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Title: National Studies on Acute Gastrointestinal Illness:

1
National Studies on Acute Gastrointestinal
Illness Results to-date and upcoming research
Dr. Shannon Majowicz Public Health Agency of
Canada December 13, 2006
2
Background

What is the picture of acute gastrointestinal
illness in the population?
Traditional surveillance and outbreak
investigations are subject to bias and
under-reporting
In order to more accurately determine whats
happening in the general community (sporadic
illness, unreported illness), population-based
studies are used
In 2000, the Public Health Agency of Canada
began the National Studies on Acute
Gastrointestinal Illness (NSAGI) initiative, to
determine the burden of acute GI in the
population
www.phac-aspc.gc.ca/nsagi-engma/index.html

3
Background
Component 1 BASELINE UNDER-REPORTING
Component 2 COMMUNITY ETIOLOGY ATTRIBUTION
Outcomes, Actions, Interventions, Policy
Component 4 RISK FACTORS HIGH RISK POPULATIONS
Component 3 CHRONIC SEQUALAE
4
NSAGI - Phase 1

In 2000, four surveys aimed at addressing the
burden and under-reporting were initiated
Population survey (pilot)
Conducted in Hamilton, ON, Feb. 2001 Feb. 2002
Physician survey (pilot)
Conducted in Hamilton, ON, Spring 2001
Laboratory survey
Conducted Canada-wide, covering the year 2000
Public health survey
? Conducted in Ontario and British Columbia, 2001

5
Results Population Survey Pilot

1.3 episodes of acute GI occurred per person-year
in Hamilton (95 C.I. 1.1 1.4)
10 monthly prevalence (95 C.I. 9.94 10.14)
Prevalence of acute GI was higher in women, and
those lt10 and 20-24 years of age
When the data and analyses were standardized, the
prevalence in Hamilton, Ontario was remarkably
comparable to the US and Australia for the same
year

Majowicz et al. 2004 Epidemiol Infect
132607-17 Scallan et al. 2005 Int J Epidemiol
34454-60
6
(No Transcript)
7
Results Population Survey Pilot

Annual estimates per 100,000 population
126,320 cases of acute GI, with
37,000 physician visits
4,400 ER visits, 30 hospitalizations
25,000 cases taking anti-diarrheals
23,000 cases and 6,000 caregivers missing
93,000 days of work
The total cost of GI was
1,089 per case
115 per capita

Majowicz et al. 2006 J Food Prot 69651-9
8
Results Physician Survey Pilot

In Hamilton, 3.4 of patients seen in last 30
days were diagnosed with acute GI
Of those, 22.3 were requested to submit a
stool
Factors that prompted a stool request
bloody diarrhea
immunocompromised status
occupation
recent travel overseas
association with an outbreak
Stool request practices
Bacteria 80 always or often request
Parasites 86 always or often request
Viruses 18 always or often request

Online www.phac-aspc.gc.ca/nsagi-enmga/phys_e.htm
l
9
Results Laboratory Survey

In 2000, approx. 3 of stools received across
Canada were rejected without testing or referral
Routine testing varied by laboratory
Canadian laboratories processed 459,982 human
stool specimens, of which
5 positive for bacteria (ex. C. difficile)
15 positive for C. difficile
8 positive for parasites
19 positive for viruses

Flint et al. 2004 Can J Public Health 95309-13
10
Results Public Health Survey

In Ontario and B.C., local health units
received reports from laboratories (91),
physicians (2), or both (7)
Nearly 80 of health units received additional
information (e.g. serotype, phagetype) after the
case had been reported to the province
29 sent this additional information on to the
province
Approx. 5 of lab-confirmed cases of GI
reported to the health unit level were not
reported to the province

Flint et al. 2004 Can J Public Health 95309-13
11
Majowicz et al. 2005 Can J Public Health 96178-81
12
Conclusions from Phase 1

Epidemiology of GI observed in the pilot
population appears similar to that observed in
other developed countries
GI represented a significant health burden in the
pilot population, with costs high enough to
justify investigating prevention and intervention
efforts
Notifiable enteric disease data appear to be
highly under-reported and should be interpreted
accordingly
more research needed to have a Canadian picture

13
NSAGI - Phase 2

In 2002, the population and physician surveys
were replicated in three health unit areas in
British Columbia
1. Population survey
Conducted Jun. 2002 Jun. 2003
Had extensive cost of illness/burden questions
2. Physician survey
Conducted Oct. 2002 Jul. 2003
Accounted for seasonality via four questionnaires

14
Results B.C. Population Survey

1.3 episodes of acute GI occurred per person-year
in B.C. (95 C.I. 1.1 1.4)
9.2 monthly prevalence (95 C.I. 8.4 10.0)
Adjusting for sex, those 0-9 years (OR1.8) and
10-14 years (OR1.6) were more likely to
experience GI than those 25-64 years
Adjusting for age, females were 1.3 times more
likely to experience GI than males
Prevalence varied significantly by region
(p0.03)
Vancouver - 8.7
East Kootenay - 9.6
Northern Interior region - 11.1

Thomas et al. BMC Public Health (in press)
15
Results B.C. Population Survey

Of 223 employed adults with GI, 14 (6) were food
handlers, 2 (1) were day care workers, and 22
(10) were health care workers
Relative risk of discontinuing working when ill
(compared to those working in low-risk employment
settings)
Health care workers 1.5
Day care workers 2.0
Food handlers 1.0
Do we need to revisit the effectiveness of
existing educational material?

Thomas et al. 2006 CCDR 3216
16
Results B.C. Physician Survey