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COVID-19 and antimicrobial resistance (AMR) are two intersecting global public health crises.We aim to describe the impact of the COVID-19 pandemic on AMR across healthcare settings.A search was conducted in December 2021 in World Health Organization's COVID-19 Research Database with forward citation searching up to June 2022.Studies evaluating the impact of COVID-19 on AMR in any population were included and influencing factors were extracted. Reporting of enhanced infection prevention and control (IPAC) and/or antimicrobial stewardship programs (ASPs) were noted.Pooling was done separately for Gram-negative and Gram-positive organisms. Random effects meta-analysis was performed.Of 6036 studies screened, 28 were included and 23 provided sufficient data for meta-analysis. The majority of studies focused on hospital settings (n=25, 89%). The COVID-19 pandemic was not associated with a change in the incidence density (IRR 0.99, 95% CI: 0.67 to 1.47) or proportion (RR 0.91, 95% CI: 0.55 to 1.49) of MRSA or VRE cases. A non-statistically significant increase was noted for resistant Gram-negatives (i.e., ESBL, CRE, MDR or carbapenem-resistant Pseudomonas aeruginosa or Acinetobacter baumannii, IRR 1.64, 95% CI: 0.92 to 2.92; RR 1.08, 95% CI: 0.91 to 1.29). The absence of reported enhanced IPAC and/or ASP initiatives was associated with an increase in Gram-negative AMR (RR 1.11, 95%CI: 1.03 to 1.20). However, a test for subgroup differences showed no statistically significant difference between the presence and absence of these initiatives (P=0.40).The COVID-19 pandemic could have hastened the emergence and transmission of AMR, particularly for Gram-negative organisms in hospital settings. But there is considerable heterogeneity in both the AMR metrics utilized and the rate of resistance reported across studies. These findings reinforce the need for strengthened infection prevention, antimicrobial stewardship, and AMR surveillance in the context of the COVID-19 pandemic.CRD42022325831.

Background Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Methods We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction–confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses. Results We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4–1) and 0.3 (0.3–0.4), respectively. Conclusions Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19–vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.

BackgroundMobile phone-derived human mobility data are a proxy for disease transmission risk and have proven useful during the COVID-19 pandemic for forecasting cases and evaluating interventions. We propose a novel metric using mobility data to characterize responsiveness to rising case rates.MethodsWe examined weekly reported COVID-19 incidence and retail and recreation mobility from Google Community Mobility Reports for 50 U.S. states and nine Canadian provinces from December 2020 to November 2021. For each jurisdiction, we calculated the responsiveness of mobility to COVID-19 incidence when cases were rising. Responsiveness across countries was summarized using subgroup meta-analysis. We also calculated the correlation between the responsiveness metric and the reported COVID-19 death rate during the study period.FindingsResponsiveness in Canadian provinces (β= -1·45; 95% CI: -2·45, -0·44) was approximately five times greater than in U.S. states (β= -0·30; 95% CI: -0·38, -0·21). Greater responsiveness was moderately correlated with a lower reported COVID-19 death rate during the study period (Spearman’sρ= 0·51), whereas average mobility was only weakly correlated the COVID-19 death rate (Spearman’sρ= 0·20).InterpretationOur study used a novel mobility-derived metric to reveal a near-universal phenomenon of reductions in mobility subsequent to rising COVID-19 incidence across 59 states and provinces of the U.S. and Canada, while also highlighting the different public health approaches taken by the two countries.FundingThis study received no funding.Research in contextEvidence before the studyThere exists a wide body of literature establishing the usefulness of mobile phone-derived human mobility data for forecasting cases and other metrics during the COVID-19 pandemic. We performed a literature search to identify studies examining the opposite relationship, attempting to quantify the responsiveness of human mobility to changes in COVID-19 incidence. We searched PubMed on October 21, 2022 using the keywords “COVID-19”, “2019-nCoV”, or “SARS-CoV-2” in combination with “responsiveness” and one or more of “mobility”, “distancing”, “lockdown”, and “non-pharmaceutical interventions”. We scanned 46 published studies and found one that used a mobile phone data-derived index to measure the intensity of social distancing in U.S. counties from January 2020 to January 2021. The authors of this study found that an increase in cases in the last 7 days was associated with an increase in the intensity of social distancing, and that this effect was larger during periods of lockdown/shop closures.Added value of the studyOur study developed a metric of the responsiveness of mobility to rising case rates for COVID-19 and calculated it for 59 subnational jurisdictions in the United States and Canada. While nearly all jurisdictions displayed some degree of responsiveness, average responsiveness in Canada was nearly five times greater than in the United States. Responsiveness was moderately associated with the reported COVID-19 death rate during the study period, such that jurisdictions with greater responsiveness had lower death rates, and was more strongly associated with death rates than average mobility in a jurisdiction.Implications of all the available evidenceMobile phone-derived human mobility data has proven useful in the context of infectious disease surveillance during the COVID-19 pandemic, such as for forecasting cases and evaluating non-pharmaceutical interventions. In our study, we derived a metric of responsiveness to show that mobility data may be used to track the efficiency of public health responses as the pandemic evolves. This responsiveness metric was also correlated with reported COVID-19 death rates during the study period. Together, these results demonstrate the usefulness of mobility data for making broad characterizations of public health responses across jurisdictions during the COVID-19 pandemic and reinforce the value of mobility data as an infectious disease surveillance tool for answering present and future threats.

The COVID-19 pandemic has demonstrated the need for real-time, open-access epidemiological information to inform public health decision-making and outbreak control efforts. In Canada, authority for healthcare delivery primarily lies at the provincial and territorial level; however, at the outset of the pandemic no definitive pan-Canadian COVID-19 datasets were available. The COVID-19 Canada Open Data Working Group was created to fill this crucial data gap. As a team of volunteer contributors, we collect daily COVID-19 data from a variety of governmental and non-governmental sources and curate a line-list of cases and mortality for all provinces and territories of Canada, including information on location, age, sex, travel history, and exposure, where available. We also curate time series of COVID-19 recoveries, testing, and vaccine doses administered and distributed. Data are recorded systematically at a fine sub-national scale, which can be used to support robust understanding of COVID-19 hotspots. We continue to maintain this dataset, and an accompanying online dashboard, to provide a reliable pan-Canadian COVID-19 resource to researchers, journalists, and the general public., Measurement(s) COVID-19 Cases • COVID-19 Mortalities • COVID-19 vaccination Technology Type(s) digital curation Sample Characteristic - Organism Homo sapiens Sample Characteristic - Location Canada Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.14331311

RESUME CONTEXTE: Les interventions non pharmacologiques demeurent le principal moyen de maitriser le coronavirus du syndrome respiratoire aigu severe 2 (SRAS-CoV-2) d’ici a ce que la couverture vaccinale soit suffisante pour donner lieu a une immunite collective. Nous avons utilise des donnees de mobilite anonymisees de telephones intelligents afin de quantifier le niveau de mobilite requis pour maitriser le SRAS-CoV-2 (c.-a-d., seuil de mobilite), et la difference par rapport au niveau de mobilite observe (c.-a-d., ecart de mobilite). METHODES: Nous avons procede a une analyse de series chronologiques sur l’incidence hebdomadaire du SRAS-CoV-2 au Canada entre le 15 mars 2020 et le 6 mars 2021. Le parametre mesure etait le taux de croissance hebdomadaire, defini comme le rapport entre les cas d’une semaine donnee et ceux de la semaine precedente. Nous avons mesure les effets du temps moyen passe hors domicile au cours des 3 semaines precedentes a l’aide d’un modele de regression log-normal, en tenant compte de la province, de la semaine et de la temperature moyenne. Nous avons calcule le seuil de mobilite et l’ecart de mobilite pour le SRAS-CoV-2. RESULTATS: Au cours des 51 semaines de l’etude, en tout, 888 751 personnes ont contracte le SRAS-CoV-2. Chaque augmentation de 10 % de l’ecart de mobilite a ete associee a une augmentation de 25 % du taux de croissance des cas hebdomadaires de SRAS-CoV-2 (rapport 1,25, intervalle de confiance a 95 % 1,20–1,29). Comparativement a la mobilite prepandemique de reference de 100 %, le seuil de mobilite a ete plus eleve au cours de l’ete (69 %, ecart interquartile [EI] 67 %–70 %), et a chute a 54 % pendant l’hiver 2021 (EI 52 %–55 %); un ecart de mobilite a ete observe au Canada entre juillet 2020 et la derniere semaine de decembre 2020. INTERPRETATION: La mobilite permet de predire avec fiabilite et constance la croissance des cas hebdomadaires et il faut maintenir des niveaux faibles de mobilite pour maitriser le SRAS-CoV-2 jusqu’a la fin du printemps 2021. Les donnees de mobilite anonymisees des telephones intelligents peuvent servir a guider le relâchement ou le resserrement des mesures de distanciation physique provinciales et regionales.

BACKGROUND: Nonpharmaceutical interventions remain the primary means of controlling severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) until vaccination coverage is sufficient to achieve herd immunity. We used anonymized smartphone mobility measures to quantify the mobility level needed to control SARS-CoV-2 (i.e., mobility threshold), and the difference relative to the observed mobility level (i.e., mobility gap). METHODS: We conducted a time-series study of the weekly incidence of SARS-CoV-2 in Canada from Mar. 15, 2020, to Mar. 6, 2021. The outcome was weekly growth rate, defined as the ratio of cases in a given week versus the previous week. We evaluated the effects of average time spent outside the home in the previous 3 weeks using a log-normal regression model, accounting for province, week and mean temperature. We calculated the SARS-CoV-2 mobility threshold and gap. RESULTS: Across the 51-week study period, a total of 888 751 people were infected with SARS-CoV-2. Each 10% increase in the mobility gap was associated with a 25% increase in the SARS-CoV-2 weekly case growth rate (ratio 1.25, 95% confidence interval 1.20–1.29). Compared to the prepandemic baseline mobility of 100%, the mobility threshold was highest in the summer (69%; interquartile range [IQR] 67%–70%), and dropped to 54% in winter 2021 (IQR 52%–55%); a mobility gap was present in Canada from July 2020 until the last week of December 2020. INTERPRETATION: Mobility strongly and consistently predicts weekly case growth, and low levels of mobility are needed to control SARS-CoV-2 through spring 2021. Mobility measures from anonymized smartphone data can be used to guide provincial and regional loosening and tightening of physical distancing measures.

Background The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance. Objective The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19. Data Sources We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020. Study Eligibility Criteria We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing. Participants The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult). Methods The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis. Results We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies. Conclusions Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Background Bacterial co-pathogens are commonly identified in viral respiratory infections and are important causes of morbidity and mortality. The prevalence of bacterial infection in patients infected with SARS-CoV-2 is not well understood. Aims To determine the prevalence of bacterial co-infection (at presentation) and secondary infection (after presentation) in patients with COVID-19. Sources We performed a systematic search of MEDLINE, OVID Epub and EMBASE databases for English language literature from 2019 to April 16, 2020. Studies were included if they (a) evaluated patients with confirmed COVID-19 and (b) reported the prevalence of acute bacterial infection. Content Data were extracted by a single reviewer and cross-checked by a second reviewer. The main outcome was the proportion of COVID-19 patients with an acute bacterial infection. Any bacteria detected from non-respiratory-tract or non-bloodstream sources were excluded. Of 1308 studies screened, 24 were eligible and included in the rapid review representing 3338 patients with COVID-19 evaluated for acute bacterial infection. In the meta-analysis, bacterial co-infection (estimated on presentation) was identified in 3.5% of patients (95%CI 0.4–6.7%) and secondary bacterial infection in 14.3% of patients (95%CI 9.6–18.9%). The overall proportion of COVID-19 patients with bacterial infection was 6.9% (95%CI 4.3–9.5%). Bacterial infection was more common in critically ill patients (8.1%, 95%CI 2.3–13.8%). The majority of patients with COVID-19 received antibiotics (71.9%, 95%CI 56.1 to 87.7%). Implications Bacterial co-infection is relatively infrequent in hospitalized patients with COVID-19. The majority of these patients may not require empirical antibacterial treatment., Graphical abstract Image 1

Objective To identify risk factors and microbiology associated with respiratory and bloodstream bacterial infection in patients with COVID-19. Methods Data Sources: We searched MEDLINE, OVID Epub and EMBASE for published literature up to February 5, 2021. Study eligibility criteria: Studies including at least 50 patients with COVID-19 in any healthcare setting. Assessment of risk of Bias: We used a validated 10-item risk of bias tool for disease prevalence Methods of data synthesis: The main outcome of interest was the proportion of COVID-19 patients with bloodstream and/or respiratory bacterial co-infection and secondary infection. We performed meta-regression to identify study population factors associated with bacterial infection including healthcare setting, age, comorbidities and COVID-19 medication. Results Out of 33,345 studies screened, 171 were included in the final analysis. Bacterial infection data were available from 171,262 patients. The prevalence of co-infection was 5.1% (95% CI: 3.6% to 7.1%) and secondary infection was 13.1% (95% CI: 9.8% to 17.2%). There was a higher odds of bacterial infection in studies with a higher proportion of patients in the intensive care unit (ICU) (adjusted OR 18.8, 95% CI: 6.5 to 54.8). Female sex was associated with a lower odds of secondary infection (adjusted OR 0.73, 95% CI: 0.55 to 0.97) but not co-infection (adjusted OR 1.05, 95% CI: 0.80 to 1.37). The most common organisms isolated included Staphylococcus aureus, coagulase-negative Staphylococci, and Klebsiella species. Conclusions While the odds of respiratory and bloodstream bacterial infection are low in patients with COVID-19, meta-regression revealed potential risk factors for infection, including ICU setting and mechanical ventilation. The risk for secondary infection is substantially greater than the risk for co-infection in patients with COVID-19. Understanding predictors of co-infection and secondary infection may help to support improved antibiotic stewardship in patients with COVID-19. Registration PROSPERO (ID CRD42021241098).

This cohort study examines whether the implementation of differentially timed restrictions in a highly interconnected metropolitan area was associated with increased interregional travel.

Urinary tract infections caused by the bacterium Escherichia coli are among the most frequently encountered infections and are a common reason for antimicrobial prescriptions. Resistance to fluoroquinolone antimicrobial agents, particularly ciprofloxacin, has increased in recent decades. It is intuitive that variation in fluoroquinolone resistance is driven by changes in antimicrobial use, but careful study of this association requires the use of time-series methods. Between April 2010 and December 2014, we studied seasonal variation in resistance to ciprofloxacin, trimethoprim-sulfamethoxazole, and ampicillin in community-acquired urinary E. coli isolates in Montreal, Quebec, Canada. Using dynamic linear models, we investigated whether seasonal variation in resistance could be explained by seasonal variation in community antimicrobial use. We found a positive association between total fluoroquinolone use lagged by 1 and 2 months and the proportion of isolates resistant to ciprofloxacin. Our results suggest that resistance to ciprofloxacin is responsive to short-term variation in antimicrobial use. Thus, antimicrobial stewardship campaigns to reduce fluoroquinolone use, particularly in the winter when use is highest, are likely to be a valuable tool in the struggle against antimicrobial resistance.

BackgroundIn the fall of 2020, the government of Ontario, Canada adopted a 5-tier, regional framework of public health measures for the COVID-19 pandemic. During the second wave of COVID-19 in Ontario, the urban core of the Greater Toronto Area (Toronto and Peel) were the first regions in the province to enter the highest restriction tier (“lockdown”) on November 23, 2020, which closed restaurants to in-person dining and limited non-essential businesses, including shopping malls, to curbside pickup. The peripheral regions of the Greater Toronto Area (York, Durham, Halton) would not enter lockdown until later the following month. In this analysis, we examine whether the implementation of differentially timed restrictions in a highly interconnected metropolitan area led to increased interregional travel, potentially driving further transmission of SARS-CoV-2.MethodsWe used anonymized smartphone data to estimate the number of visits by residents of regions in the urban core to shopping malls and restaurants in peripheral regions in the week before compared to the week after the November 23 lockdown.ResultsResidents of Toronto and Peel took fewer trips to shopping malls and restaurants in the week following lockdown. This was entirely driven by reductions in visits within the locked down regions themselves, as there was a significant increase in trips to shopping malls in peripheral regions by these residents in the same period (Toronto: +40.7%, Peel: +65.5%). Visits to restaurants in peripheral regions also increased slightly (Toronto: +6.3%, Peel: +11.8%).DiscussionHeterogeneous restrictions may undermine lockdowns in the urban core as well as driving residents from zones of higher transmission to zones of lower transmission. These concerns are likely generalizable to other major metropolitan areas, which often comprise interconnected but administratively independent regions.

BackgroundAmong non-pharmaceutical interventions, individual movement restrictions have been among the most impactful methods for controlling COVID-19 case growth. While nighttime curfews to control COVID-19 case growth have been implemented in certain regions and cities, few studies have examined their impacts on mobility or COVID-19 incidence. In the second wave of COVID-19, Canada’s two largest and adjacent provinces implemented lockdown restrictions with (Quebec) and without (Ontario) a nighttime curfew, providing a natural experiment to study the association between curfews and mobility.MethodsThis study spanned from December 1, 2020 to January 23, 2021 and included the populations of Ontario (including Toronto) and Quebec (including Montreal). The intervention of interest was a nighttime curfew implemented across Quebec on January 9, 2021. Unadjusted and adjusted difference-in-differences models (DID) were used to measure the incremental impact of the curfew on nighttime mobility in Quebec as compared to Ontario.ResultsThe implementation of the curfew was associated with an immediate reduction in nighttime mobility. The adjusted DID analysis indicated that Quebec experienced a 31% relative reduction in nighttime mobility (95%CI: -36% to -25%) compared to Ontario, and that Montreal experienced a 39% relative reduction compared to Toronto (95%CI: -43, -34).DiscussionHowever, this natural experiment among two neighbouring provinces provides useful evidence that curfews lead to an immediate and substantial decrease nighttime mobility, particularly in these provinces’ largest urban areas hardest hit by COVID-19.

IntroductionAntimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports.Methods and analysisA non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports.Ethics and disseminationAll sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.

IntroductionAntimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing.Methods and analysisApproximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention.Ethics and disseminationResearch ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.

Background: Suicide prevention is a salient public health responsibility, as it is one of the top ten leading causes of premature mortality in the United States. Risk factors of suicide transcend the individual and societal level as risk can increase based on climatic variables. Previous studies have been country-based. Currently, studies focused solely on regions, provinces, or states, such as California, are limited. The present study holds two purposes: i) to assess the effect of maximum temperature on suicides, and ii) to evaluate the effect of number of monthly heat events on suicide rates, in California from 2008-2017.Methods: The exposure was measured as the average Californian daily maximum temperature within each month, and the number of monthly heat events, which was calculated as a count of the days exhibiting a >15% increase from the historical monthly temperature. The outcome was measured as California’s monthly suicide rate. Negative binomial regression models assessed the relationship between maximum temperature and suicides, and heat events and suicide. A seasonal decomposition of a time series and auto-correlogram further analyzed the seasonality of suicide and the trend from 2008-2017. Results: There were 40,315 deaths by suicide in California between 2008-2017. Negative binomial regression indicated a 6.1% increase in suicide incidence rate ratio (IRR) per 10°F increase in maximum temperature (IRR=1.00590 per 1°F, 95% CI: 1.00387, 1.00793, pp=0.572). The time series analysis and auto-correlogram suggested seasonality of deaths by suicide.Conclusion: The present study provided preliminary evidence that will generate future directions for research. We must seek to further illuminate the relationship of interest and apply our findings to public health interventions that will lower the rates of death by suicide as we are confronted with the effects of climate change.

Background Suicide is among the top 10 leading causes of premature morality in the United States and its rates continue to increase. Thus, its prevention has become a salient public health responsibility. Risk factors of suicide transcend the individual and societal level as risk can increase based on climatic variables. The purpose of the present study is to evaluate the association between average temperature and suicide rates in the five most populous counties in California using mortality data from 1999 to 2019. Methods Monthly counts of death by suicide for the five counties of interest were obtained from CDC WONDER. Monthly average, maximum, and minimum temperature were obtained from nCLIMDIV for the same time period. We modelled the association of each temperature variable with suicide rate using negative binomial generalized additive models accounting for the county-specific annual trend and monthly seasonality. Results There were over 38,000 deaths by suicide in California’s five most populous counties between 1999 and 2019. An increase in average temperature of 1 °C corresponded to a 0.82% increase in suicide rate (IRR = 1.0082 per °C; 95% CI = 1.0025–1.0140). Estimated coefficients for maximum temperature (IRR = 1.0069 per °C; 95% CI = 1.0021–1.0117) and minimum temperature (IRR = 1.0088 per °C; 95% CI = 1.0023–1.0153) were similar. Conclusion This study adds to a growing body of evidence supporting a causal effect of elevated temperature on suicide. Further investigation into environmental causes of suicide, as well as the biological and societal contexts mediating these relationships, is critical for the development and implementation of new public health interventions to reduce the incidence of suicide, particularly in the face increasing temperatures due to climate change.

BackgroundSuicide prevention is a salient public health responsibility, as it is one of the top ten leading causes of premature mortality in the United States. Risk factors of suicide transcend the individual and societal level as risk can increase based on climatic variables. Previous studies have been country-based. Currently, studies focused solely on regions, provinces, or states, such as California, are limited. The present study holds two purposes: i) to assess the effect of maximum temperature on suicides, and ii) to evaluate the effect of number of monthly heat events on suicide rates, in California from 2008-2017.MethodsThe exposure was measured as the average Californian daily maximum temperature within each month, and the number of monthly heat events, which was calculated as a count of the days exhibiting a >15% increase from the historical monthly temperature. The outcome was measured as California’s monthly suicide rate. Negative binomial regression models assessed the relationship between maximum temperature and suicides, and heat events and suicide. A seasonal decomposition of a time series and auto-correlogram further analyzed the seasonality of suicide and the trend from 2008-2017. ResultsThere were 40,315 deaths by suicide in California between 2008-2017. Negative binomial regression indicated a 6.1% increase in suicide incidence rate ratio (IRR) per 10°F increase in maximum temperature (IRR=1.00590 per 1°F, 95% CI: 1.00387, 1.00793, pp=0.572). The time series analysis and auto-correlogram suggested seasonality of deaths by suicide.ConclusionThe present study provided preliminary evidence that will generate future directions for research. We must seek to further illuminate the relationship of interest and apply our findings to public health interventions that will lower the rates of death by suicide as we are confronted with the effects of climate change.

For nearly 150 years the University of Toronto has integrated public health into its teaching and research. From early lectures in sanitation (1871) to the discovery of insulin (1921), the University of Toronto’s rich history is reflected in its prominence as a global leader in public health research and education. Therefore, it is fitting for the University of Toronto to host an academic journal of public health that showcases both high-impact scholarship and public health practice. Founded in 2020, the University of Toronto Journal of Public Health has an ambitious, yet essential, vision: to foster the next generation of public health researchers and practitioners in order to improve population health nationally and globally. In this editorial, we honour the diverse and complementary nature of the fields of biostatistics, epidemiology, health policy and practice, and social and behavioural health sciences by highlighting an important historical date from each. We reflect on these milestones within a historical and contemporary context, and conclude by considering the importance of each discipline for the future of public health in Canada and abroad.

A recent publication in CMAJ [1][1] highlights the critical need for timely, accurate and accessible epidemiologic data for the ongoing coronavirus disease 2019 (COVID-19) outbreak to inform public health response efforts. In Canada, the first case was reported on Jan. 25, 2020, in a returning

BackgroundGovernments have implemented population-wide physical distancing measures to control COVID-19, but metrics evaluating their effectiveness are not readily available.MethodsWe used a publicly available mobility index from a popular transit application to evaluate the effect of physical distancing on infection growth rates and reproductive numbers in 40 jurisdictions between March 23 and April 12, 2020.FindingsA 10% decrease in mobility was associated with a 14.6% decrease (exp(β) = 0·854; 95% credible interval: 0·835, 0·873) in the average daily growth rate and a −0·061 (95% CI: −0·071, −0·052) change in the instantaneous reproductive number two weeks later.InterpretationOur analysis demonstrates that decreases in urban mobility were predictive of declines in epidemic growth. Mobility metrics offer an appealing method to calibrate population-level physical distancing policy and implementation, especially as jurisdictions relax restrictions and consider alternative physical distancing strategies.FundingNo external funding was received for this study.Research in ContextEvidence before this studyWidespread physical distancing interventions implemented in response to the COVID-19 pandemic led to sharp declines in global mobility throughout March 2020. Real-time metrics to evaluate the effects of these measures on future case growth rates will be useful for calibrating further interventions, especially as jurisdictions begin to relax restrictions. We searched PubMed on May 22, 2020 for studies reporting the use of aggregated mobility data to measure the effects of physical distancing on COVID-19 cases, using the keywords “COVID-19”, “2019-nCoV”, or “SARS-CoV-2” in combination with “mobility”, “movement”, “phone”, “Google”, or “Apple”. We scanned 252 published studies and found one that used mobility data to estimate the effects of physical distancing. This study evaluated temporal trends in reported cases in four U.S. metropolitan areas using a metric measuring the percentage of cell phone users leaving their homes. Many published papers examined how national and international travel predicted the spatial distribution of cases (particularly outflow from Wuhan, China), but very little has been published on metrics that could be used as prospective, proximal indicators of future case growth. We also identified a series of reports released by the Imperial College COVID-19 Response Team and several manuscripts deposited on preprint servers such as medRxiv addressing this topic, demonstrating this is an active area of research.Added value of this studyWe demonstrate that changes in a publicly available urban mobility index reported in over 40 global cities were associated with COVID-19 case growth rates and estimated reproductive numbers two to three weeks later. These cities, spread over 5 continents, include many regional epicenters of COVID-19 outbreaks. This is one of only a few studies using a mobility metric applicable to future growth rates that is both publicly available and international in scope.Implications of all the available evidenceRestrictions on human mobility have proved effective for controlling COVID-19 in China and the rest of the world. However, such drastic public health measures cannot be sustained indefinitely and are currently being relaxed in many jurisdictions. Publicly available mobility metrics offer a method of estimating the effects of changes in mobility before they are reflected in the trajectory of COVID-19 case growth rates and thus merit further evaluation.

Empirical treatment of urinary tract infections should be based on susceptibility profiles specific to the locale and patient population. Additionally, these susceptibility profiles should account for correlations between resistance to different types of antimicrobials., Empirical treatment of urinary tract infections should be based on susceptibility profiles specific to the locale and patient population. Additionally, these susceptibility profiles should account for correlations between resistance to different types of antimicrobials. We used hierarchical logistic regression models to investigate geographic, temporal, and demographic trends in resistance to six antimicrobials in community-acquired and nosocomial urinary E. coli isolates from three communities in the province of Quebec, Canada, procured between April 2010 and December 2017. A total of 74,986 community-acquired (patient age, ≥18 years) and 4,384 nosocomial isolates (patient age, ≥65 years) were analyzed. In both community-acquired and nosocomial isolates, we found geographic variation in the prevalence of resistance. Male sex (community-acquired hierarchical mean odds ratio [OR], 1.24; 95% credible interval [CI], 1.02 to 1.50; nosocomial hierarchical mean OR, 1.16, 95% CI, 0.92 to 1.41) and recent hospitalization (community-acquired hierarchical mean OR, 1.49; 95% CI, 1.33 to 1.66; nosocomial hierarchical mean OR, 1.31; 95% CI, 0.99 to 1.78) were associated with a higher risk of resistance to most types of antimicrobials. We found distinct seasonal trends in both community-acquired and nosocomial isolates, but only community-acquired isolates showed a consistent annual pattern. Ciprofloxacin resistance increased sharply with patient age. We found clinically relevant differences in antimicrobial resistance in urinary E. coli isolates between locales and patient populations in the province of Quebec. These results could help inform empirical treatment decisions for urinary tract infections. In the future, similar models integrating local, provincial, and national resistance data could be incorporated into decision support systems for clinicians.

Background: Lyme disease (LD) is a bacterial infection transmitted by the black-legged tick (Ixodes scapularis) in eastern North America. It is an emerging disease in Canada due to the expanding range of its tick vector. Environmental risk maps for LD, based on the distribution of the black-legged tick, have focused on coarse determinants such as climate. However, climatic factors vary little within individual health units, the level at which local public health decision-making takes place. We hypothesize that high-resolution environmental data and routinely collected passive surveillance data can be used to develop valid models for tick occurrence and provide insight into ecological processes affecting tick presence at fine scales. Methods: We used a maximum entropy algorithm (MaxEnt) to build a habitat suitability model for I. scapularis in Ottawa, Ontario, Canada using georeferenced occurrence points from passive surveillance data collected between 2013 and 2016 and high-resolution land cover and elevation data. We evaluated our model using an independent tick presence/absence dataset collected through active surveillance at 17 field sites during the summer of 2017. Results: Our model showed a good ability to discriminate positive sites from negative sites for tick presence (AUC = 0.878 ± 0.019, classification accuracy = 0.835 ± 0.020). Heavily forested suburban and rural areas in the west and southwest of Ottawa had higher predicted suitability than the more agricultural eastern areas. Conclusions: This study demonstrates the value of passive surveillance data to model local-scale environmental risk for the tick vector of LD at sites of interest to public health. Given the rising incidence of LD and other emerging vector-borne diseases in Canada, our findings support the ongoing collection of these data and collaboration with researchers to provide a timely and accurate portrait of evolving public health risk.

Social interactions have been invoked as potential major selective forces structuring natural microbial communities and thus may help explain the astonishing bacterial diversity of natural ecosystems. Here, we investigate the prevalence and structure of exotoxin-mediated antagonistic interactions among free-living soil Pseudomonas strains collected over the course of 2 years at distances of up to 1 km. Unlike some previous studies on antagonistic interactions among natural isolates, we found the prevalence of exotoxin-mediated inhibitions to be relatively low. When present, antagonistic interactions show a weakly positive relationship with genetic relatedness and metabolic similarity. Isolates sampled from the same growing season were significantly more likely to inhibit each other than they were to inhibit isolates from different growing seasons. Exotoxin-mediated antagonistic interactions between soil pseudomonads thus seem to be structured in time but do not appear to be a major selective force shaping free-living soil bacterial communities of pseudomonads.