2016 Health Watch - Vancouver Coastal Health

2016 Health Watch
Issue # 90
Sep - Dec 2015
This bulletin is a surveillance update
for our region and includes public
health program highlights. This
issue covers the time period from
September - December 2015.
Contents
Summary............................. 1
Our Region.......................... 2
Immunization Update.......... 3
Surveillance Updates.......... 6
Healthy Plate....................... 13
Environmental Health......... 14
Summary
Syphilis rates continue to rise across the region.
InfIuenza and Norovirus seasons are underway.
More overdose deaths across BC in December
2015 than any month in the past 10 years.
Eat your greens (and purples and oranges…)!
Vancouver Coastal Health releases new nutrition
recommendations with the Healthy Plate
campaign.
This issue’s feature topic:
Immunization Update
Read more on page 3
All data herein should only be used with reference to the
“2015 Health Watch prepared by Vancouver Coastal Health, Public Health Surveillance Unit”.
For questions or comments please contact phsu@vch.ca.
2016 Health Watch
Sep - Dec 2015
2
Our Region
The Vancouver Coastal Health (VCH) is one of five geographically distinct health authorities in British Columbia (BC).
The VCH region covers a large geographic area and includes both urban and rural communities. It is comprised of three
health service delivery areas (HSDA): North Shore/Coast Garibaldi (i.e. Coastal Urban and Coastal Rural), Richmond, and
Vancouver.
The Vancouver HSDA is further divided into six local health areas (LHA), and the North Shore/Coast Garibaldi HSDA
further divided into seven (two LHAs in Coastal Urban and five in Coastal Rural). The estimated VCH population is
1.2 million, approximately 25% of BC’s population.
2016 Health Watch
Sep - Dec 2015
3
Immunization Update
Vancouver Coastal Health (VCH) continues to promote the benefits of immunization and provide immunizations to
residents of all ages. Childhood immunization coverage is typically assessed at age two years and at specific school
grades. This issue, we review the current coverage rates as well as recent changes in coverage across the region in both
young children and school age children.
Two-year-old coverage – 2012 and 2009 birth cohorts
Because young children are immunized by both family doctors and public health nurses, the best quality data on
coverage is collected by surveys of parents of a random selection of two-year-olds performed every few years. The figure
below compares the 2012 birth cohort to the 2009 birth cohort to examine two year old immunization coverage (Figure 1).
The coverage rates for each individual vaccine remained the same or improved, although any changes are not statistically
significant.
100.0%
Figure 1. Two-year-old immunization coverage rates and 95% confidence intervals.
Vancouver Coastal Health, 2012 compared to 2009 birth cohort
2009 birth cohort
2012 birth cohort
Immunization coverage rate (%)
80.0%
60.0%
40.0%
20.0%
0.0%
*MB = minus booster. Note: Rotavirus was introduced in the 2-year old immunization schedule in 2012.
Data source: Vancouver Coastal Health Authority and Fraser Health Authority, 2012 Cohort Two-Year-Old Immunization Coverage Survey.
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit, September 2015.
Almost all individual vaccines had coverage of 80% or greater. Up to date coverage, which means completion of all doses
of recommended immunizations, was lower for the 2012 cohort. Measles, Mumps and Rubella (MMR) immunization had
the highest coverage rate at over 90% for both cohorts. Although rotavirus immunization is fairly new to the schedule, it
has had an encouragingly high uptake on par with other immunizations.
2016 Health Watch
Immunization Update continued
School age coverage – 2013-2014 and 2014-2015 school
years
Each year, VCH public health nurses work with schools to immunize
kindergarten, grade 6, and grade 9 students and collect immunization
records. Public health nurses perform scheduled immunizations and
catch-up any missed immunizations as recommended by the BC
immunization schedule. By the end of the school year, immunization
records can be analyzed to examine immunization coverage by school
and region. The vaccines assessed are listed in Box 1.
Kindergarten coverage
Sep - Dec 2015
4
Box 1. Immunization antigens assessed by grade,
BC, 2014-2015
Kindergarteners
• Diphtheria, Tetanus, acellular
Pertussis, and Polio-(DTaP-P)
•Measles
•Mumps
•Rubella
•Varicella
•Meningococcal C
•Hepatitis B (HBV)
6th graders
•Hepatitis B
•Meningococcal C
•Varicella
•Human papilloma virus (HPV) (girls only)
This year saw modest improvements in VCH overall for kindergarten
coverage. Up-to-date coverage increased from 72% to 77% , while
most individual vaccines increased slightly. This may indicate success
in bringing partially immunized children completely up-to-date. There
9th graders
was also a small decrease in the proportion of children with zero
•
TDaP: primary series + booster
immunizations on record, which may indicate better record collection or •
HPV
outreach to previously unvaccinated children (Figure 2).
Note: Please see online annual report for full
description of valid vaccine doses by school grade.
Figure 2. Kindergarten immunization coverage rates,
Vancouver Coastal Health, 2014-2015 compared to 2013-2014
Immunization coverage rate (%)
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
Source: VCH Primary Access Regional Information System
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit, December 2015
2013-2014
2014-2015
Some areas with lower coverage experienced success in improving coverage rates between the two school years, most
notably in Coastal Rural and Coastal Urban. For example:
• In Vancouver, up-to-date coverage remained unchanged at 77%.
• In Coastal Rural, up-to-date coverage increased from 52% to 75% and DTaP-P increased from 74% to 83%.
• In Coastal Urban, up-to-date coverage increased from 62% to 70% and DTaP-P increased from 71% to 77%.
• Richmond has the highest up-to-date coverage at 86%.
• Areas with moderate to large increases in vaccine-specific coverage included Howe Sound, North Vancouver,
West-Vancouver Bowen Island and in Vancouver city centre.
Across the whole region, 59% of reporting schools had improved up-to-date coverage for kindergarten. Because the
number of children in each school is small, there can be a lot of year-to-year variability in school-level coverage just by
chance. The change in vaccination status of a few children can make a large difference to coverage rates for an individual
school.
2016 Health Watch
Sep - Dec 2015
5
Immunization Update continued
Grade 6 coverage
Across VCH, the changes in grade 6 vaccination rates were also mostly positive. Meningococcal rates increased from 92%
to 95% and HPV among girls increased from 64% to 66%, while HBV remained stable at 93%.
When broken down to the local level, only Richmond saw a substantial increase in HPV coverage, increasing from 61% to
75%. HPV coverage in Coastal Rural decreased from 68% to 66% (Figure 3).
Figure 3. Grade 6 HPV vaccination coverage rates,
Vancouver Coastal Health HSDAs, 2014-2015 compared to 2013-2014
Immunization coverage rate (%)
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Vancouver
Richmond
Coastal Urban
2013-2014
Source: VCH Primary Access Regional Information System
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit, December 2015
Coastal Rural
2014-2015
Grade 9 coverage
Grade 9 immunization coverage in VCH overall remained stable. However, in Richmond HPV
coverage decreased from 90% to 78% and Coastal Rural TDaP coverage decreased from 84% to 79%.
The 2014/2015 school-age children immunization rates are available on VCH’s website, both by HSDA and school, along
with some information on previous years as well.
For more information visit: http://www.vch.ca/your-health/disease-surveillance/immunization-coverage/
2016 Health Watch
Sep - Dec 2015
6
Surveillance Updates
Investigations
Vibrio parahaemolyticus outbreak from BC raw oyster consumption
From June 1 – September 30, 2015, 41 cases of Vibrio parahaemolyticus were reported to VCH with 73% of cases
associated with raw oyster consumption. In response to the outbreak, on August 12, 2015 VCH ordered restaurants to
stop the sale of raw B.C. oysters until further notice. The order was lifted on September 17, 2015, once water temperature
measurements, oyster testing results, and historical disease trends had all indicated that risk of infection with Vibrio
parahaemolyticus had returned to baseline.
An important outcome resulting from this outbreak was the development of a working group comprised of shellfish
industry stakeholders, public health (BCCDC and Regional Health Authorities), Canadian Food Inspection Agency,
Department of Fisheries & Oceans, and BC Ministry of Agriculture. The group is collaborating to develop a more robust
surveillance system along with a prevention and response plan for Vibrio parahaemolyticus outbreaks in the future.
Clostridium perfrigens outbreak related to farm-to-table dining event
One thousand people attended the UBC Centennial Harvest Feast on September 24, 2015. VCH received the first
report of foodborne illness associated with the event on September 25, 2015. By Monday October 5, 2015, 213 attendees
reported symptoms of abdominal pain or diarrhea with a median time to symptom onset of 11 hours and a median
duration of symptoms of 18 hours. The analysis of the online questionnaire indicated the chicken entrée as the likely
source of illness. Site investigation of the event identified multiple occurrences where temperature abuse likely had
occurred over the course of the event by AMS Conferences and Catering (AMS). The laboratory results of one stool
sample and both chicken entrée samples were positive for Clostridium perfringens. This bacterium can cause a
toxin-mediated illness that is consistent with the symptoms described by attendees, the symptom onset time and illness
duration. The consistency between the epidemiological findings, laboratory results and environmental health
inspection, identified the chicken entrée as the cause of the outbreak. The public health intervention included a review
of AMS’s food safety plan in consultation with the district Environmental Health Officer, which included an emphasis on
temperature monitoring and record keeping. This is a point source outbreak with no ongoing risk to the public.
2016 Health Watch
Sep - Dec 2015
7
Surveillance Updates
Investigations
Continuing syphilis outbreak - UPDATE
The number of infectious syphilis cases reported in VCH continues to increase through October of 2015 for a rate of 44
new cases per 100,000 population, greater than 3.5 times the rate observed in 2011. The epidemic remains concentrated
with 97% of diagnoses being male and over 90% identifying as gay, bisexual, or other men who have sex with men (MSM).
Compared with the beginning of the epidemic, the age group most affected has shifted younger with the highest rate of
new diagnoses being between the ages of 25-29 years. Over 50% of the syphilis cases provincially are co-infected with
HIV. Public health strategies including a targeted awareness and testing campaign will be launched in the winter of 2016
as well as enhanced patient follow up and partner notification services that are currently underway (Figure 4).
Figure 4. Number of Infectious Syphilis (IS) Cases Reported in VCH by Year
160
148
Number of Infectious Syphilis Cases
140
120
120
115
119
100
94
112
107
106
94
90
91
80
71
70
60
56
54
40
40
22
20
28
34
32
28
56
17
0
Q1
Q2
Q3
2010
Q4
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Q1
Q2
Q3
2013
Q4
Q1
Q2
Q3
2014
Year
IS-VCH
Data source: VCH STI Surveillance Data
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit. December 15, 2015
Prev 4 Quart Avg
Q4
Q1
Q2
2015
Q3
2016 Health Watch
Sep - Dec 2015
8
Surveillance Updates
Respiratory illness
The influenza season is underway with sentinel physician visits due to influenza-like illness (ILI) at or below historical
averages since October 2015 (Figure 5).
Figure 5. Proportion of patient visits due to influenza-like illness (ILI) by epidemiological week.
Sentinel Physicians, British Columbia, 2015-2016 compared to historical average*
*Historical average based on 2015-16 season based on 2003-04 to 2014-15 seasons, excluding 2008-09 and 2009-10 due to atypical seasonality. CI=confidence interval.
Source: BC Centre for Disease Control, BC Influenza Surveillance Bulletin – 2014-15: Number 6, Weeks 50-52
The BCCDC Public Health Laboratory shows a steady increase in respiratory virus specimens with close to 50% of
specimens being positive for influenza. Interestingly, in weeks 51 and 52, more influenza specimens were positive for
Influenza B than Influenza A, which is in contrast to trends normally observed at the beginning of recent annual influenza
seasons where Influenza A was predominant (Figure 6).
Figure 6. Influenza and other virus detections and proportion of respiratory specimens submitted to
BC Provincial Laboratory diagnosed positive for a virus by epidemiological week. British Columbia, 2015-2016
Source: BC Centre for Disease Control, BC Influenza Surveillance Bulletin - 2015-2016: Number 6, Weeks 50-52.
2016 Health Watch
Sep - Dec 2015
Surveillance Updates
Respiratory illness
No facility outbreaks from ILI were reported to VCH from week 45 (mid-November 2015) to January 9, 2016 (Figure 7).
Figure 7. Influenza-like illness (ILI) outbreaks reported in facilities* by epidemiological week.
Vancouver Coastal Health, 2015/2016 compared to previous 3-week average and historical 3-week average†
10
Number of reported outbreaks
8
Unknown
Other Virus
Influenza B and Other Virus
Influenza A and Other Virus
Influenza A & B
Influenza B
Influenza A
Previous 3-week average
Historical 3-week average
6
4
2
0
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
SEP
OCT
NOV
2015
DEC
1
2
3
JAN
Epidemiological week
*Facilites include acute care, long-term care and rehabilitation settings. †Includes data since 2008.
Source: Vancouver Coastal Health, Public Health Surveillance Unit (Enteric and ILI Outbreak Reports Database).
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit.
4
5
6
7
8
9
FEB
10 11 12 13 14 15 16 17
MAR
2016
APR
9
2016 Health Watch
Sep - Dec 2015
10
Surveillance Updates
Gastrointestinal illness
Between November 15, 2015 – January 2, 2016, 26 outbreaks were reported to VCH, more than double what was observed
historically, with 31% confirmed as norovirus (Figure 8).
Figure 8. Enteric outbreaks reported in facilities* by epidemiological week.
Vancouver Coastal Health, 2015/16 compared to previous 5-week average and historical 5-week average†
10
Health care facilities
Child day care facilities
Previous 5-week average
Historical 5-week average
Number of reported outbreaks
8
6
4
2
0
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
SEP
OCT
NOV
DEC
1
2
3
JAN
2015
4
5
6
7
8
9
FEB
MAR
2016
Epidemiological week
Includes
data since 2008.
*Facilites include acute care, long-term care, rehabilitation settings and child day care.
Source: Vancouver Coastal Health, Public Health Surveillance Unit (Enteric and ILI Outbreak Reports Database).
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit.
10 11 12 13 14 15 16 17
APR
2016 Health Watch
Sep - Dec 2015
11
Surveillance Updates
Overdose surveillance
Week 46 saw the highest increase in ER visits due to heroin in 2015 along with an increasing trend through week 51 that
rose well above the historical average (Figure 9).
Figure 9. Number of ER and Vancouver Insite* visits related to heroin overdose† by epidemiological week.
Vancouver Coastal Health, 2015/2016
Heroin overdoses at Insite
Insite previous 3-week average
Insite historical average
ER visits
ER previous 3-week average
ER historical average
Week with cheque issued
80
50
70
40
60
30
50
20
40
10
30
0
20
-10
10
-20
0
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 1
SEP
OCT
NOV
DEC
2
3
JAN
4
5
6
7
FEB
8
9 10 11 12 13 14 15 16 17
MAR
-30
APR
Epidemiological week
*Supervised injection site. †Heroin misuse related visits are monitored through ICD-9 codes 304.0, 304.7, 305.5, 965.01, E850.0, E935.0, and ICD-10 codes F119B and T401 and a keyword search where the term "heroin" is indicated in
presenting complaint, discharge diagnosis, nature of injury and mechanism of injury.
Data sources: 1. Emergency room visits: Vancouver Coastal Health, CareCast System (Richmond Hospital, UBC Hospital, Vancouver General Hospital), Eclipsys System (Mount Saint Joseph Hospital, St. Paul's Hospital) and McKesson System
(Lions Gate Hospital, Pemberton Health Centre, Squamish General Hospital, Whistler Health Care Centre).
2. Insite visits: Insite, Vancouver Coastal Health, HIV/AIDS & Harm Reduction Programs.
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit.
Heroin overdoses at ER
Insite visits
2016 Health Watch
Sep - Dec 2015
12
Surveillance Updates
Overdose surveillance
The highest number of overdoses at Insite in this period was observed in weeks 50 and 51. The weeks with the highest
proportion of heroin overdoses requiring naloxone intervention at Insite were week 46 (81%) followed by week 52 (68%)
and week 49 (67%), which might suggest that fentanyl contamination of the drug supply was greater during those weeks
(Figure 10). The BC Coroners’ Service reported that in 2015, the number and rate of illicit drug overdose deaths increased
in the region and across BC with December 2015 seeing more overdose deaths than any month in the past 10 years. They
also reported that the proportion of illicit drug overdose deaths for which fentanyl was detected rose to 30% in 2015.
Figure 10. Number of Vancouver Insite* visits resulting in an overdose by epidemiological week.
VCHA, 2015/2016 compared to previous 3-week average and historical average†
Overdoses involving heroin/other opiates requiring Narcan intervention
Overdoses involving other/unknown drugs requring Narcan intervention
Historical average (overall overdoses)
Week with cheque issued
Overdoses at Insite
40
Overdoses involving heroin/other opiates not requiring Narcan intervention
overdoses involving other/unknown drugs not requiring Narcan intervention
Previous 3-week average (overall overdoses)
30
20
10
0
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52
SEP
OCT
NOV
DEC
1
2
3
JAN
Epidemiological week
*Supervised injection site. †Historical data includes data since week 10 of 2004.
Data source: Insite, Vancouver Coastal Health, HIV/AIDS & Harm Reduction Programs.
Prepared by: Vancouver Coastal Health, Public Health Surveillance Unit.
4
5
6
7
FEB
8
9
10 11 12 13 14 15 16 17
MAR
APR
2016 Health Watch
Sep - Dec 2015
13
Public Health Update
Healthy Plate
Want a simple, evidence-based meal planning tool? Look no further than the Healthy Plate!
VCH has undertaken region wide promotion of the Healthy Plate by promoting its use with VCH staff and all family
physicians. Dr. Réka Gustafson and Public Health Dietitians Gerry Kasten and Rani Wangsawidjaya, have held a
continuing professional development physician workshop and a record-setting webinar (109 participants!) to promote
the Healthy Plate and educate physicians on how to use the plate in practice. Although physicians see the promotion of
healthy eating as their role and are viewed by patients as credible sources for nutrition information, the lack of time,
clinic-friendly resources and their own limited nutrition education are often concerns. The plate is a great
synthesis of the current nutrition evidence and the use of the plate is well-suited to physician practice where time is
limited.
How does it work? For a healthy, balanced meal fill half your plate or bowl with a variety of vegetables, a quarter with
whole grains and a quarter with meats & alternatives. Eating more vegetables and less refined carbohydrates is a great
way to reduce the risk of chronic diseases and increase dietary nutrient content.
Remember to look on the back of the Healthy Plate for information about portion sizes, how to use the plate with children
and youth, as well as helpful tips such as:
• Satisfy your thirst with water.
• Include fruit in either the vegetable portion of your healthy plate or as a healthy snack.
• Include two servings of milk or alternatives in your day.
For more information and resources visit: www.vch.ca/healthyplate
2016 Health Watch
Sep - Dec 2015
Environmental Health
Health Protection
Below are internet resources for more information about VCH Health Protection
(http://www.vch.ca/your-environment/) and our environmental health.
Food Service Establishment Inspection Results & Closures
http://www.vch.ca/your-environment/food-safety/
Water Quality
Beach Water Quality Reports
http://www.vch.ca/your_environment/water_quality/recreational-water/beach-water-quality-report/beach_water_quality_report
Pool Water Quality Reports
http://www.vch.ca/your_environment/water_quality/recreational-water/pool_water_quality_report/pool-water-quality-reports
Air Quality
BC
http://www.bcairquality.ca/readings/index.html
Metro Vancouver
http://www.metrovancouver.org/services/air/currentairquality/Pages/default.aspx
14