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Ocular mycobacterial infections are an under-recognized cause of morbidity in the domestic cat. This study aimed to explore the distribution, histopathological appearance, and severity of feline ocular mycobacterial lesions, and to characterize the immune cell population with immunohistochemistry. Routine histological staining with hematoxylin and eosin, and Masson’s trichrome, was performed to identify ocular lesions and assign an inflammation score based on the number of cells present. Acid-fast bacilli were detected with Ziehl-Neelsen, and immunohistochemistry for ionized calcium-binding adaptor protein-1 (Iba1), calprotectin, cluster of differentiation 3 (CD3), and Pax5 was undertaken on formalin-fixed paraffin-embedded tissue samples from 24 cases of ocular mycobacteriosis. Posterior or panuveitis with concurrent retinitis was identified in 20/24 cases (83%), with retinal detachment in 16/20 (80%) of these cases. Choroidal lesions had the highest median inflammation score. Ziehl-Neelsen-positive organisms were detected in 20/24 cases (83%), with the highest prevalence of acid-fast bacilli detected in choroidal lesions (16/20, 80%). Lesions were typically granulomatous to pyogranulomatous, characterized by abundant numbers of Iba1-positive macrophages, followed by calprotectin-positive granulocytes and monocytes, fewer T cells, and rarer B cells. However, where iritis was identified, inflammation was typically lymphoplasmacytic (11/16 cases, 69%). Where diagnostic testing was performed, tuberculosis (ie, infection with Mycobacterium bovis, Mycobacterium microti, or a nonspeciated Mycobacterium tuberculosis-complex pathogen) was diagnosed in 20/22 cats (91%), with Mycobacterium lepraemurium infection identified in the other 2/22 cats (9%). These results suggest the choroid is the primary site of lesion development in most cases of feline ocular mycobacteriosis, and inflammatory changes are associated with the presence of mycobacteria localized to ocular tissues.

Aortic valve stenosis (AVS) is a progressive fibrotic disease that is caused by thickening and stiffening of valve leaflets. At the cellular level, quiescent valve interstitial cells (qVICs) activate to myofibroblasts (aVICs) that persist within the valve tissue. Given the persistence of myofibroblasts in AVS, epigenetic mechanisms have been implicated. Here, we studied changes that occur in VICs during myofibroblast activation by using a hydrogel matrix to recapitulate different stiffnesses in the valve leaflet during fibrosis. We first compared the chromatin landscape of qVICs cultured on soft hydrogels and aVICs cultured on stiff hydrogels, representing the native and diseased phenotypes respectively. Using assay for transposase-accessible chromatin sequencing (ATAC-Seq), we found that open chromatin regions in aVICs were enriched for transcription factor binding motifs associated with mechanosensing pathways compared to qVICs. Next, we used RNA-Seq to show that the open chromatin regions in aVICs correlated with pro-fibrotic gene expression, as aVICs expressed higher levels of contractile fiber genes, including myofibroblast markers such as alpha smooth muscle actin (αSMA), compared to qVICs. In contrast, chromatin remodeling genes were downregulated in aVICs compared to qVICs, indicating qVICs may be protected from myofibroblast activation through epigenetic mechanisms. Small molecule inhibition of one of these remodelers, CREB Binding Protein (CREBBP), prevented qVICs from activating to aVICs. Notably, CREBBP is more abundant in valves from healthy patients compared to fibrotic valves. Our findings reveal the role of mechanical regulation in chromatin remodeling during VIC activation and quiescence and highlight one potential therapeutic target for treating AVS.

First Nations Peoples in the province of British Columbia (BC), Canada, have been disproportionately affected by the overdose crisis. In 2016, a public health emergency was declared by BC’s Provincial Health Officer (PHO) in response to the significant rise in opioid-related overdose deaths reported in BC. New surveillance systems were required to identify trends in overdose events and related deaths in the province as a whole, and for First Nations Peoples. Data sharing and analysis processes that adhered to the principles of OCAP® (ownership, control, access, and possession), and to the Truth and Reconciliation Commission of Canada’s Calls to Action, needed to be developed. The First Nations Health Authority (FNHA), BC Centre for Disease Control, PHO, and the BC Ministry of Health have worked collaboratively to facilitate identification of First Nations persons in surveillance data for appropriate analysis by FNHA. This paper outlines the data stewardship and governance context, principles, and operational considerations for creating overdose surveillance systems to measure overdose events among First Nations Peoples in BC.

Background Cryptococcosis due to Cryptococcus neoformans and Cryptococcus gattii varies with geographic region, populations affected, disease manifestations, and severity of infection, which impact treatment. Methods We developed a retrospective cohort of patients diagnosed with culture-proven cryptococcosis during 1995–2013 from 5 centers in North America and Australia. We compared underlying diseases, clinical manifestations, treatment, and outcomes in patients with C. gattii or C. neoformans infection. Results A total of 709 patients (452 C. neoformans; 257 C. gattii) were identified. Mean age was 50.2 years; 61.4% were male; and 52.3% were white. Time to diagnosis was prolonged in C. gattii patients compared with C. neoformans (mean, 52.2 vs 36.0 days; P Conclusions This study emphasizes differences in species-specific epidemiology and outcomes of patients with cryptococcosis, including underlying diseases, site of infection, and mortality. Species identification in patients with cryptococcosis is necessary to discern epidemiologic patterns, guide treatment regimens, and predict clinical progression and outcomes.

BACKGROUND & AIMS: The province of British Columbia (BC), Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last four years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large-scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted. DESIGN: We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose-death risk, along with the impact of interventions. SETTING/CASES: Overdose events and overdose-related deaths in BC from January 2012 to December 2017. INTERVENTIONS: The interventions considered were take-home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy MEASUREMENTS: Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention, and in combination. FINDINGS: Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl-detected). During the same period, an estimated 3 030 (2 900 – 3 240) death events were averted by all interventions combined. In isolation, 1 580 (1 480 – 1 740) were averted by take-home naloxone, 230 (160 – 350) by overdose prevention services, and 590 (510 – 720) were averted by opioid agonist therapy. CONCLUSIONS: A combined intervention approach has been effective in averting overdose deaths during British Columbia’s opioid overdose crisis in the period since declaration of a public health emergency (April 2016 to December 2017). However, the absolute numbers of overdose deaths have not changed.

IntroductionBritish Columbia has the highest rate of opioid overdose in Canada, driven by the use of illegal opioids such as fentanyl. In addition to ongoing surveillance, there is a need for more comprehensive data to identify risk factors, inform the development of interventions, and evaluate the public health emergency response. Objectives and ApproachThe Provincial Overdose Cohort is a linked administrative dataset based on information from hospital admissions, physician visits, prescription dispensations, poison centre calls, ambulance, emergency department, coroner’s data, and First Nations Client File. Overdoses in the province were identified for the period January 2015-November 2016. Overdoses occurring within a 24 hour period across data sources were grouped as a single episode. For identified cases and for a control population (a 20% random sample of the BC residents), health care and prescribing history was appended dating back to 2010. Initial analyses were conducted based on a prioritization process with knowledge users. ResultsIntegration of distinct data sources about overdose events provided a more complete understanding of the extent of the opioid crisis than use of a single dataset alone. Between January 1, 2015 and November 30, 2016 10,456 overdoses occurred in BC. Overdose deaths represented only 13% of individuals overdosing; 54% of all overdoses were captured through ambulance records and 46\% through emergency and hospital records, with some overlap between the datasets. Most cases had contact with the health care system in the year before overdose suggesting opportunities for intervention. Some demographic differences were noted when comparing fatal and non-fatal overdoses, but few differences in health or prescribing histories were identifiable using administrative data. Conclusion/ImplicationsThe Provincial Overdose Cohort is a uniquely comprehensive dataset in a jurisdiction at the forefront of the opioid overdose response. Jurisdictions developing surveillance systems should consider the inclusion of ambulance, emergency room and hospital data in order to more completely characterize the population at risk.

IntroductionBritish Columbia (BC), Canada declared a public health emergency in April 2016 for opioid overdose. Comprehensive data was needed to identify risk factors, inform interventions, and evaluate response actions. We describe the development of an overdose cohort, including linkage strategy, case definitions, and data governance model, and present the resulting characteristics, including data linkage yields and case overlap among data sources.MethodsOverdose events from hospital admissions, physician visits, poison centre and ambulance calls, emergency department visits, and coroner's data were grouped into episodes if records were present in multiple sources. A minimum of five years of universal health care records (all prescription dispensations, fee-for-service physician billings, emergency department visits and hospitalizations) were appended for each individual. A 20% random sample of BC residents and a 1:5 matched case-control set were generated. Consultation and prioritization ensured analysts worked to address questions to directly inform public health actions.Results10,456 individuals suffered 14,292 overdoses from January 1, 2015 to Nov 30, 2016. Only 28% of overdose events were found in more than one dataset with the unique contribution of cases highest from ambulance records (32%). Compared with fatal overdoses, non-fatal events more often involved females, younger individuals (20 to 29 years) and those 60 or older. In 78% of illegal drug deaths, there was no associated ambulance response. In the year prior to first recorded overdose, 60% of individuals had at least one ED visit, 31% at least one hospital admission, 80% at least one physician visit, and 87% had filled at least one prescription in a community pharmacy.ConclusionWhile resource-intensive to establish, a linked cohort is useful for characterizing the full extent of the epidemic, defining sub-populations at risk, and patterns of contact with the health system. Overdose studies in other jurisdictions should consider the inclusion of multiple data sources.

It has been over a decade since Cryptococcus gattii was first recognized as the causative organism of an outbreak of cryptococcosis on Vancouver Island, British Columbia. A number of novel observations have been associated with the study of this emergent pathogen. A novel genotype of C. gattii, VGIIa was described as the major genotype associated with clinical disease. Minor genotypes, VGIIb and VGI, are also responsible for disease in British Columbians, in both human and animal populations. The clinical major genotype VGIIa and minor genotype VGIIb are identical to C. gattii isolated from the environment of Vancouver Island. There is more heterogeneity in VGI, and a clear association with the environment is not apparent. Between 1999 and 2010, there have been 281 cases of C. gattii cryptococcosis. Risk factors for infection are reported to be age greater than 50 years, history of smoking, corticosteroid use, HIV infection, and history of cancer or chronic lung disease. The major C. gattii genotype VGIIa is as virulent in mice as the model Cryptococcus, H99 C. neoformans, although the outbreak strain produces a less protective inflammatory response in C57BL/6 mice. The minor genotype VGIIb is significantly less virulent in mouse models. Cryptococcus gattii is found associated with native trees and soil on Vancouver Island. Transiently positive isolations have been made from air and water. An ecological niche for this organism is associated within a limited biogeoclimatic zone characterized by daily average winter temperatures above freezing.

This organism should be recognized as an emerging pathogen in the United States., Cryptococcus gattii has emerged as a human and animal pathogen in the Pacific Northwest. First recognized on Vancouver Island, British Columbia, Canada, it now involves mainland British Columbia, and Washington and Oregon in the United States. In Canada, the incidence of disease has been one of the highest worldwide. In the United States, lack of cryptococcal species identification and case surveillance limit our knowledge of C. gattii epidemiology. Infections in the Pacific Northwest are caused by multiple genotypes, but the major strain is genetically novel and may have emerged recently in association with unique mating or environmental changes. C. gattii disease affects immunocompromised and immunocompetent persons, causing substantial illness and death. Successful management requires an aggressive medical and surgical approach and consideration of potentially variable antifungal drug susceptibilities. We summarize the study results of a group of investigators and review current knowledge with the goal of increasing awareness and highlighting areas where further knowledge is required.

The costs associated with gastrointestinal infection (GI) in the province of British Columbia, Canada, were estimated using data from a population-based survey in three health service delivery areas, namely Vancouver, East Kootenay and Northern Interior. The number of cases of disease, consequent expenditure of resources and associated economic costs were modeled as probability distributions in a stochastic model. Using 2004 prices, the estimated mean annual cost per capita of gastrointestinal infection was CAN$128.61 (207.96 euros), with a mean annual cost per case of CAN$1,342.57 (2,170.99 euros). The mean estimate of the overall economic burden to British Columbia was CAN$514.2 million (831.5 million euros) (95% CFI CAN$161.0 million to CAN$5.8 billion; 260.3 million euros to 9.38 billion euros). The major element of this cost was the loss of productivity associated with time away from paid employment by both the sick and their caregivers. Sensitivity analysis suggested that the uncertainty associated with the base model assumptions did not significantly affect the estimates. The results are comparable to those obtained in an earlier study using a similar analytical framework and data from the city of Hamilton, Ontario, Canada.

Geographic Information Systems (GIS) analysis of 34 forecasted high West Nile virus (WNV) risk communities in British Columbia (BC), Canada was useful to assess feasibility and planning of the operational logistics of an emergency spray event in advance of a WNV outbreak. The geographic coverage and operational time required to perform ground- and aerial-based ultra-low volume (ULV) adulticiding were calculated using GIS. The mean geographic coverages of the ground-, aerial-, and combination of ground- and aerial-based adulticiding strategies were 39%, 61%, and 69%, respectively. The driving distance, driving time, and number of treatment nights required to perform ground-based spraying of an entire community were also calculated. Due to the large variability of treatment coverage estimates within and among the communities, no single treatment method was identified as the best strategy for province-wide ULV adulticiding in BC. Instead, the strategy for each community should be examined individually with local knowledge and expertise.

In January 2004, an increase in gastrointestinal illness following oyster consumption was reported in British Columbia. An investigation was initiated to explore the association between norovirus infection and consumption of British Columbia oysters and to identify the source of oyster contamination.The outbreak investigation included active surveillance for human cases, two cohort studies, trace-back of oysters, and laboratory testing of oysters and human stools.Enhanced surveillance identified 26 confirmed and 53 clinical cases over 3 months. Oyster consumption was associated with illness in one cohort and suggestive in the other. Oysters were traced to 14 geographically dispersed harvest sites, 18 suppliers, and 45 points of purchase. Norovirus BCCDC03-028 (genotype I.2) was detected in 50% of human specimens. Experimental methods detected norovirus in 12 oyster samples. Sequencing identified mixed clonal patterns in the oysters with one direct sequence match between an oyster sample and the associated human specimen.The consumption of raw oysters led to norovirus infection. The source of oyster contamination remained unidentified. The geographical dispersion of implicated harvest sites was unusual.This outbreak is unlike most shellfish outbreaks that can be traced back to a common source and challenges conventional thinking that all oyster-related norovirus outbreaks of are a result of point source contamination.

C. gattii may be spread through soil disturbances, wind, water, distribution of tree and soil byproducts, and human movement., Recent Cryptococcus gattii infections in humans and animals without travel history to Vancouver Island, as well as environmental isolations of the organism in other areas of the Pacific Northwest, led to an investigation of potential dispersal mechanisms. Longitudinal analysis of C. gattii presence in trees and soil showed patterns of permanent, intermittent, and transient colonization, reflecting C. gattii population dynamics once the pathogen is introduced to a new site. Systematic sampling showed C. gattii was associated with high-traffic locations. In addition, C. gattii was isolated from the wheel wells of vehicles on Vancouver Island and the mainland and on footwear, consistent with anthropogenic dispersal of the organism. Increased levels of airborne C. gattii were detected during forestry and municipal activities such as wood chipping, the byproducts of which are frequently used in park landscaping. C. gattii dispersal by these mechanisms may be a useful model for other emerging pathogens.

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

Background Cryptococcus gattii (Cg) infection emerged in British Columbia in 1999. A longitudinal, clinical description of patients has not been reported. Methods Medical records were reviewed for Cg patients identified through surveillance (1999-2007). Risk factors for Cg mortality were explored using multivariate Cox regression; longitudinal patterns in serum cryptococcal antigen (SCrAg) titers and the probability of chest cryptococcomas over time were estimated using cubic B-splines in mixed-effects regression models. Results Among 152 patients, 111 (73.0%) were culture confirmed. Isolated lung infection was present in 105 (69.1%) patients; 47 (30.9%) had central nervous system infection, with or without lung involvement. Malignancy was the provisional diagnosis in 64 (42.1%) patients. Underlying diseases were present in 91 (59.9%) patients; 23 (15.1%) were immunocompromised, and 23 (15.1%) had asymptomatic disease. There were only 2 (1.8%) culture positive relapses, both within 12 months of follow-up. The estimated median time to resolution of lung cryptococcomas and decline in SCrAg titer to 50 years (hazard ratio [HR], 15.6; 95% confidence interval [CI], 1.9-130.5) and immunocompromise (HR, 5.8; CI, 1.5-21.6). All Cg-related mortality occurred among culture-positive cases within 1 year of diagnosis. Conclusions Cryptococcomas and serum antigenemia were slow to resolve. However, late onset of failed therapy or relapse was uncommon, suggesting that delayed resolution of these findings does not require prolongation of treatment beyond that recommended by guidelines.

A total of 184 methicillin-resistant Staphylococcus aureus (MRSA) strains were collected from patients who sought treatment primarily for skin and soft tissue infections from January 1, 1999, to March 31, 2002, in east-central Saskatchewan, Canada. Molecular subtyping analysis using pulsed-field gel electrophoresis showed 2 major clusters. Cluster A (n = 55) was composed of a multidrug-resistant MRSA strain associated with a long-term care facility and was similar to the previously reported nosocomial Canadian epidemic strain labeled CMRSA-2. Cluster B (n = 125) was associated with cases identified at community health centers and was indistinguishable from a community-associated (CA)-MRSA strain identified previously in the United States (USA400). Cluster B remained susceptible to a number of classes of antimicrobial agents and harbored the lukF-PV and lukS-PV toxin genes. Over 50% of both clonal groups displayed high-level resistance to mupirocin. This is the first report of the USA400 strain harboring the lukF-PV and lukS-PV toxin genes in Canada.

Cryptococcus gattii causes life-threatening infection of the pulmonary and central nervous systems in hosts with normal immunity and traditionally has been considered to be restricted geographically to tropical and subtropical climates. The recent outbreak of C. gattii in the temperate climate of Vancouver Island, BC, Canada, led to a collaborative investigation. The objectives of the current study were to ascertain the environmental source of the outbreak infections, survey the molecular types of the outbreak and environmental cryptococcal isolates, and determine the extent of genetic diversity among the isolates. PCR-fingerprinting and amplified fragment length polymorphism (AFLP) were used to examine the genotypes, and mating assays were performed to determine the mating type of the isolates. All outbreak and environmental isolates belonged to C. gattii . Concordant results were obtained by using PCR-fingerprinting and AFLP analysis. The vast majority of clinical and veterinary infections were caused by isolates of the molecular type VGII/AFLP6, but two were caused by molecular type VGI/AFLP4. All environmental isolates belonged to molecular type VGII/AFLP6. Two or three subtypes were observed within VGII/AFLP6 among outbreak and environmental isolates. All mating-competent isolates were of the α-mating type. The emergence of this usually tropical pathogen on Vancouver Island highlights the changing distribution of this genotype and emphasizes the importance of an ongoing collaborative effort to monitor the global epidemiology of this yeast.

We investigated personal protective behaviors against West Nile virus infection. Barriers to adopting these behaviors were identified, including the perception that DEET (N,N-diethyl-m-toluamide and related compounds) is a health and environmental hazard. Televised public health messages and knowing that family or friends practiced protective behaviors were important cues to action.

Salmonella enterica var. Heidelberg was isolated from an unusual food source during routine case follow-up, prompting a case control investigation of frozen chicken nuggets and strips. Most frozen nuggets and strips are raw; however, par-frying lends a cooked appearance. As such, suitable food preparation precautions might not be undertaken by consumers. Cases were confirmed in the laboratory between 1 January and 1 April 2003. Controls were generated through forward-digit dialing and individually matched by age category. Telephone interviews were conducted, and limited sampling of unopened product was performed. Eighteen matched pairs were interviewed. The odds of infection were 11 times higher in individuals who had consumed frozen processed chicken nuggets and strips (95% confidence interval, 1.42 < odds ratio < 85.20). One-third of cases and controls considered frozen nuggets and strips to be precooked, and one quarter used the microwave, an ill-advised cooking method. Consumer misconceptions contributed to the risk of infection. Clear labels identifying nuggets and strips as raw poultry are needed.

The Canadian blood system is a critical interface between public health and the delivery of patient care. The organization of the blood system plays a vital role in ensuring that its functions are effectively fulfilled. Previous structural problems in the blood system led to serious health consequences by contributing to the blood transmission of hepatitis C and HIV in the 1980s. To address these problems, the Canadian blood system has recently undergone considerable organizational reform. However, policy-makers, particularly in Ontario, are considering further structural reform specifically focusing on how the blood system is financed. This move for reform is partially motivated by the rising cost of blood products and the perception that the current system has failed to provide incentives for the efficient use of these products. The suggested payment mechanism, a "chargeback system," involves the provincial ministries of health funding hospitals so that hospitals can directly purchase blood products from the Canadian Blood Services. This approach would replace the current system in which the provinces directly fund the Canadian Blood Services, which in turn provides blood products free of charge to hospitals. Based on a review of documents and stakeholder interviews, we report the potential advantages and disadvantages of a change to a new system of funding and make recommendations on how provinces should proceed.

Experience Based Design (EBD) uses patient and staff experiences to identify quality improvement opportunities in healthcare settings. An EBD Collaborative was established to share successes and challenges related to the EBD projects. This paper summarizes the various lessons learned. A document analysis was conducted that examined meeting minutes and audio recordings, email communications, newsletters, project updates, project spotlights and evaluation surveys and interviews. A total of ten key themes were identified. While EBD teams encountered challenges, overall the experience led to successful quality improvement initiatives. In particular, staff gained new insights from the patients’ perspective, which enhanced their understanding of patient experience. Engaging patients in the work to co-design and improve the patient experience requires work, commitment, time and leadership. There are several strategies that the EBD teams found effective as outlined in this paper; however, the most important element of success is the ability to listen and act on what is heard.

Cryptococcus gattii (Cg) infection emerged in British Columbia in 1999. A longitudinal, clinical description of patients has not been reported.Medical records were reviewed for Cg patients identified through surveillance (1999-2007). Risk factors for Cg mortality were explored using multivariate Cox regression; longitudinal patterns in serum cryptococcal antigen (SCrAg) titers and the probability of chest cryptococcomas over time were estimated using cubic B-splines in mixed-effects regression models.Among 152 patients, 111 (73.0%) were culture confirmed. Isolated lung infection was present in 105 (69.1%) patients; 47 (30.9%) had central nervous system infection, with or without lung involvement. Malignancy was the provisional diagnosis in 64 (42.1%) patients. Underlying diseases were present in 91 (59.9%) patients; 23 (15.1%) were immunocompromised, and 23 (15.1%) had asymptomatic disease. There were only 2 (1.8%) culture positive relapses, both within 12 months of follow-up. The estimated median time to resolution of lung cryptococcomas and decline in SCrAg titer to1:8 was 2.8 and 2.9 years, respectively. Cg-related and all-cause mortality among culture-confirmed cases at 12 months' follow-up was 23.3% and 27.2%, respectively. Cg-related mortality was associated with age50 years (hazard ratio [HR], 15.6; 95% confidence interval [CI], 1.9-130.5) and immunocompromise (HR, 5.8; CI, 1.5-21.6). All Cg-related mortality occurred among culture-positive cases within 1 year of diagnosis.Cryptococcomas and serum antigenemia were slow to resolve. However, late onset of failed therapy or relapse was uncommon, suggesting that delayed resolution of these findings does not require prolongation of treatment beyond that recommended by guidelines.

This chapter outlines issues that were quickly explored, starting with the realization in 2001 that Vancouver Island was a hot spot for a pathogen not previously described as endemic and not restricted to tropical and subtropical climates. The picture of the outbreak that has developed has implications for global travel, climate change, land use patterns, and environmental colonization. Importantly, cryptococcosis caused by Cryptococcus gattii now serves as an excellent illustration of the impact of pathogen spread into a clement ecological niche, in this case, one that happened to be in a major population center of western Canada and the Pacific Northwest. Symptoms and clinicopathological changes in animals on Vancouver Island were consistent with disease reported elsewhere. The most common primary system involved was respiratory, followed by the central nervous system (CNS), in both cats and dogs. Animal cryptococcosis due to C. gattii is a nonregulated disease in Canada. Molecular typing of C. gattii environmental isolates from Vancouver Island using PCR fingerprinting and/or restriction fragment length polymorphism methodologies revealed that the majority of isolates belonged to the VGII molecular type and a small number belonged to the VGI molecular type. A number of solid culture media, biochemical tests, and stains can confirm the diagnosis of Cryptococcus to the genus level. Ecological niche modeling was employed to identify geographical areas in British Columbia with suitable environmental conditions to support the permanent colonization of C. gattii in the environment.

We compared travel histories of case-patients with Cryptococcus gattii infection during 1999–2006 to travel destinations of the general public on Vancouver Island, British Columbia, Canada. Findings validated and refined estimates of risk on the basis of place of residence and showed no spatial progression of risk areas on this island over time.

Lyme disease (LD) is rare in British Columbia (BC) and, despite being a reportable condition since 1994, may be underreported. Here we review all provincial laboratory and clinical databases to determine the number of LD cases reported in BC from 1997 to 2008. We analyzed demographic characteristics of LD cases and used capture-recapture methodology to estimate the true number of cases in BC for this period. From 1997 to 2008, 93 confirmed cases of LD were reported in BC. Conservative capture-recapture estimates place the true number of LD cases in BC during this period at 142 (95% confidence interval: 111-224), indicating up to 40% underreporting of this rare disease. Despite this underreporting, BC continues to have low endemic risk of LD. Strategies are needed to increase both physician awareness and the use of preventive measures in the BC population, including for those traveling to other endemic areas.

To estimate seasonal proportions of patient visits due to acute gastrointestinal illness (GI), assess factors influencing physicians’ stool sample requests, their understanding of laboratory testing protocols and adherence to provincial stool request guidelines in three British Columbia (BC) health regions. During a one-year period, eligible physicians were mailed four self-administered questionnaires used to estimate proportions of patients diagnosed with GI, related stool sample requests in the preceding month, and to assess factors prompting stool sample requests. The response rate overall for the initial comprehensive questionnaire was 18.6%; 7.4% responded to all four questionnaires. An estimated 2.5% of patient visits had a GI diagnosis; of these, 24.8% were asked to submit stool samples. Significant (p 7 days; “non-patient” factors included: laboratory availability, time to receive laboratory results, and cost. Physicians’ perceptions of which organisms were tested for in a ‘routine’ stool culture varied. BC physicians appear to adhere to existing standardized guidelines for sample requests. This may result in systematic under-representation of certain diseases in reportable communicable disease statistics. Estimer, dans trois regions sanitaires de la Colombie-Britannique (C.-B.), les pourcentages saisonniers de visites medicales en raison de maladies gastrointestinales (MGI) aigues, et determiner les facteurs incitant les medecins a demander des echantillons de selles, leurs connaissances des protocoles d’essai des laboratoires et leur respect des lignes directrices relatives aux demandes d’echantillons de selles. Sur une periode d’un an, les medecins admissibles ont recu par la poste quatre questionnaires a remplir soi-meme, qui ont servi a estimer le pourcentage de patients chez qui une MGI avait ete diagnostiquee et le nombre connexe d’echantillons de selles demandes le mois precedent, et a evaluer les facteurs incitant les medecins a demander un echantillon de selles. Le taux global de reponse au premier questionnaire general s’est eleve a 18,6 %, et 7,4 % des medecins ont repondu aux quatre questionnaires. Un taux estimatif de 2,5 % des patients avaient recu un diagnostic de MGI, et les medecins avaient demande a 24,8 % d’entre eux de fournir des echantillons de selles. Des variations regionales et saisonnieres importantes (p

SUMMARYUnder-reporting of infectious gastrointestinal illness (IGI) in British Columbia, Canada was calculated using simulation modelling, accounting for the uncertainty and variability of input parameters. Factors affecting under-reporting were assessed during a cross-sectional randomized telephone survey. For every case of IGI reported to the province, a mean of 347 community cases occurred (5th and 95th percentile estimates ranged from 181 to 611 community cases, respectively). Vomiting [odds ratio (OR) 2·15, 95% confidence interval (CI) 1·03–4·49] and antibiotic use in the previous 28 days (OR 3·59, 95% CI 1·17–10·97) significantly predicted health-care visits in a logistic regression model. In bivariate analyses, physicians were significantly less likely to request stool samples from patients with vomiting (RR 0·09, 95% CI 0·01–0·65) and patients of North American as opposed to non-North American cultural groups (RR 0·38, 95% CI 0·15–0·96). Physicians were more likely to request stool samples from older patients (P=0·003), patients with fewer household members (P=0·002) and those who reported anti-diarrhoeal use following illness (RR 3·33, 95% CI 1·32–8·45). People with symptoms of vomiting were under-represented in provincial communicable disease statistics. Differential degrees of under-reporting must be understood before biased surveillance data can be adjusted.

A cross-sectional telephone survey was performed in the province of British Columbia, Canada, to investigate drinking water consumption patterns and their associations with various demographic characteristics and acute gastrointestinal illness (AGI). Water consumption included plain water and water used in the preparation of cold beverages. The median amount of water consumed daily was four-250 mL servings (1.0 L), although responses were highly variable (0 to 9.0 L). Alternative water use was common: bottled water was the primary source of drinking water (i.e. ≥ 75% of the total daily water intake) for 23% of respondents and 47% of households used in-home water treatment methods. Approximately 10% of respondents reported an episode of AGI (vomiting or diarrhea) in the previous 4-week period. Such illness was associated with age (continuous variable in years, OR = − 0.98), sex (male vs. female, OR = 0.8) and the amount of water consumed (continuous variable in 250-mL servings, OR = 1.06); however, a causal relationship with water consumption cannot be established based on this study alone. Overall, the associations of drinking water patterns with age, sex, education, and household income serve as important reminders to researchers and public health professionals of the non-uniform nature of drinking water consumption, and indicate potential differences in exposure to waterborne hazards in this population.

159 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are to promote the adoption of electronic symptom assessment using a standardized tool and to increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are (a) manage cancer symptoms through a patient reported measurement tool; (b) improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and (c) drive improvement through the adoption of an electronic symptom assessment platform. The following aims were established for this work: (1) aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month); (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores); (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan); and (4)aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success: a) leadership at all levels of the system; b) clinical tools at the point of care; c) engagement of patients in the design of care; d) communications support to spread information to all stakeholders; and e) using to data to drive performance improvement and accountability.

67 Background: Cancer Care Ontario (CCO) is an Ontario government agency which drives quality and improvement in the delivery of care and the patient experience for the Ontario cancer system. Person-Centred Care (PCC) has been identified as a goal from the recent Institute of Medicine (IOM) report and as a corporate strategic priority at CCO. As an initial step in a province-wide PCC strategy, CCO is developing and internally disseminating a patient engagement toolkit and eLearning module with expansion to regional cancer programs. Methods: The PCC eLearning module defines the care approach and explains the corporate goals and objectives of practicing PCC at CCO. Pre- and post-evaluation metrics are embedded to measure module impact on a rating scale with respect to: (1) understanding of PCC; (2) willingness to include the patient voice in CCO work; and (3) understanding of the role of patients who serve as advisors at CCO. The Patient Engagement Toolkit was developed as a step-by-step guide on why and how to engage Patients and Family Advisors (PFAs) in different organizational contexts. To test effectiveness and impact, we piloted the toolkit in 6 interactive sessions across 7 departments with 184 CCO employees over 2 months (Clinical Program and Quality Initiatives, Regional Program, Communication, Finance/Procurement/Facilities, HR, Business Analyst/Project Management Office). We are taking a comprehensive mixed methods evaluation approach with online surveys and key informant interviews to identify uptake and barriers. Results: Preliminary findings suggest considerable increase in the understanding of PCC and the role of PFAs at CCO, with 138 current instances of patient engagement in 1 quarter. After an introduction to the toolkit, many employees (86.7%) understood the value of engaging PFAs and most (63.7%) felt willing to start. Conclusions: Initial program evaluation demonstrates an increase in the understanding and implementation of direct (e.g., joining committees/working groups) and indirect PFA engagement (e.g., speaking at events/in focus groups) across CCO departments. Further evaluation of the toolkit at a provincial level is needed.

56 Background: The goal of the collaborative is to improve the quality and consistency of physical and emotional symptom management across the cancer journey. Objectives are: (a) promote the adoption of electronic symptom assessment using a standardized tool and (b) increase the clinical use of evidence based guidelines to effectively manage patient identified symptoms. Methods: The actions taken for this initiative are to manage cancer symptoms through a patient reported measurement tool; improve the quality of symptom management through the uptake of symptom management guides and algorithms for care; and drive improvement through the adoption of an electronic symptom assessment platform The following aims were established for this work: (1) Aim for symptom screening and assessment (70% of ambulatory cancer clinic patients are screened for symptom severity using ESAS at least once/month) (2) aim for symptom management (evidence from chart audits show intervention as per evidence based guidelines for patients reported symptom scores) (3) aim for patient satisfaction (90% of target population indicates that their health care team took their scores into consideration when developing a care plan) and (4) aim for evidence of use (90% of patients state that their doctor or nurse spoke with them about their symptom screen). Results: 60% of cancer patients are screened each month representing over 28,000 people. Six of fourteen cancer regions are above the provincial target of 70%, with some close to 90%. 92% of patients felt ESAS was important to complete to help health care providers know how they are feeling. Conclusions: Cancer Care Ontario has been able to drive improvements in symptom management through the implementation of system wide electronic symptom assessment. For other jurisdictions interested in adopting this approach, the following areas are critical for success. (a.) Leadership at all levels of the system; (b.) clinical tools at the point of care; (c) engagement of patients in the design of care; (d) communications support to spread information to all stakeholders; and (e) using to data to drive performance improvement and accountability.

69 Background: The Experience Based Design (EBD) approach uses patient and clinician experiences to identify opportunities for improvement in the healthcare system. The EBD approach elicits subjective and personal patient, carer, and staff experiences at crucial points in the care pathway by encouraging them to share their stories. Methods: Cancer Care Ontario (CCO), an agency that oversees cancer services in Ontario, held an EBD workshop with the objectives of capacity building and facilitating healthcare improvements throughout the province. 110 participants (27 teams) from across Ontario attended the workshop to engage participants to take an active role in developing actionable plans to address patient experience issues. An evaluation following two years of EBD was necessary to: (a) determine EBD progress and effectiveness; (b) identify successes/challenges for getting projects off the ground; and (c) identify additional resources required to spread EBD across Ontario. The evaluation consisted of: 1) two province-wide electronic surveys (long survey for those directly involved in EBD projects; short survey for frontline staff) and 2) semi-structured phone interviews with patients/caregivers. Results: Some EBD projects have completed multiple initiatives; others are just beginning. Projects address process improvement (e.g., streamlining patient bookings), resource/tool development (e.g., symptom screening tools) and establishing patient advisory boards and committees. Five (28%) survey respondents said that EBD projects elicited implementation of 6 to 10 changes and 6 (38%) respondents indicated that: (1) respect for patient preferences and (2) communication, information and education were two principles of Person-Centred Care (PCC) that improved the most. Conclusions: Future steps include development of a collaborative website, a symposium to showcase projects, an evaluation of the EBD initiative and peer-reviewed publication.