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Procter TD, Ogasawara H, Spruin S, Wijayasri S, Abraham N, Blaser C, Hutchings K, Shaw A, Ogunnaike-Cooke S. Thrombosis with thrombocytopenia syndrome (TTS) following adenovirus vector COVID-19 vaccination in Canada. Vaccine 2023:S0264-410X(23)01159-3. [PMID: 37806804 DOI: 10.1016/j.vaccine.2023.09.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/01/2023] [Accepted: 09/29/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Identifying and monitoring adverse events following vaccination contributed to the safety and effectiveness of COVID-19 mass vaccination campaigns. In March 2021, international reports emerged of an adverse event following vaccination with adenovirus vector COVID-19 vaccines (ChAdOx1-S [recombinant] and Ad26.COV2.S) of thrombosis with low platelet counts, referred to as thrombosis with thrombocytopenia syndrome (TTS). We described TTS reports in Canada following adenovirus vector COVID-19 vaccines and investigated whether the observed number of events were higher than expected. METHODS Reports of TTS following receipt of ChAdOx1-S [recombinant] or Ad26.COV2.S meeting the Canadian case definition for TTS and diagnostic certainty levels 1-3 of the Brighton Collaboration case definition, submitted to the Canadian Adverse Events Following Immunization Surveillance System and Canada Vigilance Database between February 26, 2021 and October 31, 2022 were included. Demographics and characteristics of the TTS reports are described along with an analysis comparing the observed number of reports to the expected number. RESULTS As of October 31, 2022, 56 reports of TTS following administration of ChAdOx1-S [recombinant] and no reports following Ad26.COV2.S vaccines were reported in Canada, of which 37 had functionally positive anti-PF4 antibodies. The median age was 56 years; males accounted for 54 % of reports. Five deaths were reported. The observed number of reports exceeded the expected for all ages and sexes combined, as well as for males aged 30-49 and 60-69 years, and females aged 40-59 years. CONCLUSION Based on international surveillance data, Canada evaluated a statistical signal of TTS following adenovirus vector vaccines. The investigation of this signal demonstrated how post-market vaccine safety surveillance systems were successful in investigating rare adverse events during the rollout of COVID-19 vaccines in Canada. As adenovirus vector vaccines continue to be administered, characterization of the association between the vaccine and TTS informs immunization programs and policies.
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Affiliation(s)
- T D Procter
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada.
| | - H Ogasawara
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Spruin
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Wijayasri
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - N Abraham
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - C Blaser
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - K Hutchings
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - A Shaw
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
| | - S Ogunnaike-Cooke
- Centre for Immunization Surveillance, Public Health Agency of Canada, Ottawa, ON, Canada
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley AR, Stukel TA, Spruin S, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Nasiri S, Benchimol EI. A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991127 DOI: 10.1093/jcag/gwac036.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality. Purpose Describe variation in care for pediatric IBD treated in 4 Canadian provinces. Method Incident cases of IBD diagnosed in children <16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I2 (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R2 quantified the residual heterogeneity in outcomes not attributable to among-province variation. Result(s) We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I2 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I2 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I2 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I2 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I2 39%) and 3.7 in AB (I2 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I2 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I2 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I2 0%, τ 0). Conclusion(s) There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest None Declared
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Affiliation(s)
- E Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto
| | - H Singh
- University of Manitoba IBD Clinical and Research Centre,Department of Internal Medicine, Max Rady College of Medicine, , University of Manitoba,Research Institute at CancerCare Manitoba, Winnipeg
| | - A Bitton
- Gastroenterology and Hepatology, McGill University Health Centre, Montreal
| | - G G Kaplan
- Medicine & Community Health Sciences, University of Calgary, Calgary
| | | | - A R Otley
- Pediatrics, Dalhousie University, Halifax
| | - T A Stukel
- ICES,Institute of Health Policy, Management and Evaluation
| | | | - A M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,Paediatrics, University of Toronto, Toronto
| | - D R Mack
- Pediatrics, University of Ottawa,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO,CHEO Research Institute, Ottawa
| | - K Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver
| | - G C Nguyen
- ICES,Institute of Health Policy, Management and Evaluation,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - L E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - W El-Matary
- Pediatrics, University of Manitoba, Winnipeg, Canada
| | | | - E I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,ICES,Institute of Health Policy, Management and Evaluation,Paediatrics, University of Toronto, Toronto
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley AR, Stukel TA, Spruin S, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Benchimol EI. A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991184 DOI: 10.1093/jcag/gwac036.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those <10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning. Purpose To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: <10y; A1b: 10 to <16y) across 5 Canadian provinces. Method Children diagnosed with IBD <16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed <10y (A1a) and 10 to <16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to <16y]) were pooled using random-effects meta-analysis. Result(s) Among 5124 children with IBD (1165 [23%] were <10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I2=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I2=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I2=74%); ED visits, 0.17 (95% CI 0.19-0.39, I2=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I2=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I2=79%); ED visits, 0.29 (95% CI 0.19-0.39, I2=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I2=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I2=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I2=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I2=40%) were significantly lower among children diagnosed <10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist. Conclusion(s) Health services utilization was generally similar for children diagnosed with IBD at <10y and between 10 and <16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I2) in the meta-analyses, is needed to understand sources of variation in care. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)
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Affiliation(s)
- E Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto
| | - H Singh
- University of Manitoba IBD Clinical and Research Centre,Department of Internal Medicine, Max Rady College of Medicine, , University of Manitoba,Research Institute at CancerCare Manitoba, Winnipeg
| | - A Bitton
- Gastroenterology and Hepatology, McGill University Health Centre, Montreal
| | - G G Kaplan
- Medicine & Community Health Sciences, University of Calgary, Calgary
| | | | - A R Otley
- Pediatrics, Dalhousie University, Halifax
| | - T A Stukel
- ICES,Institute of Health Policy, Management and Evaluation
| | | | - A M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,Paediatrics, University of Toronto, Toronto
| | - D R Mack
- Pediatrics, University of Ottawa,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO,CHEO Research Institute, Ottawa
| | - K Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver
| | - G C Nguyen
- ICES,Institute of Health Policy, Management and Evaluation,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - L E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - W El-Matary
- Pediatrics, University of Manitoba, Winnipeg, Canada
| | - E I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,ICES,Institute of Health Policy, Management and Evaluation,Paediatrics, University of Toronto, Toronto
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley A, Stukel TA, Spruin S, Nugent Z, Tanyingoh D, Cui Y, Filliter C, Coward S, Griffiths A, Mack D, Jacobson K, Nguyen GC, Targownik L, El-Matary W, Benchimol EI. A26 PEDIATRIC-ONSET INFLAMMATORY BOWEL DISEASE INCREASES THE RISK OF VENOUS THROMBOEMBOLISM: A CANGIEC POPULATION-BASED STUDY. J Can Assoc Gastroenterol 2020. [DOI: 10.1093/jcag/gwz047.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Inflammatory bowel disease (IBD) increases the risk of venous thromboembolism (VTE) in patients of all ages but the risk of VTE among Canadian children with IBD has not previously been investigated.
Aims
Report the incidence of VTE and subtypes pulmonary embolism (PE) and deep vein thrombosis (DVT) in children with and without IBD.
Methods
Children diagnosed with IBD <16y were identified from health administrative data in Ontario (2002–2014), Alberta (2007–2015), and Nova Scotia (2002–2012) using validated algorithms and matched by age and sex to children without IBD (1:5 ratio). Validated ICD-10 codes identified hospitalizations for incident VTE (DVT, PE, and sinovenous thrombosis). Province-specific 5-year cumulative incidence per 1000 person-years (PY) of VTEs were pooled using fixed-effects generalized linear mixed models with a Freeman-Tukey double arcsine transformation. Incidence rate ratios (IRR) within 5 years of diagnosis were pooled using fixed-effects generalized linear mixed models to compare children with and without IBD, and children with Crohn’s disease (CD) and ulcerative colitis (UC).
Results
3127 children with IBD (1826 CD; 1045 UC) were matched to 15,635 children without IBD. The cumulative incidence of VTE within 5 years of IBD diagnosis was 2.8 (95% CI 2.1–3.8) per 1000 PYs compared to 0.13 (95% CI 0.07–0.24) per 1000 PYs in children without IBD (Table). The 5-year cumulative incidences of VTE, DVT, and PE were significantly higher in children with IBD than in children without IBD (VTE: IRR 21.44, 95% CI 10.73–42.82; DVT: IRR 25.15, 95% CI 11.12–56.89; PE: IRR 4.01, 95% CI 1.22–13.18). Compared to UC patients, children with CD were at lower risk of VTE (IRR 0.53, 95% CI 0.29–0.96) and numerically, but not statistically, lower risk of DVT (IRR 0.59, 95% CI 0.30–1.14).
Conclusions
Although VTEs are relatively rare among children with IBD, these children are at much greater risk than children without IBD. Gastroenterologists caring for these patients should be cognizant of VTE risk and provide appropriate prophylaxis to those at high risk of VTE.
Funding Agencies
CCC
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Affiliation(s)
- E Kuenzig
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - H Singh
- University of Manitoba, Winnipeg, MB, Canada
| | - A Bitton
- Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - G G Kaplan
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - M W Carroll
- Pediatric Gastroenterology, Univeristy of Alberta, Edmonton, AB, Canada
| | - A Otley
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | | | - Z Nugent
- University of Manitoba, Winnipeg, MB, Canada
| | - D Tanyingoh
- Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Y Cui
- Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - C Filliter
- Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - S Coward
- University of Calgary, Calgary, AB, Canada
| | - A Griffiths
- Hospital for Sick Children, Toronto, ON, Canada
| | - D Mack
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K Jacobson
- BC Children’s Hospital, Vancouver, BC, Canada
| | - G C Nguyen
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - L Targownik
- Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - W El-Matary
- Pediatric Gastroenterology, University of Manitoba, Winnipeg, MB, Canada
| | - E I Benchimol
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
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