Background: Outbreaks of invasive group A streptococcal infection (iGAS) have historically occurred in institutional settings. Increasingly, community-based outbreaks have been reported, often among marginalized populations, yet few guidelines exist for managing iGAS outbreaks in such settings. Objective: To describe the ongoing outbreak of iGAS in Middlesex-London, Ontario, and the challenges that arose while applying current guidelines to a marginalized population in a community setting. Methods: The outbreak investigation included all iGAS cases in Middlesex-London with an onset date from April 1, 2016 to February 28, 2018. Clinical specimens were submitted to provincial and federal laboratories for typing. Public health management of the outbreak involved environmental health inspections, contact tracing, chemoprophylaxis of close contacts, swabbing to determine colonization rates of Streptococcus pyogenes, and communicating with stakeholders and the public. Results: A total of 156 confirmed cases of iGAS corresponding to 147 individuals were reported in less than two years. More than 60% of cases occurred in men (n=91) and almost half (n=71) of the total number of cases were persons who used drugs (PWUD) and/or were under-housed. Of the PWUD cases, 58 of 65 (89%) used injection drugs. Key challenges in controlling this outbreak included reaching PWUD and under-housed people; completing a case history and contact list; facilitating completion of treatment; dealing with concurrent infections such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV); and optimizing environmental health conditions. Guidelines were adapted so contacts who shared drugs or injection drug equipment with a known iGAS case would be offered chemoprophylaxis regardless of the clinical severity of the case. To optimize treatment completion, a single-dose of azithromycin for individuals in close contact with PWUD and/or under-housed cases was given. Cases with macrolide-resistant strain emm9 have recently emerged. Conclusion: The application of institution-based guidelines for iGAS outbreaks has been ineffective in controlling this particular community outbreak. There is a need for guidelines on managing outbreaks of iGAS in the community especially when an outbreak involves marginalized populations.
The tradition of leaving high school and finding full-time employment after grade 8 has put Low German-speaking (LGS) Mennonites in rural Southwestern Ontario in a vulnerable economic position. Consequently, alternative education programs have been developed by Ontario public school boards in areas containing high numbers of LGS Mennonites. The programs strive to keep LGS Mennonite youth in school by creating spaces where primarily male LGS Mennonite students feel more comfortable and can pursue a high school diploma while maintaining their religious beliefs, cultural identity, and work responsibilities. This article draws from qualitative interview data and open-ended survey responses to explore perceptions of LGS Mennonite men’s experiences in alternative education programs, and it highlights factors that caused the men to avoid or leave the programs. This article offers recommendations on how to strengthen the programs to increase the number of LGS Mennonite students attending them. It emphasizes the importance of LGS Mennonite students receiving strong messages from educators that their language, culture, and religious beliefs are valued even if that means separating the youth from Canadian society rather than integrating them on equal terms to minimize their marginalization.
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