Ontario Public Health Research Articles

Epidemiology of serogroup C and Y invasive meningococcal disease (IMD) in Ontario, 2000–2013: Vaccine program impact assessment

ObjectivesA publicly-funded meningococcal serogroup C conjugate vaccine (MCCV) program was introduced in Ontario, in 2004/2005 for 1-year-old children as well as adolescents (approximately 12 years old). In 2009, quadrivalent meningococcal conjugate vaccine (MCV4) replaced MCCV for grade seven students. Our objective was to determine meningococcal vaccine program impact on reported cases of serogroup C and Y invasive meningococcal disease (IMD) at the population level in Ontario, Canada. MethodsData were obtained from the Ontario reportable diseases system, the integrated Public Health Information System (iPHIS), and Public Health Ontario Laboratories (PHOL) for 2000–2013. Descriptive epidemiologic analyses, including age-specific rates for age groups based on program eligibility, were conducted. Changes over the 14-year observation period and comparison of pre- and post-program periods for MCCV and MCV4 were assessed. Analyses were conducted using SAS 9.3. ResultsThere were 161 serogroup C IMD cases and its annual incidence decreased significantly over time (17.2% reduction per year [95% CI: 13.4 to 20.7]). The incidence of serogroup C IMD decreased significantly in children aged 1–17 years in the post-program period, based on age-specific incidence rate ratios (IRRs) and their 95% confidence intervals (CIs). Adolescents 12–16 years had the lowest serogroup C IRR (0.07 [95% CI: 0.01 to 0.55]); the rate decreased more than 14-fold between the pre- and post-periods. There were 187 serogroup Y IMD cases and there was a non-significant 1.6% reduction per year [95% CI: −1.9 to 5.1]) over the surveillance period. Likewise, there was a non-significant decrease in serogroup Y IMD among persons 12–16 years (MCV4 eligible) in the post-program period. ConclusionsReductions in serogroup C IMD among program eligible and ineligible age groups suggest both direct and indirect MCCV vaccine program impact. Continued surveillance of IMD in Ontario is important to further assess MCV4 program impact.

Correlation of Real Time PCR Cycle Threshold Cut-Off with Bordetella pertussis Clinical Severity.

Bordetella pertussis testing performed using real-time polymerase chain reaction (RT-PCR) is interpreted based on a cycle threshold (Ct) value. At Public Health Ontario Laboratories (PHOL), a Ct value <36 is reported as positive, and Ct values ≥36 and <40 are reported as indeterminate. PHOL reported indeterminate results to physicians and public health units until May 2012, after which these results were only reported to physicians. We investigated the association between Ct value and disease symptom and severity to examine the significance of indeterminate results clinically, epidemiologically and for public health reporting. B. pertussis positive and indeterminate RT-PCR results were linked to pertussis cases reported in the provincial Integrated Public Health Information System (iPHIS), using deterministic linkage. Patients with positive RT-PCR results had a lower median age of 10.8 years compared to 12.0 years for patients with indeterminate results (p = 0.24). Hospitalized patients had significantly lower Ct values than non-hospitalized patients (median Ct values of 20.7 vs. 31.6, p<0.001). The proportion of patients reporting the most indicative symptoms of pertussis did not differ between patients with positive vs. indeterminate RT-PCR results. Taking the most indicative symptoms of pertussis as the gold-standard, the positive predictive value of the RT-PCR test was 68.1%. RT-PCR test results should be interpreted in the context of the clinical symptoms, age, vaccination status, prevalence, and other factors. Further information on interpretation of indeterminate RT-PCR results may be needed, and the utility of reporting to public health practitioners should be re-evaluated.

A risk screening tool for ethical appraisal of evidence-generating initiatives.

BackgroundThe boundaries between health-related research and practice have become blurred as initiatives traditionally considered to be practice (e.g., quality improvement, program evaluation) increasingly use the same methodology as research. Further, the application of different ethical requirements based on this distinction raises concerns because many initiatives commonly labelled as “non-research” are associated with risks to patients, participants, and other stakeholders, yet may not be subject to any ethical oversight. Accordingly, we sought to develop a tool to facilitate the systematic identification of risks to human participants and determination of risk level across a broad range of projects (e.g., clinical research, laboratory-based projects, population-based surveillance, and program evaluation) and health-related contexts. This paper describes the development of the Public Health Ontario (PHO) Risk Screening Tool.MethodDevelopment of the PHO Risk Screening Tool included: (1) preparation of a draft risk tool (n = 47 items); (2) expert appraisal; (3) internal stakeholder validation; (4) external validation; (5) pilot testing and evalution of the draft tool; and (6) revision after 1 year of testing.ResultsA risk screening tool was generated consisting of 20 items organized into five risk domains: Sensitivity; Participant Selection, Recruitment and Consent; Data/Sample Collection; Identifiability and Privacy Risk; and Commercial Interests. The PHO Risk Screening Tool is an electronic tool, designed to identify potential project-associated risks to participants and communities and to determine what level of ethics review is required, if any. The tool features an easy to use checklist format that generates a risk score (0–3) associated with a suggested level of ethics review once all items have been completed. The final score is based on a threshold approach to ensure that the final score represents the highest level of risk identified in any of the domains of the tool.ConclusionsThe PHO Risk Screening Tool offers a practical solution to the problem of how to maintain accountability and appropriate risk oversight that transcends the boundaries of research and practice. We hope that the PHO Risk Screening Tool will prove useful in minimizing the problems of over and under protection across a wide range of disciplines and jurisdictions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12910-015-0039-3) contains supplementary material, which is available to authorized users.

Working Through and Around: Exploring Rural Public Health Nursing Practices and Policies To Promote Rural Women’s Health

Purpose : To discuss findings from research in Ontario, Canada, that addresses the following objectives: 1) identify organizational attributes and local and provincial health policies that enable or impede the work of Ontario public health nurses to improve rural women's health, and 2) critically examine roles, job descriptions, and practices of Ontario PHNs that will improve rural women's health. Sample: 20 frontline PHNs and 14 supervisors and managers in three Ontario public health units that serve people who live in rural locations. Method : Six focus group interviews were conducted with PHNs and PHN managers in three rural Ontario public health units. Study participants were asked to describe policies and practices that guided their practice regarding rural women's health, identify organizational attributes that enable or impede public health nursing practice regarding rural women's health, and indicate roles and practices for PHNs to improve rural women's health. Findings : 1) Policies address rural women's health and rural public health minimally or not at all, 2) PHN practice is primarily focused on child bearing women and children to the exclusion of other populations of rural women such as seniors, 3) PHNs work through and around policies to address rural women' s health more effectively, and 4) institutional, government, community, professional, and personal factors play significant roles in shaping public health nursing practice and policy regarding rural women's health. Conclusions : This research facilitates understanding regarding policies, contexts, and values that shape rural PHN practice, and provides evidence for policies and practices that enhance and support public health nursing for more effective promotion of rural women's health. Clearly, more investigation is needed; this research forms the basis for ongoing inquiry in this area. Keywords : rural public health nursing, rural women's health, policy, practice, Canada DOI : h ttp://dx.doi.org/10.14574/ojrnhc.v15i1.342

Built environment interventions aimed at improving physical activity levels in rural Ontario health units: a descriptive qualitative study.

BackgroundFew studies to date have explored the relationship between the built environment and physical activity specifically in rural settings. The Ontario Public Health Standards policies mandate that health units in Ontario address the built environment; however, it is unclear how public health practitioners are integrating the built environment into public health interventions aimed at improving physical activity in chronic disease prevention programs.MethodsThis descriptive qualitative study explored interventions that have or are being implemented which address the built environment specifically related to physical activity in rural Ontario health units, and the impact of these interventions. Data were collected through twelve in-depth semi-structured interviews with rural public health practitioners and managers representing 12 of 13 health units serving rural communities. Key themes were identified using qualitative content analysis.ResultsThemes that emerged regarding the types of interventions that health units are employing included: Engagement with policy work at a municipal level; building and working with community partners, committees and coalitions; gathering and providing evidence; developing and implementing programs; and social marketing and awareness raising. Evaluation of interventions to date has been limited.ConclusionsPublic health interventions, and their evaluations, are complex. Health units who serve large rural populations in Ontario are engaging in numerous activities to address physical activity levels. There is a need to further evaluate the impact of these interventions on population health.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1786-2) contains supplementary material, which is available to authorized users.

Understanding action on the social determinants of health: a critical realist analysis of in-depth interviews with staff of nine Ontario public health units.

BackgroundAddressing the social determinants of health (SDH) is identified as a role for local public health units (PHUs) in the province of Ontario. Despite this authorization to do so there is wide variation in PHU practice. In this article we consider the factors that shape local PHU action on the SDH through a critical realist analysis.MethodsInterviews with Medical Officers of Health (MOHs) and lead staff from nine PHUs in Ontario identify the structures and powers that allow PHUs to address the SDH as well as the many factors that either activate or inhibit these structures and powers.ResultsWe found that personal backgrounds and attitudes of MOHs and leading staff people as well as local jurisdictional characteristics shape whether and how PHUs carry out SDH-related activities.ConclusionsAction on the SDH is a result of a complex interplay of micro-, meso- and macro-level factors that requires recognition of the contested nature of public health, presence of Ministry of Health mandates, local jurisdictional characteristics, and politics. The most effective way to assure PHU action on the SDH is for the Ministry of Health and Long-Term Care to mandate such activities and develop accountability mechanisms that assure implementation.

Establishment of Culex (Melanoconion) erraticus (Diptera: Culicidae) in Southern Ontario, Canada.

Culex (Melanoconion) erraticus (Dyar and Knab) is now established in southern Ontario, Canada. This species was first discovered in 2002 during a province-wide adult mosquito surveillance program for West Nile virus. Using CO2-baited CDC miniature light traps, a few Cx. erraticus were collected from 2002 to 2011, but the total number increased during the 2012 and 2013 seasons. The number of Ontario Public Health Units with records for Cx. erraticus has also increased since 2002, demonstrating that the geographic distribution of this species is expanding northward. Cx. erraticus is a potential arboviral bridge vector for a number of pathogens and its establishment in Ontario should be considered a potential public health concern.

Development of an Infectious Disease Surveillance Framework at Public Health Ontario

Since its inception in 2008, Public Health Ontario (PHO) has grown through new funding, as well as a series of program transfers from the Government of Ontario, including infectious disease (ID) surveillance. In an effort take a strategic approach to ID surveillance, PHO has developed its first Infectious Disease Surveillance Framework. The overarching aim of the framework is to establish key priorities, strategies, and actions to guide ID surveillance over the next five years. The presentation will outline the development process for the framework, highlight its key elements, and identify examples of initiatives planned for implementation.

Build on Success: CIPHI Challenges for the Next Millennium

Build on Success: CIPHI Challenges for the Next Millennium

Risk of Mycobacterial Infections Associated With Rheumatoid Arthritis in Ontario, Canada

Patients with rheumatoid arthritis (RA) are at increased risk of TB. Little is known about the risk of nontuberculous mycobacteria (NTM) disease in these patients. We sought to ascertain the rate of NTM infection and TB in all residents of Ontario, Canada, with and without RA. In a cohort study, all Ontarians aged ≥ 15 years in January 2001 were followed until December 2010. Individuals with RA were identified using a validated algorithm to search hospitalization and physician billing claims. We linked Public Health Ontario Laboratory data to identify all cases of laboratory-confirmed TB and NTM disease. Analysis was performed using Cox proportional hazards regression. We identified 113,558 Ontarians with RA and 9,760,075 Ontarians without RA. Relative to the non-RA group, adjusted hazard ratios (HRs) and 95% CIs for TB (1.92, [1.50-2.47]) and NTM disease (2.07, [1.84-2.32]) demonstrated increased risks in the RA group. Among those with RA, per 100,000 person-years, NTM disease (HR, 41.6; 95% CI, 37.1-46.5) was more common than TB (HR, 8.5; 95% CI, 6.5-10.8). After full adjustment, people with RA who developed NTM disease were 1.81 times as likely to die than uninfected people with RA. Mycobacterial infections are more common in Ontarians with RA, with NTM disease more likely than TB. NTM disease is associated with an increased risk of death in patients with RA. Given the rising rates of NTM disease worldwide, determining whether this risk is due to the use of immunosuppressive medications vs RA itself is an important objective for future research.

What makes public health studies ethical? Dissolving the boundary between research and practice.

BackgroundThe generation of evidence is integral to the work of public health and health service providers. Traditionally, ethics has been addressed differently in research projects, compared with other forms of evidence generation, such as quality improvement, program evaluation, and surveillance, with review of non-research activities falling outside the purview of the research ethics board. However, the boundaries between research and these other evaluative activities are not distinct. Efforts to delineate a boundary – whether on grounds of primary purpose, temporality, underlying legal authority, departure from usual practice, or direct benefits to participants – have been unsatisfactory.Public Health Ontario has eschewed this distinction between research and other evaluative activities, choosing to adopt a common framework and process to guide ethical reflection on all public health evaluative projects throughout their lifecycle – from initial planning through to knowledge exchange.DiscussionThe Public Health Ontario framework was developed by a working group of public health and ethics professionals and scholars, in consultation with individuals representing a wide range of public health roles. The first part of the framework interprets the existing Canadian research ethics policy statement (commonly known as the TCPS 2) through a public health lens. The second part consists of ten questions that guide the investigator in the application of the core ethical principles to public health initiatives.The framework is intended for use by those designing and executing public health evaluations, as well as those charged with ethics review of projects. The goal is to move toward a culture of ethical integrity among investigators, reviewers and decision-makers, rather than mere compliance with rules. The framework is consonant with the perspective of the learning organization and is generalizable to other public health organizations, to health services organizations, and beyond.SummaryPublic Health Ontario has developed an ethics framework that is applicable to any evidence-generating activity, regardless of whether it is labelled research. While developed in a public health context, it is readily adaptable to other health services organizations and beyond.

Antimicrobial susceptibility of clinical isolates of anaerobic bacteria in Ontario, 2010–2011

The local epidemiology of antimicrobial susceptibility patterns in anaerobic bacteria is important in guiding the empiric treatment of infections. However, susceptibility data are very limited on anaerobic organisms, particularly among non-Bacteroides organisms. To determine susceptibility profiles of clinically-significant anaerobic bacteria in Ontario Canada, anaerobic isolates from sterile sites submitted to Public Health Ontario Laboratory (PHOL) for identification and susceptibility testing were included in this study. Using the E-test method, isolates were tested for various antimicrobials including, penicillin, cefoxitin, clindamycin, meropenem, piperacillin-tazobactam and metronidazole. The MIC results were interpreted based on guidelines published by Clinical and Laboratory Standards Institute. Of 2527 anaerobic isolates submitted to PHOL, 1412 were either from sterile sites or bronchial lavage, and underwent susceptibility testing. Among Bacteroides fragilis, 98.2%, 24.7%, 1.6%, and 1.2% were resistant to penicillin, clindamycin, piperacillin-tazobactam, and metronidazole, respectively. Clostridium perfringens was universally susceptible to penicillin, piperacillin-tazobactam, and meropenem, whereas 14.2% of other Clostridium spp. were resistant to penicillin. Among Gram-positive anaerobes, Actinomyces spp., Parvimonas micra and Propionibacterium spp. were universally susceptible to β-lactams. Eggerthella spp., Collinsella spp., and Eubacterium spp. showed variable resistance to penicillin. Among Gram-negative anaerobes, Fusobacterium spp., Prevotella spp., and Veillonella spp. showed high resistance to penicillin but were universally susceptible to meropenem and piperacillin-tazobactam. The detection of metronidazole resistant B. fragilis is concerning as occurrence of these isolates is extremely rare. These data highlight the importance of ongoing surveillance to provide clinically relevant information to clinicians for empiric management of infections caused by anaerobic organisms.

What's missing? Anti-racist sex education!

Contemporary sexual health curricula in Canada include information about sexual diversity and queer identities, but what remains missing is any explicit discussion of anti-racist sex education. Although there exists federal and provincial support for multiculturalism and anti-racism in schools, contemporary Canadian sex education omits crucial anti-racist work, and foundational anti-racist education frameworks are silent about the sex education curriculum. To show how race is discussed in sex education, a content analysis based on a keyword search of Ontario public secondary school health provincial curricula and federal sex education policy was conducted. English language curricula created within the same nine-year range (1999–2008) were selected from Ontario and Canada to maximise the congruency of politics and country of origin. Content analysis findings point to major deficiencies and provide the basis for future anti-racist sex education policy recommendations. As anti-racism critically examines the institution of education, and sexual health curricula are an increasingly politicised example of potentially transformative education, anti-racism must be incorporated into future sex education work.

Coxsackieviruses in Ontario, January 2005 to December 2011

In 2010, there was an increase in enterovirus meningitis in the province of Ontario, Canada. Concurrently, there was also an increase in coxsackievirus A9-positive specimens in Alberta, Canada. This study aimed to describe the results of an investigation into the increase in coxsackievirus (A9 serotype) in 2010 in Ontario. For the purpose of this study, we report on specimens tested by viral culture at Public Health Ontario Laboratory as part of routine laboratory testing from January 1, 2005 to December 31, 2011. Coxsackieviruses represented more than one third of enteroviruses detected, with A9 being the serotype most commonly identified. The most common specimen source in which A9 was isolated was cerebrospinal fluid, followed by nasopharyngeal swabs and stool. Patients in whom A9 was detected were older than individuals with any other coxsackievirus serotype. The increase in enterovirus meningitis in Ontario in 2010 was likely due to an increase in A9 circulation. A9 was most commonly identified among children; however A9 may cause severe illness in both children and adults. Monitoring the circulation and epidemiology of enteroviruses can inform clinicians about circulating pathogens to optimize clinical testing and antibiotic use.

Bacteriological testing of private well water: a trends and guidelines assessment using five years of submissions data from southeastern Ontario.

Rural populations are at an elevated risk of gastrointestinal illness, as they are dependent on private groundwater sources, and water quality remains the responsibility of the owner. Previous research suggests that only a minority of well water owners test their wells for bacteriological contamination. The aim of this study was to use testing records, in conjunction with current provincial guidelines, to assess submission rates and temporal trends in southeastern Ontario. Using five years of data (2008-2012) from the Public Health Ontario Laboratory in Kingston, Ontario, submissions of well water samples from unique properties (identified through geocoding) were descriptively analyzed. Temporal trends in guideline compliance were tested using a Cochran Armitage test. Finally, correlations between time and submission numbers were investigated using a 10-year provincial dataset to identify long-term temporal trends. There were 107,547 submissions in the five years studied, 84% of which were geocoded, culminating in 30,687 unique properties. Although 11%-12% of owners met the guidelines in any given year, only 0.3% met them every year in the five-year study. Statistically significant decreases were found temporally both in the number of properties that met current guidelines and in all samples tested. This study is the first to use submission records, rather than surveys, to definitively demonstrate that private well water submission guidelines are not being met in Ontario. However, there are no consistent guidelines across the country or continent, and limited supporting scientific literature is available. Significant research is required to develop evidence-based policies.

Cost Effectiveness of EML4-ALK Fusion Testing and First-Line Crizotinib Treatment for Patients With Advanced ALK-Positive Non–Small-Cell Lung Cancer

ALK-targeted therapy with crizotinib offers significant improvement in clinical outcomes for the treatment of EML4-ALK fusion-positive non-small-cell lung cancer (NSCLC). We estimated the cost effectiveness of EML4-ALK fusion testing in combination with targeted first-line crizotinib treatment in Ontario. A cost-effectiveness analysis was conducted using a Markov model from the Canadian Public health (Ontario) perspective and a lifetime horizon in patients with stage IV NSCLC with nonsquamous histology. Transition probabilities and mortality rates were calculated from the Ontario Cancer Registry and Cancer Care Ontario New Drug Funding Program (CCO NDFP). Costs were obtained from the Ontario Case Costing Initiative, CCO NDFP, University Health Network, and literature. Molecular testing with first-line targeted crizotinib treatment in the population with advanced nonsquamous NSCLC resulted in a gain of 0.011 quality-adjusted life-years (QALYs) compared with standard care. The incremental cost was Canadian $2,725 per patient, and the incremental cost-effectiveness ratio (ICER) was $255,970 per QALY gained. Among patients with known EML4-ALK-positive advanced NSCLC, first-line crizotinib therapy provided 0.379 additional QALYs, cost an additional $95,043 compared with standard care, and produced an ICER of $250,632 per QALY gained. The major driver of cost effectiveness was drug price. EML4-ALK fusion testing in stage IV nonsquamous NSCLC with crizotinib treatment for ALK-positive patients is not cost effective in the setting of high drug costs and a low biomarker frequency in the population.

Reply to “Further Proofs of Concept for the Carba NP Test”

We acknowledge the [letter by Dortet et al.][1] ([1][2]) in response to our evaluation of the Carba NP test ([2][3]), performed in two independent Canadian laboratories (the National Microbiology Laboratory, the national reference lab, and Public Health Ontario, a provincial reference lab). In

Electronic immunization data collection systems: application of an evaluation framework

BackgroundEvaluating the features and performance of health information systems can serve to strengthen the systems themselves as well as to guide other organizations in the process of designing and implementing surveillance tools. We adapted an evaluation framework in order to assess electronic immunization data collection systems, and applied it in two Ontario public health units.MethodsThe Centers for Disease Control and Prevention’s Guidelines for Evaluating Public Health Surveillance Systems are broad in nature and serve as an organizational tool to guide the development of comprehensive evaluation materials. Based on these Guidelines, and informed by other evaluation resources and input from stakeholders in the public health community, we applied an evaluation framework to two examples of immunization data collection and examined several system attributes: simplicity, flexibility, data quality, timeliness, and acceptability. Data collection approaches included key informant interviews, logic and completeness assessments, client surveys, and on-site observations.ResultsBoth evaluated systems allow high-quality immunization data to be collected, analyzed, and applied in a rapid fashion. However, neither system is currently able to link to other providers’ immunization data or provincial data sources, limiting the comprehensiveness of coverage assessments. We recommended that both organizations explore possibilities for external data linkage and collaborate with other jurisdictions to promote a provincial immunization repository or data sharing platform.ConclusionsElectronic systems such as the ones described in this paper allow immunization data to be collected, analyzed, and applied in a rapid fashion, and represent the infostructure required to establish a population-based immunization registry, critical for comprehensively assessing vaccine coverage.

The integration of barcode scanning technology into Canadian public health immunization settings

BackgroundAs part of a series of feasibility studies following the development of Canadian vaccine barcode standards, we compared barcode scanning with manual methods for entering vaccine data into electronic client immunization records in public health settings. MethodsTwo software vendors incorporated barcode scanning functionality into their systems so that Algoma Public Health (APH) in Ontario and four First Nations (FN) communities in Alberta could participate in our study. We compared the recording of client immunization data (vaccine name, lot number, expiry date) using barcode scanning of vaccine vials vs. pre-existing methods of entering vaccine information into the systems. We employed time and motion methodology to evaluate time required for data recording, record audits to assess data quality, and qualitative analysis of immunization staff interviews to gauge user perceptions. ResultsWe conducted both studies between July and November 2012, with 628 (282 barcoded) vials processed for the APH study, and 749 (408 barcoded) vials for the study in FN communities. Barcode scanning led to significantly fewer immunization record errors than using drop-down menus (APH study: 0% vs. 1.7%; p=0.04) or typing in vaccine data (FN study: 0% vs. 5.6%; p<0.001). There was no significant difference in time to enter vaccine data between scanning and using drop-down menus (27.6s vs. 26.3s; p=0.39), but scanning was significantly faster than typing data into the record (30.3s vs. 41.3s; p<0.001). Seventeen immunization nurses were interviewed; all noted improved record accuracy with scanning, but the majority felt that a more sensitive scanner was needed to reduce the occasional failures to read the 2D barcodes on some vaccines. ConclusionEntering vaccine data into immunization records through barcode scanning led to improved data quality, and was generally well received. Further work is needed to improve barcode readability, particularly for unit-dose vials.

Public Health in Health Sector Reform

In this edition of Healthcare Papers, Miller et al. make the case for greater engagement of the public health sector in healthcare system reform. Although I agree with many of the points made, I challenge the premise that public health is unwilling and/or unprepared to lead or participate in system change. Ontario's public health sector is not only ready to participate in transformation of the healthcare system, provincial and local involvement is well under way. Public health has been actively engaging colleagues in both the healthcare and non-health sectors to discuss health system evolution and transformation. Make No Little Plans - Ontario's Public Health Sector Strategic Plan sets out the vision, strategic goals and collective areas of focus for the next three to five years, and includes an immediate emphasis on establishing collaborative mechanisms within the sector and with others in the health sector and non-health sectors. As an initial step, public health is identifying and analyzing key intersection points between public health and primary care to enable better alignment and integration. In Ontario, public health is not only participating in health reform, we are in a position to help drive it.