Canada-wide bloodstream infectious diseases surveillance: Quantum leap or a baby step toward a comprehensive electronic national infections surveillance system?

The COVID-19 pandemic unmasked regional differences in the Canadian health care system and highlighted the need for surveillance of infections at a national population level. Surveillance is a fundamental component of infectious diseases management that includes monitoring of burden (ie, incidence, morbidity, and mortality) and defining determinants (ie, risk factors) for illness. Such information is critical to identify emerging pathogens and to inform interventions to reduce the adverse impact of infectious diseases. Health care in Canada is a provincial responsibility administered under federal rules, and there is wide variability in surveillance capacity across the country. While public health surveillance does occur at the federal level (1), national surveillance programs are limited by several factors: inclusion of selected

reportable pathogens, lack of clinical detail, passive reporting, lack of timeliness, and/or inability to adapt to changing needs, and heterogeneous data systems that do not always cross talk. An enhanced comprehensive nationwide infection surveillance system would be a valued tool to not only better manage and understand current and emerging infectious diseases epidemiology, but also enable sensible preparation for the inevitable next pandemic. This aligns with the Public Health Agency of Canada's vision of an adaptable and collaborative public health surveillance system by 2030 to improve health (2).

A comprehensive national infection surveillance system may be a dream that is subject to the reality of awakening. While anything is potentially possible with vast funding and political will, the reality is that any new system will likely need to be developed within the confines of existing health care funding boundaries. However, our unique Canadian system and attributes coupled with developments in information technology and our newfound collective national purpose opens the door to realization of a national infectious diseases surveillance system.

While ideally a comprehensive system would be planned at the outset, it may be sensible to start by building the foundation of a system that is subsequently scalable. We suggest a good starting place would be focusing on bloodstream infections as they are relatively common, are not restricted to any one demographic or social cohort, include a wide range of etiologies, and are undoubtedly significant infections for which preventive and treatment interventions impact outcome. In addition, unlike many infections that require complex diagnostic considerations and frequent subjective evaluation, use of simple algorithms in association with positive blood cultures may be used to objectively ascertain and classify them (3).

There are many potential benefits of a national database and surveillance system for bloodstream infections. First, it enables early detection of emerging pathogens or changes in antimicrobial resistance patterns, without pre-specification of selected etiology. Recently, there has been emergence of antimicrobial resistant pathogens across Canada that can cause bloodstream infections such as Candida auris (4) and carbapenemase-producing Enterobacteriaceae (5), which subsequently led to dedicated national surveillance programs. A pre-established bloodstream infection surveillance system would have presumably detected the first emergence of these new resistant pathogens and facilitated their monitoring earlier than ad hoc identification and reactive set up of novel dedicated organism-specific surveillance programs.

Second, by virtue of economy of scale, a large database of bloodstream infections would allow the characterization of rare pathogens. A national system would include a surveillance population of more than 40 million Canadians such that infections occurring at incidence as low as 1 per million population annually could be studied. Most of our knowledge of rare pathogens is based on individual case reports and small case series. There are limited examples of surveillance studies that involve tens of millions of patient years of observation, such as with examples of bloodstream infections due to Sphingomonas paucimobilis or Pseudomonas stutzeri that have led to insights on risk factors, clinical presentation, antibiotic susceptibility profile, and prognosis for these infections (6,7).

Third, a national surveillance system would routinely generate contemporary data that can guide health policies and public health interventions to address the underlying risk factors and prevent future cases. For example, there was a recent Canada-wide epidemic of emm74 group A streptococcus invasive disease among a disadvantaged population with a history of alcohol use disorder, homelessness, and injection drug use (8). The emm74 group A Streptococcus originated from an outbreak in a shelter for homeless men in Toronto that then rapidly spread across rest of Canada (8). Early identification of risk factors for these cases could have led to timely public health interventions to protect these vulnerable people and prevent the spread across other Canadian provinces.

Fourth, availability of a national system would facilitate and advance infectious diseases research in numerous ways. The surveillance system can help identify eligible patients for intervention studies such as clinical trials and help determine study outcomes without the need for individual patient follow-up per se. Set up fit for purpose, a system could serve as a platform for registry-embedded trials with outcomes obtained electronically through national vital statistics databases. Take, for example, the ongoing debate surrounding cefazolin versus cloxacillin for the treatment of methicillin-susceptible Staphylococcus aureus bloodstream infection (9). Based on a population of 40 million residents and a crude incidence of approximately 300 cases per million per year, a single year observational study would result in a tripling of information available in published meta-analysis (9). If a mechanism could be devised to allocate one or the other of these treatments over a 1-year time frame, the effect on mortality outcome would be definitively addressed in this cohort of 12,000 subjects. The data provided by the surveillance system can also provide feedback on the effectiveness of population health interventions or policies. As an example, hospital-onset bacteremia defined as any blood culture growing a bacteria or fungi collected after 3 days of hospital stay is emerging as a new hospital quality metric (10). It overcomes limitations of previous quality measures such as central line-associated bloodstream infection because hospital-onset bacteremia data are simpler to collect without the need for manual chart review, it captures broader cases of hospital-acquired infections, it better discriminates health care facilities, and the perceived preventability for it is similar to or higher than other accepted measures of health care quality (10–13). The effectiveness of policies and interventions aimed to prevent health care-associated infections could be measured by hospital-onset bacteremia as an outcome. Grading based on hospital-onset bacteremia as a quality metric that is tied to funding may provide an incentive for Canadian hospitals to decrease health care–associated infections.

By virtue of several novel aspects of the Canadian health care system and documented successes, a national bloodstream infections surveillance system is likely feasible. A nationwide surveillance system for positive blood cultures have been successfully set up in Finland and Denmark (14,15) demonstrating the possibility. These countries, although with much smaller populations, share many similarities with Canada. Both Finland and Denmark have comprehensive publicly funded health care systems with centralized microbiology labs and electronic data reporting that could be linked with administrative databases (14,15). The existing infrastructure within Canada that has extensive use of electronic laboratory information systems and centralized microbiology laboratory services in many regions lends itself to low-cost contribution to surveillance. There is extensive precedent for the successful development of population-based databases for bloodstream infection across many Canadian regions not limited to Ontario (16,17), Alberta (3,18), regions within Quebec (19,20), regions within British Columbia (21,22), and northern Canada (23). Public funding of virtually all medically necessary health care implies that inclusion of bloodstream infections within the public system will be comprehensive. Canada has a highly skilled information technology workforce and experience with artificial intelligence applications such that it may be expected that required data will be available electronically and processed into usable information internally.

There are some evident obstacles to a national surveillance system. Assuming the absence of vast funding parcels, progress would require the collaboration and in-kind efforts from an array of individuals and institutions from across the country. To this end, a “top down” administrative approach will likely not be effective and “grass roots” development will be required. Participant health care regions and provinces will need to view contribution as a collective effort with the understanding that the whole is greater than the sum of its parts. Rewards, including access to the database to pursue participant-driven inquiry and authorship in resulting publications, would need to reflect this collective effort. Data confidentiality, security, and quality control would need major attention and maintenance. Timeliness would be a challenge as for the data to be of optimal use, it would ideally be near real time, such that traditional or paper-based reporting systems would not be possible. Ideally, the data would be made available to a wide range of researchers, policy-makers, administrators, and potentially the public. This ideal may pose intellectual property challenges and/or conflicts.

As laid out by Public Health Agency of Canada, the end goal of a functional national surveillance system on bloodstream infections would need to be a system of systems—a coordinated network of surveillance system and programs that is agile, collaborative, connected, coordinated, equitable, and high quality (2). This system should be built based on a unified purpose and government, inclusive partnership, well-supported workforce, integrated health information, as well as operational efficiency (2).

A comprehensive, electronic national infectious diseases surveillance system is feasible. Our universal health care system represents a solid foundation for which we as Canadians can demonstrate our ability to adapt and innovate as well as exploit our world-renowned expertise in medicine and data sciences. Daunting as it may be, we need to take the first step and prove concept by successful development of a limited scope system (bloodstream infections) before taking the leap toward a comprehensive national system. This will not be easy, but we may draw inspiration from the wave of common purpose in achieving a “made in Canada” solution.

Funding Statement

No funding was received for this article

Contributors:

Conceptualization, AD Bai, Y Keynan, KB Laupland; Writing – Original Draft, AD Bai, Y Keynan, KB Laupland; Writing – Review & Editing, AD Bai, Y Keynan, KB Laupland.

Ethics Approval:

Ethics approval was not required for this article.

Informed Consent:

N/A

Registry and the Registration No. of the Study/Trial:

N/A

Data Accessibility:

N/A

Funding:

No funding was received for this article

Disclosures:

The authors have nothing to disclose.

Animal Studies:

N/A