[Show abstract][Hide abstract] ABSTRACT: Drug resistance indexes (DRIs) quantify the cumulative impact of antimicrobial resistance on the likelihood that a given pathogen will be susceptible to antimicrobial therapy.
To derive a DRI for community urinary tract infections caused by Escherichia coli in British Columbia for the years 2007 to 2010, and to examine trends over time and across patient characteristics.
Indication-specific utilization data were obtained from BC PharmaNet for outpatient antimicrobial prescriptions linked to diagnostic information from physician payment files. Resistance data for E coli urinary isolates were obtained from BC Biomedical Laboratories (now part of LifeLabs Medical Laboratory Services). DRIs were derived by multiplying the rate of resistance to a specific antimicrobial by the proportional rate of utilization for that drug class and aggregating across drug classes. Higher index values indicate more resistance.
Adaptive-use DRIs remained stable over time at approximately 18% (95% CI 17% to 18%) among adults ≥15 years of age and approximately 28% (95% CI 26% to 31%) among children <15 years of age. Similar results were observed when proportional drug use was restricted to the baseline year (ie, a static-use model). Trends according to age group suggest a U-shaped distribution, with the highest DRIs occurring among children <10 years of age and adults ≥65 years of age. Males had consistently higher DRIs than females for all age groups.
The stable trend in adaptive-use DRIs over time suggests that clinicians are adapting their prescribing practices for urinary tract infections to local resistance patterns. Results according to age group reveal a higher probability of resistance to initial therapy among young children and elderly individuals.
The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale / AMMI Canada 03/2015; 26(1):33-8. · 0.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To understand the epidemic resurgence of influenza due to the 2009 pandemic influenza A(H1N1) strain (A[H1N1]pdm09) during
the 2013–2014 influenza season, we compared age-related cross-sectional estimates of seroprotection before the pandemic (during
2009) and after the pandemic (during 2010 and 2013) to subsequent surveillance-based, laboratory-confirmed incidence of influenza
due to A(H1N1)pdm09 in British Columbia, Canada. Prepandemic seroprotection was negligible except for very old adults (defined
as adults aged ≥80 years), among whom 80% had seroprotection. Conversely, postpandemic seroprotection followed a U-shaped
distribution, with detection in approximately 35%–45% of working-aged adults but in ≥70% of very old adults and young children,
excluding children aged <5 years in 2013, among whom seroprotection again decreased to <20%. The incidence was 5-fold higher
during 2013–2014, compared with 2010–2011, and was highest among children aged <5 years and working-aged adults, reflecting
a mirror image of the age-based seroprotection data.
The Journal of Infectious Diseases 06/2014; 211(1). DOI:10.1093/infdis/jiu366 · 6.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cases of a novel swine-origin influenza A(H3N2) variant (H3N2v) have recently been identified in the US, primarily among children. We estimated potential epidemic attack rates (ARs) based on age-specific estimates of sero-susceptibility and social interactions. A contact network model previously established for the Greater Vancouver Area (GVA), Canada was used to estimate average epidemic (infection) ARs for the emerging H3N2v and comparator viruses (H1N1pdm09 and an extinguished H3N2 seasonal strain) based on typical influenza characteristics, basic reproduction number (R(0)), and effective contacts taking into account age-specific sero-protection rates (SPRs). SPRs were assessed in sera collected from the GVA in 2009 or earlier (pre-H1N1pdm09) and fall 2010 (post-H1N1pdm09, seasonal A/Brisbane/10/2007(H3N2), and H3N2v) by hemagglutination inhibition (HI) assay. SPR was assigned per convention based on proportion with HI antibody titre ≥40 (SPR40). Recognizing that the HI titre ≥40 was established as the 50%sero-protective threshold we also explored for ½SPR40, SPR80 and a blended gradient defined as: ¼SPR20, ½SPR40, ¾SPR80, SPR160. Base case analysis assumed R(0) = 1.40, but we also explored R(0) as high as 1.80. With R(0) = 1.40 and SPR40, simulated ARs were well aligned with field observations for H1N1pdm09 incidence (AR: 32%), sporadic detections without a third epidemic wave post-H1N1pdm09 (negligible AR<0.1%) as well as A/Brisbane/10/2007(H3N2) seasonal strain extinction and antigenic drift replacement (negligible AR<0.1%). Simulated AR for the novel swine-origin H3N2v was 6%, highest in children 6-11years (16%). However, with modification to SPR thresholds per above, H3N2v AR ≥20% became possible. At SPR40, H3N2v AR ≥10%, ≥15% or ≥30%, occur if R(0)≥1.48, ≥1.56 or ≥1.86, respectively. Based on conventional assumptions, the novel swine-origin H3N2v does not currently pose a substantial pandemic threat. If H3N2v epidemics do occur, overall community ARs are unlikely to exceed typical seasonal influenza experience. However risk assessment may change with time and depends crucially upon the validation of epidemiological features of influenza, notably the serologic correlate of protection and R(0).
PLoS ONE 01/2013; 8(1):e54015. DOI:10.1371/journal.pone.0054015 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. Cases of infection due to a novel swine-origin variant of influenza A virus subtype H3N2 (H3N2v) have recently been identified in the United States, primarily among children. We estimate levels of cross-reactive antibody to H3N2v by age and assess whether seasonal trivalent inactivated influenza vaccine (TIV), with or without adjuvant, may increase seroprotection.Methods. Antibody to H3N2v was assessed by hemagglutination inhibition (HI) assay and, for a subset, also by microneutralization assay. Seroprevalence and seroprotection were defined as an HI titer of ≥40, and levels were compared with those for ancestral and contemporary human strains. The analysis included 1116 sera collected during fall 2010, corresponding to approximately 100 sera per decade of life. Vaccine-induced antibody levels were also assessed in sera from 136 children aged <10 years and 65 adults aged 20-59 years before and after receipt of 2010-2011 split TIV and in sera from 182 elderly individuals aged ≥65 years before and after receipt of 2011-2012 split TIV (for 31 individuals), MF59-adjuvanted TIV (for 72), or unadjuvanted subunit TIV (for 79).Results. The overall prevalence of HI titers of ≥40 against A(H3N2)v was 25%. No children aged <5 years and <20% of individuals aged ≤14 years or ≥40 years had an HI titer of ≥40. Conversely, among individuals aged 15-39 years, half of teens and adults showed H3N2v seroprotection. Following TIV receipt, <15% of individuals in any vaccine group developed a 4-fold increase in antibody level.Conclusions. A substantial proportion of adolescents and young adults have cross-reactive antibody against emerging H3N2v, whereas children and older adults show broad susceptibility. Recent formulations of TIV do not substantially increase seroprotection. A specific vaccine would be needed if H3N2v establishes epidemic spread.Clinical Trials Registration. NCT01140009 and NCT01368796.
The Journal of Infectious Diseases 08/2012; 206(12). DOI:10.1093/infdis/jis500 · 6.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Antibiotic resistance is accelerated by the overuse of antibiotics. Do Bugs Need Drugs? is an educational program adapted in British Columbia to target both the public and health care professionals, with the aim of reducing unnecessary prescribing. The current article presents a descriptive evaluation of the impact of the program over the first four years.
Program implementation was measured by the amount of educational material distributed and the level of participation in educational sessions. The impact of the program was assessed by measuring changes in knowledge and prescribing habits of participating physicians, and by investigating provincial trends in antibiotic use.
A total of 51,367 children, assisted-living residents and health care professionals have participated in the program since its inception in the fall of 2005. Pre- and postcourse assessments of participating physicians indicated significant improvements in clinical knowledge and appropriate antibiotic treatment of upper respiratory tract infections. Overall rates of antibiotic use in the province have stabilized since 2006. The rates of consumption of fluoroquinolones and macrolides have levelled off since 2005. Utilization rates for acute bronchitis are at the same level as when the program was first implemented, but rates for other acute upper respiratory tract infections of interest have declined.
The Do Bugs Need Drugs? program significantly improves physician antibiotic prescription decisions and is ecologically associated with desirable change in population antibiotic consumption patterns.
The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale / AMMI Canada 03/2011; 22(1):19-24. · 0.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pandemic H1N1 (pH1N1) surveillance data showed lower attack rates but higher risk of severe outcomes with advanced age. We explored immuno-epidemiologic correlates of surveillance findings including humoral and cell-mediated immunity (CMI).
In an age-based design, ∼100 banked/residual sera per 10-year age stratum were assessed by hemagglutination inhibition (HI) and microneutralization (MN) assays for preexisting antibody to pH1N1 and recent seasonal H1N1 and H3N2 strains. In a separate birth cohort design defined by childhood influenza A/subtype priming (1919-1929: H1N1; 1945-1949: H1N1; 1958-1960: H2N2; 1969-1970: H3N2; 1978-1989: H3N2/H1N1), whole blood was collected from up to 50 volunteers per birth cohort. The ratio of Th1(IFN-γ):Th2(IL-10) cytokine responses was evaluated in vitro.
Antibody to seasonal viruses was highest in school-age children. Cross-reactive HI/MN antibody to pH1N1 was low among participants <70 years of age (yoa; 6%/4% ≥ 40), but seroprevalence increased at 70-79 yoa (27%/6%), increased even more at 80-89 yoa (65%/47%), and was highest at ≥90 yoa (88%/76%). CMI to pH1N1 was evident in all 5 birth cohorts but was lower compared with seasonal strains. There was little differentiation by subtype priming, but the Th1:Th2 ratio for all viruses dropped significantly in the 2 oldest cohorts.
Preexisting antibody may have protected the very old from pH1N1 infection, while diminished CMI may have contributed to greater severity once infected. In the young, cross-reactive pH1N1 antibody was mostly absent, while more intact CMI may have protected against severe outcomes.
The Journal of Infectious Diseases 01/2011; 203(2):158-67. DOI:10.1093/infdis/jiq039 · 6.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Before pandemic (H1N1) 2009, less than 10% of serum samples collected from all age groups in the Lower Mainland of British Columbia, Canada, showed seroprotection against the pandemic (H1N1) 2009 virus, except those from very elderly people. We reassessed this profile of seroprotection by age in the same region six months after the fall 2009 pandemic and vaccination campaign.
We evaluated 100 anonymized serum samples per 10-year age group based on convenience sampling. We measured levels of antibody against the pandemic virus by hemagglutination inhibition and microneutralization assays. We assessed geometric mean titres and the proportion of people with seroprotective antibody levels (hemagglutination inhibition titre ≥ 40). We performed sensitivity analyses to evaluate titre thresholds of 80, 20 and 10.
Serum samples from 1127 people aged 9 months to 101 years were obtained. The overall age-standardized proportion of people with seroprotective antibody levels was 46%. A U-shaped age distribution was identified regardless of assay or titre threshold applied. Among those less than 20 years old and those 80 years and older, the prevalence of seroprotection was comparably high at about 70%. Seroprotection was 44% among those aged 20-49 and 30% among those 50-79 years. It was lowest among people aged 70-79 years (21%) and highest among those 90 years and older (88%).
We measured much higher levels of seroprotection after the 2009 pandemic compared than before the pandemic, with a U-shaped age distribution now evident. These findings, particularly the low levels of seroprotection among people aged 50-79 years, should be confirmed in other settings and closer to the influenza season.
Canadian Medical Association Journal 10/2010; 182(17):1851-6. DOI:10.1503/cmaj.100910 · 5.96 Impact Factor