Danielle Grenier

Beyond counting cases: Public health impacts of national paediatric surveillance units

Paediatric Surveillance Units (PSUs) have been established in 14 countries and facilitate national, prospective, active surveillance for a range of conditions, with monthly reporting by child health specialists. The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and facilitates international collaboration among member PSUs and allows for sharing of resources, simultaneous data collection and hence comparison of data from different geographical regions. The impact of data collected by PSUs, both individually and collectively as members of INoPSU, on public health outcomes, clinical care and research is described.

Clinical Characteristics of Pediatric Myasthenia: A Surveillance Study

OBJECTIVE: To evaluate the incidence, clinical features, diagnostic, and treatment trends of pediatric myasthenia in Canada. METHODS: Through established Canadian Pediatric Surveillance Program methodology, physicians were anonymously surveyed for cases of pediatric myasthenia using a standardized clinical questionnaire containing deidentified data. Inclusion criteria were any child <18 years old with ≥1 of the following: (1) fluctuating ptosis or extraocular weakness, (2) skeletal muscle weakness or fatigue, and (3) any of the following supportive tests: clinical response to acetylcholinesterase inhibitor, positive antibodies, abnormal slow repetitive nerve stimulation, or single-fiber electromyography. RESULTS: In 2 years of surveillance, 57 confirmed cases were reported. There were 34 generalized and 18 ocular reports of juvenile myasthenia gravis plus 5 congenital myasthenic syndrome cases. There were 14 incident cases in 2010 and 6 in 2011. Age of onset ranged from “birth” to 17 years for the generalized form compared with 18 months to 11 years for the ocular subtype. Positive acetylcholine receptor titers were found in 22 (67%) of 33 generalized cases and 8 (44%) of 18 ocular patients. Of patients started on pyridostigmine, improvement was noted in 33 (100%) of 33 generalized cases and 15 (88%) of 17 ocular cases. CONCLUSIONS: This study represents the largest descriptive series of pediatric myasthenia in North America and provides valuable information about clinical characteristics. A high index of suspicion is important for this treatable disease. Children generally respond promptly to readily available therapies.

The Canadian Paediatric Surveillance Program: a framework for the timely data collection on head injury secondary to suspected child maltreatment.

The extent and nature of head injury secondary to child maltreatment in Canada is inadequately understood. These cases, although reasonably rare, are of great clinical importance as a large proportion of them result in death or permanent neurologic deficits. Internationally, published incidence data may underestimate the extent of the problem because of the failure of professionals to recognize and report inflicted head injury. National data on head injury secondary to suspected child maltreatment can inform educational efforts for early detection, guide prevention strategies, and be a foundation for the development of policies and programs to effectively address the needs of victims and their families. The Canadian Paediatric Surveillance Program is described as a system for active surveillance of uncommon high-impact conditions and is ideally suited to the collection of data on head injury secondary to child maltreatment.

Respiratory syncytial virus infections in pediatric transplant recipients: A Canadian Paediatric Surveillance Program study

The incidence and spectrum of severity of RSV infections in SOT or HSCT recipients is not known. From September 2010 through August 2013, pediatricians were surveyed monthly by the CPSP for SOT or HSCT recipients with RSV infection within two yr post‐transplant. There were 24 completed case report forms that fit the inclusion criteria (10 HSCT and 14 SOT recipients). Six of 24 cases (25%) remained outpatients, and 11 (46%) were managed on an inpatient ward, while seven (29%) required intensive care of which five required mechanical ventilation and two died of RSV infection. Ten of 23 cases (43%) were nosocomial with these data not recorded for one case. Many transplant recipients recover uneventfully from RSV infection in the first two yr post‐transplant. However, severe disease and death also occur. Larger studies are required to establish risk factors for poor outcomes. Prevention of nosocomial RSV should be a priority in transplant recipients.

Canadian Allergists' and Nonallergists' Perception of Epinephrine Use and Vaccination of Persons with Egg Allergy

BACKGROUND Studies suggest knowledge gaps about epinephrine use and vaccination of persons with egg allergy. OBJECTIVE We compared the perception of Canadian allergists and nonallergists on issues related to epinephrine use and vaccination of persons with egg allergy. METHODS Canadian allergists, pediatricians, general practitioners/family physicians and emergency room physicians were recruited through medical associations and surveyed on these issues. Multivariate logistic regression models were used to identify determinants of specific responses. RESULTS One-hundred fourteen allergists and 613 nonallergists participated. For most issues with accepted best practices, allergists were more likely to adhere to recommendations. Allergists versus nonallergists were more likely to recommend intramuscular epinephrine for anaphylaxis (odds ratio [OR] = 3.8; 95% CI, 1.43-10.11). Older physicians (OR = 0.98; 95% CI, 0.97-0.99), Canadian-Paediatric-Surveillance-Program participants (OR = 0.48; 95% CI, 0.24-0.96), family physicians (OR = 0.39; 95% CI, 0.16-0.96), and general practitioners (OR = 0.14; 95% CI, 0.04-0.52) were less likely to recommend intramuscular use. However, in severe anaphylaxis, >25% of both groups would not give epinephrine for patients presenting with breathing difficulties or hypotension. Use of epinephrine for severe anaphylaxis was less likely in older physicians (OR = 0.97; 95% CI, 0.95-0.99), female physicians (OR = 0.60; 95% CI, 0.39-0.89), and those practicing in Ontario (OR = 0.56; 95% CI, 0.36-0.86), Manitoba (OR = 0.42; 95% CI, 0.19-0.90), or Nova-Scotia (OR = 0.31; 95% CI, 0.12-0.78). Allergists (OR = 6.22; 95% CI, 3.60-10.72) and physicians treating mainly children (OR = 3.41; 95% CI, 1.87-6.25), or practicing in Quebec (OR = 1.68; 95% CI, 1.12-2.55) were more likely to recommend measles-mumps-rubella vaccination in a community facility. CONCLUSION Knowledge gaps about mode and indications for epinephrine administration and vaccination policies need to be addressed in future education programs to ensure prompt epinephrine use and to avoid unnecessary restriction of vaccines.

Performance of acute flaccid paralysis surveillance compared with World Health Organization standards.

To compare acute flaccid paralysis (AFP) surveillance systems used by members of the International Network of Paediatric Surveillance Units (INoPSU) across the five AFP surveillance performance indicators recommended by the World Health Organization (WHO) for the maintenance of polio‐free certification.

52 Paediatric Neurological Diseases: What Does Active Canadian Surveillance Tell Us?

Background Paediatric neurological diseases individually are rare; however, collectively affect thousands of children and have life-long impacts. The incidence of many of these is not readily available, and yet essential for improving clinical care, advocacy and health service planning. Aims To obtain/examine national population-based data, in a timely manner, on acute flaccid paralysis (AFP), progressive intellectual and neurological deterioration (PIND), acquired demyelinating syndromes of the central nervous system (ADS), congenital myotonic dystrophy (CMD) and paediatric myasthenia (PM). Methods Studies were conducted through the Canadian Paediatric Surveillance Program, a network of >2,500 paediatricians, reporting cases monthly according to preset protocols. Confidentiality is mandatory; studies receive ethical approval. Results The AFP study, with 657 cases in 15 years, affirms that Canada is free of wild-type poliovirus. The PIND study demonstrated several genetically defined neurodegenerative disorders, and only one case of iatrogenic Creutzfeldt-Jakob disease. A yearly incidence of 0.9 per 100,000 was estimated to affect Canadian children during the ADS study, with optic neuritis being the most common presentation. Awareness of multiple sclerosis as a possible outcome of ADS increased remarkedly. Of 38 confirmed CMD cases in six years, 61% were index cases for families. In year one of surveillance, 33 cases of PM were confirmed; almost half not having elevated titers of acetylcholine receptor antibodies, and 21% having other co-existing or familial immune disorders. Conclusion Active national surveillance has more reliably characterized several rare neurological disorders and their associated burdens, supporting and informing the development of medical and public health interventions.