Note: NACI has not identified any preference between high-dose TIV and standard-dose QIV products. * Fluzone® High-Dose will be prioritized to patients in long term care homes and retirement homes but will also be available to hospitals and primary care providers. Persons 65 years and over may receive either high-dose TIV or standard-dose QIV
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In older adults, influenza vaccine effectiveness is roughly half of that in healthy adults. Due to progressive weakening of the immune system High-dose inactivated influenza vaccine (IIV3-HD) • FLUZONE® High-Dose • TIV containing 4x the dose of regular influenza vaccines for adults aged 65+ There is insufficient evidence to make comparative individual-level recommendations on the use of IIV3-Adj or IIV4-SD over IIV3-SD or among IIV3-Adj, IIV3-HD, and IIV4-SD
Over half of Canadians age 65+ reported having AT LEAST one of the following high-risk conditions • Asthma • Cancer • COPD • Diabetes • Obesity • Heart disease • Stroke
Halton Region http://webaps.halton.ca/forms/mailchimp/influenza.cfm PHO https://www.publichealthontario.ca/en/data-and-analysis/infectious-disease/respiratory-pathogens-weekly Health Canada https://www.canada.ca/en/public-health/services/diseases/flu-influenza/influenza-surveillance/weekly-influenza-reports.html
Youth vaping is an emerging public health concern
Youth who vape are up to five times more likely to initiate tobacco smoking
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Halton Public Health Department is providing the following vaping resources and services to our community: General information about vapes and vaping is available on our website, Halton.ca Curriculum and resources for schools to use to address the topic of vaping Development of a youth vaping prevention communication campaign, “Use Your Instincts”, that is planning to be implemented later this fall
29%
2017
37%
2018International Tobacco Control Policy Evaluation Project, 2019
Canadian youth (aged 16-19) using
vaping products have
increased significantly
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We know that vaping product use is growing rapidly throughout North America, especially among youth. In just one year, the percentage of Canadian youth having ever-used a vaping product increased from 29% to 37% (Hammond, D. et al, 2019). Local data on vaping product use in Halton is currently limited, especially among youth. A 2016 report found that 8% of Halton adults (18+) had ever used a vaping product, with the highest use among young adults 18-24. In 2017, 21% of high school students in the Mississauga Halton LHIN reported using an electronic cigarette in the past year (Ontario Student Drug Use and Health Survey, 2017). School partners in Halton have anecdotally reported a significant increase in vaping product use.
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Vaping Products
Image: Steve Neavling
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Presentation Notes
Vaping products have changed significantly since they entered the market around 2007. These products are often referred to as e-cigarettes, vapes or vapourizers. In general, vaping products operate similarly; using battery power to heat an e-liquid that produces an aerosol. These products continue to change rapidly and vary widely in their look and size. Some are made to look like regular cigarettes or pipes, while some resemble USB sticks and other everyday items. E-liquids are usually flavoured and often contain different levels of nicotine, which is highly addictive. Some mixtures have more nicotine than in a typical tobacco cigarette. E-liquids that include others substances, such as cannabis, can also be used in vaping products. There are over 460 brands of vapour devices (each with its own website) and over 7,000 unique flavours of e-juices available for purchase. Newer vapour products are more diverse in their design, sometimes resembling common items such as pens, flashlights, or computer flash drives making them appear trendy and easy to conceal. Popular e-juices include fruit and candy flavours, which appeal to children and youth. Availability of flavours is one of the most frequently reported reasons for vaping in youth, followed by low perceived harm compared to other tobacco products.
• In the USA as of October 1, 2019, a total of 1,080 lung injury cases and 15 deaths associated with vaping have been reported to CDC from 48 states and 1 U.S. territory
• Approximately 80% of patients are under 35 years old– 16% of patients are under 18 years old– 21% of patients are 18 to 20 years old
• Two cases in Canada to date– One confirmed case in Quebec– One possible case in Middlesex-London– No deaths reported
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Vaping-Related Severe Pulmonary Disease
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On Sept. 4, 2019, Health Canada released a safety alert advising Canadians who use vaping products to monitor themselves for symptoms of pulmonary illness (e.g., cough, shortness of breath, chest pain) and to seek medical attention if they have concerns about their health. The caution follows recent cases of severe pulmonary illnesses and deaths potentially linked to the use of e-cigarettes in the United States. While the source of the illness remains unclear, the U.S. CDC reports that chemical exposure from vaping is the likely cause. On Sept. 18th, the first case of severe pulmonary disease linked to vaping was confirmed in Canada. Deputy Premier and Minister of Health, Christine Elliott issued a Minister’s Order under the Health Protection and Promotion Act requiring public hospitals in Ontario to provide the Chief Medical Officer of Health with statistical, non-identifying information related to incidences of vaping-related severe pulmonary disease. It’s important to note that while there are significant risks associated with vaping, it is currently believed that vaping is less harmful than smoking (these products may reduce some health risks for smokers who can’t or don’t want to quit using nicotine but should not be used by those who do not use combustible cigarettes). Health Canada advises that non-smokers, people who are pregnant and young people should not vape.
• Ask all patients about their use of e-cigarettes or vaping products as part of routine care
• Ask all patients who report e-cigarette or vaping product use within the last 90 days about signs and symptoms of pulmonary illness– Symptoms may include shortness of breath, cough, chest pain,
with or without vomiting, diarrhea, abdominal pain, and fever
• In Ontario at this time, family physicians are not under obligation to report but public hospitals are required to provide the Chief Medical Officer of Health with statistical, non-identifying information for cases that meet case definition
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Advice to Physicians
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According to the CDC’s investigation, features of vaping-related SPD may include: Respiratory symptoms such as non-productive cough, pleuritic chest pain, and shortness of breath; Systemic signs/symptoms such as tachycardia, fever, chills or fatigue; Gastrointestinal symptoms such as nausea/vomiting, abdominal pain, and diarrhea; and Abnormal radiographic findings such as infiltrates on chest x-ray and ground glass opacities on CT scan In the interim, physicians could apply the principles of screening, brief intervention and referral (SBIR) and consider vaping as general “substance use”. This would involve screening universally for use, then assessing frequency and “amount” of use. However, because the fluids and e-cigarettes are not regulated, it is difficult to determine the degree of nicotine dependence, although it can be assumed that the patient has some nicotine addiction. Use smoking cessation billing codes for vaping cessation counselling as it is for nicotine cessation CAMH coming up with nicotine practice guidelines (March 2020) – vaping and smoking are a medium of consuming nicotine Refer the patient to public health and we will guide them to appropriate counselling services.
Vaping Related Severe Pulmonary Disease
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Smokers’ Helpline replaced by Telehealth Ontario for cessation servicesPatients looking for support to quit tobacco and vaping can contact Telehealth Ontario for support. Effective October 1, 2019
Public health will continue to monitor evidence on effective cessation approaches for vaping and will update you as evidence emerges.
In Canada, the animals that most often transmit rabies are bats, skunks, raccoons, and foxes. Small rodents and reptiles do not transmit rabies.
RABIES
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Rabies is a viral disease that attacks the central nervous system of mammals, including humans. Once clinical signs appear, rabies is almost always fatal in animals and people.
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Rabies response and prevention in Ontario is a joint effort involving members of the public, Public Health, veterinarians, the Ministry of Health and Long-Term Care (MOHLTC), the Ministry of Agriculture Food and Rural Affairs (OMAFRA) and the Ministry of Natural Resources and Forestry (MNRF) and Canadian Food Inspection Agency (CFIA). Image Retrieved from: The Rabies Reporter The Ministry of Natural Resources and Forestry MNRF Publication 51709, Volume 29, Issue 2 July–December 2018 A case of rabies detected in a skunk in King City was confirmed by the Canadian Food Inspection Agency as bat strain rabies (not included on map or in totals below). We are currently at 468 cases of raccoon strain, and 21 cases of fox strain rabies in Ontario to date (since December 2015) Number of DRIT tests: >3,300 Number of baits distributed: >950,000
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As shown in Figure 1, the incidence of rabies in the wild and domestic animal populations had decreased significantly in Halton Region since 1990, due to successful aerial baiting implementation in 1989. However, due to the re-introduction of raccoon stain rabies in Ontario in 2015, the incidence of rabies cases in Halton increased in 2016 and continued to increase in 2017. In 2018 there were no positive raccoon strain cases identified. However, one positive bat was reported in Burlington. As of September 2019, 4 rabies positive animals (bats) have been reported in Halton in 2019.
• Calculate the dose of RabIg (20 IU/kg body weight) and infiltrate as much of the calculated dose as possible around the wound(s)
• DO NOT inject the remaining RabIg at a separate site IM
• If there is no visible wound, then give the entire RabIg dose IM
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RabIg-Sparing Protocol This protocol relates to the use of RabIg. Treatment of any wounds (thorough cleaning, flushing, antibiotics, analgesics, tetanus vaccination etc.) and the administration of rabies vaccines should follow normal protocols. 1. Calculate the dose of RabIg (20 IU/kg body weight) and the number of vials required for this dose. 2. Draw up one vial at a time in order to save any unopened vials that you don’t use. 3. Infiltrate as much of the calculated dose as possible around the wound(s) or site of exposure (if a bite or scratch is not evident). Note: Infiltration of wounds with RabIg in some anatomical sites (finger tips) must be carried out with care in order to avoid increased pressure in the tissue compartment. When more than one wound exists, each wound should be locally infiltrated with a portion of the RabIg using a separate needle and syringe. In such instances, the RabIg can be diluted in a diluent permitted by the specific product labelling in order to provide the full amount of RabIg required for thorough infiltration of all wounds..2 4. If the entire calculated dose of RabIg cannot anatomically be infiltrated around the wound(s) or site of exposure, do NOT give the remainder of the dose IM. Save any unopened vials for use in another case. 5. For situations that are not clear, the attending healthcare provider makes the final decision regarding the administration of RabIg, along with input from the Medical Officer of Health
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Awareness poster from The City of Hamiltonhttps://www.cbc.ca/news/canada/hamilton/hamilton-hopes-these-strange-creatures-make-you-more-aware-of-rabies-risks-1.3782285
Call and fax Halton Region
Health Department as soon as possible
to report any exposure.
call311
fax905-825-8791
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The Health Protection and Promotion Act requires you to report information concerning any animal bite or other animal contact that may result in rabies in your patients. Public Health is working on a reporting form that can be used by physicians to report animal exposures
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Immunization Update
High School Suspension and Elementary Suspension – 2019-2020
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Elementary Suspension2010-2012 birth years
High School Suspension2002-2005 birth years 2019
Early OctoberStudents mailed notices requesting updated immunization records be provided
Mid November
Second notice mailed requesting updated immunization records be provided
Second notice mailed requesting updated immunization records be
provided
Early January
Suspension orders delivered to schools and mailed to students who do not have up-to-date immunizations
Early February – Early March
Suspension period for students who still do not have up-to-date immunization records
Mid FebruarySuspension orders delivered to
schools and mailed to students who do not have up-to-date immunizations
Suspension period for students who still do not have up-to-date
immunization records
Late March – Late April
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This timeline provides an overview of some of the key activities in the Immunization of School Pupils Act enforcement process plans for the 2019-2020 school year.
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HPV4 TO HPV 9As of March 2019, HPV4 no longer available
Finish series started with HPV4 with the equivalent number of doses of HPV9
Age at first dose # doses of HPV4 given # doses of HPV9 needed
< 15 years
1 1
2 (given < 6 months apart) 1
2 (given > 6 months apart) 0
15 + years
1 2
2 1
3 0
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Do not restart a series Only PF for the recommended total number of doses. Will have full protection against 6, 11, 16 and 18 but not for the additional 5 strains in HPV9 NACI does not recommend population wide re-starting of a series. This will be an individual decision based on the conversation between provider and client. PF schedule will only provide the required number of doses.
Ordering MenC-ACYW135 (Menactra®)www.halton.ca/physicians• Required for all students in Grades
7 – 12 under ISPA
• Available in community clinics
• Providers can order for students in Grades 8 – 12 who missed in school
• Students in Grade 7 - school clinics are not offered until January / February 2020
Physicians MUST report suspected or confirmed cases to the Halton Regional Medical Officer of Health.
Diseases of Public Health Significance
Duty to Report
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Certain diseases need to be reported to the local Medical Officer of Health. Formerly known as “reportable diseases” they are now referred to as Diseases of Public Health Significance or DOPHS. Reports should include suspect and confirmed cases. Ontario's Health Protection and Promotion Act (HPPA)(external link) creates a legal duty for physicians and other healthcare professionals/practitioners, laboratories, and hospital administrators to report specified diseases to the Medical Officer of Health. These reporting duties are reinforced by the College of Physicians and Surgeons of Ontario.(external link) The following slide lists the diseases of public health significance. Information available on halton.ca.
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Diseases of Public Health Significance
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These reports are useful in many ways, including assurance of provision of appropriate medical therapy (e.g., for tuberculosis), isolation requirements, contact management, detection of common-source outbreaks (e.g., in food-borne outbreaks), and planning and evaluating prevention and control programs (e.g., for vaccine-preventable diseases). Diseases with asterisk are to be called immediately to MOH by calling 311, others can be reported next business day. The rationale for immediate reporting is generally because the disease has time sensitive actions that public health needs to follow-up on i.e. chemoprophylaxis for contacts. If in doubt, report.
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TestingResources
Please refer to PHL for details about specific diseases.
You can also c a l l 3 1 1 to speak to a public health inspector or nurse who can help you get the information you need
P u b l i c H e a l t h L a b o r a t o r i e s a t a G l a n c e
Find information on:• Test information Index• Test requisitions• Test Results
Public Health Lab website provides information on testing for DOPHS including specimen collection and handling, test methods, and test frequency and turnaround time. They also provide link to public health lab requisitions you can use and an ordering form for test kits.
Missing clinical information such as on-set date (i.e. pulmonary
tuberculosis) or reason for testing (chickenpox or shingles)
Testing is done but wrong test ordered or it was done with the wrong testing kit
i.e. pertussis swab
Missing or in-correct patient information
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Information on the public health lab requisitions is very useful. For example, with varicella zoster it would be useful to indicate if you were testing for shingles or chickenpox as chickenpox is reportable to health department and requires follow-up. When testing is done using the wrong kit it will not be tested by the lab. For example, if testing for pertusiss is done with wrong kit i.e. viral respiratory kit versus one for borderella pertussis. Getting someone to return to health care office for re-testing using correct specimen type is often unsuccessful. Please complete all demographic fields of the requisition, such as: the patient’s full name, date of birth, Health Card Number, source of specimen, date of onset, date of collection, physician name and address, and clinical diagnosis.
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Periods of Exclusion
Children with the following diseases should remain home and away from others:
DiseaseChicken pox (Varicella)
Period of Exclusion• Children with mild chickenpox can attend child care regardless of the state of their rash,
as long as they feel well enough to participate in all program activities
Diarrhea • Daycare: Until 24 hours after diarrhea stops• Schools: Until diarrhea stops
Fifth's Disease (Parvovirus) • No exclusion• Children well enough to participate in all activities can attend school
Impetigo • Until the antibiotic prescribed by a doctor has been taken for at least 24 hours and they feel well enough to participate
Periods of Exclusion for common childhood illness can be found on our website (source Canadian Paediatric Society). For DOPHS the health department may recommend additional isolation and exclusions for the ill person and/or their contacts as needed (i.e. per ID protocol). For example, a health care worker who does not have proof of immunity and has an exposure, may be asked to stay off work from 5 days after the first exposure and up to 21 days after the last exposure, or until the individual is:3 • Adequately immunized according to age (further description below); or • Demonstrates laboratory confirmation of immunity; or • Has received immune globulin.
Halton Region Health Department will be hosting our annual CME on the evening of March 24, 2020. Learn about opioids, vaping and cannabis in Haltonand how you can support your patients. CME will be available in-person and by webcast. Registration details to follow.
