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There is a need to reflect on the COVID-19 vaccine distribution plans across Canada and the extent to which they considered equity-deserving populations, as lessons from the rollout can inform future emergency responses and foster trust in public health. This paper examined and compared strategies implemented by six Canadian provinces to increase access and promote the uptake of COVID-19 vaccines among selected priority populations. We also explored the factors that impacted the implementation of these strategies. In six provinces (Alberta, British Columbia, Manitoba, Nova Scotia, Ontario, and Quebec), we conducted an environmental scan of provincial rollout documents and media sources reporting vaccine distribution among selected priority populations: First Nations, Inuit, and Métis; Black communities; essential workers; people experiencing homelessness; and people with disabilities. We subsequently interviewed 39 key informants to validate the environmental scan results, identify additional strategies to increase COVID-19 vaccine uptake, and uncover perceptions of the facilitators and challenges that influenced the strategies implementation. We identified that provincial health authorities employed several strategies to overcome structural, geographical, and attitudinal barriers to COVID-19 vaccines experienced by the priority populations. Most provinces implemented walk-in, mobile, and pop-up vaccination clinics, mobilized their public and private health workforce, and designed multilingual communication materials. Facilitators in implementing COVID-19 vaccination strategies included harmonizing communication efforts, leveraging existing relationships and networks, and ensuring representation and leadership of community partners. Challenges to implementing COVID-19 vaccination strategies included uncoordinated communication efforts, inadequate distribution of vaccines to areas with the greatest need, mistrust in the government and healthcare system, vaccine hesitancy, and lack of cultural competence by vaccine providers. This study highlights the divide between well-intentioned strategies and interventions and the reality of on-the-ground implementation. The findings offer valuable insights and can inform the implementation of strategies to distribute vaccines equitably in future large-scale vaccination efforts in Canada and globally.

In Ethiopia, the reduction in perinatal mortality rates is still falling short of national and global targets set for 2030. Additionally, accurate recording is challenging, as many births occur at home. This study aimed to assess the trends and determinants of perinatal mortality using population-based longitudinal data from 2009 to 2016 across three Health and Demographic Surveillance Systems (HDSS) in Ethiopia: Gelgel-Gibe, Dabat, and Kilite-Awlaelo. Data on vital events and pregnancies were continuously collected at these HDSS sites. The study utilized follow-up data from prospective linked pregnancy and birth cohorts from January 2009 to December 31, 2016. Perinatal mortality was defined as deaths occurring from 28 weeks of gestation until six days after birth, measured per 1000 live births. Relevant health, demographic, and socioeconomic data were included in the analysis. Poisson regression was employed to assess factors associated with perinatal mortality. Out of 38,691 pregnancies that led to births, there were 1214 perinatal deaths (456 stillbirths and 758 early neonatal deaths), resulting in a perinatal mortality rate of 31 deaths per 1000 total births. The early neonatal death rate was higher, at 19.6 deaths per 1000 total births, compared to the stillbirth rate of 11.8 per 1000 total births. The perinatal mortality rate declined from 40.6 in 2009 to 29.1 per 1000 total births in 2016, reflecting an average annual rate reduction of 2.4%. Determinants of perinatal mortality included being a male newborn, multiple births, first-time pregnancies (primi-gravidity), lack of antenatal care visits, absence of delivery services, and residing in tropical zones. The primary causes of death were asphyxia, sepsis, and preterm birth. Overall, perinatal mortality rates were high in the three HDSS sites, with slow reductions over time and significant variations between them. Addressing the issue of stillbirths and improving the availability and quality of emergency obstetric care are crucial. Continuous home visits in rural communities to prevent stillbirths and newborn deaths, are also essential.

Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the \"reverse causality\" in which the mothers deliver at a health facility due to adverse perinatal events. We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care. In the larger study of 2004-8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2-2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4-0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001-4 births. The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).

Objective To evaluate risk factors for severe outcomes in patients with seasonal and pandemic influenza. Design Systematic review. Study selection Observational studies reporting on risk factor-outcome combinations of interest in participants with influenza. Outcomes included death, ventilator support, admission to hospital, admission to an intensive care unit, pneumonia, and composite outcomes. Data sources Medline, Embase, CINAHL, Global Health, and the Cochrane Central Register of Controlled Trials to March 2011. Risk of bias assessment Newcastle-Ottawa scale to assess the risk of bias. GRADE framework to evaluate the quality of evidence. Results 63 537 articles were identified of which 234 with a total of 610 782 participants met the inclusion criteria. The evidence supporting risk factors for severe outcomes of influenza ranged from being limited to absent. This was particularly relevant for the relative lack of data for non-2009 H1N1 pandemics and for seasonal influenza studies. Limitations in the published literature included lack of power and lack of adjustment for confounders was widespread: adjusted risk estimates were provided for only 5% of risk factor-outcome comparisons in 39 of 260 (15%) studies. The level of evidence was low for “any risk factor” (odds ratio for mortality 2.77, 95% confidence interval 1.90 to 4.05 for pandemic influenza and 2.04, 1.74 to 2.39 for seasonal influenza), obesity (2.74, 1.56 to 4.80 and 30.1, 1.74 to 2.39), cardiovascular diseases (2.92, 1.76 to 4.86 and 1.97, 1.06 to 3.67), and neuromuscular disease (2.68, 1.91 to 3.75 and 3.21, 1.84 to 5.58). The level of evidence was very low for all other risk factors. Some well accepted risk factors such as pregnancy and belonging to an ethnic minority group could not be identified as risk factors. In contrast, women who were less than four weeks post partum had a significantly increased risk of death from pandemic influenza (4.43, 1.24 to 15.81). Conclusion The level of evidence to support risk factors for influenza related complications is low and some well accepted risk factors, including pregnancy and ethnicity, could not be confirmed as risks. Rigorous and adequately powered studies are needed.

With global survival increasing for children younger than 5 years of age, attention is required to reduce the approximately 1 million deaths of children aged 5–14 years occurring every year. Causes of death at these ages remain poorly documented. We aimed to explore trends in mortality by causes of death in India, China, Brazil, and Mexico, which are home to about 40% of the world's children aged 5–14 years and experience more than 200 000 deaths annually at these ages. We examined data on 244 401 deaths in children aged 5–14 years from four nationally representative data sources that obtained direct distributions of causes of death: the Indian Million Death Study, the Chinese Disease Surveillance Points, mortality data from the Mexican Instituto Nacional de Estadística y Geografía, and mortality data from the Brazilian Institute of Geography and Statistics. We present data on 12 main disease groups in all countries, with breakdown by communicable and nutritional diseases, non-communicable diseases, injuries, and ill-defined causes. To calculate age-specific and sex-specific death rates for each cause, we applied the national cause of death distribution to the UN mortality envelopes for 2005–16 for each country. Unlike Brazil, China, and Mexico, communicable diseases still account for nearly half of deaths in India in children aged 5–14 years (73 920 [46·1%] of 160 330 estimated deaths in 2016). In 2016, India had the highest death rates in nearly every category, including from communicable diseases. Fast declines among girls in communicable disease mortality narrowed the gap by 2016 with boys in India (32·6 deaths per 100 000 girls vs 26·2 per 100 000 boys) and China (1·7 vs 1·5). In China, injuries accounted for the greatest proportions of deaths (20 970 [53·2%] of 39 430 estimated deaths, in which drowning was a leading cause). The homicide death rate at ages 10–14 years was higher for boys than for girls in Brazil, increasing annually by an average of 0·7% (0·3–1·1). In India and China, the suicide death rates were higher for girls than for boys at ages 10–14 years. By contrast, in Mexico it was higher for boys than for girls, increasing annually by an average of 2·8% (2·0–3·6). Deaths from transport injuries, drowning, and cancer are common in all four countries, with transport accidents among the top three causes of death for both sexes in all countries, except for Indian girls, and cancer in the top three causes for both sexes in Mexico, Brazil, and China. Most of the deaths that occurred between 2005 and 2016 in children aged 5–14 years in India, China, Brazil, and Mexico arose from preventable or treatable conditions. This age group is important for extending some of the global disease-specific targets developed for children younger than 5 years of age. Interventions to control non-communicable diseases and injuries and to strengthen cause of death reporting systems are also required. WHO and the University of Toronto Connaught Global Challenge.

Background13-valent pneumococcal conjugate vaccine (PCV13) has been part of publicly funded childhood immunisation programmes in Ontario and British Columbia (BC) since 2010. We assessed the indirect impact of infant PCV13 programmes on invasive pneumococcal disease (IPD) and all-cause pneumonia hospitalisation in older adults (aged ≥65 years) using a retrospective observational study.MethodsWe extracted monthly IPD and all-cause pneumonia cases from laboratory and health administrative databases between January 2005 and December 2018. Using a quasi-experimental difference-in-differences design, we calculated the ratio of risk ratios (RRRs) using incidence rates of IPD or all-cause pneumonia cases before (pre-PCV13 period) and after (PCV13 period) 2010 with rates of fractures as controls.ResultsThe rates of all IPD or PCV serotype-specific IPD for older adults in both Ontario and BC did not change in 8 years after childhood PCV13 programme implementation. All-cause pneumonia increased in Ontario (RRR 1.38, 95% CI 1.11 to 1.71) but remained unchanged in BC.ConclusionsIndirect community protection of older adults from hospitalisation with pneumococcal disease stalled despite maturation of childhood PCV13 vaccination programmes in two Canadian provinces.

Aim To determine factors associated with a serious outcome (hospital admission or severe outcome: critical care or death) and associated with illness caused by laboratory‐confirmed influenza, with a specific interest in low‐ and middle‐income countries (LMIC). Method Databases were searched on 11 March 2016 for reports of influenza and factors associated with mortality or morbidity in humans, with no language restrictions. Pooled risks were estimated using random‐effects models. Results Despite the heterogeneity of results across studies, known risk factors for serious disease were associated with both hospital admission and severe outcomes (critical care and/or death). In LMIC, but not in high income countries (HIC), pregnant women, people with HIV/AIDS and children < 5 years old (compared with older children) were at increased risk of a severe outcome. Also, although all patients with neurological conditions were at higher risk of severe outcomes than those without, children were at higher risk than adults and children who lived in a LMIC were at significantly higher risk than those living in HIC. Adults were more likely than children to suffer a severe outcome if they had diabetes or a hematologic condition, were obese or had liver disease. Asthma is a risk factor for hospital admission but not for severe outcomes. Conclusion Known risk factors for serious disease remain important predictors of hospital admission and severe outcomes with few differences between HIC and LMIC countries. These differences likely reflect differences in health‐seeking behaviours and health services, but high heterogeneity between studies limits conclusions about the effect size.

Background COVID-19 hit Canada hard and exacerbated health inequities, notably among ethnoracially minoritized populations. By August 2021, some areas in Peel region (Ontario, Canada) continued to have high COVID-19 infection rates and low COVID-19 vaccine coverage. To increase first dose uptake, Peel Public Health implemented smaller community-based vaccination clinics in addition to pre-existing mass vaccination (fixed) clinics. This study describes these community clinics and those who received their first dose at a community clinic to determine whether local public health efforts to implement community clinics reached different population groups and whether these community clinics contributed to an increase in uptake of the first dose of COVID-19 vaccines. Methods We conducted a descriptive, cross-sectional study using data from the Ontario COVID-19 vaccination registry (COVaxON). We included eligible Peel residents 12 years and older who received a COVID-19 vaccine within community and fixed clinics between September 2021 and August 2022. Clinics were classified based on clinic type (community/fixed), and location. COVID-19 vaccine uptake for smaller geographic areas designated by postal codes was calculated at the beginning and end of the study period. Clinic and attendee characteristics were analyzed using descriptive statistics. Results There were 177 community and 11 fixed clinic sites that operated during the study period. Community clinics administered 98,965 doses (27%) of COVID-19 vaccine and fixed clinics administered 264,021 doses (73%). A slightly higher proportion of first doses were administered in community clinics (8.1%) compared to fixed clinics (7.9%) and community clinics saw a higher proportion of first dose recipients from low-coverage areas (23% versus 19% in fixed clinics). Clinics in faith-based organizations, schools and shopping areas administered the most doses among community clinic locations. The absolute increase in first dose vaccine uptake was 11% over the study period. Conclusions Almost 100,000 doses of COVID-19 vaccine were administered in community clinics, which contributed to increased overall vaccine coverage in Peel region. A slightly higher proportion of first doses were administered in community clinics compared to fixed clinics and a higher proportion of doses to residents of low-coverage areas.

Background Pneumococcal disease is a leading cause of morbidity and mortality worldwide, with older adults aged 65 and above at particularly high risk for invasive pneumococcal infections. In Canada, pneumococcal vaccination has been recommended for this age group since 1989, yet coverage remains below national targets. Currently, only about 55% of older adults report being vaccinated, falling short of the 80% target. This study assessed knowledge, attitudes, willingness, and barriers to pneumococcal vaccination among unvaccinated older adults. Methods We used baseline data from a randomized controlled trial conducted as a cross-sectional survey among community-dwelling adults aged 65 years and older, residing in any of the ten Canadian provinces, and who self-identified as unvaccinated against pneumococcal disease. The survey was administered online using a tailored web-based electronic data capture system. Data were collected between June 20, 2024, and December 12, 2024, capturing data on participants’ knowledge, attitudes, and willingness to receive the vaccine, along with perceived barriers. Ordinal logistic regression was used to identify factors associated with willingness to be vaccinated, categorized as “willing”, “not willing”, and “I don’t know”. Results A total of 720 participants completed the baseline survey. Ninety percent of the respondents had moderate to good knowledge, and 47% reported positive attitudes toward the vaccine. 59% of respondents reported willingness to be vaccinated, 20% were unwilling, and 21% were unsure. We also found that positive attitudes were the strongest predictor of willingness to be vaccinated (aOR 14.8, 95% CI: 9.2-23.9), followed by good knowledge of pneumococcal vaccines and pneumococcal disease (aOR 2.6, 95% CI: 1.4-5.0). Regional differences emerged, with significantly higher willingness among those residing in the Prairies versus Ontario. Commonly reported barriers included affordability concerns and lack of awareness about where to get vaccinated. Conclusion Our findings underscore the need to address attitudes alongside knowledge in public health efforts to improve pneumococcal vaccine uptake among older adults. Tailored interventions that reduce logistical and informational barriers may help close the coverage gap and support national immunization goals.

Background There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs. Objective To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults. Design We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions. Results Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination ( n  = 14 studies), followed by primary care interventions ( n  = 8 studies), then information campaigns ( n  = 5 studies). Conclusion Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.