Fawziah Lalji
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Understanding the quality of antibiotic prescribing to migrants in two Canadian provinces (British Columbia and Ontario) for common infections
Antibiotics are very important medications that are used a lot in Canada. These medicines help stop infections caused by bacteria. However, antibiotic treatment can lead to superbugs, which then go on to become more common in our population. Consequently, antibiotics may stop working properly. This can happen when doctors prescribe antibiotics incorrectly for infections not caused by bacteria but by viruses like the flu or a common cold. In Canada, programs have been in place for almost two decades to educate the public on responsible antibiotic use. However, each year we also welcome migrants at some of the highest global rates. Researchers have been working to ensure the careful use of antibiotics in the general population, however, prescribing to migrants in Canada has not been closely examined. Understanding how antibiotics are used across this growing proportion of Canadians will help expand the efforts to protect the effectiveness of these essential drugs.
In this study, we will use large healthcare databases from two Canadian provinces, British Columbia and Ontario, to compare overall antibiotic prescribing practices between migrants and non-migrants, and to understand how often patients incorrectly receive antibiotic prescriptions. We will then try to understand the factors of unnecessary prescribing by looking at the characteristics of the patient and the prescribing doctor. This information will help us determine how to better educate newly arrived individuals in Canada and doctors about the careful use of antibiotics. Overall, we aim to contribute to the appropriate use of antibiotics for migrants across Canada, where the correct choice of drugs, dose and duration of antibiotic therapy is imperative to safeguard the healing power of these important drugs.
Determining equitable and effective pneumococcal vaccination strategies in adults with underlying medical and social conditions in two Canadian provinces (British Columbia and Ontario)
Pneumococcal infection is caused by Streptococcus pneumoniae bacteria. The bacteria can cause serious and life-threatening infections such as meningitis, an infection of the lining that covers the brain; septicemia, an infection of the blood; and pneumonia, an infection of the lungs. Anyone can get pneumococcal disease, but children under two years of age, adults 65 years or older, and people with certain medical and social conditions are at the highest risk. Social determinants such as not having housing or smoking cigarettes also increase the risk of invasive disease after infection. Immunization has saved more lives in Canada in the last 50 years than any other health measure. To protect individuals from pneumococcal disease, routine immunization is publicly available for young children two years of age or less and older adults 65 years old or over.
Recently, new vaccines have become available for the protection of pneumococcal disease in adults, but the burden of disease that may be prevented with the new products is unknown for people with underlying medical conditions or choices of lifestyle. In this study, we will use large healthcare databases from two Canadian provinces, British Columbia and Ontario, to understand how often young adults with underlying medical or social conditions get pneumococcal infections. Given the risk and differences in public funding of vaccines across provinces for this age group, we will also determine opportunities for equity-informed vaccination strategies. Our research findings will help decision-makers shape healthcare policy to reduce Canada's pneumococcal disease burden and advance our national healthy aging strategy.
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Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.
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BACKGROUND: Streptococcus pneumoniae causes substantial health and economic burden. Two vaccines available to combat pneumococcal disease are the 23-valent pneumococcal polysaccharide vaccine (PPV23) for adults and the 13-valent pneumococcal conjugate vaccine (PCV13) for children. This thesis evaluated changes in health and economic burden from pneumococcal disease following the PCV13 introduction in the infant immunization program in British Columbia (BC), Canada.METHODS: A literature search and meta-analyses determined the indirect effect of the PCV13 childhood immunization on invasive pneumococcal disease (IPD) among adults worldwide. Then, pneumococcal disease, i.e., IPD, and acute otitis media (AOM), acute sinusitis (AS), and community-acquired pneumonia (CAP) cases and associated healthcare costs were identified using administrative databases for the years 2000-2018. Costs were adjusted to 2018 Canadian dollars. Changes in the incidence, annual healthcare utilization, and associated costs for pneumococcal disease were evaluated across vaccine eras (pre-PCV13 era: 2000-2010, PCV13 era: 2011-2018) using generalized linear models and adjusted for the PCV7 program (2004-2010). RESULTS: A substantial decline in overall IPD (18%), PCV7 (55%), and PCV13 (40%) serotype IPD were observed among adults following the PCV13 vaccine use in the infant immunization program globally. However, a concurrent 112% increase in non-vaccine serotype IPD occurred during the PCV13 period. Similar declines in overall IPD (18%), PCV7-related (70%), and PCV13-related (24%) vaccine serotype IPD among adults and increase in non-vaccine serotype (NVT) IPD (154%) were noted in BC. A substantial rate reduction in AOM (30%) and AS (15%) across all ages was recorded. Although CAP incidence decreased among young children aged 0-2 years (9%), there was a modest increase in the older age groups: 50-64 years (7%), and ≥65 years (5%). As such, temporal declines in total annual cost were observed in the PCV13 era for IPD (27%), AOM (30%), and AS (32%) compared to the pre-PCV13 era, but not CAP, where an increase of 4% in total costs was seen across all ages. CONCLUSIONS: Increasing NVT IPD and pneumonia rates in the post-PCV13 necessitates a need for newer vaccines and stresses the importance of improving public health messaging to increase the PPV23 uptake rates.
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BACKGROUND: In many low tuberculosis (TB) incidence countries, TB rates have stagnated. In these countries, TB disproportionately affects migrant populations due to reactivation of latent TB infection (LTBI) acquired prior to immigration. Treatment of LTBI can significantly reduce risk of TB. The objective of this thesis is to determine the performance of common LTBI diagnostic tests in migrant populations and evaluate the cost-effectiveness of LTBI screening and treatment at various stages of the migration process and in migrants with chronic diseases, such as chronic kidney disease (CKD), that increase risk of TB.METHODS: A literature search determined the sensitivity of LTBI diagnostic tests: the tuberculin skin test (TST) and interferon-gamma release assay (IGRA). A meta-analysis was completed to determine the proportion of migrants testing positive with TST and IGRA from countries of various TB incidences. Discrete event simulation models evaluated the cost-effectiveness of LTBI screening and treatment in migrants: immediately post- immigration, prior to immigration, and at time of late stage CKD diagnosis or dialysis initiation. Incremental cost- effectiveness ratios (ICERs) were calculated for quality-adjusted life years.RESULTS: Sensitivities of 88.9% and 78.2% were found for the IGRA and TST, respectively. Fewer migrants test positive with an IGRA compared with a TST. Immediately after immigration, no LTBI screening was cost-effective when applied universally to all migrants (ICERs >$138,484), but can reduce the TB burden in migrants >20%. IGRA screening pre-immigration and rifampin treatment post-arrival can reduce the TB burden by >40% and results in ICERs
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Objectives: The primary objectives of this thesis were to: (1) measure health-related quality of life (HRQL) and health state utility values (HSUVs) among patients with active tuberculosis (TB) disease and latent tuberculosis infection (LTBI); (2) investigate the relationship betwee HRQL and adverse drug reactions (ADR)among active TB patients; (3) quantify patients' preferences for LTBI preventive treatment. Methods: Two groups of patients were administered questionnaires: (1) Short-Form 36 (SF-36), Health Utility Index (HUI) and a Visual Analog Scale (VAS) were administered to 119 LTBI and 114 active TB patients at baseline and 3 months of their treatment. (2) A discrete choice experiment (DCE) survey was developed and administered among 214 LTBI patients. Conditional logit and latent class analysis were conducted to quantify respondents' preferences toward six treatment attributes (i.e. treatment length, clinic visit frequency, and risk of developing active TB, liver damage, skin rash and fatigue). Results: The baseline SF-36, HUI-2, HUI-3, Short-Form 6D (SF-6D) and VAS scores from active TB patients were significantly lower than those from LTBI patients. Major ADRs were shown to have significant impacts on active TB patients' HRQL and patients with lower baseline SF-36 scores were more likely to develop ADRs during the treatment. The three health utility instruments (HUI-2, HUI-3, and SF-6D) displayed acceptable construct validity when applying among TB population. However, they did not generate identical HSUV scores for the same individual. The DCE study results showed that all six attributes significantly influenced respondents' treatment decision and preference estimates were reasonable and consistent with our hypotheses. Substantial preference heterogeneity was observed among respondents. Latent class analysis assigned respondents into three groups and five socio-demographic factors significantly predicted the class assignment (i.e. origin of birth, education, employment, had children or not, and use of over-the counter medications).Conclusions: Active TB disease and the treatment associated ADR have substantial impacts on patients' HRQL. HRQL measurements might have the potential to predict patients' treatment outcomes. The DCE technique provides a useful tool of understanding patients' preferences surrounding health care products. this work demonstrates the value and importance of incorporating patient-reported outcome measurements into clinical research and practice.
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Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
Tuberculosis (TB) remains a major public health concern, and a delay in its diagnosis leads to continued disease transmission, and at the population level, may result in ineffective TB control programs. This delay may be associated with the inappropriate use of antibiotics, particularly the respiratory fluoroquinolones (FQ). In our study we determined whether the use of fluoroquinolones and other antibiotics results in a delay inthe diagnosis of TB. We used population-based data from the British Columbia Linked Health Databases(BCLHD), which collects longitudinal health care information. Residents who had active pulmonary TB from January 1, 1997 to December 31, 2006 as identified through the provincial TB control database were included and linked with data in BCLHD. Negative binomial regression was used to calculate the relative risk (RR) of health care delay (the time between first patient contact with the health care system for a respiratory conditionand the initiation of anti-TB medication) and antibiotic delay (the time between first patient prescription fill for antibiotics and initiation of anti-TB medication) compared to controls, adjusting for potential confounders. A total of 2232 patients had active TB diagnosed in BC between 1997 and 2006. Of these, 1544 participants were included in the study with health care contact six months prior to the date of diagnosis. After adjusting for gender, age, foreign-born status, socioeconomicstatus, prior chest radiograph and physician specialist visit, the health care delay forpatients exposed to antibiotics was found to be significant at RR 2.10 (95% CI 1.80-2.44).Gender, age, foreign-born status and socioeconomic status were not found to be significant factors. When categorizing this delay by antibiotic type, all antibiotic categories were at a significantly increased risk for delay. In addition, this delayincreased as the antibiotics prescribed also increased for the patient. Delay related toantibiotic exposure was found to be significant for the combination of FQ and non-FQ antibiotics at RR 1.35 (95% CI 1.08-1.70), but not for the FQ or non-FQ only categories. Our results indicate a delay in TB diagnosis due to previous exposure to any antibiotic and not just fluoroquinolones.
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