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Domnich A, Ferrari A, Ogliastro M, Orsi A, Icardi G. Web search volume as a near-real-time complementary surveillance tool of tick-borne encephalitis (TBE) in Italy. Ticks Tick Borne Dis 2024; 15:102332. [PMID: 38484539 DOI: 10.1016/j.ttbdis.2024.102332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
The Internet is an important gateway for accessing health-related information, and data generated through web queries have been increasingly used as a complementary source for monitoring and forecasting of infectious diseases and they may partially address the issue of underreporting. In this study, we assessed whether tick-borne encephalitis (TBE)-related Internet search volume may be useful as a complementary tool for TBE surveillance in Italy. Monthly Google Trends (GT) data for TBE-related information were extracted for the period between January 2017 and September 2022, corresponding to the available time series of TBE notifications in Italy. Time series modeling was performed by applying seasonal autoregressive integrated moving average (SARIMA) models with or without GT data. The search terms relative to tick bites reflected best the observed temporal distribution of TBE cases, showing a correlation coefficient of 0.81 (95 % CI: 0.71-0.88). Particularly, both the reported number of TBE cases and GT searches occurred mainly during the summer. The peak of disease notifications coincided with that of Google searches in 4 of 6 years. Once calibrated, SARIMA models with or without GT data were applied to a validation set. Retrospective forecast made by the model with GT data was associated with a lower prediction error and accurately predicted the peak timing. By contrast, the traditional SARIMA model underestimated the actual number of TBE notifications by 65 %. Timeliness, easy availability, low cost and transparency make monitoring of the TBE-related Internet search queries a promising addition to the traditional methods of TBE surveillance in Italy.
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Affiliation(s)
- Alexander Domnich
- Hygiene Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Allegra Ferrari
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Andrea Orsi
- Hygiene Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Giancarlo Icardi
- Hygiene Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
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2
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Riccò M, Corrado S, Marchesi F, Bottazzoli M. Tick-Borne Encephalitis Virus Vaccination among Tourists in a High-Prevalence Area (Italy, 2023): A Cross-Sectional Study. Trop Med Infect Dis 2023; 8:491. [PMID: 37999610 PMCID: PMC10674593 DOI: 10.3390/tropicalmed8110491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
Tick-borne encephalitis (TBE) represents a potential health threat for tourists in high-risk areas, including the Dolomite Mountains in northeastern Italy. The present questionnaire-based survey was, therefore, designed in order to assess knowledge, attitudes, and preventive practices (KAP) in a convenience sample of Italian tourists visiting the Dolomite Mountains, who were recruited through online discussion groups. A total of 942 participants (39.2% males, with 60.2% aged under 50) filled in the anonymous survey from 28 March 2023 to 20 June 2023. Overall, 24.1% of participants were vaccinated against TBE; 13.8% claimed to have previously had tick bites, but no cases of TBE were reported. The general understanding of TBE was relatively low; while 79.9% of participants acknowledged TBE as a potentially severe disease, its occurrence was acknowledged as high/rather high or very high in the Dolomites area by only 51.6% of respondents. Factors associated with the TBE vaccine were assessed by the calculation of adjusted odds ratios (aOR) and 95% confidence intervals through a logistic regression analysis model. Living in areas considered at high risk for TBE (aOR 3.010, 95%CI 2.062-4.394), better knowledge on tick-borne disorders (aOR 1.515, 95%CI 1.071-2.142), high risk perception regarding tick-borne infections (aOR 2.566, 95%CI 1.806-3.646), a favorable attitude toward vaccinations (aOR 3.824, 95%CI 1.774-8.224), and a tick bite(s) in a previous season (aOR 5.479, 95%CI 3.582-8.382) were characterized as being positively associated with TBE vaccination uptake. Conversely, being <50 years old (aOR 0.646, 95%CI, 0.458-0.913) and with a higher risk perception regarding the TBE vaccine (aOR 0.541, 95%CI 0.379-0.772) were identified as the main barriers to vaccination. In summary, tourists to the high-risk area of the Dolomites largely underestimate the potential occurrence of TBE. Even though the uptake of the TBE vaccine in this research was in line with European data, public health communication on TBE is required in order to improve acceptance of this effective preventive option.
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Affiliation(s)
- Matteo Riccò
- Occupational Health and Safety Service on the Workplace/Servizio di Prevenzione e Sicurezza Ambienti di Lavoro (SPSAL), Department of Public Health, AUSL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Silvia Corrado
- ASST Rhodense, Dipartimento della donna e Area Materno-Infantile, UOC Pediatria, 20024 Garbagnate Milanese, Italy;
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Marco Bottazzoli
- Department of Otorhinolaryngology, APSS Trento, 31223 Trento, Italy;
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Colucci M, Fonzo M, Miccolis L, Amoruso I, Mondino S, Trevisan A, Cazzaro R, Baldovin T, Bertoncello C. Emergency Department Syndromic Surveillance to Monitor Tick-Borne Diseases: A 6-Year Small-Area Analysis in Northeastern Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6822. [PMID: 37835091 PMCID: PMC10572455 DOI: 10.3390/ijerph20196822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
Tick-borne diseases (TBD) are endemic in Europe. However, surveillance is currently incomplete. Alternative strategies need to be considered. The aim of this study was to test an Emergency Department Syndromic Surveillance (EDSyS) system as a complementary data source to describe the impact of tick bites and TBD using a small-area analysis approach and to monitor the risk of TBD to target prevention. ED databases in the Local Health Authority 8 District (Veneto, Italy) were queried for tick-bite and TBD-related visits between January 2017 and December 2022. Hospitalisations were also collected. Events involving the resident population were used to calculate incidence rates. A total of 4187 ED visits for tick-bite and 143 for TBD were recorded; in addition, 62 TBD-related hospitalisations (of which 72.6% in over 50 s and 22.6% in over 65 s). ED visits peaked in spring and in autumn, followed by a 4-week lag in the increase in hospital admissions. The small-area analysis identified two areas at higher risk of bites and TBD. The use of a EDSyS system allowed two natural foci to be identified. This approach proved useful in predicting temporal and geographic risk of TBD and in identifying local endemic areas, thus enabling an effective multidisciplinary prevention strategy.
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Affiliation(s)
- Massimiliano Colucci
- Hospital Direction, Local Health Authority 8 (Azienda ULSS Berica), Veneto Region, 36100 Vicenza, Italy
| | - Marco Fonzo
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
| | - Liana Miccolis
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
| | - Irene Amoruso
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
| | - Sara Mondino
- Hospital Direction, Local Health Authority 8 (Azienda ULSS Berica), Veneto Region, 36100 Vicenza, Italy
| | - Andrea Trevisan
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
| | - Romina Cazzaro
- Hospital Direction, Local Health Authority 8 (Azienda ULSS Berica), Veneto Region, 36100 Vicenza, Italy
| | - Tatjana Baldovin
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
| | - Chiara Bertoncello
- Hygiene and Public Health Unit, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35131 Padova, Italy
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Chiffi G, Grandgirard D, Leib SL, Chrdle A, Růžek D. Tick-borne encephalitis: A comprehensive review of the epidemiology, virology, and clinical picture. Rev Med Virol 2023; 33:e2470. [PMID: 37392370 DOI: 10.1002/rmv.2470] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/31/2023] [Accepted: 06/12/2023] [Indexed: 07/03/2023]
Abstract
Tick-borne encephalitis virus (TBEV) is a flavivirus commonly found in at least 27 European and Asian countries. It is an emerging public health problem, with steadily increasing case numbers over recent decades. Tick-borne encephalitis virus affects between 10,000 and 15,000 patients annually. Infection occurs through the bite of an infected tick and, much less commonly, through infected milk consumption or aerosols. The TBEV genome comprises a positive-sense single-stranded RNA molecule of ∼11 kilobases. The open reading frame is > 10,000 bases long, flanked by untranslated regions (UTR), and encodes a polyprotein that is co- and post-transcriptionally processed into three structural and seven non-structural proteins. Tick-borne encephalitis virus infection results in encephalitis, often with a characteristic biphasic disease course. After a short incubation time, the viraemic phase is characterised by non-specific influenza-like symptoms. After an asymptomatic period of 2-7 days, more than half of patients show progression to a neurological phase, usually characterised by central and, rarely, peripheral nervous system symptoms. Mortality is low-around 1% of confirmed cases, depending on the viral subtype. After acute tick-borne encephalitis (TBE), a minority of patients experience long-term neurological deficits. Additionally, 40%-50% of patients develop a post-encephalitic syndrome, which significantly impairs daily activities and quality of life. Although TBEV has been described for several decades, no specific treatment exists. Much remains unknown regarding the objective assessment of long-lasting sequelae. Additional research is needed to better understand, prevent, and treat TBE. In this review, we aim to provide a comprehensive overview of the epidemiology, virology, and clinical picture of TBE.
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Affiliation(s)
- Gabriele Chiffi
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Denis Grandgirard
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Stephen L Leib
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Aleš Chrdle
- Department of Infectious Diseases, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
- Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic
- Royal Liverpool University Hospital, Liverpool, UK
| | - Daniel Růžek
- Veterinary Research Institute, Emerging Viral Diseases, Brno, Czech Republic
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
- Institute of Parasitology, Biology Centre of the Czech Academy of Sciences, Ceske Budejovice, Czech Republic
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The Prevalence of Asymptomatic Infections with Tick-Borne Encephalitis Virus and Attitude towards Tick-Borne Encephalitis Vaccine in the Endemic Area of Northeastern Poland. Vaccines (Basel) 2022; 10:vaccines10081294. [PMID: 36016182 PMCID: PMC9412675 DOI: 10.3390/vaccines10081294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
In Poland, tick-borne encephalitis (TBE) vaccination rate is low despite high incidence of severe infections with TBE virus (TBEV). However, infection with TBEV can be asymptomatic or mild, which makes the total number of cases difficult to assess. We aimed at assessing asymptomatic TBEV infections and describing attitudes towards the TBE vaccine. We studied 298 healthy adult blood donors and 180 children from the TBE endemic area of northeastern Poland for the presence of anti-TBEV IgG antibodies. We also surveyed a separate cohort of 444 adults. Thirty-eight blood donors (13%) and 38 survey respondents (9%) reported a history of a prior anti-TBEV vaccination. Forty respondents (9%) reported vaccinating their child in the past. Fourteen unvaccinated blood donors (5%) and four children (2%) were seropositive for specific anti-TBEV antibodies, suggesting a history of an undiagnosed TBEV infection. In the surveyed cohort, 130 (32%) expressed their intention to be vaccinated and 144 (36%) expressed their intention to vaccinate their child. This intention was significantly higher in respondents with a recent tick-bite, a diagnosis of tick-borne disease in a close relative, and in males. Our study shows that asymptomatic TBEV infections are common. The acceptance of TBE vaccine is low, but might be increased by communicating risks associated with tick bites.
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Banović P, Díaz-Sánchez AA, Đurić S, Sević S, Turkulov V, Lendak D, Mikić SS, Simin V, Mijatović D, Bogdan I, Potkonjak A, Savić S, Obregón D, Cabezas-Cruz A. Unexpected TBEV Seropositivity in Serbian Patients Who Recovered from Viral Meningitis and Encephalitis. Pathogens 2022; 11:pathogens11030371. [PMID: 35335695 PMCID: PMC8951648 DOI: 10.3390/pathogens11030371] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/12/2022] Open
Abstract
The tick-borne encephalitis virus (TBEV) causes a life-threatening disease named Tick-borne encephalitis (TBE). The clinical symptoms associated with TBE range from non-specific to severe inflammation of the central nervous system and are very similar to the clinical presentation of other viral meningitis/encephalitis. In consequence, TBE is often misclassified by clinical physicians, mainly in the non-identified high-risk areas where none or only a few TBE cases have been reported. Considering this situation, we hypothesized that among persons from northern Serbia who recovered from viral meningitis or encephalitis, there would be evidence of TBEV infection. To test this hypothesis, in this observational study, we evaluated the seroreactivity against TBEV antigens in patients from northern Serbia who were hospitalized due to viral meningitis and/or viral encephalitis of unknown etiology. Three cases of seroreactivity to TBEV antigens were discovered among convalescent patients who recovered from viral meningitis and/or encephalitis and accepted to participate in the study (n = 15). The clinical and laboratory findings of these patients overlap with that of seronegative convalescent patients. Although TBE has been a notifiable disease in Serbia since 2004, there is no active TBE surveillance program for the serologic or molecular screening of TBEV infection in humans in the country. This study highlights the necessity to increase the awareness of TBE among physicians and perform active and systematic screening of TBEV antibodies among patients with viral meningitis and/or encephalitis.
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Affiliation(s)
- Pavle Banović
- Ambulance for Lyme Borreliosis and Other Tick-Borne Diseases, Department of Prevention of Rabies and Other Infectious Diseases, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia;
- Department of Microbiology with Parasitology and Immunology, Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia
- Correspondence: (P.B.); (A.C.-C.)
| | | | - Selena Đurić
- Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (S.Đ.); (S.S.); (V.T.); (D.L.); (S.S.M.)
| | - Siniša Sević
- Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (S.Đ.); (S.S.); (V.T.); (D.L.); (S.S.M.)
- Clinic for Infectious Diseases, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Vesna Turkulov
- Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (S.Đ.); (S.S.); (V.T.); (D.L.); (S.S.M.)
- Clinic for Infectious Diseases, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Dajana Lendak
- Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (S.Đ.); (S.S.); (V.T.); (D.L.); (S.S.M.)
- Clinic for Infectious Diseases, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Sandra Stefan Mikić
- Faculty of Medicine in Novi Sad, University of Novi Sad, 21000 Novi Sad, Serbia; (S.Đ.); (S.S.); (V.T.); (D.L.); (S.S.M.)
- Clinic for Infectious Diseases, Clinical Center of Vojvodina, 21000 Novi Sad, Serbia
| | - Verica Simin
- Department of Microbiology, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia; (V.S.); (I.B.)
| | - Dragana Mijatović
- Ambulance for Lyme Borreliosis and Other Tick-Borne Diseases, Department of Prevention of Rabies and Other Infectious Diseases, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia;
| | - Ivana Bogdan
- Department of Microbiology, Pasteur Institute Novi Sad, 21000 Novi Sad, Serbia; (V.S.); (I.B.)
| | - Aleksandar Potkonjak
- Department of Veterinary Medicine, Faculty of Agriculture, University of Novi Sad, 21000 Novi Sad, Serbia;
| | - Sara Savić
- Scientific Veterinary Institute “Novi Sad”, 21000 Novi Sad, Serbia;
| | - Dasiel Obregón
- School of Environmental Sciences, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Alejandro Cabezas-Cruz
- Anses, INRAE, Ecole Nationale Vétérinaire d’Alfort, UMR BIPAR, Laboratoire de Santé Animale, F-94700 Maisons-Alfort, France
- Correspondence: (P.B.); (A.C.-C.)
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Vaccination against Tick-Borne Encephalitis (TBE) in Italy: Still a Long Way to Go. Microorganisms 2022; 10:microorganisms10020464. [PMID: 35208918 PMCID: PMC8880353 DOI: 10.3390/microorganisms10020464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023] Open
Abstract
Tick-borne encephalitis (TBE) is endemic in several European countries, and its incidence has recently increased. Various factors may explain this phenomenon: social factors (changes in human behavior, duration and type of leisure activities and increased tourism in European high-risk areas), ecological factors (e.g., effects of climate change on the tick population and reservoir animals), and technological factors (improved diagnostics, increased medical awareness). Furthermore, the real burden of TBE is not completely known, as the performance of surveillance systems is suboptimal and cases of disease are under-reported in several areas. Given the potentially severe clinical course of the disease, the absence of any antiviral therapy, and the impossibility of interrupting the transmission of the virus in nature, vaccination is the mainstay of prevention and control. TBE vaccines are effective (protective effect of approximately 95% after completion of the basic vaccination—three doses) and well tolerated. However, their uptake in endemic areas is suboptimal. In the main endemic countries where vaccination is included in the national/regional immunization program (with reimbursed vaccination programs), this decision was driven by a cost-effectiveness assessment (CEA), which is a helpful tool in the decision-making process. All CEA studies conducted have demonstrated the cost-effectiveness of TBE vaccination. Unfortunately, CEA is still lacking in many endemic countries, including Italy. In the future, it will be necessary to fill this gap in order to introduce an effective vaccination strategy in endemic areas. Finally, raising awareness of TBE, its consequences and the benefit of vaccination is critical in order to increase vaccination coverage and reduce the burden of the disease.
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Riccò M, Gualerzi G, Ranzieri S, Ferraro P, Bragazzi NL. Knowledge, Attitudes, Practices (KAP) of Italian Occupational Physicians towards Tick Borne Encephalitis. Trop Med Infect Dis 2020; 5:tropicalmed5030117. [PMID: 32708662 PMCID: PMC7559127 DOI: 10.3390/tropicalmed5030117] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023] Open
Abstract
Tick-Borne Encephalitis (TBE) is an occupational health threat with increasing incidence in the geographic area of Italy. Despite this, TBE vaccination rates have ranged from 10% to 40% in Italy, even in at-risk workers. The reasons for this low rate are investigated in this present study of the knowledge, attitudes, and practices of occupational physicians (OP) regarding TBE disease and vaccination in at-risk workers. A total of 229 OP participated in an internet-based survey by completing a structured questionnaire. Adequate general knowledge of TBE disease was found in 58% of OP. Accurate perception of TBE risk in occupational settings was found in 20%. TBE vaccination for at-risk workers was recommended by 19%. Willingness to recommend TBE vaccination was more likely by OP practicing in endemic areas (Odds Ratio 3.10, 95% confidence intervals 1.47–6.55), who knew the existence of the term “arboviruses” (3.10, 1.29–7.44), or exhibited a better understanding of TBE (2.38, 1.11–5.12)—and were positive predictors for promoting TBE vaccine, while acknowledging that TBE as a severe disease was a negative one. Tick-borne disorders in Italy are a still rare (but increasing) occupational health threat, and vaccination gaps for TBE virus may find an explanation in OP incomplete knowledge of evidence-based recommendations.
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Affiliation(s)
- Matteo Riccò
- AUSL–IRCCS di Reggio Emilia, Occupational Health and Safety Service on the Workplaces of the Local Health Unit of Reggio Emilia (SPSAL), Via Amendola n.2, I-42122 Reggio Emilia, Italy
- Correspondence: or
| | - Giovanni Gualerzi
- Department of Medicine and Surgery, School of Medicine, University of Parma, Via Gramsci n.14, 43123 Parma, Italy;
| | - Silvia Ranzieri
- Department of Medicine and Surgery, School of Occupational Medicine, University of Parma, Via Gramsci n.14, I-43123 Parma, Italy;
| | - Pietro Ferraro
- ASL Foggia, Department of Prevention, Occupational Health and Safety Service on the Workplaces of the Local Health Unit of Foggia, Piazza Pavoncelli 11, I-41121 Foggia, Italy;
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada;
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