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National Collaborating Centre for Methods and Tools

February 2014 · Issue 69

In this issue:

The Fast Track to Evidence-Informed Public Health

a user story from Manitoba Health

Dr. Joselito Montalban, a policy analyst for Communicable Disease Control (CDC) at Manitoba Health, continues to try to formulate the “perfect search expression”. He is a clear proponent of using as much research as it takes to arrive at the best possible policy advice, using journals, online resources and contact with experts in the particular areas he is investigating. Joselito does get frustrated though, with the filtering process – dealing with an onslaught of material if search criteria are too broad, or running the risk of missing that one key article by using a narrower search.   
Shortly after starting work at Manitoba Health, Joselito attended a workshop on Evidence-Informed Public Health (EIPH) held by the NCCMT. Since then, he refers to the EIPH “wheel” regularly. The wheel identifies the stages involved in evidence-informed public health: define, search, appraise, synthesize, adapt, implement and evaluate. The workshop explains the process of finding, appraising, distilling and disseminating the best available evidence from research – both quantitative and qualitative – and using that evidence to inform and improve health policy and practice.

When Joselito was tasked with creating a methodology for reviewing a post-exposure prophylaxis (PEP) brochure for HIV, Hepatitis B and Hepatitis C, designed for the general public, he drafted guidelines for reviewing and revising all CDC documents, including those intended for health professionals.

Joselito started his review of the original PEP brochure at the “appraise” step in the EIPH wheel. His proposed next step in reviewing documents was to search for the most recent and appropriate research evidence to ensure that any advice is completely up-to-date. For this, the EIPH wheel points to the 6S Pyramid as a way to find the best research evidence with the least amount of time and effort.

According to Joselito, “[NCCMT's] EIPH wheel is like a snap-shot of everything that we do as policy analysts. It can thus serve as a reminder in a neat, handy package of the different facets of our work, thereby allowing us to approach our tasks more systematically.”

Read more user stories! http://www.nccmt.ca/registry/user_story/archive-eng.html

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Reminder of resources available: Webinar Companions

Short summaries of previous Spotlight on KT Methods and Tools webinars

What is a Webinar Companion?

Over the past few years, NCCMT has presented a series of Spotlight on KT Methods & Tools webinars in partnership with CHNET-Works! These webinars have been well received and have allowed us to reach a wide audience; however, we understand that language constraints, time limitations, and learning styles mean that these webinars may not always be accessible to everyone. That’s why we created Webinar Companions.

These brief, plain language summaries distill the key points of each Spotlight webinar down to a few pages and are available in both French and English. Our goal is to provide an alternative for those unable to participate in Spotlight on KT Methods & Tools webinars as well as a supplementary resource for those looking to revisit a webinar they previously attended.

These webinar companions summarize Spotlight on KT Methods and Tools presentations. The webinars are presented in partnership with the University of Ottawa’s CHNET-Works!

Did you miss a Spotlight webinar?

We’ve captured the main messages from the webinar in 4 or 5 pages with the associated presentation slides. Watch for this icon beside a method or tool in the Registry. The icon indicates that a companion is available for this resource.

Webinar companions are available for the following Registry resources:

  • Using the Applicability and Transferability Tool from the National Collaborating Centre for Methods and Tools
    • Featuring a story of Implementation from Dr. Megan Ward, Region of Peel Public Health
  • Using the Knowledge Transfer Guide developed by the Institute for Work & Health, presented by Jane Brennemen Gibson, KTE consultant.
  • Using the Critical Appraisal Skills Programme with Dr. Burls, Director of Post-Graduate Programmes in Evidence-Based Health Care in the Department of Primary Health Care at the University of Oxford
  • How to use the “Is Research Working for You?” from the Canadian Health Services Research Foundation (now called the Canadian Foundation for Healthcare Improvement)
    • Featuring a story of implementation from Julie Charlebois, Health Promotion Consultant with Toronto Public Health
  • How to use the Knowledge Translation Planning Template-R™, presented by developer Dr. Melanie Barwick, Scientific Director of Knowledge Translation at The Hospital for Sick Children.
    • Featuring a story of implementation from the Centre for Addiction and Mental Health
  • How to use the University of Alberta’s Policy Readiness Tool.
    • Featuring a story of implementation from the Alberta Policy Coalition for Chronic Disease Prevention
  • How to use the NCCMT’s Search Pyramids featuring Donna Ciliska (McMaster University) and Jessie McGowan (University of Ottawa).

More information about the Spotlight on KT Methods and Tools webinars is available:

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New from Public Health+

Effects of Home Visits by Paraprofessionals and by Nurses on Children: Follow-up of a Randomized Trial at Ages 6 and 9 Years.

IMPORTANCE The Nurse-Family Partnership delivered by nurses has been found to produce long-term effects on maternal and child health in replicated randomized trials. A persistent question is whether paraprofessional home visitors might produce comparable effects. OBJECTIVE To examine the impact of prenatal and infancy/toddler home visits by paraprofessionals and by nurses on child development at child ages 6 and 9 years. DESIGN, SETTING, AND PARTICIPANTS Randomized trial in public and private care settings in Denver, Colorado, of 735 low-income women and their first-born children (85% of the mothers were unmarried; 47% were Hispanic, 35% were non-Hispanic white, 15% were African American, and 3% were American Indian/Asian). INTERVENTIONS Home visits provided from pregnancy through child age 2 years delivered in one group by paraprofessionals and in the other by nurses. MAIN OUTCOMES AND MEASURES Reports of children`s internalizing, externalizing, and total emotional/behavioral problems, and tests of children`s language, intelligence, attention, attention dysfunction, visual attention/task switching, working memory, and academic achievement. We hypothesized that program effects on cognitive-related outcomes would be more pronounced among children born to mothers with low psychological resources. We report paraprofessional-control and nurse-control differences with P < .10 given similar effects in a previous trial, earlier effects in this trial, and limited statistical power. RESULTS There were no significant paraprofessional effects on emotional/behavioral problems, but paraprofessional-visited children born to mothers with low psychological resources compared with control group counterparts exhibited fewer errors in visual attention/task switching at age 9 years (effect size = -0.30, P = .08). There were no statistically significant paraprofessional effects on other primary outcomes. Nurse-visited children were less likely to be classified as having total emotional/behavioral problems at age 6 years (relative risk [RR] = 0.45, P = .08), internalizing problems at age 9 years (RR = 0.44, P = .08), and dysfunctional attention at age 9 years (RR = 0.34, P = .07). Nurse-visited children born to low-resource mothers compared with control-group counterparts had better receptive language averaged over ages 2, 4, and 6 years (effect size = 0.30, P = .01) and sustained attention averaged over ages 4, 6, and 9 years (effect size = 0.36, P = .006). There were no significant nurse effects on externalizing problems, intellectual functioning, and academic achievement. CONCLUSIONS AND RELEVANCE Children born to low-resource mothers visited by paraprofessionals exhibited improvement in visual attention/task switching. Nurse-visited children showed improved behavioral functioning, and those born to low-resource mothers benefited in language and attention but did not improve in intellectual functioning and academic achievement. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00438282 and NCT00438594.

The full text may be available from PubMed

Systematic Review of the Benefits and Risks of Metformin in Treating Obesity in Children Aged 18 Years and Younger.

IMPORTANCE Childhood obesity is an important public health problem with increasing prevalence. Because treatment often has limited success, new approaches must be identified. OBJECTIVE To evaluate the effectiveness and safety of metformin for treating obesity in children aged 18 years and younger without a diagnosis of diabetes mellitus. EVIDENCE REVIEW We included randomized clinical trials identified through searches of MEDLINE, the Cochrane Library, and ClinicalTrials.gov. Our primary outcome measure was change in body mass index (BMI, calculated as weight in kilograms divided by height in meters squared). We assessed study quality, pooled data using a random-effects model, and performed subgroup and sensitivity analyses. FINDINGS Fourteen randomized clinical trials were eligible. For BMI, moderate-strength evidence indicated a reduction of -1.38 (95% CI, -1.93 to -0.82) from baseline compared with control at 6 months. A similar, if less dramatic, effect was observed in studies less than 6 months, but the pooled estimate from studies of 1 year of treatment was not statistically significant. Subgroup analyses indicated smaller, but significant, effects for those with baseline BMI below 35, those of Hispanic ethnicity, those with acanthosis nigricans, those who had tried and failed diet and exercise programs, and in studies with more girls or higher mean age (adolescents). Moderate-strength evidence indicated that with metformin, 26% reported a gastrointestinal event compared with 13% in control groups (relative risk, 2.05; 95% CI, 1.19-3.54), although there was no difference in discontinuations due to adverse events. No serious adverse events were reported. CONCLUSIONS AND RELEVANCE Metformin provides a statistically significant, but very modest reduction in BMI when combined with lifestyle interventions over the short term. A large trial is needed to determine the benefits to subgroups or impacts of confounders. In the context of other options for treating childhood obesity, metformin has not been shown to be clinically superior.

The full text may be available from PubMed

Intermittent versus daily therapy for treating tuberculosis in children.

BACKGROUND: Childhood tuberculosis (TB) is a neglected global public health problem. Short treatment courses with rifampicin-containing anti-TB drugs given daily for six-months cure over 90% of infected children, but poor adherence reduces treatment success. Intermittent, short-course anti-TB regimens, given two or three times a week under direct observation, are associated with higher adherence in observational studies; but how they compare with daily treatment in relation to cure is unclear. Current international and national recommendations differ on use of intermittent regimens to treat TB in children. OBJECTIVES: To compare the efficacy and safety of intermittent, short-course anti-TB regimens (twice- or thrice-weekly) with daily short-course anti-TB regimens in treating childhood TB. SEARCH METHODS: We searched the Cochrane Infectious Disease Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, clinical trials registries, regional databases, conference proceedings, and references without language restrictions up to 30 May 2013; and contacted experts for relevant published, unpublished, and on-going trials. SELECTION CRITERIA: Randomized controlled trials (RCTs) and quasi-RCTs of children aged 15 years or younger, diagnosed with TB (according to the World Health Organization diagnostic categories 1, 2, or 3), who were treated with intermittent twice-weekly or thrice-weekly, short-course anti-TB regimens compared to daily short-course anti-TB treatment regimens. All regimens had to contain rifampicin for at least the first two months. DATA COLLECTION AND ANALYSIS: The review authors independently screened and selected trials, assessed risk of bias, and extracted data. We sought clarifications from trial authors. We pooled relative risks with their 95% confidence intervals and used a random-effects model where there was significant heterogeneity. We assessed overall evidence-quality using the GRADE approach. MAIN RESULTS: We included four trials published between 1996 to 2000 that randomized 563 children (465 evaluable) aged five months to 15 years to intermittent twice-weekly versus daily anti-TB treatment. Two trials were from India, one from South Africa, and one from Turkey. All trials used rifampicin and isoniazid, three trials used pyrazinamide, and one trial used streptomycin. The drug combination, and the duration of intermittent and daily treatments differed between trials, and no trials used drug combinations and schedules currently recommended for childhood TB. No trial reported if any child was HIV-positive.In comparisons of twice-weekly versus daily anti-TB treatment regimens, the trials did not detect differences in the number of patients cured, but trials were small, and the comparator regimens were not standard (four trials, 465 children; very low quality evidence). Trials were underpowered to provide estimates for death (two trials, 213 participants, very low quality evidence), relapse (one trial, 214 participants,very low quality evidence), and treatment limiting adverse events (four trials, 441 participants, very low quality evidence)Reported adherence to treatment was similar (87% versus 84%; four trials, 458 children, very low quality evidence)We did not find trials comparing the commonly used thrice-weekly anti-TB short-course regimen with the daily treatment regimen. AUTHORS` CONCLUSIONS: Trials conducted to date are insufficient to support or refute the use of intermittent twice- or thrice-weekly, short-course treatment regimens over daily short-course treatment in children with TB. Further randomized trials conducted in high TB-transmission settings will help inform policy and practice.

The full text may be available from PubMed

Xpert(R) MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults.

BACKGROUND: Accurate, rapid detection of tuberculosis (TB) and TB drug resistance is critical for improving patient care and decreasing TB transmission. Xpert(R) MTB/RIF assay is an automated test that can detect both TB and rifampicin resistance, generally within two hours after starting the test, with minimal hands-on technical time. The World Health Organization (WHO) issued initial recommendations on Xpert(R) MTB/RIF in early 2011. A Cochrane Review on the diagnostic accuracy of Xpert(R) MTB/RIF for pulmonary TB and rifampicin resistance was published January 2013. We performed this updated Cochrane Review as part of a WHO process to develop updated guidelines on the use of the test. OBJECTIVES: To assess the diagnostic accuracy of Xpert(R) MTB/RIF for pulmonary TB (TB detection), where Xpert(R) MTB/RIF was used as both an initial test replacing microscopy and an add-on test following a negative smear microscopy result.To assess the diagnostic accuracy of Xpert(R) MTB/RIF for rifampicin resistance detection, where Xpert(R) MTB/RIF was used as the initial test replacing culture-based drug susceptibility testing (DST).The populations of interest were adults presumed to have pulmonary, rifampicin-resistant or multidrug-resistant TB (MDR-TB), with or without HIV infection. The settings of interest were intermediate- and peripheral-level laboratories. The latter may be associated with primary health care facilities. SEARCH METHODS: We searched for publications in any language up to 7 February 2013 in the following databases: Cochrane Infectious Diseases Group Specialized Register; MEDLINE; EMBASE; ISI Web of Knowledge; MEDION; LILACS; BIOSIS; and SCOPUS. We also searched the metaRegister of Controlled Trials (mRCT) and the search portal of the WHO International Clinical Trials Registry Platform to identify ongoing trials. SELECTION CRITERIA: We included randomized controlled trials, cross-sectional studies, and cohort studies using respiratory specimens that allowed for extraction of data evaluating Xpert(R) MTB/RIF against the reference standard. We excluded gastric fluid specimens. The reference standard for TB was culture and for rifampicin resistance was phenotypic culture-based DST. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data using a standardized form. When possible, we extracted data for subgroups by smear and HIV status. We assessed the quality of studies using QUADAS-2 and carried out meta-analyses to estimate pooled sensitivity and specificity of Xpert(R) MTB/RIF separately for TB detection and rifampicin resistance detection. For TB detection, we performed the majority of analyses using a bivariate random-effects model and compared the sensitivity of Xpert(R) MTB/RIF and smear microscopy against culture as reference standard. For rifampicin resistance detection, we undertook univariate meta-analyses for sensitivity and specificity separately to include studies in which no rifampicin resistance was detected. MAIN RESULTS: We included 27 unique studies (integrating nine new studies) involving 9557 participants. Sixteen studies (59%) were performed in low- or middle-income countries. For all QUADAS-2 domains, most studies were at low risk of bias and low concern regarding applicability.As an initial test replacing smear microscopy, Xpert(R) MTB/RIF pooled sensitivity was 89% [95% Credible Interval (CrI) 85% to 92%] and pooled specificity 99% (95% CrI 98% to 99%), (22 studies, 8998 participants: 2953 confirmed TB, 6045 non-TB).As an add-on test following a negative smear microscopy result, Xpert(R)MTB/RIF pooled sensitivity was 67% (95% CrI 60% to 74%) and pooled specificity 99% (95% CrI 98% to 99%; 21 studies, 6950 participants).For smear-positive, culture-positive TB, Xpert(R) MTB/RIF pooled sensitivity was 98% (95% CrI 97% to 99%; 21 studies, 1936 participants).For people with HIV infection, Xpert(R) MTB/RIF pooled sensitivity was 79% (95% CrI 70% to 86%; 7 studies, 1789 participants), and for people without HIV infection, it was 86% (95% CrI 76% to 92%; 7 studies, 1470 participants). Comparison with smear microscopy In comparison with smear microscopy, Xpert(R) MTB/RIF increased TB detection among culture-confirmed cases by 23% (95% CrI 15% to 32%; 21 studies, 8880 participants).For TB detection, if pooled sensitivity estimates for Xpert(R) MTB/RIF and smear microscopy are applied to a hypothetical cohort of 1000 patients where 10% of those with symptoms have TB, Xpert(R) MTB/RIF will diagnose 88 cases and miss 12 cases, whereas sputum microscopy will diagnose 65 cases and miss 35 cases. Rifampicin resistanceFor rifampicin resistance detection, Xpert(R) MTB/RIF pooled sensitivity was 95% (95% CrI 90% to 97%; 17 studies, 555 rifampicin resistance positives) and pooled specificity was 98% (95% CrI 97% to 99%; 24 studies, 2411 rifampicin resistance negatives). Among 180 specimens with nontuberculous mycobacteria (NTM), Xpert(R) MTB/RIF was pos

The full text may be available from PubMed

Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial.

BACKGROUND: Rates of varicella have decreased substantially in countries implementing routine varicella vaccination. Immunisation is possible with monovalent varicella vaccine or a combined measles-mumps-rubella-varicella vaccine (MMRV). We assessed protection against varicella in naive children administered one dose of varicella vaccine or two doses of MMRV. METHODS: This study was done in ten European countries with endemic varicella. Healthy children aged 12-22 months were randomised (3:3:1 ratio, by computer-generated randomisation list, with block size seven) to receive 42 days apart (1) two doses of MMRV (MMRV group), or (2) MMR at dose one and monovalent varicella vaccine at dose two (MMR+V group), or (3) two doses of MMR (MMR group; control). Participants and their parents or guardians, individuals involved in assessment of any outcome, and sponsor staff involved in review or analysis of data were masked to treatment assignment. The primary efficacy endpoint was occurrence of confirmed varicella (by detection of varicella zoster virus DNA or epidemiological link) from 42 days after the second vaccine dose to the end of the first phase of the trial. Cases were graded for severity. Efficacy analyses were per protocol. Safety analyses included all participants who received at least one vaccine dose. This trial is registered with ClinicalTrials.gov, number NCT00226499. FINDINGS: Between Sept 1, 2005, and May 10, 2006, 5803 children (mean age 14.2 months, SD 2.5) were vaccinated. In the efficacy cohort of 5285 children, the mean duration of follow-up in the MMRV group was 36 months (SD 8.8), in the MMR+V group was 36 months (8.5) and in the MMR group was 35 months (8.9). Varicella cases were confirmed for 37 participants in the MMRV group (two moderate to severe), 243 in the MMR+V group, and 201 in the MMR group. Second cases occurred for three participants (all in the MMR+V group). Varicella cases were moderate to severe for two participants in the MMRV group, 37 in the MMR+V group (one being a second case that followed a mild first case); and 117 in the MMR group. Efficacy of two-dose MMRV against all varicella was 94.9% (97.5% CI 92.4-96.6), and against moderate to severe varicella was 99.5% (97.5-99.9). Efficacy of one-dose varicella vaccine against all varicella was 65.4% (57.2-72.1), and against moderate to severe varicella (post hoc) was 90.7% (85.9-93.9). The most common adverse event in all groups was injection-site redness (up to 25% of participants). Within 15 days after dose one, 57.4% (95% CI 53.9-60.9) of participants in the MMRV group reported fever of 38 degrees C or more, by contrast with 44.5% (41.0-48.1) with MMR+V, and 39.8% (33.8-46.1) with MMR. Eight serious adverse events were deemed related to vaccination (three MMRV, four MMR+V, one MMR). All resolved within the study period. INTERPRETATION: These results support the implementation of two-dose varicella vaccination on a short course, to ensure optimum protection from all forms of varicella disease. FUNDING: GlaxoSmithKline Vaccines.

The full text may be available from PubMed

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KT graduate student award

Deadline for applications is March 10, 2014.  

Each year, the National Collaborating Centres for Public Health (NCCPH) recognizes the work of graduate students regarding knowledge translation (KT) in public health in Canada.  The award is open to students who are currently enrolled in a graduate program (full or part-time) OR students who completed a graduate degree in the last 12 months. Applicants must be students at a Canadian academic institution, and in a discipline relevant to public health.

For further information, please click here (http://www.nccph.ca/273/nccph-kt-awards-2014.ccnsp) or contact Donna Ciliska at ciliska@mcmaster.ca

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Save the date!

Health for all: Putting equity into practice

April 30 - May 1, 2014

Moncton, NB

The public health associations in NB-PEI and NS are partnering to deliver a conference on April 30th and May 1st 2014 in Moncton, NB. The event will focus on health equity leadership, advocacy, and collective action in the Maritimes. Participants will learn new skills and tools for enhancing a health equity approach in their day?to?day work. The NCCDH and other partners are planning educational components for this event. 

For more information, please visit www.healthforall.hpclearinghouse.ca.

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NCCMT is funded by the Public Health Agency of Canada and affiliated with McMaster University.
Production of this newsletter has been made possible through a financial contribution from the Public Health Agency of Canada.
The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.
Contact us at nccmt@mcmaster.ca or www.nccmt.ca.