Background: Beaches are popular summertime destinations in Canada. However, they can be affected by specific fecal pollution sources, increasing the risk of recreational water illness. Objectives: This study was conducted to determine the risks of acute gastrointestinal illness (AGI) among Canadian beachgoers and to evaluate the influence of different fecal indicator bacteria (FIB) and other water quality measures on assessing these risks. Methods: In a prospective cohort design, beachgoers were recruited at sites across Canada from 2023 to 2025. Sociodemographic characteristics and exposures were determined through an on-site survey, with a 7-day follow-up survey to determine risks of AGI. Bayesian mixed-effects logistic regression models were fitted to evaluate the effects of an ordinal water contact variable (no contact, minimal contact, body immersion, and swallowed water) on the incident risk of AGI, with an interaction included for water quality indicators. The levels of six FIB and water quality measures were assessed: Escherichia coli, enterococci DNA, three microbial source tracking DNA markers (human HF183/BacR287, human mitochondria, seagull Gull4), and turbidity. Results: A total of 4085 participants were recruited, with 67.6% completing the follow-up survey. The overall incident risk of AGI was 2.6%. Both swallowing water and body immersion increased AGI risks compared to no water contact: median of 20 excess cases (95% Credible Interval [CrI]: 4, 64) and 5 excess cases (95% CrI: 1, 19) of AGI predicted per 1000 beachgoers, respectively. Escherichia coli and seagull DNA marker levels were associated with AGI among those who had water contact, particularly among those who reported swallowing water. Discussion: While the overall burden of AGI due to beach water contact in Canada was low, increased risks are associated with E. coli levels particularly among those who swallow water. This could be related to fecal contamination from seagulls. However, there is substantial uncertainty in the predicted effect sizes. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement This work was supported by the Canadian Institutes of Health Research (CIHR), grant numbers PJT 185894 and PJT 192023 (P.I. Young) ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Toronto Metropolitan University Research Ethics Board gave ethical approval for this work (REB# 2023-043). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors [https://github.com/iany33/Beach\_cohort\_AGI][1] [1]: https://github.com/iany33/Beach_cohort_AGI

BACKGROUND:Foodborne diseases are important causes of illness and death. The first estimates of their burden were published by WHO in 2015. We updated WHO estimates of the global, regional, subregional, and national foodborne disease burden caused by 42 infectious and chemical hazards in 2021, including time trends for 2000-21. METHODS:We provide a high-level summary of foodborne disease burden, expressed as incidence, deaths, and disability-adjusted life-years (DALYs). Data for burden estimation were provided from a WHO-commissioned series of systematic reviews on the incidence, aetiology, sequelae, and case fatality or mortality of the hazards. Data were analysed using hierarchical meta-regression modelling with geographical clustering and a global linear time trend, disease-specific computational models, and uncertainty propagation through Monte Carlo simulations to calculate 95% uncertainty intervals. Attribution to foodborne transmission was principally based on a structured expert judgement process. Economic impact was measured as lost productivity. FINDINGS:For 2021, foodborne transmission of the 42 hazards caused 866 million (95% uncertainty interval 680-1090) illnesses, 1·52 million (0·783-2·51) deaths, and 57·1 million (39·4-81·1) DALYs. Inorganic arsenic, lead, and non-typhoidal Salmonella enterica (diarrhoeal and invasive disease) resulted in the most DALYs. The greatest burden of foodborne disease was in the African and South-East Asia regions. The incidence in children younger than 5 years was 2·7 times higher than in people aged 5 years or older, resulting in 4·3 times the rate of DALYs. The total burden from all hazards decreased over time. In 2021, these 42 hazards resulted in productivity losses of US$310 billion in nominal terms, and US$647 billion after adjusting for purchasing power parity. INTERPRETATION:Foodborne diseases causes a burden similar to that from tuberculosis, HIV and AIDS, or malaria. The high burden of both communicable and non-communicable foodborne diseases requires countries to prioritise developing strategies to improve the safety of the food supply. FUNDING:WHO.

BACKGROUND:Foodborne diseases cause substantial illness and death globally. We updated WHO estimates of the burden caused by non-diarrhoeal enteric disease hazards: Brucella spp; Clostridium botulinum; hepatitis A virus; Listeria monocytogenes; Mycobacterium bovis,Mycobacteriumcaprae, and Mycobacteriumorygis; invasive non-typhoidal Salmonella enterica (iNTS); S enterica serotypes Paratyphi A, B, and C; and S enterica serotype Typhi (S Typhi). METHODS:We estimated illnesses, deaths, and disability-adjusted life-years (DALYs) for 194 countries for 2000-21 using data from systematic reviews, the 2021 Global Burden of Diseases, Injuries, and Risk Factors Study 2021, a structured expert judgement study, and WHO country consultations. We used disease-specific computational models and hierarchical metaregression modelling with geographical clustering, a global linear time trend, and uncertainty propagation. FINDINGS:In 2021, transmission of these eight hazards by food collectively caused 24·0 million illnesses (95% uncertainty interval 16·9-31·7), 106 000 deaths (63 900-169 000), and 7·26 million DALYs (4·15-12·0). S Typhi, iNTS, and hepatitis A virus caused most DALYs. The greatest burden was in the WHO African region, followed by the South-East Asia region. Mortality was 5·2 times higher and DALY rates were 8·3 times higher in children younger than 5 years compared with people aged 5 years and older. The burden for all hazards, except L monocytogenes, decreased from 2000 to 2021, with S Typhi replacing iNTS as the leading cause of foodborne DALYs. INTERPRETATION:Non-diarrhoeal enteric diseases still cause considerable foodborne disease burden, despite decreases over time. Vulnerable populations, particularly children in low-income countries, bear the greatest burden. Integrated efforts including vaccination, food safety, clean water, sanitation, hygiene, and improved health-care access are required. FUNDING:WHO.

BACKGROUND:Over 10 years ago, WHO estimates of hazard-specific foodborne disease burdens showed that parasites exert considerable health burdens globally. We updated these estimates, focusing on 14 invasive parasitic diseases. METHODS:Incidences, deaths, and disability-adjusted life-year (DALY) burdens were estimated for each parasitic disease from 2000 to 2021, using data from systematic reviews and the Global Burden of Diseases, Injuries, and Risk Factors Study. For some diseases, structured expert judgement was used to estimate proportions of foodborne infection. Data were pooled via hierarchical meta-regression models with uncertainty propagated through Monte Carlo simulations following disease-specific computational models defined by incidence rates and probability parameters. FINDINGS:We estimated that 277 million illnesses were caused by potentially foodborne invasive parasites, with approximately 171 million attributable to foodborne transmission. Considerable heterogeneity by parasite, in magnitude and uncertainty, was observed. Of 4·89 million foodborne DALYs associated with these diseases, highest contributions were from Taenia solium (1·3 million) and Clonorchis sinensis (0·921 million), both also associated with most foodborne deaths. Burden was greatest in the region of the Americas, predominantly due to Chagas disease, followed by the African region, where neurocysticercosis-associated epilepsy caused most burden. Burdens decreased globally from 2000 to 2021, except in the Western Pacific region, where the burden, predominantly associated with clonorchiasis, is rising. INTERPRETATION:Foodborne parasitoses cause considerable suffering, with some populations and regions particularly at risk. These data provide a baseline by which effects of interventions can be assessed and emphasis directed to those parasites exerting the greatest burden. FUNDING:WHO.

BACKGROUND:Foodborne diseases cause significant illness and death globally. We updated WHO estimates of the burden caused by diarrhoeal hazards commonly transmitted by food: Campylobacter jejuni, Campylobacter coli, and other thermotolerant Campylobacter species; Cryptosporidium spp; Cyclospora cayetanensis; Entamoeba histolytica; enteroaggregative Escherichia coli; enteropathogenic E coli; enterotoxigenic E coli; Giardia duodenalis; norovirus; rotavirus; non-typhoidal Salmonella enterica; Shiga toxin-producing E coli; Shigella spp; and Vibrio cholerae. METHODS:We estimated illnesses, deaths, and disability-adjusted life-years (DALYs) for 194 countries for the period 2000-21 using data from systematic reviews; the Global Burden of Diseases, Injuries, and Risk Factors Study 2021; a structured expert judgement study; and country consultations. We used disease-specific computational models, and a hierarchical meta-regression model with geographical clustering, a global linear time trend, and uncertainty propagation. FINDINGS:In 2021, the 14 diarrhoeal hazards caused 666 million (95% UI 483-884) illnesses, 265 000 deaths (196 000-351 000), and 15·2 million (11·6-19·1) DALYs from foodborne transmission. Shigella spp, Campylobacter, and rotavirus caused the most DALYs from foodborne transmission. The greatest burden was in the African region (773·5 DALYs [95% UI 559·7-1033·3] per 100 000 population due to foodborne transmission). Mortality rates were 7·1 times higher and DALY rates 18·9 times higher in children younger than 5 years than in people aged 5 years or older. While the overall foodborne burden decreased between 2000 (692·3 DALYs [517·9-938·1] per 100 000 population) and 2021 (193·6 [147·2-243·0] per 100 000), this trend was not consistent for all hazards. INTERPRETATION:Diarrhoeal hazards continue to cause a substantial foodborne disease burden, despite decreases over time. Children in low-income countries bear the greatest burden. Prevention requires concerted efforts, including expanding global diarrhoeal disease prevention efforts beyond water, sanitation, and hygiene and vaccination to include improvements in the safety of the food supply. FUNDING:WHO.

Identifying the sources of foodborne diseases is crucial for guiding national food safety strategies and supporting policies that promote safe and sustainable food production. Here we present global estimates of the proportions of burden of disease attributable to foodborne transmission, other major transmission pathways, and specific food categories for 29 viral, bacterial, parasitic, and chemical hazards, based on a structured expert judgement (SEJ) study commissioned by the World Health Organization (WHO) and supervised by the WHO Foodborne Disease Burden Epidemiology Reference Group (FERG) for 2021-2025. One-hundred forty-six experts provided 1463 assessments across 17 subregions within six WHO regions. The assessments were analyzed using Cooke's Classical Model and reviewed by FERG. Results showed that 13 of the 29 hazards were mainly (>50%) attributable to foodborne transmission, with non-typhoidal Salmonella (59-74%) and Campylobacter (45-71%) estimated to be predominantly foodborne in nearly all subregions. While plant-based foods were important sources of several pathogens, such as hepatitis A virus (63-74%) and Cryptosporidium (60-95%), foods of animal origin, including poultry, beef, eggs, seafood, and dairy products, remain critical intervention targets for several others, e.g., Campylobacter (86-97%), Salmonella (77-92%), Shiga toxin-producing E. coli (67-96%), and Listeria monocytogenes (50-85%). Regional differences in attributions highlight the influence of local epidemiological patterns, food systems, sanitation, and cultural practices. These estimates provide a global, uncertainty-quantified knowledge base to guide context-specific food safety interventions and future empirical data collection. Given persistent data gaps, SEJ remains a feasible approach to generate evidence supporting efforts to reduce the burden of foodborne diseases.

Abstract Background Foodborne diseases cause substantial global morbidity and mortality, yet remain largely unattended. To support countries to address this public health concern, the World Health Assembly Resolution 73.5 called for strengthening global food safety efforts and led to the development of the WHO Global Strategy for Food Safety 2022–2030, adopted at the 75th WHA (2022). To this end, the World Health Organization (WHO) reconvened the Foodborne Disease Burden Epidemiology Reference Group (FERG) to advise and support the work to generate updated global, regional, and national estimates of the foodborne disease burden for the reference period 2000–2021. Methods We developed an incidence-based framework expanding coverage to 42 foodborne hazards. Standardized systematic reviews, Global Health Estimates and Global Burden of Disease envelopes, and United Nations population data informed the evidence base. Missing epidemiological data were imputed using Bayesian hierarchical meta-regression models. Disease models mapped acute and chronic health outcomes, applying updated disability weights, life tables, and probabilistic Monte Carlo calculations to estimate incidence, mortality, Years Lived with Disability, Years of Life Lost and Disability-Adjusted Life Years for all 194 WHO Member States. Transparency and analysis reproducibility were ensured through availed open source R packages and standardized workflows. Results The computational framework provides annual, country-level estimates with improved internal consistency and an expanded hazard scope compared with the WHO 2015 edition. Advances include refined modelling, enhanced uncertainty propagation, and broader inclusion of microbial, parasitic, and chemical hazards. Persistent data gaps—especially in high-burden regions—were filled through extensive imputation. Conclusions The computational framework for the WHO 2026 edition delivers the most comprehensive and transparent assessment of the global burden of foodborne diseases to date. Despite remaining limitations, it enables routine monitoring, supports evaluation of global food safety efforts, and highlights priorities for strengthening national data systems.

Diarrheal disease is caused by diverse species of viruses, bacteria and protozo that are transmitted from different sources, including from contaminated food. Sustaining progress in reducing diarrheal illnesses and deaths, including vaccines and food safety measures, may require interventions targeting specific pathogens. In 2015, the WHO's published etiology-specific estimates by their Foodborne Disease Burden Epidemiology Reference Group (FERG) of the incidence and mortality of diarrheal diseases caused by 11 pathogens at global and regional scales in 2010. Since then, much new evidence has been published about the epidemiology of enteropathogens. This study aims to update estimates to the year 2021 with the addition of three pathogens (Rotavirus, Cyclospora cayetanensis, Enteroaggregative E. coli (EAEC)). For low- and middle-income countries (LMICs), we conducted a systematic review of publications that reported the prevalence of pathogens diagnosed in stool samples from asymptomatic subjects, community-detected and outpatient diarrhea cases, and those treated as inpatients. Hierarchical, mixed effects models were fitted to pathogen-specific prevalence data extracted from studies that met prespecified inclusion criteria, and population attributable fractions (PAF) were calculated from the model parameter estimates, adjusting for background asymptomatic transmission where appropriate. The PAFs were applied to previously estimated diarrhea incidence and mortality envelopes. A separate, parallel systematic review identified studies that estimated diarrhea incidence and mortality due to specific etiologies for high income countries (HICs) from surveillance data. Meta-analytical models were fitted to data extracted from these. Data from 324 studies published between 1990 and 2023 representing results from up to 540,000 samples were used in the meta-analysis. Globally the 14 pathogens were responsible for 2.2 billion diarrheal disease cases and 880,000 deaths in 2021, with the largest number of cases occurring in South-East Asia, the largest number of deaths in Sub-Saharan Africa, and Europe being the region with the lowest burden by both measures. We found the leading causes of diarrhea morbidity to be bacteria - Shigella (426.4 million cases in 2021), Campylobacter (291.4 million) and ETEC (259.7 million)) - as well as the protozoon Giardia (321.2 million), in contrast to previous studies that have ranked rotavirus and norovirus highest. Our estimates support a much higher morbidity burden for Shigella than previously estimated with an incidence rate for 2021 (5,400 per 100,000). This is due to its high PAF in outpatients aged ≥5 years. As causes of diarrhea mortality, our estimates rank rotavirus first (214,700 deaths in 2021), Shigella second (152,500), and V. cholerae (94,100) third, due to the latter's large PAF in inpatients aged ≥5 years and high case fatality rate. Caution is urged when interpreting PAFs for pathogens that elicit prolonged residual shedding following resolution of symptoms (e.g., norovirus, Campylobacter, Giardia). These findings, derived from rigorous systematic review and statistical methodologies and the largest database yet compiled of pathogen detection rates, will serve as inputs for the WHO's broader estimates of hazard-specific incidence and mortality from foodborne diseases and are made available to the research and policy-making communities to inform targeted strategies for global diarrheal disease control.

Beach water leisure activities can increase the risk of acquiring infections from recreational water, and children are particularly at risk. However, gaps exist in public awareness of accessing and understanding beach water quality information and the risk of acquiring illnesses. There is no such available research in Canada, and this study was conducted to explore risk perceptions and behaviours of parent beachgoers. We conducted two focus groups in each of three Canadian provinces: Ontario, Manitoba, and British Columbia in July 2023. Participants were parents or guardians of children 15 years or younger, who had taken their children to the beach in the past year. Participants were asked about their family's beach activities, their habits with beach warnings, and any illness experiences related to beach visits. The discussions were recorded, transcribed, and de-identified. Two team members created a coding scheme, analyzed all transcripts independently, and compiled the coded text for thematic analysis. We refined, organized, and interpreted the results in the context of the Health Belief Model (HBM). Four overarching themes were identified: (i) parents and kids participate in and enjoy beach activities, even when water quality advisories are present; (ii) parents acknowledge significant health risks associated with water exposure, though their risk perception often did not recognize risks from ingestion; (iii) parents’ and kids’ health behaviours at the beach are influenced by preconceived notions and attitudes concerning germs, both before arrival and during their visit; and (iv) parents require accessible and timely beach advisories to help them decide how to enjoy beach activities safely. This study highlights limited awareness among parents and a tendency to downplay the health risks of contaminated beach environments. It emphasizes the need for effective communication about water quality advisories to ensure safer beach experiences, particularly for children, and thereby minimizing impacts on public health.

This study examined whether COVID-19 Vaccine Hesitancy (VH) and COVID-19-related factors interact to influence COVID-19 booster doses uptake among university students in Canada, from a syndemic perspective. A cross-sectional survey was conducted among 4453 students at the University of Waterloo in 2024. VH was measured toward both COVID-19 primary and booster doses. Change in VH scores were computed to capture shifts in hesitancy over time. Logistic regression models assessed the main effects of VH and COVID-19-related factors on booster uptake. Interactions were tested using additive and multiplicative scales. Increased VH was associated with a 23% decrease in booster uptake. Younger ages, not being hospitalized due to COVID-19, not receiving the influenza vaccine, noncompliance with COVID-19 guidelines, and belief in conspiracy theories predicted lower booster uptake. Significant interactions were found between change in VH scores and COVID-19 diagnosis and hospitalization history, guideline adherence, and conspiracy beliefs. For students who did not receive booster doses, the change in VH was greater among those who reported following public health guidance than those who did not. Similarly, for students who did not receive booster doses, the change in VH was greater among those who reported not believing in conspiracy theories compared to those who did. The findings support a syndemic model, indicating that VH and COVID-19-related experiences jointly influence booster uptake. Targeted interventions such as rebuilding trust, addressing misinformation, and reducing stigma may improve booster uptake even if not all barriers are addressed. Further research is needed to examine these interactions.

BACKGROUND:Vaccine hesitancy (VH) continues to impede COVID-19 vaccine coverage. Booster dose uptake lags behind primary dose uptake, especially among younger adults. Unlike most studies that focus on initial stages of VH, the aim of this study was to validate the COVID-19 Vaccine Hesitancy Scale (CVHS) for both primary and booster doses among University of Waterloo (UW) students. METHODS:An online survey was conducted among UW students in Ontario, Canada, between March and May 2024. The CVHS items were adapted for primary and booster doses. Exploratory (EFA) and confirmatory factor analyses (CFA) assessed the factor structure and model fit. Reliability was evaluated using Cronbach's alpha and composite reliability (CR). Convergent and discriminant validity were assessed through average variance extracted (AVE). Significant differences between primary and booster dose hesitancy were determined via 95 % Confidence Interval. RESULTS:A total of 4453 students participated. Respondents were predominantly female (57.2 %), aged 18-22 years (84.0 %), and undergraduates (94.8 %). EFA and CFA confirmed a three-factor structure for both primary and booster dose scales. Both scales had high reliability (Cronbach's alpha >0.60, CR >0.7). CFA results indicated a good model fit (Comparative Fit Index = 0.94; Root Mean Square Error of Approximation = 0.07), and demonstrated adequate convergent, discriminant, and criterion validity. Known-group validity was supported by significant differences in VH scores across gender and academic level, with men and undergraduate students reporting higher hesitancy than women and graduate students (p < 0.001). VH was higher for booster doses (33.4 %) than primary doses (19.3 %) with more students delaying (32.1 %) or refusing boosters (29.3 %) than delaying (11.5 %) or refusing (6.2 %) primary doses. CONCLUSION:Our adapted scales performed well psychometrically to measure VH across different COVID-19 vaccine phases. These scales can help in identifying key barriers of VH to understand shifting trajectories over time, thereby informing targeted interventions to promote vaccination uptake among younger adults.

BACKGROUND:Vaccine hesitancy (VH) poses a major challenge to achieving high COVID-19 vaccination rates. Universities, with mandatory primary dose policies but optional boosters, offer a unique setting to study VH dynamics. This study aimed to estimate COVID-19 VH prevalence and identify key factors influencing VH across primary and booster doses among university students. METHODS:In this cross-sectional study, all actively enrolled students at the University of Waterloo, Ontario, Canada, during Winter 2024 were invited to complete an online survey. Means and standard deviations were calculated for VH scores and proportions were calculated for the binary VH. Differences were compared using paired t-tests and chi-square. Generalized Estimating Equations was applied to model changes in VH scores from primary to boosters and identify key predictors of VH. Interaction terms were tested to evaluate dose-specific effects on VH. RESULTS:Among 4453 respondents, VH prevalence increased from 17 % for primary doses to 33.4 % for boosters, with higher VH scores for boosters (Mean ± SD: 10.9 ± 8.1) than primary doses (Mean ± SD: 7.3 ± 7.1). Women (aOR = 1.06, 95 % CI 1.01-1.11) and younger students (aOR = 1.62, 95 % CI 1.25-2.10) showed the largest VH increases, especially for boosters. Students with low perceived risk, negative perceptions of boosters' safety and effectiveness, low intention to follow government recommendations, and no prior flu or meningococcal vaccination exhibited the greatest VH increases when shifting from primary to booster doses. Conversely, students with no religious affiliation and those whose decisions were unaffected by mandates showed smaller changes in VH. CONCLUSION:The rise in VH from primary to booster doses appears driven by demographic, psychological, and behavioral factors. Tailored interventions that promote clear communication, improve access, and strengthen confidence in booster recommendations rather than reliance on mandates are critical for reducing VH and sustaining vaccine uptake in this population.

INTRODUCTION:Campylobacter spp. and non-typhoidal Salmonella spp. (NTS) are major causes of enteric diseases in Ontario, Canada and worldwide. Although low socioeconomic status is generally associated with poor health outcomes, its relationship with enteric diseases in Ontario is not well known. We investigated area-level socioeconomic risk factors for reported enteric infections caused by Campylobacter spp. and NTS, commonly transmitted by food in Ontario, Canada, between 2015 and 2017. METHODS:Using negative binomial regression models, we examined the association between age- and sex-adjusted incidence rates (IRs) of laboratory-confirmed cases of Campylobacter spp. and NTS (aggregated to the forward sortation area [FSA] level), and FSA-level socioeconomic factors (median household income; percent population with bachelor's degree or higher; unemployment rate; and percent visible minorities, Indigenous peoples [as defined by Statistics Canada], total immigrants, recent immigrants and lone-parent families), adjusting for the population of the FSA from the 2016 Census. RESULTS:After controlling for the other variables in the final multivariable models, an increase in the percentage of the population with a bachelor's degree or higher and in the percentage of total immigrants in an FSA significantly increased the IRs of Campylobacter infections, while an increase in the median income and the percentage of total immigrants in an FSA increased the IRs of NTS infections. CONCLUSIONS:Results from our study may inform public health interventions to reduce the rate of infections, for example, via food safety supports relevant to communities with larger numbers of Canadian immigrants. Further individual-level investigations of the socioeconomic factors identified in this study are needed. Also, future studies should assess the mechanisms through which socioeconomic risk factors affect infection rates in different communities.

Introduction Sustaining declines in global infectious disease burden will increasingly require efforts targeted to specific aetiological agents and common transmission pathways, particularly in this era of global change and human interconnectivity accelerating transmission and emergence of infectious pathogens. Systematic reviews and meta-analyses can be an effective and resource-efficient method for synthesising evidence regarding disease epidemiology for a wide range of pathogens and are the evidence source used by initiatives like the Planetary Child Health and Enterics Observatory (Plan-EO) and the WHO to determine the aetiology-specific epidemiology of diarrhoeal disease. Therefore, we developed this integrated systematic review methodology and protocol that aims to compile a database of published prevalence estimates for 17 diarrhoea-causing pathogens as inputs for disease burden estimation.Methods and analysis We will seek estimates of the prevalence of each endemic enteric pathogen estimated from published population-based studies that diagnosed their presence in stool samples from both asymptomatic subjects and those experiencing diarrhoea. The pathogens include the enteric viruses adenovirus, astrovirus, norovirus, rotavirus and sapovirus, the bacteria Campylobacter, Shigella, Salmonella enterica, Vibrio cholerae and the Escherichia coli (E. coli) pathotypes enteroaggregative E. coli, enteropathogenic E. coli, enterotoxigenic E. coli and Shiga-toxin-producing E. coli and the intestinal protozoa Cryptosporidium, Cyclospora, Entamoeba histolytica and Giardia. Meta-analytical methods for analyses of the resulting database (including risk of bias analysis) will be published alongside their findings.Ethics and dissemination This systematic review is exempt from ethics approval because the work is carried out on published documents. The database that results from this review will be made available as a supplementary file of the resulting published manuscript. It will also be made available for download from the Plan-EO website, where updated versions will be posted on a quarterly basis.PROSPERO registration number CRD42023427998.

Objective: The research objectives were to evaluate factors that influence Canadian secondary school students' milk and milk alternatives (MMA) consumption and to explore associations through age and gender lenses.Design: A qualitative design was used, consisting of semi-structured interviews and photo-elicitation methods. Analysis was guided by the Theory of Planned Behaviour (TPB). Deductive and inductive thematic analyses were used to generate themes, charting data based on attributes such as gender and age.Setting: Interviews were held virtually or via telephone.Participants: Participants were twenty-eight high school students from Ontario, Canada, diverse in terms of gender and age.Results: Both desirable and undesirable beliefs about the health outcomes of consuming MMA were commonly discussed. These included health benefits such as strong bones, muscular strength, and growth, and health consequences like unwanted skin conditions, weight gain, and diseases. While boys and girls associated MMA consumption with muscular strength, boys predominantly considered this favourable, while girls discussed outcomes like unwanted skin conditions and weight gain more often. Adolescents' perspectives on taste/perceived enjoyment, environmentally friendly choices and animal welfare also influenced their MMA preferences. Parental influences were most cited among social factors, which appeared to be stronger during early adolescence. Factors involving cost, time and accessibility affected adolescents' beliefs about how difficult it was to consume MMA.Conclusions: Recommendations for shifting attitudes towards MMA are provided to address unfavourable beliefs towards these products. Interventions to increase MMA consumption among adolescents should include parents and address cost barriers.

BackgroundRecreational water activities at beaches are popular among Canadians. However, these activities can increase the risk of recreational water illnesses (RWI) among beachgoers. Few studies have been conducted in Canada to determine the risk of these illnesses. This protocol describes the methodology for a study to determine the risk and burden of RWI due to exposure to fecal pollution at beaches in Canada.MethodsThis study will use a mixed-methods approach, consisting of a prospective cohort study of beachgoers with embedded qualitative research. The cohort study involves recruiting and enrolling participants at public beaches across Canada, ascertaining their water and sand contact exposure status, then following-up after seven days to determine the incidence of acute RWI outcomes. We will test beach water samples each recruitment day for culture-based E. coli, enterococci using rapid molecular methods, and microbial source tracking biomarkers. The study started in 2023 and will continue to 2025 at beaches in British Columbia, Manitoba, Ontario, and Nova Scotia. The target enrollment is 5000 beachgoers. Multilevel logistic regression models will be fitted to examine the relationships between water and sand contact and RWI among beachgoers. We will also examine differences in risks by beachgoer age, gender, and beach location and the influence of fecal indicator bacteria and other water quality parameters on these relationships. Sensitivity analyses will be conducted to examine the impact of various alternative exposure and outcome definitions on these associations. The qualitative research phase will include focus groups with beachgoers and key informant interviews to provide additional contextual insights into the study findings. The study will use an integrated knowledge translation approach.DiscussionInitial implementation of the study at two Toronto, Ontario, beaches in 2023 confirmed that recruitment is feasible and that a high completion rate (80%) can be achieved for the follow-up survey. While recall bias could be a concern for the self-reported RWI outcomes, we will examine the impact of this bias in a negative control analysis. Study findings will inform future recreational water quality guidelines, policies, and risk communication strategies in Canada.

This study investigated cases of pregnancy-related listeriosis in British Columbia (BC), Canada, from 2005 to 2014. We described all diagnosed cases in pregnant women (n = 15) and neonates (n = 7), estimated the excess healthcare costs associated with listeriosis, and calculated the fraction of stillbirths attributable to listeriosis, and mask cell sizes 1-5 due to data requirements. Pregnant women had a median gestational age of 31 weeks at listeriosis onset (range: 20-39) and on average delivered at a median of 37 weeks gestation (range: 20-40). Neonates experienced complications but no fatalities. Stillbirths occurred in 1-5 of 15 pregnant women with listeriosis, and very few (0.05-0.24%) of the 2,088 stillbirths in BC in the 10 years were attributed to listeriosis (exact numbers masked). Pregnant women and neonates with listeriosis had significantly more hospital visits, days in the hospital and physician visits than those without listeriosis. Pregnant women with listeriosis had 2.59 times higher mean total healthcare costs during their pregnancy, and neonates with listeriosis had 9.85 times higher mean total healthcare costs during their neonatal period, adjusting for various factors. Despite small case numbers and no reported deaths, these results highlight the substantial additional health service use and costs associated with individual cases of pregnancy-related listeriosis in BC.

Abstract Introduction: Antimicrobial resistance (AMR) is a growing One Health crisis that can be impacted by other challenges of sustainable development, such as climate change, but few interventions have been assessed with a systems-wide lens. The objectives of this study were to use a previously defined fuzzy cognitive map (FCM) of the Swedish One Health system to: 1) identify areas in the system to target interventions; and 2) test the potential ability and viability of interventions to reduce AMR under a changing climate. Methods: The FCM, based on participatory modelling workshops and literature scan, was used to assess the sustainability of eight interventions under potential climate change conditions. Network metrics were calculated to describe the system structure and identify highly impactful nodes. Results: The network metrics identified high-leverage nodes including alternative productions systems and good farming practices. None of the scenarios evaluated were able to adequately reduce AMR within the system. Conclusions: Overall, fuzzy cognitive mapping provides an innovative way to analyse the AMR system, identify high-leverage interventions, and examine potential impact of interventions using a broader systems lens.

IntroductionThe issue of communications in the public space, and in particular, in the workplace, became critical in the early stages of the SARS-CoV-2 pandemic and was exacerbated by the stress of the drastic transformation of the organization of work, the speed with which new information was being made available, and the constant fear of being infected or developing a more severe or even fatal form of the disease. Although effective communication is the key to fighting a pandemic, some business sectors were more vulnerable and affected than others, and the individuals in particular socio-demographic and economic categories were proportionately more affected by the number of infections and hospitalizations, and by the number of deaths. Therefore, the aim of this article is to present data related to issues faced by essential workers interacting with the public and their employers to mitigate the contagion of SARS-CoV-2 (COVID-19) at work.MethodsFollowing the constructivist paradigm, an interpretative qualitative design was used to conduct one-on-one interviews with precarious/low-wage, public-contact workers (N = 40), managers (N = 16), and key informants (N = 16) on topics related to their work environments in the context of COVID-19 prevention.ResultsThis article has highlighted some aspects of communication in the workplace essential to preventing COVID-19 outbreaks (e.g., access to information in a context of fast-changing instructions, language proficiency, transparency and confidentiality in the workplace, access to clear guidelines). The impact of poor pre-pandemic working relations on crisis management in the workplace also emerged.DiscussionThis study reminds us of the need to develop targeted, tailored messages that, while not providing all the answers, maintain dialog and transparency in workplaces.

BACKGROUND:The COVID-19 pandemic necessitated public health policies to limit human mobility and curb infection spread. Human mobility, which is often underestimated, plays a pivotal role in health outcomes, impacting both infectious and chronic diseases. Collecting precise mobility data is vital for understanding human behavior and informing public health strategies. Google's GPS-based location tracking, which is compiled in Google Mobility Reports, became the gold standard for monitoring outdoor mobility during the pandemic. However, indoor mobility remains underexplored. OBJECTIVE:This study investigates in-home mobility data from ecobee's smart thermostats in Canada (February 2020 to February 2021) and compares it directly with Google's residential mobility data. By assessing the suitability of smart thermostat data, we aim to shed light on indoor mobility patterns, contributing valuable insights to public health research and strategies. METHODS:Motion sensor data were acquired from the ecobee "Donate Your Data" initiative via Google's BigQuery cloud platform. Concurrently, residential mobility data were sourced from the Google Mobility Report. This study centered on 4 Canadian provinces-Ontario, Quebec, Alberta, and British Columbia-during the period from February 15, 2020, to February 14, 2021. Data processing, analysis, and visualization were conducted on the Microsoft Azure platform using Python (Python Software Foundation) and R programming languages (R Foundation for Statistical Computing). Our investigation involved assessing changes in mobility relative to the baseline in both data sets, with the strength of this relationship assessed using Pearson and Spearman correlation coefficients. We scrutinized daily, weekly, and monthly variations in mobility patterns across the data sets and performed anomaly detection for further insights. RESULTS:The results revealed noteworthy week-to-week and month-to-month shifts in population mobility within the chosen provinces, aligning with pandemic-driven policy adjustments. Notably, the ecobee data exhibited a robust correlation with Google's data set. Examination of Google's daily patterns detected more pronounced mobility fluctuations during weekdays, a trend not mirrored in the ecobee data. Anomaly detection successfully identified substantial mobility deviations coinciding with policy modifications and cultural events. CONCLUSIONS:This study's findings illustrate the substantial influence of the Canadian stay-at-home and work-from-home policies on population mobility. This impact was discernible through both Google's out-of-house residential mobility data and ecobee's in-house smart thermostat data. As such, we deduce that smart thermostats represent a valid tool for facilitating intelligent monitoring of population mobility in response to policy-driven shifts.