases. We classified HCV and HIV infection status into five combinations: HIV-/HCV-, HIV+monoinfected, HIV-/HCV+seroconverters, HIV-/HCV+prevalent, and HIV+/HCV+. Results Of 1.37 million eligible individuals, 4.1% were HIV-/HCV+prevalent, 0.5% HIV+monoinfected, 0.3% HIV+/HCV+ co-infected and 0.5% HIV-/HCV+seroconverters. Overall, HIV+monoinfected individuals lived in urban areas (92%), had low injection drug use (IDU) (4%), problematic alcohol use (4%) and were materially more privileged than other groups. HIV+/HCV+ co-infected and HIV-/HCV+seroconverters were materially most deprived (37%, 32%), had higher IDU (28%, 49%), problematic alcohol use (14%, 17%) and major mental illnesses (12%, 21%). IDU, opioid substitution therapy, and material deprivation increased in HIV-/HCV+seroconverters over time. In multivariable multinomial regression models, over time, the odds of IDU declined among HIV-/HCV+prevalent and HIV+monoinfected individuals but not in HIV-/HCV+seroconverters. Declines in odds of problematic alcohol use were observed in HIV-/HCV+seroconverters and coinfected individuals over time. Conclusions These results highlight need for designing prevention, care and support services for HIV and HCV infected populations based on the evolving syndemics of infections and social conditions which vary across groups.

Introduction: The following adverse outcomes have been described in patients treated in hospital for opioid overdose: pulmonary edema, cardiac dysrhythmias, neurologic injury secondary to hypoxia, prolonged opioid toxicity, recurrent opioid toxicity. In addition, patients who take an overdose of fentanyl may develop fentanyl induced chest rigidity, a life-threatening complication that appears to be uniquely related to fentanyl. The prevalence of adverse outcomes and the clinical course of patients that develop these complications have been described in patients who have taken an overdose of heroin. However, in British Columbia there has been a dramatic increase in the number of patients who overdose on fentanyl and other ultrapotent opioids. The proportion of illicit drug overdose deaths in British Columbia for which fentanyl was detected was only 5% in 2012 but, by 2016, this proportion had increased to 62%. It is very important to know the prevalence of adverse outcomes and the clinical course of patients that develop these adverse outcomes in patients with an overdose of fentanyl or another ultrapotent opioid. Methods: We are completing a retrospective cohort study to evaluate the prevalence of the following adverse outcomes for patients treated in hospital for an opioid overdose: i) pulmonary edema, ii) cardiac dysrhythmias, iii) fentanyl induced chest rigidity, iv) neurologic injury secondary to hypoxia, v) prolonged opioid toxicity, vi) recurrent opioid toxicity. Health records of patients treated for opioid overdose in the emergency departments of six greater Vancouver hospitals from Jan 1, 2014 to Dec 31, 2016 are being reviewed. Results: All Institutional approvals have been obtained. The dataset of 3600 ED visits for opioid overdose has been obtained and 160 health records have now been reviewed as of January 8, 2017. We will describe the type and prevalence (with 95% confidence intervals) of complications sustained by these patients. Conclusion: The results of this study will guide management of opioid overdose in a setting were ultrapotent opioids are commonly ingested. All health records will have been reviewed and the data analysis completed by May 2017.

Introduction: In 2015, there were 476 apparent illicit drug overdose deaths, prompting BC’s Provincial Health Officer to declare a public health emergency on 14 Apr 2016. Paramedics of BC’s Ambulance Service (BCAS) are on the front lines in this crisis. Here we examine recent trends in the number of suspected overdose events attended by the BCAS and the use of naloxone, an opioid antagonist, by BCAS paramedics. Methods: The BC Centre for Disease Control receives a weekly data feed from BC Emergency Health Services that includes all records from the BCAS Patient Care Record where: naloxone was administered by paramedics; the primary impression code indicates poisoning or overdose; or, the originating call is associated with ingestion poisoning (‘card 23’). Here, we report a descriptive analysis of these data for suspected drug overdose events during the period January 1, 2010 to September 30, 2016. Results: Between January 2010 and September 2016 BCAS paramedics attended 164,227 suspected overdose events; 12% of these events (n=16,944) included naloxone administration by BCAS paramedics. Paralleling the rise in illicit drug overdose deaths in BC, naloxone administration by paramedics has been increasing rapidly, doubling from approximately 180/month in 2014, to 370/month in 2016. When naloxone was administered by paramedics, 90% of these patients were transported, whereas 77% were transported when naloxone was not administered. Administrations occurred most frequently on Friday and Saturday evenings. Almost half (46%) of all naloxone administrations by paramedics were recorded as being in a home or residence; 18% were recorded as occurring on a street or highway. The proportion of naloxone administrations among males has increased yearly. In 2010, 58% of naloxone administrations were in males compared to 69% in 2016. Conclusion: The number of overdose deaths in BC has risen drastically in recent years and the proportion of ambulance calls requiring administration of naloxone by BCAS has climbed correspondingly. The vast majority of overdose cases-especially those requiring naloxone-are transported to the emergency department. With the overdose crisis showing little sign of abating, the administration of naloxone by BC paramedics will continue to be a critical element of the provincial response.

Background The Youth Injection Prevention (YIP) project aimed to identify factors associated with the prevention of transitioning to injection drug use (IDU) among street-involved youth (youth who had spent at least 3 consecutive nights without a fixed address or without their parents/caregivers in the previous six months) aged 16–24 years in Metro Vancouver, British Columbia. Methods Ten focus groups were conducted by youth collaborators (peer-researchers) with street-involved youth (n = 47) from November 2009-April 2010. Audio recordings and focus group observational notes were transcribed verbatim and emergent themes identified by open coding and categorizing. Results Through ongoing data analysis we identified that youth produced risk and deficiency rather than resiliency-based answers. This enabled the questioning guide to be reframed into a strengths-based guide in a timely manner. Factors youth identified that prevented them from IDU initiation were grouped into three domains loosely derived from the risk environment framework: Individual (fear and self-worth), Social Environment (stigma and group norms – including street-entrenched adults who actively discouraged youth from IDU, support/inclusion, family/friend drug use and responsibilities), and Physical/Economic Environment (safe/engaging spaces). Engaging youth collaborators in the research ensured relevance and validity of the study. Conclusion Participants emphasized having personal goals and ties to social networks, supportive family and role models, and the need for safe and stable housing as key to resiliency. Gaining the perspectives of street-involved youth on factors that prevent IDU provides a complementary perspective to risk-based studies and encourages strength-based approaches for coaching and care of at-risk youth and upon which prevention programs should be built.

BACKGROUND: Perinatal transmission of hepatitis B virus (HBV) can occur despite postexposure prophylaxis (PEP). Recent literature suggests that antiviral treatment during pregnancy when maternal HBV DNA levels are elevated can further decrease vertical transmission. However, HBV DNA screening is not routinely performed antenatally.OBJECTIVE: To determine the rates of HBV prevalence and perinatal transmission in an antenatal cohort.METHODS: A retrospective review of public health records (December 2008 to December 2010) was performed for both mothers and newborns.RESULTS: A total of 725 mother-infant pairs were included. Of these, 574 of 715 (80%) women had antenatal hepatitis B e antigen (HBeAg) testing performed, and 127 of 574 (22%) were HBeAg positive (HBeAg+). Of babies born to hepatitis B surface antigen-positive (HBsAg+) mothers, only 573 of 725 (79%) received complete PEP. In addition, 172 of 725 (24%) infants did not receive post-PEP blood testing or were lost to follow-up. Of the 552 infants with results available, seven cases (1.3%) of mother-to-child HBV transmission were observed, six of which involved infants born to HBeAg+ women.CONCLUSIONS: Our findings suggest that routine HBeAg screening could identify a subset of mother-infant pairs among HBsAg+ pregnant women who are at higher risk for vertical HBV transmission. Determination of viral load in expectant HBeAg+ mothers may provide more precise insight into HBV transmission to their infants.

Objectives:(1) Investigate the ability of a sinus-specific health-related quality of life questionnaire (HRQoL) to distinguish clinically significant chronic rhinosinusitis (CRS) among adults with cystic fibrosis (CF). (2) Determine an appropriate cutoff score on the Sinonasal Outcomes Test-22 (SNOT-22) with sufficient test sensitivity and specificity, to assist caregivers in identifying adults with CF who may warrant specialist referral and treatment.Methods:Participants were enrolled at an adult-specific CF clinic in a tertiary academic hospital in Vancouver, Canada. Subjects completed the SNOT-22 followed by endoscopic assessment by otolaryngologists. The Canadian Clinical Practice Guidelines for Chronic Rhinosinusitis were used to confirm diagnosis of CRS.Results:To date, 52 of 80 individuals with a confirmed diagnosis of CF have participated in this study. Thirty-nine (75.0%) individuals were identified with CRS, 12 (30.8%) of whom presented with nasal polyposis. Aggregate SNOT-22 scores were signifi...

This article uses a Positive Youth Development framework to explore the experiences of six experiential youth coresearchers (YCs) in the Youth Injection Prevention (YIP) participatory research project, and the parallel track process of empowerment and capacity building that developed. The YIP project was conducted in Metro Vancouver at the BC Centre for Disease Control and community organizations serving street-involved youth. A process evaluation was conducted to explore themes in the YCs experience in the project, as well as process strengths and challenges. Semistructured interviews with the YCs, researcher field notes, and team meeting and debrief session minutes were analyzed. The YIP project appears to have exerted a positive influence on the YCs. Positive self-identities, sense of purpose, reconceptualization of intellectual ability, new knowledge and skills, supportive relationships, finding a voice, and social and self-awareness were among the positive impacts. Process strengths included team-building activities, team check-in and checkout sessions, and professional networking opportunities. Process challenges included the time required to help YCs overcome personal barriers to participation. The YIP project demonstrates that participatory research with street-involved youth is a viable research option that contributes to positive youth development and empowerment.

The antibody response to a single influenza vaccination and the effect of influenza revaccination was assessed in healthy elderly persons. Travelers > or =65 years old who had received influenza vaccine before travel were enrolled in the study and were offered a second vaccination after 12 weeks. Geographic and age-matched control subjects received a single vaccination. A second influenza vaccination was not associated with increased adverse effects. There was no significant difference between log(10) hemagglutinin-inhibiting (HI) antibody titers or an HI antibody titer > or =1:40 (considered to be protective) in 28 control subjects and 28 revaccinated travelers for any antigen. Probable protection for influenza A antigens remained high 24 weeks after a single immunization and revaccination (A/Sydney/05/97 [H3N2], 92% and 96%, and A/Beijing/262/95 [H1N1], 80% and 96%, respectively). Response to B/Harbin was less throughout the study. A/Sydney antibody titer was lower with more times vaccinated in the previous 5 years. Therefore, a second vaccine did not enhance the immune response.

BACKGROUND:Amantadine, an antiviral agent, is the only drug currently approved in Canada for prophylaxis of influenza A virus infection. To minimize side effects, the amantadine dose is adjusted for age and estimated creatinine clearance (CrCl) based on plasma creatinine (Cr) levels. As amantadine is used more frequently for influenza A outbreak control in care facilities for elderly people, physicians are increasingly called on to prescribe it for residents and to consider the necessity of requesting plasma Cr levels.OBJECTIVE:To determine whether previous Cr levels are predictive in estimating current CrCl and safe amantadine dose determination.DESIGN AND SETTING:Residents' charts were reviewed in two facilities in Vancouver, British Columbia. CrCl estimated using previous or current Cr results, current weight and age, as well as recommended amantadine doses based on Canadian National Advisory Committee on Immunization guidelines, were studied.RESULTS:165 charts with Cr results in March 1998 were included; 122 had results before March 1998, and 103 had Cr results after March 1998. Pearson's correlation coefficient for CrCl estimated from current and previous Cr values was 0.929 for results less than six months previously, 0.974 for six to 12 months previously and 0.952 for 12 to 18 months previously. The same or a more conservative dose of amantadine was predicted in 92% of cases when using a Cr result taken within the previous year and in 76% of cases when using a Cr result taken 12 to 18 months previously.CONCLUSION:In long term care facilities, Cr levels measured up to 12 months previously can usually safely be used to estimate CrCl. Using previous Cr results permits advance preparation of doctor's orders for amantadine prophylaxis and avoids repeating Cr testing on every resident when an outbreak occurs, reducing related staff time and cost.

Methamphetamine, a central nervous system stimulant, was first synthesized in 1919 as a synthetic substitute for ephedrine. Occult methamphetamine laboratories emerged in California in the 1960s, and its recreational use spread up and down the Pacific Coast. In the 1980s, d-methamphetamine

BACKGROUND Although prostate cancer is the most common life-threatening cancer among males in North America, relatively little is known about its etiology. We have conducted a proportional mortality study to generate hypotheses concerning occupational risk factors for the disease. METHODS Age standardized proportional mortality ratios (PMR) for prostate cancer were calculated for a total of 216 occupations and 88 industries. Separate calculations were done for all male deaths age 20 and up and for deaths that occurred during men's working lifetime (age 20-65). RESULTS Elevated mortality from prostate cancer was seen among business owners and managers (PMR = 110; 95% CI = 101-118), brokers (PMR = 184; 95% CI = 122-266), farmers and farm managers (PMR = 112; 95% CI = 105-120), and school teachers (PMR = 133; 95% CI = 101-174). Evaluation by industry shows elevated prostate cancer mortality in agriculture (PMR = 110; 95% CI = 103-118), financial institutions (PMR = 138, 95% CI = 112-170), and transportation equipment manufacture (PMR = 136; 95% CI = 109-168). CONCLUSIONS The findings suggest that workers in a number of occupations have elevated risks of prostate cancer including farmers and teachers. More detailed cohort and case-control studies, evaluating specific exposures are required before primary prevention programs in the workplace are feasible.

To report the findings of a knowledge survey of nurse and physician immunization providers.Cross-sectional postal survey assessing demographic characteristics and vaccine knowledge.British Columbia (BC).Nurse and physician immunization providers in BC.Knowledge of vaccine-preventable diseases, vaccines in general, and vaccine administration and handling practices.Survey responses were received from 256 nurses and 292 physicians (response rates of 48.6% and 18.3%, respectively). Most nurses (98.4%) reported receiving immunization training outside of the academic setting compared with 55.6% of physicians. Overall, nurse immunizers scored significantly higher than physician immunizers on all 3 domains of immunization knowledge (83.7% vs 72.8%, respectively; P.001). Physicians scored highest on the vaccine-preventable disease domain and least well on the general vaccine domain. Nurses with more experience as health care providers scored higher. Physicians scored higher if they were female, served patient populations predominantly younger than 5 years, or received immunization training outside of academic settings.In BC, nurse immunizers appear to have higher overall immunization knowledge than physicians and are more likely to receive immunization training when in practice. Physician immunizers might benefit most from further training on vaccines and vaccine administration and handling.

Objectives. We investigated whether periodic increases in minimum alcohol prices were associated with reduced alcohol-attributable hospital admissions in British Columbia. Methods. The longitudinal panel study (2002–2009) incorporated minimum alcohol prices, density of alcohol outlets, and age- and gender-standardized rates of acute, chronic, and 100% alcohol-attributable admissions. We applied mixed-method regression models to data from 89 geographic areas of British Columbia across 32 time periods, adjusting for spatial and temporal autocorrelation, moving average effects, season, and a range of economic and social variables. Results. A 10% increase in the average minimum price of all alcoholic beverages was associated with an 8.95% decrease in acute alcohol-attributable admissions and a 9.22% reduction in chronic alcohol-attributable admissions 2 years later. A Can$ 0.10 increase in average minimum price would prevent 166 acute admissions in the 1st year and 275 chronic admissions 2 years later. We also estimated significant, though smaller, adverse impacts of increased private liquor store density on hospital admission rates for all types of alcohol-attributable admissions. Conclusions. Significant health benefits were observed when minimum alcohol prices in British Columbia were increased. By contrast, adverse health outcomes were associated with an expansion of private liquor stores.

Social responsibility and accountability can be important core values in medical education. At the University of British Columbia, undergraduate medical students engage in prison health community service-learning opportunities in regional correctional facilities.To describe the impact of prison health exposure on pre-clinical medical students, in-depth individual interviews were conducted with individuals who had participated in a prison health medical education program. All interviews were transcribed verbatim, and interpretive descriptive methods were used to inductively derive thematic findings to describe students' experiences.Major themes emerged as students reported how (1) exposure to incarcerated populations increases students' insight into issues that diverse marginalized sub-populations encounter; (2) positive interactions with the incarcerated individuals enhances relationship building; (3) collaboration reinforces teamwork skills and (4) community placements garner important learning opportunities within the medical school curriculum.Our findings demonstrated that pre-clinical exposure to incarcerated individuals and prison health education provided a unique setting for medical students to develop an increased sense of social responsibility and accountability.

While intensive drug law enforcement is recognized as a social-structural driver of HIV epidemics among people who inject drugs (IDU), few studies have investigated the effects of direct encounters with police, particularly in Asian settings. Using multivariate log-binomial regression, we examined the relationship between syringe sharing and exposures to two types of policing practices among IDU in Bangkok, Thailand: having been beaten by police and having been tested for illicit drugs by police. Between July and October 2011, 435 IDU participated in the study, with 75 (17.2 %) participants reporting syringe sharing in the past 6 months. In multivariate analyses, exposures to the two types of policing practices had an independent effect on syringe sharing, with experiencing both practices showing the greatest effect. These findings highlight the importance of addressing the policy and social environment surrounding IDU as a means of HIV prevention.

Background Thailand has relied on drug law enforcement in an effort to curb illicit drug use. While anecdotal reports suggest that Thai police frequently use urine toxicology to identify drug users, little is known about the prevalence or impacts of this practice among people who inject drugs (IDU). Therefore, we sought to examine experiences with urine drug testing by police among IDU in Bangkok. Methods Data were derived from a community-recruited sample of IDU in Bangkok participating in the Mitsampan Community Research Project between July and October 2011. We assessed the prevalence and correlates of being subjected to urine toxicology testing by police using multivariate Poisson regression. Results In total, 438 IDU participated in this study, with 293 (66.9%) participants reporting having been tested for illicit drugs by police. In multivariate analyses, reports of drug testing by police were independently and positively associated with younger age (adjusted prevalence ratio [APR]: 1.28), a history of methamphetamine injection (APR: 1.22), a history of incarceration (APR: 1.21), having been in compulsory drug detention (APR: 1.43), avoiding healthcare (APR: 1.15), and HIV seropositivity (APR: 1.19), and negatively associated with access to voluntary drug treatment (APR: 0.82) (all p Conclusion A high proportion of IDU in Bangkok were subjected to drug testing by police. Young people and methamphetamine injectors were more likely to have been tested. The findings indicate that drug testing by police is associated with the compulsory drug detention system and may be interfering with IDU's access to healthcare and voluntary drug treatment. These findings raise concern about the widespread practice of drug testing by police and its associated impacts.

Background Injection drug use has been identified as a key source of morbidity and mortality, primarily from overdose and the transmission of blood-borne diseases such as HIV. Experts have therefore called for the prioritization of resources toward the prevention of injection drug use. However, these strategies have not been systematically assessed. Methods PRISMA guidelines were used to systematically review and extract findings from the peer-reviewed literature evaluating the effectiveness of interventions to prevent injecting initiation. We searched 10 English language electronic databases (PubMed, PsycINFO, EMBASE, Cochrane CENTRAL, CINAHL, Web of Science, TOXNET, AIDSLINE, AMED and ERIC), the Internet (Google, Google Scholar), and article reference lists, from database inception to June 1st, 2012. Results Overall, out of 384 studies identified in the initial search, eight met the inclusion criteria. Studies evaluated four different types of interventions: social marketing, peer-based behavior modification, treatment, and drug law enforcement. Four studies observed a significant effect of the intervention on reducing rates of injecting initiation. Peer-based behavior modification and addiction treatment interventions were found to be most effective. Two of three studies assessing the impact of drug law enforcement on patterns of injecting initiation found no impact on injecting initiation, while one study reported inconclusive results. Conclusion There exists a limited scientific literature on strategies to prevent injecting initiation. Resources should be allocated toward increased research and development of effective interventions to prevent this phenomenon.

Background Despite its increasing prevalence and acceptance among the general public, cannabis use continues to be viewed as an aberrant activity in many contexts. However, little is known about how stigma associated with cannabis use affects individuals who use cannabis for therapeutic purposes (CTP) and what strategies these individuals employ to manage associated stigma. The aim of this Canadian study was to describe users’ perceptions of and responses to the stigma attached to using CTP. Methods Twenty-three individuals who were using CTP for a range of health problems took part in semi-structured interviews. Transcribed data were analyzed using an inductive approach and comparative strategies to explore participants’ perceptions of CTP and identify themes. Results Participant experiences of stigma were related to negative views of cannabis as a recreational drug, the current criminal sanctions associated with cannabis use, and using cannabis in the context of stigmatizing vulnerability (related to existing illness and disability). Strategies for managing the resulting stigma of using CTP included: keeping CTP ‘undercover’; educating those who did not approve of or understand CTP use; and using cannabis responsibly. Conclusions Understanding how individuals perceive and respond to stigma can inform the development of strategies aimed at reducing stigma associated with the use of CTP and thereby address barriers faced by those using this medicine.

People who smoke crack cocaine are described as chaotic and more likely to engage in risky sex, polysubstance use and contract infectious diseases. However, little is known about how individuals perceive smoking crack as compared to other forms of cocaine use, especially injection. We explored the lived experience of people who smoke crack cocaine. Six gender-specific focus groups (n=31) of individuals who currently smoke crack in Vancouver, Canada, were conducted using a semi-structured interview guide. Focus groups were transcribed and analyzed by constant comparative methodology. We applied Rhodes’ risk environment to the phenomenological understanding that individuals have regarding how crack has affected their lives. Subjects reported that smoking rather than injecting cocaine allows them to begin “controlling chaos” in their lives. Controlling chaos was self-defined using nontraditional measures such as the ability to maintain day-to-day commitments and housing stability. The phenomenological lens of smoking crack instead of injecting cocaine “to control chaos” contributes a novel perspective to our understanding of the crack-smoking population. This study examines narratives which add to prior reports of the association of crack smoking and increased chaos and suggests that, for some, inhaled crack may represent efforts towards self-directed harm reduction.

Objectives This study sought to identify factors that may be associated with help-seeking by witnesses during overdoses where naloxone is administered. Setting Overdose events occurred in and were reported from the five regional health authorities across British Columbia, Canada. Naloxone administration forms completed following overdose events were submitted to the British Columbia Take Home Naloxone programme. Participants All 182 reported naloxone administration events, reported by adult men and women and occurring between 31 August 2012 and 31 March 2015, were considered for inclusion in the analysis. Of these, 18 were excluded: 10 events which were reported by the person who overdosed, and 8 events for which completed forms did not indicate whether or not emergency medical help was sought. Primary and secondary outcome measures Seeking emergency medical help (calling 911), as reported by participants, was the sole outcome measure of this analysis. Results Medical help was sought (emergency services—911 called) in 89 (54.3%) of 164 overdoses where naloxone was administered. The majority of administration events occurred in private residences (50.6%) and on the street (23.4%), where reported rates of calling 911 were 27.5% and 81.1%, respectively. Overdoses occurring on the street (compared to private residence) were significantly associated with higher odds of calling 911 in multivariate analysis (OR=10.68; 95% CI 2.83 to 51.87; p

Background Needle and syringe programmes (NSPs) have been shown to reduce HIV risk among people who inject drugs (IDUs). However, concerns remain that NSPs delay injecting cessation. Methods Individuals reporting injection drug use in the past six months in the greater Vancouver area were enrolled in the Vancouver Injection Drug Users Study (VIDUS). Annual estimates of the proportion of IDU reporting injecting cessation were generated. Generalized estimating equation (GEE) analysis was used to assess factors associated with injecting cessation during a period of NSP expansion. Results Between May 1996 and December 2010, the number of NSP sites in Vancouver increased from 1 to 29 (P

Background: Public health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool. Methods/Design: A brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson’s correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument. Discussion: This research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.

Background Hepatitis C virus (HCV) infection is a major preventable and treatable cause of morbidity and mortality. The ability to link population based centralized laboratory HCV testing data with administrative databases provided a unique opportunity to compare mortality between HCV seronegative and seropositive individuals. Through the use of laboratory testing patterns and results, the objective of this study was to differentiate the viral effects of mortality due to HCV infection from risk behaviours/activities that are associated with acquisition of HCV infection. Methods Serological testing data from the British Columbia (BC) Centre for Disease Control Public Health Microbiology and Reference Laboratory from 1992–2004 were linked to the BC Vital Statistics Agency death registry. Four groups of HCV testers were defined by their HCV antibody (anti-HCV) testing patterns: single non-reactive (SNR); serial multiple tested non-reactive (MNR); reactive at initial testing (REAC); and seroconverter (SERO) (previously seronegative followed by reactive, a marker for incident infection). Standardized mortality ratios (SMRs) were calculated to compare the relative risk of all cause and disease specific mortality to that of the BC population for each serological group. Time dependent Cox proportional hazard regression was used to compare hazard ratios (HRs) among HCV serological groups. Results All anti-HCV testers had higher SMRs than the BC population. Referent to the SNR group, the REAC group had higher risks for liver (HR: 9.62; 95% CI=8.55-10.87) and drug related mortality (HR: 13.70; 95% CI=11.76-16.13). Compared to the REAC group, the SERO group had a lower risk for liver (HR: 0.53; 95% CI=0.24-0.99), but a higher risk for drug related mortality (HR: 1.54; 95% CI=1.12-2.05). Conclusions These findings confirm that individuals who test anti-HCV positive have increased mortality related to progressive liver disease, and that a substantial proportion of the mortality is attributable to drug use and risk behaviours/activities associated with HCV acquisition. Mortality reduction in HCV infected individuals will require comprehensive prevention programming to reduce the harms due to behaviours/activities which relate to HCV acquisition, as well as HCV treatment to prevent progression of chronic liver disease.

There are no national guidelines specific for handling prion-associated specimens in Canadian medical laboratories. Medical laboratory workers may perceive themselves at risk of prion transmission and, on occasion, decline to process such specimens.To examine the knowledge, attitudes and reported behaviours of medical laboratory workers in relation to prion disease to understand their risk perception and the need for national laboratory guidelines on prion infection control.Survey development and cross-sectional web-based administration.The survey was developed through key informant interviews and a modified Delphi process. Medical laboratory workers across Canada were invited by laboratory managers and national organizations to complete the web-based survey.Twelve key informant interviews were performed. Consensus for questionnaire content was reached through two rounds of the Delphi process. Responses were received from 426 Canadian medical laboratory workers; 37% of medical laboratory staff reported processing prion-associated specimens. Different protocols for specimen processing were followed, and 18% believed they were at risk when processing these specimens. Less than one-third of those receiving specimens believed they were adequately trained. The mean (±SD) knowledge score was 9.25±4.5/24; individuals who had received training scored significantly higher than those who were untrained (P0.01). Eighty-one per cent of respondents would be more comfortable processing specimens if national guidelines existed and were used in their laboratory.There is a high perception of risk and few perceived benefits of processing prion-associated specimens. National guidelines for prion infection control in medical laboratories and adequate training would enable medical laboratory workers to process these specimens efficiently and confidently.Il n’existe pas de lignes directrices nationales propres à la manipulation d’échantillons associés aux infections à prion dans les laboratoires médicaux canadiens. Les travailleurs de ces laboratoires peuvent se percevoir comme vulnérables à la transmission d’une infection à prion et parfois refuser de traiter ces échantillons.Examiner les connaissances, les attitudes et les comportements déclarés des travailleurs de laboratoire pour comprendre leur perception du risque et la nécessité de préparer des lignes directrices nationales de laboratoire sur le contrôle des infections à prion.Élaboration de l’administration transversale d’un sondage par voie électronique.Les chercheurs ont préparé le sondage par suite d’entrevues avec des informateurs clés et d’une méthode Delphi modifiée. Des directeurs de laboratoire et des organisations nationales ont invité les travailleurs de laboratoire du Canada à répondre au sondage par voie électronique.Les chercheurs ont effectué 12 entrevues auprès d’informateurs clés. Ils sont parvenus à un consensus quant au contenu du questionnaire après deux rondes de la méthode Delphi. Ils ont reçu la réponse de 426 travailleurs de laboratoire canadiens, dont 37 % déclaraient traiter des échantillons liés à des infections à prion. Divers protocoles de traitement des échantillons étaient respectés, et 18 % des travailleurs se sentaient vulnérables dans le cadre de ce traitement. Moins du tiers des travailleurs qui recevaient ces échantillons se sentaient bien formés pour le faire. L’indice de connaissance moyen s’élevait à 9,25/24 (ÉT±4,5). Les personnes qui avaient reçu une formation obtenaient un indice considérablement plus élevé que celles qui n’en avaient pas reçu (P0,01). Quatre-vingt-un pour cent des répondants seraient plus à l’aise de traiter les échantillons s’il existait des lignes directrices nationales mises en œuvre dans leur laboratoire.La perception du risque est élevée et celle des avantages du traitement des échantillons liés à des infections à prion est faible. Des lignes directrices nationales sur le contrôle des infections à prion dans les laboratoires médicaux et une formation convenable permettraient aux travailleurs de laboratoire de traiter ces échantillons avec efficacité et en toute confiance.

Background Crack pipe sharing can increase health risks among people who use drugs, yet the reasons for sharing these pipes have not been well described. Therefore, we sought to identify the prevalence and correlates of crack pipe sharing among a community-recruited sample of people who use illicit drugs in Vancouver, a setting where crack pipes are provided at low or no cost. Findings Data for this study were derived from two prospective cohorts of people who use drugs: the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS). Multivariate logistic regression was used to identify factors independently associated with crack pipe sharing. Among 503 crack users, 238 (47.3%) participants reported having shared a crack pipe in the previous six months. Having acquired a mouthpiece in the last six months (adjusted odds ratio [AOR] = 1.91; 95% confidence interval [CI]: 1.31 - 2.79) and difficulty finding new pipes (AOR = 2.19; 95%CI: 1.42 - 3.37) were positively associated with pipe sharing. Binge drug use (AOR = 1.39; 95%CI: 0.96 - 2.02) was marginally associated with sharing pipes. Discussion There was a high prevalence of crack pipe sharing in a setting where crack pipes are distributed at low or no cost. Difficulty accessing crack pipes was independently and positively associated with this behavior. These findings suggest that additional efforts are needed to discourage crack pipe sharing as well as increase access to crack pipes.