Aboriginal Ethnicity Research Articles

Paediatric community‐associated Staphylococcus aureus: A retrospective cohort study

We aimed to characterise the demographic and clinical features of paediatric community-associated Staphylococcus aureus (CA-SA) infection. We aimed to identify factors associated with methicillin-resistant S.aureus (MRSA) infection evident at the point of care with the potential to guide antibiotic choice. A retrospective chart review in 2008 of CA-SA infections at the Children's Hospital at Westmead (CHW), a 300-bed tertiary paediatric hospital in western Sydney, Australia. We calculate rates of MRSA and perform univariate and multivariate analysis for predictors of MRSA. Of 431 patients with CA-SA infections, 19.3% were MRSA. In univariate analysis, MRSA was predicted by age greater than 1 year, Aboriginal race, rural/regional residence, previous history of skin and soft tissue infection (SSTI) or a family history of SSTI, at least 48 h of antibiotics active against methicillin-sensitive S.aureus (MSSA), invasive infection and abscess formation. In a multivariate analysis factors that independently predicted MRSA in the entire cohort, and in the non-invasive subgroup included abscess formation, a family history of staphylococcal infection or SSTI, Aboriginal ethnicity, at least 48 h of anti-MSSA antibiotics at presentation, presentation during spring and age greater than 1 year. One fifth of CA-SA infections at our tertiary paediatric hospital in 2008 were MRSA. Several clinical and demographic factors evident at the point of care were highly significant predictors of CA-MRSA infection.

Association between ethnicity and human leukocyte antigen (HLA) alleles on late presentation to care and high rates of opportunistic infections in patients with HIV

Within Manitoba, Aboriginal people make up 15% of the province’s population, but accounted for 53% of new human immunodeficiency virus (HIV) diagnoses in 2011. For over a decade, research has linked the human leukocyte antigen (HLA) class I alleles as having both protective and harmful effects in HIV disease progression. The abundance of HLA alleles that predispose to rapid disease progression, together with the rarity of protective HLA allele types, may be a contributing factor to a more rapid disease progression amongst individuals of Aboriginal ethnicity. We completed an epidemiological study on all HIV patients new to care in the Manitoba HIV Program in 2010, looking at markers of disease severity, such as CD4 cell count, rates of opportunistic infections (OI), and HLA type. In this cohort, the Aboriginal population was overrepresented, and presented with significantly more advanced HIV infection (lower CD4 counts, higher rates of OI), compared to patients from a Caucasian background. Our data supports previously identified associations between HLA type and disease progression, and demonstrates a difference in distribution of HLA type by ethnicity. Key words: Aboriginal, disease progression, ethnicity, HLA B27, HLA B35, HLA B51, HLA B5701, human immunodeficiency virus, human leukocyte antigen, opportunistic infection.

Type 2 Diabetes in Aboriginal Peoples

Type 2 Diabetes in Aboriginal Peoples

Incidence and Predictors of Hospitalization for Bacterial Infection in Community-Based Patients with Type 2 Diabetes: The Fremantle Diabetes Study

BackgroundThe few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.Methods and FindingsWe studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).ConclusionsThe risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Prevalence and key covariates of non‐medical prescription opioid use among the general secondary student and adult populations in Ontario, Canada

To assess the prevalence and key covariates of non-medical prescription opioid use (NMPOU) in two representative surveys of adults (Centre for Addiction and Mental Health Monitor, CM) and secondary-school students (Ontario Student Drug Use and Health Survey, OSDUHS). Data from the 2010 and 2011 cycles (n = 4023) of CM--a stratified, multi-stage, random-digit-dialling telephone survey of adults (18 years and older)--and the 2011 cycle of OSDUHS (n = 3266)--a self-administered written questionnaire-based survey of grade 7-12 public system students--were used. Besides NMPOU prevalence, associations were assessed by univariate and multi-step multivariate (logistic regression) analyses. NMPOU and key socioeconomic (i.e. sex, age, Aboriginal ethnicity, household location, income, subjective social status), health indicators (physical health status, psychological distress, suicidal ideation), drug use (cigarette smoking, binge drinking, cannabis use, other drug use) were measured. NMPOU (past year) prevalence was 15.5% in students and 5.9% in adults. Various univariate associations with social, health and drug use factors were found in both populations, with differences by sex. Based on multivariate analyses, other drug use (male students) and rural residence, subjective social status, other drug use and suicidal ideation (female students); marital status and cannabis use (male adults) and binge drinking (female adults) were independently associated with NMPOU in the respective study populations. NMPOU was high in adults and especially students. Independent predictors of NMPOU were largely inconsistent by sex. Notably, NMPOU is widely distributed across socio-demographic and -economic strata, and thus requires broad-based interventions.

Results of the Computerized Mental Health Screening System for Female Offenders

Objective: To estimate the proportion of incoming female offenders in the Canadian federal correctional system requiring mental health services based on results of a Computerized Mental Health Intake Screening System (CoMHISS). Method: Consecutive admissions to the five regional women’s prisons in the Correctional Service of Canada were approached to consent to participate in the CoMHISS. The screening process combines two psychological self-report measures, the Brief Symptom Inventory, and the Depression Hopelessness and Suicide Screening Form. Results were analyzed based on the percentage of women who met established cut-off scores on the measures and further analyzed by Aboriginal ethnicity. Results: Sixty-two percent of the sample reported elevated levels of psychological distress that would warrant further assessment. Although higher for Aboriginal women, the mean scores did not differ significantly from those of non-Aboriginal women. The rate of co-occurring substance abuse among women reporting psychological distress was estimated at 70%. Conclusions: Planning for the delivery of mental health services for federally sentenced women should consider their high rates and variety of psychological problems. Specific correctional treatment planning requires attention to criminogenic needs as well as mental health issues and serious substance abuse problems. Mental health providers for women in prison should be aware of the significant likelihood of co-morbid substance abuse disorders and mental health problems and prepare women to identify follow up services to address these problems on release.

Ethnic and gender differences in rates of congenital adrenal hyperplasia in Western Australia over a 21 year period

To evaluate the incidence, sex distribution, ethnicity, age at diagnosis, clinical presentation and morbidity of all childhood-onset congenital adrenal hyperplasia (CAH) cases in Western Australia (WA) between 1990 and 2010, a state where newborn screening for CAH is not in place. The total number of all known CAH cases was identified. Case files were reviewed retrospectively to determine clinical details. Classical CAH (C-CAH) was defined as patients presenting before 6 months of age and non-classical (NC-CAH) as presenting after 6 months. Of the 41 CAH cases (26 female) born in WA, 5(12.2%) were of Aboriginal ethnicity. CAH was due to 21-hydroxylase deficiency in 40 cases. Of those with 21-hydroxylase deficiency, 37 were C-CAH (25 female) and 3 NC-CAH (all male). The incidence of C-CAH in WA was estimated to be 0.67 per 10, 000 live births (1:14, 869). The incidence rate ratio of Aboriginal compared with non-Aboriginal C-CAH was 2.45 (95% confidence interval 0.96-6.29). The mean age of diagnosis of C-CAH cases was lower in females (8.9 ± 2.5 days) compared to males (23.4 ± 9.8 days). Among these males, 72.7% presented initially with adrenal crisis. The estimated incidence of classical CAH is similar to composite worldwide data. The increased female-to-male ratio is not in keeping with the expected sex distribution seen in a recessively inherited disease. The delayed diagnosis in males, with a significant proportion presenting with adrenal crisis, could be avoided with newborn screening. The higher rate of CAH in patients with Aboriginal ethnicity is a novel observation.

Distribution of human papillomavirus types, cervical cancer screening history, and risk factors for infection in Manitoba

We conducted a study to investigate the prevalence of human papillomavirus (HPV) infections in an opportunistic sample of women in Manitoba, Canada. We inquired about risk factors associated with HPV infections and linked the HPV typing results with the cervical cancer screening history of the participants. The study population included 592 women attending Papanicolaou (Pap) test clinics. After signing a consent form, participants were given a self-administered questionnaire on risk factors and received a conventional Pap test. Residual cells from the Pap tests were collected and sent for HPV typing. The mean age of the population was 43 years. A total of 115 participants (19.4%) had an HPV infection, 89 of whom had a normal Pap test. Of those who were HPV-positive, 61 (10.3%) had high-risk (Group 1) HPV. HPV-16 was the most prevalent type (15/115: 13.0% of infections). The most consistent risk factors for HPV infection were young age, Aboriginal ethnicity, higher lifetime number of sexual partners and higher number of sexual partners in the previous year. The prevalence of HPV types in Manitoba is consistent with the distributions reported in other jurisdictions. These data provide baseline information on type-specific HPV prevalence in an unvaccinated population and can be useful in evaluating the effectiveness of the HPV immunization program. An added benefit is in the validation of a proof of concept which links a population-based Pap registry to laboratory test results and a risk behaviour survey to assess early and late outcomes of HPV infection. This methodology could be applied to other jurisdictions across Canada where such capacities exist.

Examining the Association Between Neighbourhood Characteristics and Gonorrhea Rates Among Women Aged 15 to 24 Years in Montreal, Canada

The reported incidence rate of gonorrhea has more than doubled from 2000 to 2010 in Montréal, increasing in both sexes and all age groups; however, the increase was particularly high in females aged 15 to 24 years. As the reasons for this increase among young women are not fully understood, we wanted to determine whether neighbourhood-level population characteristics were associated with incidence rates in this group, to help target intervention strategies.Incident gonorrhea cases were female residents of Montréal aged 15 to 24 years who met Québec's gonorrhea surveillance definition, with a notification date from 2002 to 2009. Adjusted incidence rate ratios (IRR) were estimated by negative binomial regression and show the change in the incidence of gonorrhea for each unit increase in neighbourhood-level independent variables, which included material and social deprivation indices (plus the latter's combination and components) and ethnic origin. In the final model, independent variables were normalized to facilitate comparison of their respective IRRs.A total of 837 cases were reported (cumulative incidence rate 5.6 per 100,000). Higher proportions of persons of African, Aboriginal and Caribbean ethnicity were associated with higher rates of gonorrhea, even after adjustment for deprivation indices.Customary methods for gonorrhea surveillance consider individual characteristics of cases as risk factors for disease. However, our results show that gonorrhea is clustered in neighbourhoods that have high proportions of three ethnic origin groups. Findings from this ecological approach suggest that although ethnicity may be strongly correlated with socio-economic status, there are factors in ethnicity that transcend poverty.

Examining the association between neighbourhood characteristics and gonorrhea rates among women aged 15 to 24 years in Montreal, Canada.

The reported incidence rate of gonorrhea has more than doubled from 2000 to 2010 in Montréal, increasing in both sexes and all age groups; however, the increase was particularly high in females aged 15 to 24 years. As the reasons for this increase among young women are not fully understood, we wanted to determine whether neighbourhood-level population characteristics were associated with incidence rates in this group, to help target intervention strategies. Incident gonorrhea cases were female residents of Montréal aged 15 to 24 years who met Québec's gonorrhea surveillance definition, with a notification date from 2002 to 2009. Adjusted incidence rate ratios (IRR) were estimated by negative binomial regression and show the change in the incidence of gonorrhea for each unit increase in neighbourhood-level independent variables, which included material and social deprivation indices (plus the latter's combination and components) and ethnic origin. In the final model, independent variables were normalized to facilitate comparison of their respective IRRs. A total of 837 cases were reported (cumulative incidence rate 5.6 per 100,000). Higher proportions of persons of African, Aboriginal and Caribbean ethnicity were associated with higher rates of gonorrhea, even after adjustment for deprivation indices. Customary methods for gonorrhea surveillance consider individual characteristics of cases as risk factors for disease. However, our results show that gonorrhea is clustered in neighbourhoods that have high proportions of three ethnic origin groups. Findings from this ecological approach suggest that although ethnicity may be strongly correlated with socio-economic status, there are factors in ethnicity that transcend poverty.

895 HEPATITIS C VIRUS SPECIFIC T LYMPHOCYTES RESPONSE INDUCED BY DENDRITIC CELL LOADED WITH NOVEL IDENTIFIED HLA-A2 RESTRICTED HEPATITIS C VIRUS EPITOPE PEPTIDES

3 ) is a collaboration of nine cohort studies from Australia, Europe and North America. Data on HCV seroconversion among IDUs between 1986 and 2009 were included. Inclusion criteria were: history of IDU, documented anti-HCV seroconversion within a two-year period and minimum of two therapy-naive HCV RNA assessments following the estimated date of seroconversion. We estimated the proportion with spontaneous clearance during the first two years following infection and identified factors associated with clearance using logistic regression. Results: Among 517 with incident HCV infection (173 females), HCV genotype (G) prevalence was: G1, 49%; G2, 6%; G3, 30%; G4, 1%; G6, 1%; mixed genotypes, 2% and unknown genotypes, 11%. The prevalence of IL28B genotypes was 50% CC, 37% CT and 12% TT (n = 406). Spontaneous clearance was observed in 26% (136 of 517). Spontaneous clearance was higher among females (38% vs. 21% males, P< 0.001) and among those with favorable CC IL28B genotype (37% vs. 24% CT/TT, P = 0.005). Among females with IL28B (n = 131), the proportion with spontaneous clearance was 58% in those with favorable CC genotypes as compared to 27% in those with unfavorable CT/TT genotypes (P = 0.002). In unadjusted analysis, factors associated with spontaneous clearance included female sex, Aboriginal ethnicity, no recent IDU and favorable CC IL28B genotype (vs. CT/TT). In adjusted analysis, female sex (AOR 2.66; 95% CI: 1.69, 4.18; P< 0.001) and favorable CC IL28B genotype (vs. CT/TT: AOR 2.03; 1.30, 3.19; P = 0.002) were independently associated with spontaneous clearance. The interaction between female sex and IL28B was assessed, but not significant. Conclusions: Female sex and IL28B genotype are independently associated with spontaneous clearance during acute HCV. Delayed therapeutic intervention during acute HCV infection could be recommended for females with favorable IL28B genotypes to allow time for spontaneous clearance.

Comparison of late HIV diagnosis as a marker of care for Aboriginal versus non-Aboriginal people living with HIV in Ontario.

Studies have found that Aboriginal people living with HIV/AIDS (APHAs) are more likely than non-APHAs to receive suboptimal HIV care, yet achieve similar clinical outcomes with proper care. To compare the proportions of individuals diagnosed late with HIV between APHAs and non-APHAs within the Ontario HIV Treatment Network Cohort Study (OCS). The analysis included OCS participants who completed the baseline visit by November 2009. Two definitions of the outcome of late HIV diagnosis were used: the proportion of participants with an AIDS-defining illness (ADI) before or within three months of HIV diagnosis; and the proportion of participants with a CD4(+) count <200 cells/mL at diagnosis. Logistic regression analysis was used to assess the association between Aboriginal ethnicity and late HIV diagnosis. APHAs were more likely to be female and have lower income, education and employment. No statistically significant differences were noted in the proportions receiving a late HIV diagnosis defined by ADI (Aboriginal 5.2% versus non-Aboriginal 6.3%; P=0.40). Multivariate logistic regression analysis revealed a significant association between Aboriginal ethnicity and late HIV diagnosis defined by CD4(+) count after adjusting for age and HIV risk factor (OR 1.55; P=0.04). APHAs were more likely to have a CD4(+) count <200 cells/mL at diagnosis but had similar clinical outcomes from late diagnosis when defined by ADI. However, differences may be underestimated due to recruitment limitations and selection bias. Additional work is needed to address the socioeconomic and health care needs of APHAs.

The persisting burden of invasive pneumococcal disease in HIV patients: an observational cohort study

BackgroundThe increasing use of highly active antiretroviral therapy (HAART) and pneumococcal immunization along with shifting community exposures may have altered the burden of Streptococcus pneumoniae disease in HIV-infected persons. We describe the burden and risk factors for pneumococcal disease in the modern era of HIV care and evaluate the use of a 23-valent pneumococcal polysaccharide vaccine (PPV-23).MethodsThe incidence of invasive pneumococcal disease (IPD) between January 1st, 2000 and January 1st, 2010 in a regional HIV population in Southern Alberta, Canada was determined by linking comprehensive laboratory and hospital surveillance data. Clinical and epidemiologic data including risk factors for S. pneumoniae, history of pneumococcal immunization, serotypes of infections, and length of any hospitalizations for pneumococcal disease were evaluated with multivariate analysis. CD4 count and viral load at immunization were evaluated with a nested case-control analysis.ResultsIn 1946 HIV-patients with 11,099 person-years of follow up, there were 68 distinct episodes of pneumococcal disease occurring in 50 patients. Increased risk was seen if female, age >60, Aboriginal ethnicity, lower education, injection drug use, smoking, nadir CD4 <200/μL, chronic obstructive pulmonary disease, and hepatitis C. Overall, the incidence of IPD was 342/100,000 person-years and was reduced to 187/100,000 within three years of PPV-23 immunization (P < 0.01). Although 78% of patients received PPV-23, 74% of IPD episodes were caused by PPV-23 serotypes. In a case-control analysis, HIV viral load at immunization was significantly predictive of PPV-23 failure, while CD4 count was not. 80% of IPD cases required hospitalization: median length of stay was 7 days (range: 1-71); four patients died.ConclusionsDespite universal access to intensive measures to prevent pneumococcal disease including the widespread use of HAART and PPV-23 immunization, the incidence of IPD remains high in HIV patients with its associated morbidity and mortality.

Graft Failure and Adaptation Period to Adult Healthcare Centers in Pediatric Renal Transplant Patients

Transfer from pediatric to adult care may require a period of adaptation to the new healthcare environment. We sought to determine whether this adaptation period was associated with an increased risk of graft failure. Children (age, 0-18 years) recorded in the Canadian Organ Replacement Register who received a first kidney transplant in a pediatric health center between 1992 and 2007, and who had more than or equal to 3 months of graft function, were followed up until death, loss to follow-up, or December 31, 2007. Cox proportional hazards models were used to estimate the excess risk associated with a period of adaptation to adult-oriented care, defined as the interval 0.5 years before to 2.5 years after the first recorded adult care visit. Models were adjusted for age, gender, donor source, and ethnicity. Of the 413 patients evaluated, 149 were transferred to adult care during study period. In total, 78 (18.9%) patients experienced graft failure-23 during the adaptation period. Compared with the period before adaptation, the adjusted hazard ratio for graft loss within the adaptation period was 2.24 (95% confidence interval [CI]: 1.19-4.20). The adjusted graft failure rate was 2.26 (1.04-4.93) times higher after 18 years of age than between 0 and 13 years. Aboriginal ethnicity and deceased donor source were also associated with a significantly higher risk of graft failure. The period of adaptation to adult-oriented care is associated with a high risk of graft failure in pediatric renal transplant patients.

Inequalities in Determinants of Health Among Aboriginal and Caucasian Persons Living With HIV/AIDS in Ontario: Results From the Positive Spaces, Healthy Places Study

Objectives: Aboriginal Canadians (i.e., First Nations, Inuit and Metis) are disproportionately affected by HIV/AIDS, and experience greater social and economic marginalization and poorer housing conditions. This study sought to understand the differences in the determinants of health and housing-related characteristics between samples of Aboriginal and Caucasian adults living with HIV/AIDS in Ontario. Methods: We analyzed baseline demographic, socio-economic, health, and housing-related data from 521 individuals (79 Aboriginal and 442 Caucasian) living with HIV/AIDS and enrolled in the Positive Spaces, Healthy Places study. We compared the characteristics of Aboriginal and Caucasian participants to identify determinants of health and housing-related characteristics independently associated with Aboriginal ethnicity. Results: Compared to Caucausian participants living with HIV, Aboriginal participants were more likely to be younger, female or transgender women, less educated, unemployed, and homeless or unstably housed. They were also more likely to have low incomes and to have experienced housing-related discrimination. In a multivariate model, gender, income, and experiences of homelessness were independently associated with Aboriginal ethnicity. Conclusion: Aboriginal individuals living with HIV/AIDS in our sample are coping with significantly worse social and economic conditions and are more likely to experience challenging housing situations than a comparison group of Caucasian individuals living with HIV/AIDS. To develop effective care, treatment and support strategies for Aboriginal peoples with HIV, it is critical to address and improve their socio-economic and housing conditions. Key words: HIV; inequality; determinants of health; housing; Aboriginal peoples

All-cause and HIV-related mortality rates among HIV-infected patients after initiating highly active antiretroviral therapy: the impact of Aboriginal ethnicity and injection drug use.

Aboriginals are over-represented in Canada's HIV epidemic and are commonly infected with HIV via injection drug use (IDU); however, little is known about the impact of Aboriginal ethnicity on mortality after starting highly active antiretroviral therapy (HAART). Therefore, we compared mortality rates between Aboriginal and non-Aboriginal HIV patients and between IDU and non-IDU HIV patients after they initiated HAART. We conducted a retrospective cohort study of antiretroviral-naïve patients starting HAART January 1999-June 2005 (baseline), followed until December 2005. We constructed two Cox proportional hazards models, one to estimate all-cause and one to estimate HIV-related mortality hazard ratios (HRs), considering sex, and baseline age, CD4 cell count, HIV RNA level, calendar year, and HAART regimen as potential confounders. The 548 study patients were followed for 1,889.8 person-years; 194 (35%) were Aboriginal, 255 (46%) were IDUs. We observed 55 deaths; 47% were HIV-related. In multivariable models, Aboriginals experienced higher all-cause (HR = 1.85, 95% CI = 1.05-3.26, p = 0.034) and HIV-related (HR = 3.47, 95% CI = 1.36-8.83, p = 0.009) mortality rates compared to non-Aboriginals; and, compared to patients with other exposures, IDUs experienced higher all-cause (HR = 2.45, 95% CI = 1.31-4.57, p = 0.005) but similar HIV-related (p = 0.27) mortality rates. Compared to non-Aboriginals, Aboriginal HIV patients suffer higher all-cause and HIV-related mortality rates after starting HAART. The strongest and most significant predictor of higher all-cause mortality was IDU. Future research should examine reasons for the observed poorer survival of Aboriginal and IDU HIV patients after initiating HAART to develop interventions to improve the prognosis for these vulnerable populations.

All-cause and HIV-related Mortality Rates Among HIV-infected Patients After Initiating Highly Active Antiretroviral Therapy: The Impact of Aboriginal Ethnicity and Injection Drug Use

All-cause and HIV-related Mortality Rates Among HIV-infected Patients After Initiating Highly Active Antiretroviral Therapy: The Impact of Aboriginal Ethnicity and Injection Drug Use

Injury prevention in child death review: child pedestrian fatalities

ObjectiveThis article describes the epidemiology of child pedestrian fatalities in British Columbia using data generated by the province's Child Death Review Unit, to demonstrate the unique capacity of child death...

Presentation and Management of Pediatric Orbital Cellulitis

Orbital cellulitis is a serious, vision-threatening infection. To review the epidemiology and clinical data of pediatric orbital cellulitis in Manitoba. A 12-year retrospective review was conducted of all children (younger than 18 years of age) with orbital cellulitis admitted to Manitoba's only tertiary pediatric centre. Admission rates for orbital cellulitis were compared over three distinct time periods, based on licensure and funding levels of the heptavalent pneumococcal conjugate vaccine (PCV7) in Manitoba. Thirty-eight patients with orbital cellulitis were identified. Of these, 11% were of Aboriginal ethnicity in contrast with 30% to 40% of children who were admitted for other respiratory illnesses. Subperiosteal abscesses occurred in 31.5%. Only eight patients (21%) required surgery. Follow-up imaging after presentation usually did not indicate a need for subsequent surgical drainage. The mean number of orbital cellulitis cases per 1000 admissions for the following periods - before PCV7 licensure, after licensure and before full provincial funding, and after licensure and full funding - were 0.39, 0.53 and 0.90, respectively. No significant difference was noted among any of the periods as PCV7 coverage increased. The rate of subperiosteal abscesses was lower than other reports. This may be due to the median age at presentation. In contrast to admissions for most other respiratory infections at the Winnipeg Children's Hospital (Winnipeg, Manitoba), Aboriginal ethnicity was uncommon. Surprisingly, rates of admissions for orbital cellulitis appeared to show an increasing trend with increasing access to PCV7 in Manitoba, although overall the number of cases was very small. Studies into the changing microbiology of orbital cellulitis and sinusitis are warranted.

Suboptimal use of HIV drug resistance testing in a universal health-care setting

HIV drug resistance testing is recommended as routine part of clinical practice in HIV/AIDS treatment and care. Our objective is to assess the determinants of accessing HIV drug resistance testing and examine the factors associated with resistance testing prior to or after starting highly active antiretroviral therapy (HAART) in a setting where access to HIV care is free and universal. The Longitudinal Investigation into Supportive and Ancillary health services (LISA) study is an open prospective cohort of HIV-positive persons on HAART in British Columbia (BC), Canada. Non-clinical data were collected through an interviewer-administered survey and clinical data were obtained through the BC Centre for Excellence in HIV/AIDS Drug Treatment Program. Independent associations between key explanatory variables and resistance testing were analyzed using logistic regression. We restricted our post-HAART analyses to those patients who met the criteria for resistance testing after HAART initiation. Of 359 LISA participants who started HAART after 2000 and at a time when resistance testing was available free of charge, almost half did not receive a baseline resistance test. Post-HAART initiation, 165 of 359 study subjects met the criteria for resistance testing based on current therapeutic guidelines due to virological failure. About 37.6% of them remain untested for resistance. Multivariable analyses show that baseline testing was less likely performed for persons of Aboriginal ethnicity and more likely performed for patients initiating HAART in 2004 or after. Additionally, persons initiating HAART in 2004 or after were less likely to have received a resistance test after virologic failure. Our results show that despite existing clinical guidelines, resistance testing is underused, even in an environment where the service is available free of charge. Further, resistance testing is particularly underutilized among vulnerable populations. Urgent efforts are needed to ensure the optimal use of resistance testing at baseline and at the time of virologic failure as recommended by current guidelines.