Quebec City

We left St Hyacinthe with a snow weather warning and travelled to Quebec City. In Canada all cars have to be fitted with snow tyres, it is illegal to drive a car without them after the 15th on November, we travelled with the hire car without the snow tyres, but we needed have worried the roads were very clear.

Quebec City had lovely buildings

A castle on a hill

Lots of art shops with lovely paintings on displays

Snowy views

Two spectacular mural’s painted onto the side of two buildings

And they were going all out with the Christmas decorations

It was a lovely place to visit and we only really saw the old town, I would thoroughly recommend it for a holiday.

After a quick visit in Quebec City we made our way back to Boston for our five flights home! and I have to commend all the airlines we travelled on every single flight left on time and we made all the connections with time to spare.

It was a very wet Boston, but we ventured out.

And that brings to an end phase 1 of my Churchill travels ( phase 2 is France in February 2019). I have met lots of interesting people and saw lots of the work being done. I now have to collate all I have learnt and look forward to arranging the next trip. I hope you have enjoyed the blog, it has been like a diary for me of all the things I saw and did and I hope it will help when it comes to writing my fellowship report.

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Lyme disease in Canada : A Federal Framework

Telephone conference with Federal Government staff at Ottowa

Rukshanda Ahmad (Medical Advisor), Michel Deilgat (Medical Advisor), Julie Theriault (Nurse Consultant), Lindsay Colas (Manager of tick-borne diseases policy team), Annie-Claude Bourgeois (Manager of vector-borne team), Karyn LaCroix (Senior policy analyst in the tick-borne unit), Anne Magnan (Policy analyst) and Nick Ogden and I in St Hyacinth.

The team gave me an overview of the Framework and their roles to co-ordinate and report on the activities tasked in the framework, the team are 1 year into the implementation and have to report progress in year 5 (2022).

The full document is available at : https://www.canada.ca/en/public-health/services/publications/diseases-conditions/lyme-disease-canada-federal-framework.html

The document is centred around 3 pillars

* Surveillance

* Guidelines and best practice

* Education and Awareness (Public and Health Professionals)

Year 1 has been spent planning, engaging with stakeholders and looking for collaborators. There was a round table event in June 2018 which included Provincial representatives, public health authorities, health professionals, academics and patient advocates.

To support framework delivery –$4 million has been committed for a Pan-Canadian Research Network on Lyme Disease in order to generate knowledge to improve diagnosis and treatment, and an additional $1.25 million to increase Canada’s capacity to respond to the health impacts of Lyme disease. More information available at https://www.canada.ca/en/institutes-health-research/news/2018/10/government-of-canada-takes-action-to-address-lyme-disease.html


Enhanced Surveillance reporting

The framework is committed to collecting accurate data and as I discussed in another post Jules at PHAC in St Hyacinthe has been instrumental in the design of the surveillance system.

Reporting form- this is 1/2 of the first page

(3 pages in total) link below to the complete form

https://www.gov.mb.ca/health/publichealth/cdc/protocol/mhsu_8232.pdf

The surveillance data published to date is available for viewing online at :


Professionals guidance and best practice resources

Monitoring and review is performed of all guidance and practice documentation that includes review of NICE guidance published in the UK in June 2018.

Management protocol

Guidance is available to health professionals with diagnosis, testing and treatment.

Defines how to diagnose the different stages and the testing that is required

https://www.gov.mb.ca/health/publichealth/cdc/protocol/lyme.pdf

An online resource is available for staff in Quebec

Institute for Santa de

https://www.inspq.qc.ca/nouvelles/un-guide-d-identification-des-tiques-du-quebec-pour-les-professionnels-de-la-sante

Prophylaxis

At a couple of the meetings I attended this week reference has been made for the use of prophylaxis in patients with a tick bite, the tick bite has to have been received in an area identified in Canada as a highly endemic area. This is not encouraged in the UK or USA.

The current use of prophylaxis can be seen on this link: https://www.canada.ca/en/public-health/services/diseases/lyme-disease/health-professionals-lyme-disease.html

The research paper that provides the recommendation for use of prophylaxis is Nadelman et al (2001) Prophylaxis with single-dose Doxycycline for the prevention of Lyme disease after an Ixodes Scapularis. The New England Journal of Medicine, 345(2).


Health education and awareness

Government staff have participated in outreach activities at national conferences attended by primary care physicians.

Speak at family medicine forums, about clinical aspects, and treatment of all tick borne diseases.

This has led to the creation of a zoonotic/climate change group to find out physicians priorities and identify areas they want to increase knowledge

Toolkits are being developed for clinical guidelines for obstetricians due to the concerns that have been raised about maternal/foetus transmission.

The school of Nursing is also committed to adding some modules into the training programme.

Resources

I have included some of the resources I have seen or were recommended to me while here in Canada, this list is not exhaustive there are other resources too.

Land management tips

Kirby Stafford from the Connecticut Agricultural Experiment Station, has a book that is the most referenced resource for environmental tick management . Kirby very kindly gave me a copy and he said the book is being reviewed and updated.

Other resources used in Canada

General public information leaflets

Small Information cards

More information available at:

https://www.gov.mb.ca/health/publichealth/factsheets/lymedisease.pdf

https://www.gov.mb.ca/health/publichealth/cdc/tickborne/docs/tbd_children.pdf

Tick warning poster I saw displayed in Bromont

Cards that were available at St Bruno National Park


INSPQ (Institute National de Santa Publique)

A website that is accessible to all and contains lots of information about all public health issues including the mapping of Lyme risk (in French).

Website address:https://www.inspq.qc.ca/en

An anecdote from one of the meetings I attended which mentioned the INSPQ website is that until 2 weeks ago Lyme disease was the most viewed page on the INSPQ website, that changed when Cannabis was legalised- looking at Cannabis has overtaken Lyme disease.


I participated in a telephone conference with Dr Ariane Adam-Poupart, Dr Alejandra Irace-Cima, Catherine and Nick (from Rue Sicotte)where they discussed the work of the Ministry of Health , this includes public and health professional awareness.

The ministry develop notices and distribute them to parks etc.

They arrange annual meetings with Dr’s, Nurses and Pharmacists in regions- the intensity of information does depend on the risk in the area- as the risk. Maps demonstrate not all areas are affected so it is important to target activities that are relevant.

They are working on projects with outdoor workers and their employers to increase awareness , developing elearning/videos etc. They are educating workers to collect data in their own parks and hey had a small pilot last year with 60 workers. Phase 2 is a ‘train the trainers’ event and extend the range of parks they work with and widen the project to include public education.

Some other ideas being considered are offering free bug spray (insect repellant) with the hand gel in parks.

At this meeting I heard about the use of prophylaxis in tick bites

St Hyacinthe

More about the staff I met at the Agence de la Santa publique du Canada in St Hyacinthe

Erin Rees

Erin is an epidemiologist who uses quantitative methods to study issues of population health for wildlife, food production animals and humans. Her research outcomes are applied to advising management of population health. This includes developing strategies to optimise use of surveillance data, identify vulnerable individuals and populations, and evaluate the effectiveness of management and disease control strategies.

Erin is also involved in the Global Public Health Intelligence Network(GPHIN). GPHIN’s mission is to be an indispensable source of early warning for potential public health threats worldwide including chemical, biological, radiological and nuclear (CBRN). The network scans news sources, social media etc for words and analysis the wording and starts to build a picture of threats as they develop.

Erin’s work with regard to Lyme disease involves developing a model to estimate tick abundance while considering the contributing covariates such as forest, elevation and temperature


Dragging for ticks in Bromont with Camille Guillot

Camille is a veterinary student ( who graduated from Edinburgh University as a medical Doctor in 2015) but she loves to study and enjoys the Zoonoses aspect, so she is now training to be a vet. Camille is helping to collect ticks. Bromont is a beautiful area up in the hills and surrounded by trees .

The community were aware of the risks and came forward looking for help/ support for the area. The studies are starting with identifying tick abundance, location of ticks ( peri-domestic or public areas) with a view to progress to testing management solutions as the project moves forward.

We found 10 ticks, which will be sent for analysis.

Camille pointed out an area which was set up for collecting maple syrup from the trees. On the first picture you will see a network of green tubing going from tree to tree and the second image is a close up of one of them. This is the modern way of collecting historically it used to be buckets/ containers sitting at the base of the tree collecting when the tree would start in ooze the syrup. The trees actively leak! the syrup in the spring after the winter frost has started to thaw.

At the beginning of the area we dragged at I noticed a couple of signs and was very disappointed to not see any tick warning notices

However further in on the path, this was displayed!!

This was very encouraging.


Jules Konan Koffi

Jules has worked for PHAC since 2009, in the Centre for Food-borne , Environmental and Zoonotic Infectious Disease he was tasked with designing a Lyme disease surveillance system.

There is a national notifiable surveillance system for a range of disease and there is a second enhanced surveillance system for Lyme disease.

Lyme disease is reported from the Doctor – Regional Government- Provincial Government -Federal Government. Currently it is a paper system which requires the data to be transferred. The data has to be validated and checked before it can be released as the national statistics and due to the way the data is collected it is a time consuming exercise. The working group can be put under pressure from Lyme advocacy groups about the release of the data but the process is adhered to strictly to ensure the data going into the public domain is correct.

There is a national working group which includes representation from the 10 Provincial governments, only 9 provinces currently input data for the Lyme enhanced surveillance but they are engaged in the process.


Yann Pelcat

Yann is a medical geographer who started with PHAC in 2009. Prior to that he worked as a neogronomist within the agriculture field.

In his role in PHAC he specialises in Geographic Information Systems (GIS), this software allows you to map out disease. Authorities provide precise data/information of cases, locations etc on a data spreadsheet and Yann transfers that onto maps.

The first map is of tick known endemic areas and suspected endemic areas

This map shows the movement of West Nile virus

This form of mapping is used nationally to map diseases and requires each province to provided consistent data.

Yann’s mapping skills have been used to support the two emergency operations centres in Canada that were used to support the response to the Ebola outbreak in the Congo.


VISIT TO ST BRUNO NATIONAL PARK

DA, Nick and I went to visit the National park at Mount Saint Bruno. Canada operates a no right to roam policy so people who wish to walk are restricted to roadside walking or travelling to the national parks. This park was lovely, it cost DA and I $17 to get in but Nick and people who live close by pay an annual membership and it gives access to all the parks in Quebec. Tick research is being undertaken within the park by a PhD student called Ariane Dumas (Ill tell you about it next).

In the summer the park is an array of walking trails and in the winter with the snowfall it becomes a cross country ski location. More information is available on the park website: https://www.sepaq.com/pq/msb/

DA and Nick

Infected ticks have been collected in the park so it was reassuring to see warning notices.

Outside display

Leaflets on tick and mosquitoes were available inside


On Friday I listened in on a teleconference with Ariane Dumas, Nick Ogden and smiling on the phone! are Robbin Lindsay and Antonia Dibernardo in Winnipeg.

The group met to discuss Ariane’s studies at St Bruno national park. Ariane is a student of the University of Montreal.

Her PhD title is ‘Ecology and emergence dynamics of Lyme disease at a fine spatial site’.

Ariane has been undertaking sites visits since 2016 , she identified 32 sites within the park and collected ticks by dragging, trapped rodents, birds and small mammals to examine them and remove ticks for analysis and identified environmental factors within the park.

The study will be looking at tick abundance, transmission hosts, environmental factors and observe changes in these over the 3 years of data collection as well as look for Borrelia burgdorferi and identify any other strains and look at what strains are prevelant in which hosts and gain information on the host activity.

Robbin and Antonia undertake the laboratory testing.


Rue Sicotte social activities

Thursday lunch with staff at Rue Sicotte (DA was there too) luckily as we struggled with the menu in french and ended up with enough chicken, rice and salad for 2 meals each.

Pandemonium

Staff are involved in a music group and they are practicing for the Christmas party!

Catherine and Camille with the Miranda Forrest glass necklaces I gave them as gifts.

Public engagement activities-eTick.ca

A public platform for image-based identification and population monitoring of ticks in Canada

Description: The emergence of Lyme disease and the rapid geographical range expansion of certain tick species in Canada are important issues for public health authorities and the public in general. Following tick populations on such a large territory is also expensive and logistically challenging. The citizen science project eTick.ca therefore invites the public to participate in the monitoring of ticks in Canada by submitting tick photos on eTick.ca for identification by a professional. The identification results, combined with other data such as collection date and locality can then be consulted and mapped so that all users may visualize the information related to any/all species for any given year and/or geographical area. 

Access to eTick.ca is free and it is not necessary to contribute data in order to consult the database.website where people are encouraged to document their experience of tick exposure.

Map- dots indicate where people have inserted data:

Next image is where I selected a dot and it shows the data that was added

The site can be accessed with this link:https://www.etick.ca/en/

The University of Montreal in collaboration with other organisations are currently looking at a project to develop a tick app. If funding is secured it will be an integrated tool for tick borne disease prevention and public health surveillance. Tick and Lyme risk is different across the regions of Canada therefore the risk communication messages would have to be adapted – the traditional communications activities delivered through websites and media would not be able to differentiate the messages for the changing risk areas.

Another public engagement online site is from Rhode Island University ‘Tick encounter.org’

It’s a very interactive site with lots of Information.

https://tickencounter.org/

Canada

We left Boston and flew to Montreal and onto Quebec, hired a car and drove to St Hyacinthe.

I am based for the week at the Public Health Agency for Canada in St Hyacinthe in Quebec.

Dr Nicholas Ogden is the Director of the Public Health Risk Sciences Division at the Public Health Agency of Canada/University of Montreal in St Hyacinthe. He started off as a Vet in the UK, and since his PhD he has continued to work in the research of ticks and tick borne disease.

Nick spoke about some of the research he has been involved and also the Department of Risk Sciences that he is the director off. The department is a division of the Public Health Agency of Canada(PHAC) and works closely with the University of Montreal.

The research group in the Epidemiology of Zoonoses and Public Health is a research group of the Faculty of Veterinary Medicine of the University of Montreal, and the result of a partnership between professors of the University of Montreal and researchers from the Public Health Agency of Canada.

The staff are all involved in research themselves and they are also tutors delivering courses in the University and the MSc and PhD Students under their supervision complete research projects that relate to ticks and Lyme disease. This structure allows for fluidity in the research and ensures it all ties together and progresses the knowledge in a structured way as opposed to students choosing random projects. Over the week I will spend time with the staff finding out about their research.

Canada has three levels of government Federal, Provincial and regional. Federal- seated in Ottawa, this level deals with the law and matters that affect the whole of Canada. The federal government published the Federal action plan for Lyme disease. Available at : https://www.canada.ca/en/public-health/services/publications/diseases-conditions/lyme-disease-canada-federal-framework.html

The framework acknowledges that Lyme disease is an emerging infectious disease in many parts of Canada, and the Government of Canada recognizes the impact that it has on Canadians and their families. Efforts to prevent and control Lyme disease are being made by a variety of stakeholders. The interim Chief Public Health Officer, expressed concern about the challenges associated with Lyme disease in Canada. The plan includes the establishment of a Lyme disease research network. As an emerging disease it is important that researchers come together with an evidence-based approach, and address knowledge gaps through further research. However Provincial governors (10 provinces 3 Territorials with responsibility for areas such as education, health care, natural resources and road regulations) and Municipal governors (city, town or district level with responsibility for libraries, parks, water systems, local police, roadways and parking) are left to prioritise what is done within their own localities, which means that there is no consistent structure to how areas mange ticks and Lyme disease.

The Public Health Risk Sciences division in collaboration with others are at the forefront of progressing research being undertaken. In response to the Federal framework a Canadian research network has been proposed, a multidisciplinary, patient-centered research program, from discovery to implementation, with the ultimate vision of reducing the impact of Lyme disease on the health of Canadians. The network will integrate researchers, patients, HCPs, public health & non-researcher stakeholders into the planning, advisory, and oversight capacities of all research activities to create short and long-term outcomes that are specific, measurable, accountable and transparent. Solutions and strategies will be developed by facilitating engagement across stakeholder groups. Patient engagement will be guided by provincial Strategy for Patient Oriented-Research (SPOR) units and patient/citizen engagement experts. Training and development of highly qualified personnel will be integrated across all research areas. We will accomplish our vision by creating foundational resources and spearheading new research initiatives.

It has been suggested that many critical knowledge gaps exist in Canada including: conflicting views on the natural history of disease, including the impact that LD strains have on the effectiveness of current diagnostic tests and on disease clinical presentation and patient outcomes, and lack of evidence on prevention/intervention strategies to reduce risk and long-term sequelae. Further, training and education of healthcare providers (HCP) is required to improve awareness and understanding of LD.

More information on the network can be seen on the website: https://www.clydrn.ca/

Dr Ogden has been involved in projects looking at the risk modelling for developing knowledge on Lyme disease. Many researchers have been involved in passive and active surveillance and there are many challenges associated with these methods, particularly when the territory under surveillance is very large and available resources are limited. The use of risk modelling has been able to predict the spread of Lyme disease and this has allowed for identification of high/low risk areas and could ensure surveillance activities were delivered in a targeted way.

The method is now being used to look at other vectors i.e Lone Star Tick movement into Canada and the progress of West Nile Virus.


Serge Olivier Kotchi

Serge is a Medical Geographer who is an expert in geomatics and earth observation. One of his recent projects was ‘Earth observations based risk maps for Lyme disease Infection in Eastern Canada’. Serge gave me permission to use his slides to explain his study.

The study used multi scale land cover variable estimations and vector habit mapping, The estimates were developed using MODIS images, MODIS is a sensor on board earth observation satellite, Landsat satellites and annual crop inventory maps from Agriculture and Agri-Food Canada

Microclimate indicators (temperature/humidity) using similar technologies.

The images developed show

And this information can now be used to compare Ixodes scapularis risk maps to active surveillance data.

Using Earth observation images will help to guide targeting of national research, surveillance and prevention and control activities in known or newly identified areas.


Catherine Bouchard

Is a veterinary epidemiologist and Professor Adjuvant at the Department of Epidemiology of the University of Montreal, she completed her PhD by looking at the variability of tick abundance across 30 micro sites.

Catherine teaches an online Epidemiology class and Conducts and co-ordinates Veterinary students undertaking PhD and MSc projects. She was very enthusiastic about the close links with the University as it ensures all studies are linked and allows for consistency in the studies and also offers future employment opportunities to the students as she acknowledges that is how she started working in PHAC.

Catherine is very interested in how the general public perceive Lyme risk and recognises the importance of sharing the knowledge of tick abundance with those in the areas affected, Catherine feels that how this is done needs to improve as many people are not aware of the risks. The data is available on websites but that is not always accessible to everyone, the difficulties with service delivery across the regions/municipalities does not help as small areas are free to decide for themselves what they do for their own community. A suggestion could be that at a Federal level communications departments and Scientists undertaking the research could collaborate more to look at innovate ways to inform people of study results.

Catherine has personal experience of field surveillance and supervising students who carry out surveillance, so is very knowledgable on the results of previous sentinel surveys and the importance on monitoring the expanding edge of areas that have previously been recorded as demonstrating high tick abundance. It is more beneficial to observe the situation in the areas out-with than to continually drag sites that are already recorded and known about. Testing also needs to expand further to check the abundance in public sites/parks and peri-domestic sites.

Catherine and I participated in a telephone conference to Sandie Briand who works at the Institute National de Santa Publique de Quebec. Sandie spoke about the work of the Lyme disease enhance surveillance working group.

Catherine and I with Sandie on the phone!!!! (First selfie on the blog)

Risk is based on data collected from human surveillance, passive tick surveillance and active tick surveillance, the map indicates the risk identified for each area, although it is in french you can still figure it out!

Sandie also spoke about some of the resources available online from INSPQ.

This link takes you to the page: https://www.inspq.qc.ca/guide-d-identification-des-tiques-du-quebec

Washington

We decided to fit in a very short visit to Washington on route to Canada.

It did not disappoint, beautiful buildings, many museums and the warmest days we have had on the trip so far.

Our hotel was around the corner from the White House

We visited Smithsonian museums

Saw the batmobile

Walked to Capital Hillwitnessed a demonstration at the White House!

Visited the Natural History Museum

They had a section on one health- how the animals, environment and humans all interact with viruses, bacteria’s… they had a giant mosquito but no mention of Lyme disease

The Hope diamond

World War Two memorial

Washington memorial

The Lincoln memorial

Overall a great place to visit

And we will definitely be back

Some highlights from Portland

Miscellaneous items I couldn’t include anywhere else:

Halloween was celebrated while we were in Portland

Lobster Roll was a local delicacy, it was lovely:

Boat trip around Casco Bay, Portland

British goods shop we found this shop on our last day, it’s in Freeport and the ladies were delighted to have a pin put on the map for visitors from South Uist in the Western Isles

My favourite tree Red Maple:

Trip to L.L. Bean large outdoor retail store… loved their animal displays

We went to dinner with Dr Rob and Professor Margaret Smith

We were also invited to dinner by Dr Donald St Germain and his family

Tick forecasting

Rebecca and Susan at MMRC are involved in a group looking at Innovations in science and the are looking at ‘tick cast’ a bit like weather forecast.

Currently the jelly fish forecast includes tick too

But they would be looking to expand this to include more information and engage with partners to advertise the page as it will require members of the public to add information and details of where they encounter ticks.

To have a look at the bigelow forecast the link is:

https://eco.bigelow.org/

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