Elgin County

2010 Community Health Status Report

Elgin St. Thomas Public Health Prepared by: Sarah Maaten and Laura Zettler

Please cite reference as: Maaten S, Zettler L (2010). 2010 Community Health Status Report: Elgin St. Thomas Public Health. St. Thomas, Ontario: Elgin St. Thomas Public Health.

Executive Summary

The focus of public health is on the health and well‐being of the population. Population health is achieved through the promotion and protection of health and the prevention of illness. There are many factors that contribute to an effective planning process for public health programs and services – a main one being population health status. Having a thorough understanding of the many elements that contribute to population health status allows for effective and informed decision‐making in the planning of public health programs. Additionally, measuring health status is a requirement of the Ontario Public Health Standards (OPHS).

The following report contains health status information on a range of topics relevant to public health. The population studied is in the City of St. Thomas and Elgin County. Topic areas range from the social determinants of health to chronic disease and injury, reproductive health and early development to communicable disease and environmental health. Some indicators examine health outcomes while others depict health behaviours. By assessing trends over time and comparing local estimates with provincial averages, this report identifies challenges and successes with respect to the health of the St. Thomas and Elgin County population. Data gaps have been identified in topic areas where there was insufficient information to assess health status. These gaps highlight topic areas where further information is required in order to fully understand the health status of the population.

Challenges: The leading cause of premature death in St. Thomas and Elgin County was cardiovascular disease. Ischemic heart disease, a chronic disease that causes heart attacks, and cerebrovascular disease (mainly stroke) were responsible for a quarter of all deaths. Compared to the province, death from cardiovascular disease was experienced at younger ages in St. Thomas and Elgin County. Men were more heavily affected than women. Lung disease was the second leading cause of death. Diseases such as chronic obstructive pulmonary disease (COPD) and other lower respiratory diseases caused about 13% of all deaths. Furthermore, the rate of death and hospitalization for lower respiratory diseases was higher than the province. While diabetes was responsible for only 5% of deaths in St. Thomas and Elgin County, the local population experienced higher diabetes‐related hospitalizations than the province. Fortunately, the rates of death and hospitalization for all of these diseases declined over the time frame studied. Injuries, while not a leading cause of death, were the fourth leading cause of hospitalizations in St. Thomas and Elgin County and rates were higher than the province. Regarding injury prevention, the data suggests that motor vehicle collisions and falls were the top priorities. To put it all into context, hospitalization rates for falls represent one quarter of that for cardiovascular disease and rates for motor vehicle collisions represent only a tenth of the rate for cardiovascular disease.

The teen pregnancy rate was higher in St. Thomas and Elgin County compared to Ontario and did not decrease over time as was seen in the trend for the province. Additionally, rates of therapeutic abortions were lower than that of the province, meaning a smaller proportion of teen pregnancies were aborted in St. Thomas and Elgin County. Infectious disease rates were relatively low compared to the province. Chlamydia was, however, the disease most commonly reported to public health. Although injury, teen pregnancy, and Chlamydia rates were lower than those of the chronic diseases, they were

more likely to affect a younger population, thereby potentially result in long term consequences for the population.

High rates of morbidity and mortality from chronic diseases may be attributed to socioeconomic factors and health behaviour patterns seen in St. Thomas and Elgin County. For instance, education rates were lower in St. Thomas and Elgin County compared to Ontario with a smaller proportion of the population having completed high school. It has been shown that lower education rates are indicative of poorer health outcomes. Local smoking rates were higher than Ontario, with nearly 30% of the St. Thomas and Elgin County population reporting they are current smokers. The difference was statistically significant. Air quality readings in Port Stanley indicate that the air quality in the region may be as poor as nearly any other place in Ontario. Both high rates of tobacco use and relatively poor air quality may be significantly contributing to the high rates of respiratory disease affecting the population. In addition, only half of the population was at least moderately active and more than half the population was considered to be overweight or obese. All of these lifestyle factors contributed to the major chronic conditions prevalent in the population, including heart disease and diabetes.

Less frequent use of protective equipment such as seatbelts and helmets was seen in St. Thomas and Elgin County compared with Ontario. It was also more common to drive, or get in the car with a driver who was, under the influence of alcohol. The higher injury rates experienced locally as compared to the province may have been influenced by poor use of protective equipment.

Successes: While important to identify the challenges that need to be addressed in the population, it is also important to recognize successes. Despite lower income levels and slightly lower median income levels in St. Thomas and Elgin County, there were far fewer people below the low income cut‐off in 2006 compared to 2001, as well as in comparison to the province. Additionally, residents of St. Thomas and Elgin County were generally considered food secure and there was a smaller proportion of lone parent families locally, compared to the province.

Infectious disease rates were low compared to the province and were substantially lower than the rates of chronic diseases. Rates of reportable diseases, including food and water borne illnesses, vector‐borne and zoonotic diseases and those prevented by routine vaccination were substantially lower than what was reported at the provincial level. Vaccination coverage rates for childhood diseases and those that affect the elderly and vulnerable populations were higher in St. Thomas and Elgin County than the province. Locally, high fertility will assist with increased population growth and there was a lower proportion of ‘low birth weight’ and pre‐term births in St. Thomas and Elgin County compared to Ontario. While cancer screening rates could be improved at the local level, available data suggests they were at least on par with those of the province. Residents of St. Thomas and Elgin County tended to experience less work and life stress than their provincial counterparts. Furthermore, the rate of suicide was lower and there were fewer motor vehicle collisions overall. Lastly, the local beaches were very infrequently posted with swimming advisories due to high bacteria levels.

Data Gaps: Unfortunately not all areas of public health in St. Thomas and Elgin County have sufficient information available to assess health status. More work is necessary to fill the existing data gaps in order to get a better grasp on issues such as parenting and healthy family dynamics, child oral health, drinking water quality, mental health, child healthy weights, child eating and physical activity, exposure to ultraviolet radiation and emergency preparedness.

Table of Contents INTRODUCTION...... 1 PURPOSE ...... 1

FOUNDATIONAL STANDARD OF THE OPHS ...... 2 METHODS ...... 3

HEALTH INDICATOR FRAMEWORK ...... 3 DATA SOURCES ...... 4 Canadian Community Health Survey (CCHS) ...... 4 Provincial Health Planning Database (PHPDB) ...... 4 Ontario Cancer Registry ...... 4 2006 Census ...... 5 Integrated Public Health Information System (iPHIS) ...... 5 Immunization Records Information System (IRIS) ...... 5 Integrated Services for Children information System (ISCIS) ...... 5 Other Sources ...... 5 ANALYSIS AND INTERPRETATION ...... 6 Rates ...... 6 Incidence versus Prevalence ...... 6 Crude versus Age‐Specific versus Age‐Standardized ...... 6 Small Counts ...... 7 Survey Data: Confidence Intervals, Statistical Significance & Coefficients of Variation ...... 7 CHAPTER 1: DEMOGRAPHICS ...... 9

OVERVIEW ...... 10 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 10 DEMOGRAPHICS INTRODUCTION ...... 11 GEOGRAPHY ...... 12 POPULATION ...... 13 IMMIGRATION ...... 16 LANGUAGE ...... 18 VISIBLE MINORITIES ...... 20 CHAPTER 2: SOCIAL DETERMINANTS OF HEALTH ...... 22

ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 23 OVERVIEW ...... 23 SOCIAL DETERMINANTS OF HEALTH INTRODUCTION ...... 24 FAMILY STRUCTURE AND HOUSEHOLDS ...... 25 EDUCATION ...... 28 EMPLOYMENT AND UNPAID WORK ...... 30 FOOD SECURITY ...... 32 INCOME ...... 33 CHAPTER 3: MORTALITY ...... 37

OVERVIEW ...... 38 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 38 MORTALITY INTRODUCTION ...... 39 LIFE EXPECTANCY ...... 39 ALL CAUSE MORTALITY ...... 40 LEADING CAUSES OF DEATH ...... 43 STANDARDIZED MORTALITY RATIOS ...... 47 POTENTIAL YEARS OF LIFE LOST ...... 50 CHAPTER 4: MORBIDITY ...... 54

OVERVIEW ...... 55 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 55 MORBIDITY INTRODUCTION ...... 56 ALL CAUSE HOSPITALIZATIONS ...... 56 LEADING CAUSES OF HOSPITALIZATIONS ...... 59 STANDARDIZED HOSPITALIZATION RATIOS ...... 65 LENGTH OF STAY ...... 67 CHAPTER 5: CHRONIC HEALTH CONDITIONS ...... 70

OVERVIEW ...... 71 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 71 CHRONIC HEALTH CONDITIONS INTRODUCTION ...... 72 PREVALENCE OF SELF‐REPORTED CHRONIC HEALTH PROBLEMS ...... 73 CHRONIC DISEASE MORBIDITY & MORTALITY ...... 76 CARDIOVASCULAR DISEASE...... 76 Ischemic Heart Disease ...... 80 Cerebrovascular Disease ...... 82 RESPIRATORY DISEASE ...... 84 Chronic Obstructive Pulmonary Disease (COPD) ...... 86 Asthma ...... 87 DIABETES ...... 88 CANCER INCIDENCE, MORTALITY, AND SCREENING...... 90 CANCER INCIDENCE AND MORTALITY ...... 90 All Cancers ...... 90 Lung Cancer ...... 94 Female Breast Cancer ...... 95 Prostate Cancer ...... 96 Colorectal Cancer ...... 97 Other Types of Cancer ...... 98 CANCER SCREENING ...... 99 CHAPTER 6: LIFESTYLE BEHAVIOURS ...... 102

OVERVIEW ...... 103 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 104 LIFESTYLE BEHAVIOURS INTRODUCTION ...... 105

HEALTHY EATING ...... 106 HEALTHY WEIGHTS ...... 108 COMPREHENSIVE TOBACCO CONTROL ...... 110 PHYSICAL ACTIVITY ...... 114 ALCOHOL USE ...... 115 STRESS ...... 118 HEALTH SERVICE USE ...... 119 CHAPTER 7: INJURIES AND INJURY PREVENTION ...... 122

OVERVIEW ...... 123 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 123 INJURIES AND INJURY PREVENTION INTRODUCTION ...... 124 INJURY PRIORITY SETTING ...... 125 SELF‐REPORTED INJURY ...... 126 INJURY HOSPITALIZATIONS AND DEATHS ...... 128 MOTOR VEHICLE COLLISIONS ...... 138 INJURY PREVENTION ...... 143 CHAPTER 8: REPRODUCTIVE HEALTH AND EARLY DEVELOPMENT ...... 148

OVERVIEW ...... 149 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 149 REPRODUCTIVE HEALTH AND EARLY DEVELOPMENT INTRODUCTION ...... 150 SEXUAL HEALTH ...... 151 Sexual Activity among Youth ...... 151 Protective Practices ...... 151 PRENATAL HEALTH ...... 152 Prenatal Class Attendance ...... 152 Folic Acid Supplementation ...... 152 Substance Use during Pregnancy ...... 153 Age of Mother at Infant’s Birth ...... 154 PREGNANCY AND FERTILITY ...... 155 Pregnancy ...... 155 Therapeutic Abortions ...... 157 Fertility ...... 159 Crude Birth Rate ...... 161 Multiple Births ...... 161 BIRTH OUTCOMES ...... 162 Birth Weight ...... 162 Preterm Births ...... 165 Stillbirths and Infant Mortality ...... 167 EARLY DEVELOPMENT ...... 168 High‐Risk Births ...... 168 Breastfeeding ...... 169 School Readiness ...... 170 CHAPTER 9: COMMUNICABLE DISEASES ...... 173

ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 174 OVERVIEW ...... 174 COMMUNICABLE DISEASES INTRODUCTION ...... 175 MOST COMMON REPORTABLE DISEASES ...... 176 SEXUALLY TRANSMITTED INFECTIONS AND BLOOD‐BORNE INFECTIONS ...... 177 Chlamydia ...... 177 Hepatitis C ...... 180 Gonorrhea ...... 182 Other Sexually Transmitted Infections and Blood‐borne infections ...... 183 FOOD‐BORNE AND WATER‐BORNE ENTERIC DISEASES ...... 184 Other Food‐borne and Water‐borne Enteric Diseases ...... 186 TUBERCULOSIS ...... 186 DISEASES PREVENTED BY ROUTINE VACCINATION ...... 186 Influenza ...... 186 Streptococcus pneumoniae ...... 187 Group A Streptococcal Disease ...... 187 Other Vaccine Preventable Diseases ...... 187 Vaccination Coverage ...... 188 Adverse Vaccine Events ...... 190 OUTBREAKS ...... 191 CHAPTER 10: ENVIRONMENTAL HEALTH ...... 193

OVERVIEW ...... 194 ONTARIO PUBLIC HEALTH STANDARDS – RELATED SECTIONS ...... 194 ENVIRONMENTAL HEALTH INTRODUCTION ...... 195 AIR QUALITY ...... 196 Air Quality Index...... 196 Smog Advisories ...... 197 EXTREME WEATHER CONDITIONS ...... 198 Extreme Heat ...... 198 Extreme Cold ...... 198 BEACH ADVISORIES ...... 199 FOOD SAFETY ...... 200 Food Premises Inspection ...... 200 Food Handler Education ...... 201 VECTOR‐BORNE AND ZOONOTIC DISEASES ...... 201 West Nile Virus ...... 201 Rabies ...... 202 APPENDIX A: ONTARIO PUBLIC HEALTH STANDARDS: ASSESSMENT AND SURVEILLANCE REQUIREMENTS...... 204

FOUNDATIONAL STANDARD (ADDRESSED THROUGHOUT REPORT) ...... I CHRONIC DISEASE PREVENTION (SEE CHRONIC HEALTH CONDITIONS CHAPTER) ...... II PREVENTION OF INJURY AND SUBSTANCE MISUSE (SEE INJURIES AND INJURY PREVENTION AND LIFESTYLE BEHAVIOURS CHAPTERS) ..... II REPRODUCTIVE HEALTH (SEE REPRODUCTIVE HEALTH CHAPTER) ...... III CHILD HEALTH (SEE REPRODUCTIVE HEALTH CHAPTER) ...... III

INFECTIOUS DISEASES PREVENTION AND CONTROL (SEE COMMUNICABLE DISEASES CHAPTER) ...... IV RABIES PREVENTION AND CONTROL (SEE ENVIRONMENTAL HEALTH CHAPTER) ...... IV TUBERCULOSIS PREVENTION AND CONTROL (SEE COMMUNICABLE DISEASES CHAPTER) ...... V SEXUAL HEALTH, SEXUALLY TRANSMITTED INFECTIONS, AND BLOOD‐BORNE INFECTIONS (INCLUDING HIV) (SEE COMMUNICABLE DISEASES AND REPRODUCTIVE HEALTH CHAPTERS) ...... VI VACCINE PREVENTABLE DISEASES (SEE COMMUNICABLE DISEASES CHAPTER) ...... VII FOOD SAFETY (SEE COMMUNICABLE DISEASES AND ENVIRONMENTAL HEALTH CHAPTERS) ...... VII SAFE WATER (SEE ENVIRONMENTAL HEALTH CHAPTER) ...... VIII HEALTH HAZARD PREVENTION AND MANAGEMENT (SEE ENVIRONMENTAL HEALTH CHAPTER) ...... IX PUBLIC HEALTH EMERGENCY PREPAREDNESS (DATA NOT AVAILABLE) ...... IX

TABLE OF FIGURES

FIGURE 1.1: MAP OF SOUTHWESTERN ONTARIO WITH ST. THOMAS AND ELGIN COUNTY ...... 12 FIGURE 1.2: PROPORTION OF POPULATION BY FIVE YEAR AGE GROUPS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 ...... 13 FIGURE 1.3: POPULATION GROWTH, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 1971 TO 2016 ...... 14 FIGURE 1.4: DEPENDENCY RATIOS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001 AND 2006 ...... 15 FIGURE 1.5: NUMBER AND PROPORTION OF IMMIGRANTS, BY MUNICIPALITY, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 ... 16 FIGURE 1.6: PROPORTION OF TOTAL IMMIGRANTS, BY YEAR OF IMMIGRATION, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 17 FIGURE 1.7: NUMBER AND PROPORTION OF PEOPLE WHO SPEAK A NON‐OFFICIAL LANGUAGE IN THE HOME, BY MUNICIPALITY, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 18 FIGURE 1.8: NUMBER AND PROPORTION OF PEOPLE WITH MOTHER TONGUE NOT ENGLISH, BY MUNICIPALITY, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 19 FIGURE 1.9: NUMBER AND PROPORTION OF PEOPLE WHO ARE A VISIBLE MINORITY, BY MUNICIPALITY, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 20 FIGURE 2.1 PROPORTION OF THE POPULATION (AGE 15 YRS +), BY MARITAL STATUS, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 25 FIGURE 2.2: NUMBER AND PROPORTION OF TWO PARENT AND LONE PARENT FAMILIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 ...... 26 FIGURE 2.3: PROPORTION OF THE POPULATION (AGE 15 YRS +), BY HOUSEHOLD TYPE, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 27 FIGURE 2.4: PROPORTION OF THE POPULATION (AGE 15 YRS +), BY HIGHEST EDUCATIONAL ATTAINMENT, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 28 FIGURE 2.5: PROPORTION OF THE POPULATION (AGE 15 YRS +), BY HIGHEST EDUCATIONAL ATTAINMENT, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 29 FIGURE 2.6: UNEMPLOYMENT RATE IN THE POPULATION (AGE 15 YRS +), ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001 TO 2009 ...... 30 FIGURE 2.7: PARTICIPATION RATE AND UNEMPLOYMENT RATE OF POPULATION (AGE 15 YRS +), ST. THOMAS AND ELGIN COUNTY, 1996, 2001, 2006 ...... 31 FIGURE 2.8: PROPORTION OF THE POPULATION (AGE 15 YRS +), BY MODE OF TRANSPORTATION TO WORK, ST. THOMAS AND ELGIN COUNTY, 2006 ...... 32 FIGURE 2.9: MEDIAN INCOME AFTER TAX, BY HOUSEHOLD TYPE, ST. THOMAS AND ELGIN COUNTY, 2005 ...... 33 FIGURE 2.10: MEDIAN INCOME AFTER TAX FOR TWO PARENT AND LONE PARENT FAMILIES, ST. THOMAS AND ELGIN COUNTY, 2005 ..... 34 FIGURE 2.11: PROPORTION OF THE POPULATION BELOW THE LOW INCOME CUT‐OFF (AFTER TAX), ST. THOMAS AND ELGIN COUNTY, 1995, 2000, 2005 ...... 35 FIGURE 3.1: NUMBER OF DEATHS AND CRUDE MORTALITY RATES FOR ALL CAUSES, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2005 ...... 40 FIGURE 3.2: AGE‐SPECIFIC MORTALITY RATES FOR ALL CAUSES, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 41 FIGURE 3.4: NUMBER, PROPORTION AND RANKING OF LEADING CAUSES OF DEATH, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2005 AVERAGE ...... 43 FIGURE 3.5: NUMBER, PROPORTION AND RANKING OF LEADING CAUSES OF DEATH, BY SEX, ST. THOMAS & ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 44 FIGURE 3.6: PROPORTION AND RANKING OF LEADING CAUSES OF DEATH, BY SEX, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2005 AVERAGE ...... 45 FIGURE 3.7: STANDARDIZED MORTALITY RATIOS FOR LEADING CAUSES OF DEATH IN MALES, ST. THOMAS AND ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 48

FIGURE 3.8: STANDARDIZED MORTALITY RATIOS FOR LEADING CAUSES OF DEATH IN FEMALES, ST. THOMAS AND ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 49 FIGURE 3.9: POTENTIAL YEARS OF LIFE LOST FOR LEADING CAUSES OF DEATH IN MALES, ST. THOMAS AND ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 51 FIGURE 3.10: POTENTIAL YEARS OF LIFE LOST FOR LEADING CAUSES OF DEATH IN FEMALES, ST. THOMAS AND ELGIN COUNTY, 2003 TO 2005 AVERAGE ...... 52 FIGURE 4.1: NUMBER OF HOSPITALIZATIONS AND CRUDE HOSPITALIZATION RATES FOR ALL CAUSES, BY SEX, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 AVERAGE ...... 56 FIGURE 4.2: AGE‐SPECIFIC HOSPITALIZATION RATES FOR ALL CAUSES, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 57 FIGURE 4.3: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR ALL CAUSES, BY SEX, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2002 TO 2008 ...... 58 FIGURE 4.4: NUMBER, PROPORTION AND RANKING OF LEADING CAUSES OF HOSPITALIZATION, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 TO 2008 AVERAGE ...... 59 FIGURE 4.5: NUMBER, PROPORTION AND RANKING OF LEADING CAUSES OF HOSPITALIZATION, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 60 FIGURE 4.6: PROPORTION AND RANKING OF LEADING CAUSES OF HOSPITALIZATION, BY SEX, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 TO 2008 AVERAGE ...... 61 FIGURE 4.7: STANDARDIZED HOSPITALIZATION RATIOS FOR LEADING CAUSES OF HOSPITALIZATION IN MALES, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 65 FIGURE 4.8: STANDARDIZED HOSPITALIZATION RATIOS FOR LEADING CAUSES OF HOSPITALIZATION IN FEMALES, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 66 FIGURE 4.9: AVERAGE LENGTH OF STAY OF IN‐PATIENT HOSPITALIZATION FOR LEADING CAUSES OF HOSPITALIZATION IN MALES, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 67 FIGURE 4.10: AVERAGE LENGTH OF STAY OF IN‐PATIENT HOSPITALIZATION FOR LEADING CAUSES OF HOSPITALIZATION IN FEMALES, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2008 AVERAGE ...... 68 FIGURE 5.1 PREVALENCE OF AT LEAST ONE CHRONIC HEALTH PROBLEM, BY SEX, BY AGE GROUP, ST. THOMAS & ELGIN COUNTY, 2007/08 ...... 73 FIGURE 5.2: PREVALENCE OF SELECTED CHRONIC HEALTH PROBLEMS (AGE 12 YRS +), ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2007/08 ...... 73 FIGURE 5.3 PREVALENCE OF SELECTED CHRONIC HEALTH PROBLEMS BY SEX (AGE 12 YRS +), ST. THOMAS & ELGIN COUNTY, 2007/08 .. 74 FIGURE 5.4: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR CARDIOVASCULAR DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 76 FIGURE 5.5: AGE‐SPECIFIC HOSPITALIZATION RATES FOR CARDIOVASCULAR DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY, 2003 TO 2008 AVERAGE ...... 77 FIGURE 5.6: AGE‐STANDARDIZED MORTALITY RATES FOR CARDIOVASCULAR DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2000 TO 2005 ...... 78 FIGURE 5.7: AGE‐SPECIFIC MORTALITY RATES FOR CARDIOVASCULAR DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY, 2000 TO 2005 AVERAGE ...... 79 FIGURE 5.8: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR ISCHEMIC HEART DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 80 FIGURE 5.9: AGE‐STANDARDIZED MORTALITY RATES FOR ISCHEMIC HEART DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2000 TO 2005 ...... 81 FIGURE 5.10: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR CEREBROVASCULAR DISEASE, BY SEX ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 82

FIGURE 5.11: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR RESPIRATORY DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 84 FIGURE 5.12: AGE‐SPECIFIC HOSPITALIZATION RATES FOR RESPIRATORY DISEASE, BY SEX, ST. THOMAS & ELGIN COUNTY, 2003 TO 2008 AVERAGE ...... 85 FIGURE 5.13: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 86 FIGURE 5.14: AGE‐STANDARDIZED HOSPITALIZATION RATES FOR DIABETES, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 88 FIGURE 5.15: AGE‐SPECIFIC HOSPITALIZATION RATES FOR DIABETES, BY SEX, ST. THOMAS & ELGIN COUNTY, 2003 TO 2008 AVERAGE .. 89 FIGURE 5.16: NUMBER OF CASES OF MOST COMMONLY DIAGNOSED CANCERS, BY SEX, ST. THOMAS & ELGIN COUNTY, 2000 TO 2005 COMBINED ...... 90 FIGURE 5.17: NUMBER OF DEATHS OF MOST COMMONLY DIAGNOSED CANCERS, BY SEX, ST. THOMAS & ELGIN COUNTY, 2000 TO 2005 COMBINED ...... 91 FIGURE 5.18: AGE‐STANDARDIZED INCIDENCE RATES FOR ALL CANCERS, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 92 FIGURE 5.19: AGE‐STANDARDIZED MORTALITY RATES FOR ALL CANCERS, BY SEX, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 93 FIGURE 5.20: AGE‐STANDARDIZED LUNG CANCER INCIDENCE RATES, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ..... 94 FIGURE 5.21: AGE‐STANDARDIZED BREAST CANCER INCIDENCE RATES, FEMALES, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 95 FIGURE 5.22: AGE‐STANDARDIZED PROSTATE CANCER INCIDENCE RATES, MALES, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 96 FIGURE 5.23: AGE‐STANDARDIZED COLORECTAL CANCER INCIDENCE RATES, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 97 FIGURE 5.24: PREVALENCE OF CANCER SCREENING (EVER AND ACCORDING TO RECOMMENDED INTERVALS) BY TYPE OF CANCER, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2007/08 ...... 99 FIGURE 6.1: RECOMMENDED NUMBER OF VEGETABLE AND FRUIT SERVINGS PER DAY, BY SEX, BY AGE GROUP ...... 106 FIGURE 6.2: PROPORTION OF PEOPLE (AGE 12 YRS +) REPORTING NUMBER OF DAILY FRUIT AND VEGETABLE SERVINGS, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2003, 2005, 2007/8 ...... 107 FIGURE 6.3: PROPORTION OF ADULTS (AGE 18 YRS +) IN EACH BODY MASS INDEX CATEGORY, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2003, 2005, 2007/8 ...... 108 FIGURE 6.4: PROPORTION OF ADOLESCENTS (AGE 12 TO 17 YRS) OF NORMAL WEIGHT, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2005, 2007/8 ...... 109 FIGURE 6.5: PROPORTION OF ADULTS (AGE 20 YRS +) WHO WERE CURRENT, FORMER AND NEVER SMOKERS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003, 2005, 2007/8 ...... 110 FIGURE 6.6: PROPORTION OF ADOLESCENT (AGE 12‐ 19 YRS) NEVER SMOKERS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003, 2005, 2007/8 ...... 111 FIGURE 6.7: MINORS’ ACCESS TO TOBACCO, ST. THOMAS AND ELGIN COUNTY, 2008 AND 2009 ...... 113 FIGURE 6.8: PROPORTION OF PEOPLE (AGE 12 YRS +) REPORTING LEVEL OF PHYSICAL ACTIVITY IN LEISURE TIME AS ACTIVE OR MODERATELY ACTIVE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003, 2005, 2007/8 ...... 114 FIGURE 6.9: PROPORTION OF MALES (AGE 19 YRS +) CONSIDERED LOW RISK DRINKERS, ST. THOMAS AND ELGIN COUNTY, 2003, 2005, 2007/8 ...... 115 FIGURE 6.10: PROPORTION OF FEMALES (AGE 19 YRS +) CONSIDERED LOW RISK DRINKERS, ST. THOMAS AND ELGIN COUNTY, 2003, 2005, 2007/8 ...... 116

FIGURE 6.11: PROPORTION OF ADULTS (AGE 19 YRS +) WHO REPORTED DRINKING 5 OR MORE DRINKS AT LEAST ONCE A MONTH IN THE PAST YEAR, BY SEX, ST. THOMAS AND ELGIN COUNTY & ONTARIO, 2003, 3005, 2007/8 ...... 117 FIGURE 6.12: PROPORTION OF PEOPLE (AGE 15 YRS +) WHO REPORT LIFE AND WORK AS QUITE STRESSFUL OR EXTREMELY STRESSFUL, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2007/8 ...... 118 FIGURE 6.13: PROPORTION OF POPULATION (AGE 12 YRS +) WHO REPORTED HAVING A FAMILY PHYSICIAN, BY SEX, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003, 2005, 2007/8 ...... 119 FIGURE 7.1: INJURY PREVENTION PRIORITIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO ...... 125 FIGURE 7.2: TYPE OF ACTIVITY RESULTING IN SERIOUS INJURY (12+ YEARS OF AGE), ST. THOMAS AND ELGIN COUNTY, 2003 ...... 126 FIGURE 7.3: AGE STANDARDIZED HOSPITALIZATION RATES FOR ALL UNINTENDED INJURIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2002 ‐2008 ...... 128 FIGURE 7.4: AGE STANDARDIZED MORTALITY RATES FOR ALL UNINTENDED INJURIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2000 TO 2005 ...... 129 FIGURE 7.5: RATES OF AGE‐STANDARDIZED HOSPITALIZATIONS AND DEATHS FOR SELECTED INJURIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2006 TO 2008 AVERAGE (HOSPITALIZATIONS) AND 2003 TO 2005 AVERAGE (MORTALITY) ...... 130 FIGURE 7.6: AGE STANDARDIZED HOSPITALIZATION RATES FOR FALLS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 ‐2008 .. 132 FIGURE 7.7: AGE STANDARDIZED HOSPITALIZATION RATES FOR MOTOR VEHICLE COLLISIONS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 133 FIGURE 7.8: AGE STANDARDIZED HOSPITALIZATION RATES FOR SELF‐HARM, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 134 FIGURE 7.9: AGE STANDARDIZED HOSPITALIZATION RATES FOR UNINTENTIONAL POISONINGS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 135 FIGURE 7.10: AGE STANDARDIZED HOSPITALIZATION RATES FOR SPORTS‐RELATED INJURIES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 136 FIGURE 7.11: AGE STANDARDIZED HOSPITALIZATION RATES FOR ASSAULT AND ABUSE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2003 TO 2008 ...... 137 FIGURE 7.12: CRUDE RATE OF TOTAL MOTOR VEHICLE COLLISIONS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2002 TO 2006 .. 138 FIGURE 7.13: CRUDE RATE OF MOTOR VEHICLE COLLISIONS INVOLVING AN INJURY, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2002 TO 2006 ...... 139 FIGURE 7.14: CRUDE RATE OF MOTOR VEHICLE COLLISIONS INVOLVING A FATALITY, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2002 TO 2006 ...... 140 FIGURE 7.15: PROPORTION OF MOTOR VEHICLE COLLISIONS INVOLVING AN INTOXICATED DRIVER, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 1995 TO 2006 COMBINED ...... 141 FIGURE 7.16: PROPORTION OF MOTOR VEHICLE COLLISIONS INVOLVING AN INTOXICATED DRIVER, BY TYPE OF COLLISIONS, BY SEX, ST. THOMAS AND ELGIN COUNTY, 1995 TO 2006 COMBINED ...... 142 FIGURE 7.17: PROPORTION OF DRIVERS, BY FREQUENCY OF REPORTED SEAT BELT USE, ST. THOMAS AND ELGIN COUNTY, 2003 ...... 143 FIGURE 7.18: PROPORTION OF DRIVERS, BY REPORTED CELL PHONE USE, ST. THOMAS AND ELGIN COUNTY, 2003 ...... 144 FIGURE 7.19: PROPORTION OF PEOPLE WHO ANSWERED NO TO 'DID DRIVER HAVE 2 + DRINKS IN THE HOUR BEFORE DRIVING IN THE PAST 12 MONTHS?’, BY TYPE OF VEHICLE, ST. THOMAS & ELGIN COUNTY AND ONTARIO, 2003 ...... 145 FIGURE 7.20: PROPORTION OF PEOPLE (AGE 12 YRS +) WHO REPORTED RARELY OR NEVER WEARING A HELMET , BY ACTIVITY, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2005 (ATV DATA, 2003) ...... 146 FIGURE 8.1: SELF‐REPORTED PREVALENCE OF EARLY SEXUAL DEBUT (BEFORE 19 YEARS OF AGE) AMONG 15 TO 49 YEAR OLDS AND PROPORTION OF YOUTH (AGE 15‐19 YRS) THAT ARE SEXUALLY ACTIVE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2007/08 ...... 151 FIGURE 8.2: PREVALENCE OF SELF‐REPORTED NOT USING TOBACCO AND ALCOHOL DURING PREGNANCY (AMONG 15 TO 55 YEAR OLDS WHO HAD A BABY IN THE LAST 5 YEARS), ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2007/08 ...... 153

FIGURE 8.3: PROPORTION OF BIRTHS BY MOTHER’S AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2001‐2005 AVERAGE ...... 154 FIGURE 8.4: OVERALL AND TEEN PREGNANCY RATE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 ...... 155 FIGURE 8.5: AGE‐SPECIFIC PREGNANCY RATES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 ...... 156 FIGURE 8.6: OVERALL AND TEEN THERAPEUTIC ABORTION RATES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 ...... 157 FIGURE 8.7: AGE‐SPECIFIC THERAPEUTIC ABORTION RATES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 AVERAGE ... 158 FIGURE 8.8: GENERAL FERTILITY RATES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 ...... 159 FIGURE 8.9: AGE‐SPECIFIC FERTILITY RATES, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 ...... 160 FIGURE 8.10: CRUDE BIRTH RATE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 161 FIGURE 8.11: LOW AND HIGH BIRTH WEIGHT RATES, BY TYPE OF LIVE BIRTH, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 AVERAGE ...... 162 FIGURE 8.12: LOW BIRTH WEIGHT RATE, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 1995 TO 2005 ...... 163 FIGURE 8.13: BIRTH WEIGHT RATES BY MOTHER’S AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 1995 TO 2005 AVERAGE ...... 164 FIGURE 8.14: PRETERM BIRTH RATES, BY TYPE OF LIVE BIRTH, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2005 AVERAGE 165 FIGURE 8.15: PRETERM LIVE BIRTH RATES, BY MOTHER’S AGE GROUP, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 1995 TO 2005 AVERAGE ...... 166 FIGURE 8.16: NUMBER AND PROPORTION OF BIRTHS IDENTIFIED AS HIGH‐RISK FOR DEVELOPMENTAL DIFFICULTIES (SCORED 9 OR GREATER ON THE POSTPARTUM PARKYN SCREEN), ST. THOMAS AND ELGIN COUNTY, 2001‐2008 ...... 168 DATA SOURCE: INTEGRATED SERVICES FOR CHILDREN INFORMATION SYSTEM. ONTARIO MINISTRY OF HEALTH AND LONG‐TERM CARE. EXTRACTED JULY14, 2010 ...... 168 FIGURE 8.17: SELF‐REPORTED BREASTFEEDING INITIATION RATES (AMONG 15 TO 49 YEAR OLDS WHO HAD A BABY IN THE LAST 5 YEARS), ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2001‐2008 ...... 169 FIGURE 9.1: NUMBER OF TOP 10 MOST COMMON REPORTABLE COMMUNICABLE DISEASES, BY SEX, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 COMBINED ...... 176 FIGURE 9.2: AGE‐STANDARDIZED INCIDENCE RATES OF CHLAMYDIA, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2000 TO 2009 177 FIGURE 9.3: AGE‐SPECIFIC INCIDENCE OF CHLAMYDIA, FEMALES, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 AVERAGE ...... 178 FIGURE 9.4: AGE‐SPECIFIC INCIDENCE OF CHLAMYDIA, MALES, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 AVERAGE ...... 179 FIGURE 9.5: AGE‐STANDARDIZED INCIDENCE RATES OF HEPATITIS C, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2000 TO 2009 180 FIGURE 9.6: AGE‐SPECIFIC INCIDENCE OF HEPATITIS C, MALES, BY AGE, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 AVERAGE ... 181 FIGURE 9.7: AGE‐SPECIFIC INCIDENCE OF HEPATITIS C, FEMALES, BY AGE GROUP, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 AVERAGE ...... 182 FIGURE 9.8: AGE‐SEX SPECIFIC CRUDE INCIDENCE COUNTS AND RATES OF CAMPYLOBACTERIOSIS, SALMONELLOSIS AND GIARDIASIS, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 AVERAGE ...... 184 FIGURE 9.9: TOTAL COUNT OF CAMPYLOBACTERIOSIS AND SALMONELLOSIS, BY MONTH, ST. THOMAS AND ELGIN COUNTY, 2000 TO 2009 ...... 185 FIGURE 9.10: PROPORTION OF STAFF AND RESIDENTS OF HOSPITALS AND LONG TERM CARE FACILITIES THAT WERE IMMUNIZED FOR SEASONAL INFLUENZA, PANDEMIC H1N1 INFLUENZA, STREPTOCOCCUS PNEUMONIAE AND DURING 2007, 2008 AND 2009 INFLUENZA SEASONS ...... 188 FIGURE 9.11: IMMUNIZATION COVERAGE FOR CHILDREN AGES 7 TO 17, BY SCHOOL YEAR, ST. THOMAS AND ELGIN COUNTY, 2004/05 TO 2008/09 ...... 189 FIGURE 9.12: IMMUNIZATION COVERAGE FOR CHILDREN IN GRADES 7 AND 8, BY SCHOOL YEAR, ST. THOMAS AND ELGIN COUNTY, 2007/08 AND 2008/09 ...... 190 FIGURE 9.13: NUMBER OF OUTBREAKS, BY SECTOR, ST. THOMAS AND ELGIN COUNTY, 2002 TO 2008 COMBINED ...... 191

1 FIGURE 10.1: NUMBER OF DAYS THAT AIR QUALITY WAS POOR OR VERY POOR , PORT STANLEY AND LONDON AND THE ONTARIO SITE WITH THE MOST POOR AIR QUALITY DAYS, 2004 TO 2008 ...... 196 FIGURE 10.2: NUMBER OF ANNUAL SMOG ADVISORIES ISSUED AND SMOG ADVISORY DAYS, ST. THOMAS AND ELGIN COUNTY AND ONTARIO, 2005 TO 2009 ...... 197 FIGURE 10.3: PROPORTION OF DAYS IN MONITORING SEASON (JUNE TO SEPTEMBER) THAT BEACHES WERE POSTED WITH SWIMMING ADVISORIES, ST. THOMAS AND ELGIN COUNTY, 2005 TO 2009...... 199 FIGURE 10.4: PROPORTION OF PREMISES THAT RECEIVED REQUIRED INSPECTIONS, BY RISK LEVEL, ST. THOMAS AND ELGIN COUNTY, 2004 – 2009 ...... 200 FIGURE 10.5: TOTAL NUMBER OF FOOD HANDLING CERTIFICATES ISSUED, ST. THOMAS AND ELGIN COUNTY, 2004 TO 2009 ...... 201 FIGURE 10.6: NUMBER OF ANIMAL INVESTIGATIONS, AND PERSONS RECEIVING RABIES PROPHYLAXIS TREATMENT, ST. THOMAS AND ELGIN COUNTY, 2006 TO 2009 ...... 202

Introduction According to the World Health Organization (WHO), health is defined as “[a] state of complete physical, mental and social well‐being and not merely the absence of disease or infirmity”1. The main focus of public health is the health and well‐being of the entire population through the promotion and protection of health and the prevention of illness. The field of public health can be credited for many of the major improvements in population health over the last century through initiatives related to childhood vaccination, the control of infectious disease, safe food handling, reproductive health, the prevention of chronic diseases, and the prevention of injury.

Health status of individuals and populations is largely influenced by complex interactions between the social and physical environment and individual behaviours and conditions. These factors are widely known as the social determinants of health and specifically include the following: • Income and social status; • Social support networks; • Education and literacy; • Employment/working conditions; • Social and physical environments; • Personal health practices and coping skills; • Healthy child development; • Biology and genetic endowment; • Health services; • Gender; • Culture; and • Language.

The Ontario Public Health Standards (OPHS), released in 2008, establish the requirements for fundamental public health programs and services in Ontario. Boards of health must assess, plan, deliver, manage, and evaluate a variety of public health programs and services that address various health needs, and the contexts in which these needs occur. Addressing the social determinants of health and reducing health inequities are fundamental to the work of public health in Ontario. Effective public health programs and services are ones that consider community needs and the impact of the social determinants of health on the achievement of intended health outcomes. Purpose The purpose of this health status report is to provide a comprehensive overview of the health experience of St. Thomas and Elgin County residents. Ontario public health units are required to assess population health status to facilitate efficient and effective decision‐making regarding program planning and policy development. Population health assessment is a main component of the foundational standard of the OPHS, which underpins all program standards. Furthermore, each specific program standard includes specific population health assessment and surveillance requirements (Appendix A).

1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19‐22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 1

Foundational Standard of the OPHS The information contained in this report corresponds to the following requirements and outcomes of the Foundational Standard of the OPHS:

Requirement #1: The board of health shall assess current health status, health behaviours, preventive health practices, health care utilization relevant to public health, and demographic indicators in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Requirement #2: The board of health shall assess trends and changes in local population health in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Requirement #3: The board of health shall use population health, determinants of health and health inequities information to assess the needs of the local population, including the identification of populations at risk, to determine those groups that would benefit most from public health programs and services (i.e., priority populations).

Requirement #4: The board of health shall tailor public health programs and services to meet local population health needs, including those of priority populations, to the extent possible based on available resources.

Requirement #5: The board of health shall provide population health information, including determinants of health and health inequities to the public, community partners, and health care providers, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes • Public health programs and services are planned and implemented to address local population health needs. • The public, community partners, and health care providers are aware of relevant and current population health information. • The board of health allocates resources to reflect public health priorities and reallocates resources, as feasible, to reflect emergent public health priorities. • Relevant audiences have available information that is necessary for taking appropriate action.

Societal Outcomes • Population health needs are anticipated, identified, addressed, and evaluated. • Emerging threats to the public’s health are prevented or mitigated. • Community‐based planning and delivery of public health programs and services incorporate new public health knowledge.

This report will address population health assessment under the following broad topic areas: 1. Demographics 2. Social Determinants of Health 3. Mortality 4. Morbidity 5. Chronic Health Conditions 6. Lifestyle Behaviours 7. Injuries and Injury Prevention 8. Reproductive Health and Early Development 9. Communicable Diseases 10. Environmental Health

This report will be of use to local health professionals, policy and decision‐makers, community partners and service providers, as well as the general public. Furthermore, this report will serve as a baseline comparison for future assessments of local health status.

It must be acknowledged that population health assessment data does not exist for all topics and all sub‐populations in St. Thomas and Elgin County. Lack of data may be due to insufficient population size for adequate survey response or insufficient resources for good data collection infrastructures. The reports generated here are based on the available data that tend to favor health promotion‐related and chronic disease topics. Identifying data gaps and building data infrastructure to fill those gaps are important to ensure priorities are developed based on the whole picture of health status.

Methods The methodology implemented in this health status report was directed by the Population Health Assessment and Surveillance Protocol of the OPHS. This protocol describes how population health status should be assessed which includes, but is not limited to, use of standardized health indicators; inclusion of multiple data sources; conducting analysis by demographic subgroup and geographic region; and determination of time trends. This report, in terms of template development and data analysis, was a collaborative project of the epidemiologists at the Elgin St. Thomas Public Health and Chatham‐Kent Public Health Unit.

Health Indicator Framework

Health indicators are used to measure health status of a given population over a defined period of time. For this report, appropriate indicators were chosen from the Core Indicators for Public Health in Ontario – a framework developed by the Association of Public Health Epidemiologist in Ontario (APHEO). This framework was developed, and it continues to be updated, in order to standardize and improve the accuracy of community health status reporting across Ontario public health units and as such, provides definitions, methods and resources for calculating over 120 health indicators. Local level, reliable data was unavailable for some indicators therefore, not all were addressed in this report.

Data Sources

Data was extracted from many sources in order to calculate the various health indicators contained in this report. A brief explanation of each is provided below.

Canadian Community Health Survey (CCHS) The Canadian Community Health Survey (CCHS) is a national population household survey of Canadians aged 12 years and older. It provides cross‐sectional information related to health status, health care utilization and health determinants. Prior to 2007, data were collected from approximately 130,000 respondents every two years, excluding Indian Reserves, Canadian Forces and some remote area populations. Since 2007, data collection occurs annually, with roughly half the sample size used in previous cycles. In order to produce accurate estimates at the health unit level, two‐year period estimates (2007 and 2008 data average) were used in this report along with estimates from the 2001, 2003 and 2005 data collection cycles. For St. Thomas & Elgin County the average sample size for 2007/08 was 607 – representing a total population of 76,572 residents, age 12 and older, in the health unit region.

Provincial Health Planning Database (PHPDB) The Provincial Health Planning Database (PHPDB) is managed by the Ontario Ministry of Health and Long‐Term Care and contains health information from numerous data sources. The following PHPDB data sources were used in this report: • Vital Statistics (live births, stillbirths, and deaths) from the Office of the Ontario Registrar General; • Ambulatory Visits (emergency room visits) from the National Ambulatory Care Reporting System (NACRS), developed and produced by the Canadian Institute for Health Information (CIHI); • Inpatient Discharges (hospitalizations) from CIHI’s Discharge Abstract Database (DAD) • Population Estimates from Statistics Canada, approved by the Ontario Ministry of Finance.

Ontario Cancer Registry Cancer Care Ontario provides access to the Ontario Cancer Registry through SEERStat software (Release 7, March 2009). The Registry is a database of information on all Ontario residents who have been newly diagnosed with cancer (incidence) or who have died of cancer (mortality). The Registry is populated from four main data sources: hospital discharges and emergency care (DAD, NACRS), pathology reports, regional cancer centre records, and death certificates. All new cancer cases are registered, with the exception of non‐melanoma skin cancer.

2006 Census Data from the most recent Canadian census (May, 2006) was provided by Statistics Canada. The census takes place every five years in Canada and is a reliable source of information for population and dwelling counts as well as demographic and other socio‐economic characteristics.

Integrated Public Health Information System (iPHIS) Communicable disease data was extracted from the Integrated Public Health Information System (iPHIS). Managed by the Ministry of Health and Long Term Care, iPHIS is the information system used for reporting case information for all provincially and nationally reportable communicable diseases. This database is used in Ontario public health units for communicable disease case and contact follow‐up as well as outbreak management.

Immunization Records Information System (IRIS) Data regarding child immunization was extracted from the Immunization Records Information System (IRIS). This database was developed by the Ministry of Health and Long term Care and is used across Ontario public health units to maintain vaccination records and exemptions for all students and children attending schools and licensed day cares in the health unit’s jurisdiction.

Integrated Services for Children information System (ISCIS) Some infant, maternal and family health indicators required data from the Integrated Services for Children information System (ISCIS). This database contains family circumstances, screening and assessment details, and data on any referrals or services provided by Healthy Babies Health Children Program (HBHC) in Ontario Health Units.

Other Sources ‐ Internal databases maintained at the Elgin St. Thomas Public Health Unit provided data on: • West Nile Virus surveillance; • Rabies investigations; • Beach water testing; • Food premise inspections and food handling certification; • Prenatal class attendance • Staff and resident vaccination at institutions ‐ The Ministry of Transportation of Ontario (MTO) provided data on motor‐vehicle collisions. ‐ Information on air quality (poor air quality and smog advisories) was obtained through the Ontario Ministry of the Environment.

Analysis and Interpretation

The following section explains some of the important epidemiological and statistical concepts related to the analysis and interpretation of the indicators presented in this report.

Rates A rate is a measure of the frequency that an event occurs in a defined population over a specified time period. Rates are calculated by dividing the number of events by the number of people in the population, and are usually multiplied by a larger number to arrive at a rate per unit of population (for example, per 1,000 or per 100,000 population.) Using rates instead of counts establishes a common denominator allowing comparison of indicators across subgroups within the same population, as well as between populations. Where possible, comparisons have been made to the province as well as between sexes, across age groups, and over time.

Incidence versus Prevalence It is important to understand the different types of rates that can be used as indicators of health status. Incidence is a type of rate that refers to the number of new cases of a disease or condition in a specified time period. Prevalence rates, on the other hand, measure the total number of cases of a disease/condition that exist at a certain period or point in time. For example, this report presents cancer incidence rates, which measure the number of newly diagnosed cancer cases in the time period specified. On the other hand, diabetes is measured using prevalence rates, which considers the total number of individuals who report ever having been diagnosed with diabetes (not just the newly diagnosed).

Crude versus AgeSpecific versus AgeStandardized In order to fully understand health outcomes in a population, it is important to examine crude rates, age‐specific rates and age‐standardized rates or ratios. Crude rates reflect the actual or true experience of a population with regard to the health indicator of interest. They are simply the total number of events divided by the total number of people in the population. Crude rates however, cannot be directly compared across populations or time, because they ignore the age and sex composition of the populations under comparison. For example, if population A has a greater proportion of elderly people than population B and elderly people are more likely to be hospitalized for falls than younger people, simply comparing the crude rate of falls in population A to B would surely show that A had a higher rate.

An age‐specific rate is calculated the same way as a crude rate, but specifically for each age group (i.e. number of events in age group / number of people in age group). Age‐specific rates are the best description of the health experience of a population and can be directly compared across populations or time.

The presentation and comparison of many age‐specific rates can become unmanageable, and often a single summary estimate is preferred – in these circumstances, a technique called age‐standardization is used to statistically adjust for differences in age structure between populations or within the same 6

population over time. In the example above, directly adjusting for the difference in age distribution, or age standardizing, imposes the same age structure on both populations A and B, allowing one to compare the rates of falls between the populations. Since the age distribution of St. Thomas and Elgin County and Ontario are different, a standard population (the 1991 Canadian population) is used to calculate age‐standardized rates in this report. Therefore, although age‐standardized rates are a fictitious description of the experience of a population, they allow accurate comparisons across populations and time.

Indirect standardization, resulting in standardized ratios, is another technique to facilitate comparisons between populations, and is helpful when rates of disease/death in each individual age/sex category are unstable due to low numbers. The standardized mortality/hospitalization ratio (SMR) is the ratio of the number of events in the St. Thomas and Elgin County population to the number expected if the population had the same age and sex specific event rates as the Ontario population. An SMR of 1 indicates that there is no difference in rates between St. Thomas and Elgin County and the province, given the same age/sex structure in both. An SMR that is higher than 1 indicates a higher rate and an SMR less than 1 indicates a lower rate, in St. Thomas and Elgin County compared to Ontario. SMRs are presented with confidence intervals – when the confidence interval does not cross 1, the rate for Elgin St. Thomas is interpreted as statistically significantly higher, or lower, than the provincial rate.

Small Counts The stability of a rate is dependent on the number of events that contribute to that rate. Therefore, rates in small populations are often unstable due to the relatively small number of events that occur each year. When comparing trends over time between St. Thomas and Elgin County and the province, we often see a larger fluctuation in rates locally than for Ontario, in which the trends are fairly smooth from year to year – this concept needs to be considered when interpreting the time trends in this report. Furthermore, the following strategies were implemented in order to present the most stable, reliable rates at the local level: • Rates based on counts less than 5 have been suppressed; • Directly age‐standardized rates have only been derived where there were 20 or more events across all age groups; • For most age‐specific rates, and rates of rare outcomes, multiple years of data have been collapsed to present an average annual rate.

Survey Data: Confidence Intervals, Statistical Significance & Coefficients of Variation When using survey data (for example, the CCHS) it is important to understand that a sample has been selected to represent the larger population of interest. Since estimates vary depending on the sample, confidence intervals (CIs) are calculated and presented with the estimate, as an indication of the reliability of the sample estimate. A 95% confidence interval is interpreted as a range in which we can be sure (or 95% confident) the true population value lies. Wide confidence intervals suggest less reliable estimates than narrow confidence intervals. Confidence intervals can also be used as tests of statistical significance – if the CIs for the estimates under comparison overlap, we can say the difference between

the estimates is not statistically significant. Confidence intervals (95%) have been calculated for all survey estimates derived from the CCHS.

Finally, estimates from survey data are subject to sampling error, which needs to be measured in order to assess the quality of the estimate. The coefficient of variation (CV) is the measure used to indicate the sampling variability associated with survey estimates. The CV is obtained by dividing the standard deviation of the estimate by the estimate itself and it is expressed as a percentage of the estimate. Statistics Canada has guidelines around the release of survey estimates, based on the magnitude of the CV: • A CV between 0 and 16.5% is considered acceptable and the estimate can be released without restriction; • Estimates with a CV between 16.6 and 33.3% can be released, but with a cautionary note regarding high sampling variability; • Estimates with a CV greater than 33.3% should be suppressed due to extreme sampling variability • Estimate release guidelines at least 10 observations For this report, all CCHS survey estimates, 95% CIs and associated CV’s have been calculated using the “bootstrap method”.

Chapter 1: Demographics

Overview St. Thomas and Elgin County are located in Southwestern Ontario on the shore of Lake Erie. In 2010 the population of St. Thomas and Elgin County is approximately 91,800. While the population growth rate in the past has been lower than the overall provincial rate, it was projected that between 2006 and 2016, St. Thomas and Elgin County’s population growth rate will be similar to that of Ontario.

In 2006, St. Thomas and Elgin County had a higher proportion of younger (age 19 and younger) and older (aged 55 and older) residents compared to Ontario as a whole. As a result, fewer people were of working age and able to take part in the labour force and there were higher child and elderly dependency ratios compared to Ontario.

In 2006, the greatest number of immigrants residing in St. Thomas and Elgin County lived in St. Thomas. The proportion of immigrants on the whole, however, was much lower relative to Ontario. Three‐quarters of the immigrants living in St. Thomas and Elgin County in 2006 had been there for at least 15 years and very few people said they spoke a language other than English at home. The proportion of visible minorities living in St. Thomas and Elgin County was nearly 10 times smaller than that of Ontario.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: i) Socio‐demographics including population counts by age, sex … immigration, culture

Demographics Introduction

This chapter uses demographics to provide a snapshot of the composition of a population. Using characteristics such as age, sex, immigration, language and visible minority status, a picture of who lives in St. Thomas and Elgin County emerges. The data is presented in two basic formats; numbers and proportions. Proportions are important in the comparison of areas of different population size. They are used to assess the similarity between groups. Numbers must also be considered to understand the magnitude of an issue.

Geography Figure 1.1: Map of Southwestern Ontario with St. Thomas and Elgin County

Key Findings: • St. Thomas and Elgin County is located in Southwestern Ontario on the shore of Lake Erie and had a population of 85,351 in 2006. • The population of Elgin County in 2010 is 91,819 (using projections generated from the 2006 Census). • It is bordered by the Municipality of Chatham‐Kent, Middlesex County, Norfolk County and Oxford County. • There is only one city, St. Thomas, which had a population of 36,110 in 2006. • In Elgin County there are seven municipalities including West Elgin, Dutton/Dunwich, Southwold, Central Elgin, Aylmer, Malahide and Bayham.

Population

Figure 1.2: Proportion of population by five year age groups, St. Thomas and Elgin County and Ontario, 2006

STE Female ON Female STE Male ON Male

85 and over 80 to 84 75 to 79 70 to 74 65 to 69 60 to 64 55 to 59 50 to 54 45 to 49 Group 40 to 44

Age 35 to 39 30 to 34 25 to 29 20 to 24 15 to 19 10 to 14 5 to 9 0 to 4

10 5 0 5 10 Percentage of the total population

Source: 2006 Census 100% Sample, Statistics Canada

Key Findings: • Compared to the Ontario population, St. Thomas and Elgin County had a greater proportion of children, teenagers (age 19 and younger) and older people (age 55 and older) in 2006. • Conversely, the proportion of adults between the ages of 20 and 55 in St. Thomas and Elgin County was smaller compared to Ontario. • This means a smaller proportion of the population was of working age and able to take part in the labour force.

Figure 1.3: Population growth, St. Thomas and Elgin County and Ontario, 1971 to 2016

STE ON

160,000 16,000,000

140,000 14,000,000

120,000 12,000,000 County

100,000 10,000,000 Ontario Elgin of 80,000 8,000,000 of

60,000 6,000,000 Population

Population 40,000 4,000,000

20,000 2,000,000

0 0 1971 1976 1981 1986 1991 1996 2001 2006 2011* 2016* Year

Data Source: 1971, 1976, 1981, 1986, 1991 Census 100% Sample (Coleman, 2000); 1996, 2001, and 2006 Census 100% Sample, Statistics Canada; 2011 and 2016 (Ministry of Finance, 2006)

Key Findings

• In 2006, the population of St. Thomas and Elgin County was 85,351. This was an increase of 4.6% from 2001. This growth rate was lower than the overall provincial rate of 6.6% over the same period. • The rate of population growth in St. Thomas and Elgin County in the past has been lower than that of the entire province. • However, the population growth rate of St. Thomas and Elgin County appears to be catching up to that of Ontario. The projected growth between 2006 and 2016 is nearly the same in Ontario (16.4%) as in St. Thomas and Elgin County (15.5%).

Figure 1.4: Dependency ratios, St. Thomas and Elgin County and Ontario, 2001 and 2006 Overall Ratio Child (0‐14) Aged (65 +) Dependency Ratio Dependency Ratio 2001 2006 2001 2006 2001 2006 St. Thomas and 0.54 0.51 0.33 0.30 0.21 0.21 Elgin County Ontario 0.48 0.47 0.29 0.27 0.19 0.20 Data Source: 2001 and 2006 Census 100% Sample, Statistics Canada

Key Findings: • The dependency ratio is calculated by adding the child dependency ratio (number of children under age 14 compared to the number aged 15 to 64) and the aged dependency ratio (number of people age 65 and older to the number between 15 and 64). The higher the dependency ratio, the greater numbers of people who may be dependent on others such as family, caregivers or government support. A dependency ratio of 0.5 means there is one child or senior for every two people between the ages of 15 and 64. • The dependency ratio for people in St. Thomas and Elgin County (0.51) was higher than Ontario (0.47) because of both high child and aged dependency ratios. • In 2006 the St. Thomas and Elgin County child dependency ratio was lower than in 2001 (0.33 vs. 0.30) however the aged dependency ratio stayed the same (0.21).

Immigration Figure 1.5: Number and proportion of immigrants, by municipality, St. Thomas and Elgin County and Ontario, 2006

Immigrants (Percent) Immigrants (Number)

30.0 12,000

25.0 10,000

20.0 8,000

15.0 6,000 Percent Number 10.0 4,000

5.0 2,000

0.0 0

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • Malahide had the largest proportion of immigrants in St. Thomas and Elgin County (21.8%), but the actual number of immigrants in Malahide (1,895) was low in comparison to St. Thomas. St. Thomas had the greatest number of immigrants in St. Thomas and Elgin County (3,670). • All municipalities had a lower proportion of immigrants compared to the Ontario average.

Figure 1.6: Proportion of total immigrants, by year of immigration, St. Thomas and Elgin County, 2006

2001 to 2006 12%

1991 to 2000 13%

Before 1991 75%

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • Three quarters (75%) of immigrants came to St. Thomas and Elgin County before 1991. • Only 12% of the immigrants in St. Thomas and Elgin County are considered recent; they arrived between 2001 and 2006.

Language Figure 1.7: Number and proportion of people who speak a non‐official language in the home, by municipality, St. Thomas and Elgin County, 2006

Non‐official language (Percent) Non‐official language (Number)

18.0 6,000 16.0 5,000 14.0

12.0 4,000 10.0 3,000 8.0 Percent Number 6.0 2,000 4.0 1,000 2.0

0.0 0

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Finding: • Bayham (15.3%), Malahide (14.8%) and Aylmer (11.7%) had the largest proportions of people who speak a non‐official language (language other than English or French) in the home.

Figure 1.8: Number and proportion of people with mother tongue not English, by municipality, St. Thomas and Elgin County, 2006

Other language (Percent) Other language(Number)

40.0 14,000

35.0 12,000 30.0 10,000 25.0 8,000 20.0 Percent 6,000 Number 15.0 4,000 10.0

5.0 2,000

0.0 0

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • Between 1986 and 2006 there was very little change in the proportion of people who spoke a language other than English at home in St. Thomas and Elgin County (4.9% vs. 6.4%) (data not shown). • Malahide had the largest proportion of people who speak a language other than English as their mother tongue (34.1%). The eastern part of the county had much larger proportions of people who have a mother tongue other than English compared to central and western Elgin County. • In 2006, the greatest numbers of people whose mother tongue was not English were in St. Thomas (2,890) and Malahide (2,965) (data not shown).

Visible Minorities Figure 1.9: Number and proportion of people who are a visible minority, by municipality, St. Thomas and Elgin County, 2006

Total visible minority population (Percent) Total visible minority population (Number)

25.0 2,500

20.0 2,000

15.0 1,500 Percent 10.0 1,000 Number

5.0 500

0.0 0

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • The proportion of visible minorities in St. Thomas and Elgin County in 2006 (2.4%) was nearly ten times lower than Ontario overall (22.8%). • St. Thomas had the largest number (1,310) and proportion (3.7%) of people who are visible minorities in St. Thomas and Elgin County.

References Coleman B.L. (2000). Elgin County Demographic Report: 1996. St. Thomas, Ontario, Elgin‐St. Thomas Health Unit.

Ministry of Finance. (2006). Population Projections by County from 2008 to 2036, based on 2006 Census. Intellihealth Database, Health Planning Branch, Ontario Ministry of Health and Longterm Care. Extracted January, 2009.

Statistics Canada. (2006). 2006 Community Profiles in 2006 Census of Canada. Retrieved January, 2009.http://www12.statcan.ca/census‐recensement/2006/dp‐pd/prof/92‐591/index.cfm?Lang=E

Statistics Canada. (2001). 2001 Community Profiles in 2001 Census of Canada. Retrieved January, 2009 http://www12.statcan.ca/english/Profil01/CP01/Index.cfm?Lang=E

Statistics Canada. (1996). 1996 Community Profiles in 1996 Census of Canada. Retrieved January, 2009 http://www12.statcan.ca/english/Profil/PlaceSearchForm1.cfm

Chapter 2: Social Determinants of Health

Overview The proportion of married people in St. Thomas and Elgin County has decreased over time. While single parent families comprised a lower proportion of all families in St. Thomas and Elgin County in 2006 compared to Ontario as a whole, the proportion of male single parents was actually higher than the Ontario average.

In 2006, St. Thomas and Elgin County had a greater proportion of people who had not completed high school than Ontario. A trade certificate or college education was the most common type of post secondary education completed in St. Thomas and Elgin County. Men were more likely than women to have an apprenticeship or trade diploma and women were more likely than men to have college or university education.

The unemployment rate in St. Thomas and Elgin County in 2009 was 13.0%, higher than the rate in Ontario by 4.0%. There was an increase in the unemployment in St. Thomas and Elgin County rate between 2008 and 2009 of just over 3% from 9.7% to 13.0%. It was 5.7% in 2007. This reflects recent changes in the economic climate in St. Thomas and Elgin County that occurred in 2009.

In 2005, median household income (after tax) was lower in St. Thomas and Elgin County ($49,711) than Ontario ($52,117). St. Thomas and Elgin County in 2005 had a much smaller proportion of the population considered low‐income, however, compared to Ontario. The proportion of children in St. Thomas and Elgin County in the low‐income category decreased substantially between 1995 and 2005.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

Social Determinants of Health Introduction

The social determinants of health are important factors that contribute to the health of individuals and populations. They include: income and social status; social support networks; education and literacy; employment/working conditions; social environments; physical environments; personal health practices and coping skills; healthy child development; biology and genetic endowment; health services; gender; and culture (PHAC, 2010). These factors have a substantial influence on health and act independently of the amount of money that is spent on the health care system (Health Canada, 1999). Furthermore, the social determinants of health are largely responsible for health inequities ‐ the disparities in health status seen both within and between countries (WHO, 2010).

An important thread of the social determinants of health is the socio‐economic environment, which can be defined as the “living and working conditions in both the economic and social realms” (Health Canada, 1999). Within the economic environment, income and its distribution largely influence health, while on the social side, education, employment, levels of social support, home and community violence, and civic engagement are key determinants of health (Health Canada, 1999). The socio‐ economic characteristics of a population are important to learn about local populations and because they can indicate potential health risk (CIHI, 2004).

Significant research from the Whitehall studies has revealed a strong association between socio‐ economic factors and health (Marmot, 1978, 1991). For a variety of outcomes, including mortality and morbidity from various chronic conditions such as heart and lung disease and their associated risk factors, a persistent social gradient has been established, whereby lower socioeconomic standing or social class is associated poorer health status.

Socio‐economic status (SES) is difficult to assess and there is no consensus as to how it is best measured (Health Canada, 1999). Several factors are considered key elements in the measurement of SES, most notably income, but also, employment, education, housing and various demographic factors, such as family composition, culture and ethnicity (MOHLTC, 2006). For the purposes of this report, this chapter will briefly examine several factors related to the social determinants of health, including family structure, education, employment, income and food security.

Family Structure and Households

Figure 2.1 Proportion of the population (age 15 yrs +), by marital status, St. Thomas and Elgin County, 2006

Widowed 6.7% Separated; but still legally married Divorced 4.0% 7.3% Never legally married (single) 27.5%

Legally married (and not separated) 54.5%

Data Source: 2006 Census 100% Sample, Statistics Canada

Key Findings: • In 2006 more than half the population of St. Thomas and Elgin County aged 15 and older was married (55%). • Eleven percent (11%) was separated or divorced.

Figure 2.2: Number and proportion of two parent and lone parent families, St. Thomas and Elgin County and Ontario, 2006 Two Parent Lone Parent Female Male Lone Families Families Lone Parent Parent Families Families

# % # % % % STE 21,255 86.1 3,420 13.9 77.9 22.1 ON 2,881,605 84.2 540,715 15.8 81.6 18.4 Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings:

• In 2006, St. Thomas and Elgin County had a lower proportion of lone parent families (13.9%) compared to Ontario (15.8%). • Nearly 78% of all lone families are headed by females. • A larger proportion of the lone parents in St. Thomas and Elgin County were males (22.1%) compared to the province (18.4%).

Figure 2.3: Proportion of the population (age 15 yrs +), by household type, St. Thomas and Elgin County, 2006

Other household types 12.8% Households containing a couple (married or common‐law) with children 32.0% One‐person households 23.0%

Households containing a couple (married or common‐law) without children 32.2%

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings:

• In 2006 there was nearly the same proportion of households with children (32.0%) as without children (32.2%) in St. Thomas and Elgin County. • Compared to Ontario, St. Thomas and Elgin County had more households with couples and fewer one‐person and other households (data not shown).

Education

Figure 2.4: Proportion of the population (age 15 yrs +), by highest educational attainment, St. Thomas and Elgin County, 2006 University certificate or diploma below the University bachelor level certificate; 2.3% diploma or degree 8.7% No High school certificate 29.8% College; CEGEP or other non‐university certificate or diploma 20.6%

Apprenticeship or trades certificate or diploma 10.0% High school certificate or equivalent 28.6%

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • In 2006 in St. Thomas and Elgin County, 29.8% of the population aged 15 and over had not completed high school. This was higher than the proportion in Ontario who had not completed high school. • Compared to the Ontario average, St. Thomas and Elgin County had a higher proportion of people with trade or college training and a lower proportion with a university degree or diploma.

Figure 2.5: Proportion of the population (age 15 yrs +), by highest educational attainment, by sex, St. Thomas and Elgin County, 2006 35.0%

30.0%

25.0%

20.0%

Percent 15.0%

10.0%

5.0%

0.0% College; University Apprentice‐ CEGEP or certificate or University No High High school ship or trades other non‐ diploma certificate; school certificate or certificate or university below the diploma or certificate equivalent diploma certificate or bachelor degree diploma level Male 31.7% 28.1% 13.1% 17.0% 1.8% 8.2% Female 27.9% 29.1% 7.1% 24.1% 2.7% 9.1% Level of Schooling

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • In St. Thomas and Elgin County, a greater proportion of men had high school as their highest educational attainment (31.7%) than women (27.9%). Men were also more likely to complete apprenticeships and trade certificates compared to women. • Conversely there were higher proportions of women than men with a college diploma and with a university degree as their highest level of education.

Employment and unpaid work

Figure 2.6: Unemployment rate in the population (age 15 yrs +), St. Thomas and Elgin County and Ontario, 2001 to 2009 14.0

12.0

10.0 (%)

Rate

8.0

6.0

Unemployment 4.0

2.0

0.0 2001 2002 2003 2004 2005 2006 2007 2008 2009 STE 5.1 6.2 6.4 6.8 8.1 7.3 5.7 9.7 13.0 ON 6.3 7.1 6.9 6.8 6.6 6.3 6.4 6.5 9.0

Year Data Source: Statistics Canada, Labour Force Survey, special tabulations

Key Findings: • The unemployment rate in St. Thomas and Elgin County in 2009 was 13.0%, higher than the rate in Ontario by 4.0%. • There was an increase in the unemployment in St. Thomas and Elgin County rate between 2008 and 2009 of just over 3% from 9.7% to 13.0%. It was 5.7% in 2007.

Figure 2.7: Participation rate and unemployment rate of population (age 15 yrs +), St. Thomas and Elgin County, 1996, 2001, 2006 Participation Rate Unemployment Rate 1996 2001 2006 1996 2001 2006 % STE 67.1 67.0 67.9 9.2 6.5 5.5 ON 66.3 67.3 67.1 9.1 6.1 6.4 Data Source: 1996, 2001, and 2006 Census 20% Sample, Statistics Canada

Key Findings: • The participation rate in St. Thomas and Elgin County has changed very little over time. The participation rate refers to the proportion of the non‐institutionalized population aged 15 years and over that is in the labour force. Whereas the unemployment rate is the proportion of the labour force that was not working (in the week before the Census). • Between 1971 and 2006 the proportion of women in the work force increased (43.1% vs. 61.1%); however the proportion of men in the work force remained constant (data not shown). • In 2006, 40.1% of people said that they did unpaid work caring for children and 19.7% said they did unpaid work caring for seniors. These proportions were both higher than the Ontario average (data not shown).

Figure 2.8: Proportion of the population (age 15 yrs +), by mode of transportation to work, St. Thomas and Elgin County, 2006

Public transit 0.6% Walked or bicycled 7.4%

Car; truck; van; as passenger 9.5%

Car; truck; van; as driver 82.5%

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Finding: • More than 80% of people in St. Thomas and Elgin County drove to work in 2006, rather than take an active form of transit or public transit.

Food Security

Key Findings (data not shown) (Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care): • The proportion of the population in St. Thomas and Elgin County considered food secure in 2007/8 was 90.5% (95%CI 87.7, 93.3). • This compares to 91.78% (95%CI 91.3, 92.3) in Ontario. • The cost of the Nutritious Food Basket to feed a reference family of four for one week, purchased in Elgin County in May 2009 was $170.60 (Elgin St. Thomas Public Health, 2009).

Income

Figure 2.9: Median income after tax, by household type, St. Thomas and Elgin County, 2005 80,000

70,000

60,000

50,000

40,000 Dollars 30,000

20,000

10,000

‐ Couple Couple All private One‐person Other households with households households households household types children without children STE 49,711 69,317 54,615 24,444 43,414 ON 52,117 74,095 58,755 26,473 46,194 Type of Household

Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • The 2005 median income after tax for all households in St. Thomas and Elgin County was $49,711 compared to $52,117 in Ontario. One‐person households had a median after tax income of $24,444, also lower than the provincial amount ($26,473). (data not shown) • In St. Thomas and Elgin County, households with children had the largest median income ($69,317) of all household types. • Couples without children had nearly $15,000 less in income than couples with children. • The median income of one‐person households was less than half of that of households with couples. This may indicate that people living on their own have lower incomes than the individuals within couple households.

Figure 2.10: Median income after tax for two parent and lone parent families, St. Thomas and Elgin County, 2005 Median Income After‐Tax ($) Two Parent Female Lone Male Lone Parent Families Parent Families Families

STE 60,771 33,011 43,460 ON 64,784 34,206 43,972 Data Source: 2006 Census 20% Sample, Statistics Canada

Key Findings: • After taxes, lone parent families generally had more than half the income of two parent families in 2005. • Male lone parents had a larger income than female lone parents.

DID YOU KNOW?

Average incomes of Canadians have risen over the years, but not for everyone.

Even though rates of low income have improved, Canadians in the lowest income category are still very poor relative to the rest of Canadians.

(CIHI, 2004)

Figure 2.11: Proportion of the population below the low income cut‐off (after tax), St. Thomas and Elgin County, 1995, 2000, 2005 18.0%

16.0%

14.0%

12.0%

10.0%

Percent 8.0%

6.0%

4.0%

2.0%

0.0% 1995 2000 2005 % in low income after tax ‐ All 10.4% 9.0% 6.2% persons % in low income after tax ‐ Persons 15.7% 12.7% 7.4% less than 18 years of age Year

Data Source: 1996, 2001, 2006 Census 20% Sample, Statistics Canada

Key Findings: • A person is considered below the low‐income cut DEFINITION: off if their family spends 20 percent more of their Low income cut‐offs (LICOs) are after tax income than the average family on food, shelter and clothing. Low income after tax cut‐offs income thresholds, determined by vary by size of family and area of residence. analyzing trends in family spending. • Between 1995 and 2005 the proportion of people in They are cutoffs below which families the low income category decreased substantially will devote a larger share of income from 10.4% to 6.2%. A decrease of 15.7% to 7.4% than the average family on the was seen for children in the low income category. necessities of food, shelter and • In 2005, St. Thomas and Elgin County had a much clothing. lower proportion of low income people (6.2%) compared to Ontario (11.1%) (data not shown). (Statistics Canada, 2009) • The urban areas of the county (Aylmer and St. Thomas) had the largest proportion of low income people (data not shown).

References Canadian Institute for Health Information (CIHI). (2004). Improving the Health of Canadians. Ottawa: Canadian Institute for Health Information. Retrieved August, 2010, from http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_39_E&cw_topic=39&cw_rel=AR_322_E

Coleman B.L. (2000). Elgin county demographic report: 1996. St.Thomas, Ontario, Elgin‐St. Thomas Health Unit.

Elgin St. Thomas Public Health. (2009). Nutritious food basket report: The cost of eating in St. Thomas and Elgin County. In Elgin St. Thomas Public Health. Retrieved August, 2010, from: http://www.elginhealth.on.ca/index.asp?ParentID=6&MenuID=61&Report=1

Health Canada. (1999). Toward a healthy future: Second report on the health of Canadians. Ottawa: Federal, Provincial and Territorial Advisory Committee on Population Health. Available from: http://www.phac‐aspc.gc.ca/ph‐sp/report‐rapport/toward/index‐eng.php

Marmot MG, Rose G, Shipley M, Hamilton PJ. (1978). Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health. 32(4):244‐9.

Marmot MG, Davey Smith G, Stansfield S, et al. (1991). Health inequalities among British civil servants: the Whitehall II study. The Lancet. 337(8754):1387‐93.

Ontario Ministry of Health and Long‐Term Care (MOHLTC). (2006). Socio‐Economic Indicators Atlas: Health System Intelligence Project (HSIP). Retrieved August, 2010, from: http://www.health.gov.on.ca/transformation/providers/information/im_resources.html#ses

Public Health Agency of Canada. (2010). What Determines Health. In Population Health Approach. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/ph‐sp/determinants/index‐eng.php

Statistics Canada. (2009). Low Income Cut‐offs for 2008 and Low Income Measures for 2007. Retrieved August, 2010 from http://www.statcan.gc.ca/pub/75f0002m/75f0002m2009002‐eng.pdf

Statistics Canada. (2006). 2006 Community Profiles. In 2006 Census of Canada. Retrieved January, 2009 http://www12.statcan.ca/census‐recensement/2006/dp‐pd/prof/92‐591/index.cfm?Lang=E

Statistics Canada. (2001). 2001 Community Profiles in 2001 Census of Canada. Retrieved January, 2009 http://www12.statcan.ca/english/Profil01/CP01/Index.cfm?Lang=E

Statistics Canada. (1996). 1996 Community Profiles in 1996 Census of Canada. Retrieved January, 2009 http://www12.statcan.ca/english/Profil/PlaceSearchForm1.cfm

World Health Organization (WHO). (2010). Social determinants of health. In World Health Organization Programmes and Projects. Retrieved August, 2010, from: http://www.who.int/social_determinants/en/

Chapter 3: Mortality

Overview The life expectancy and rate of premature death from many of the leading causes of diseases were found to be higher in St. Thomas and Elgin County compared to Ontario, due mostly to chronic diseases. A review of the top 10 causes of death indicated that age standardized death rates from these illnesses were higher than those of the province. Additionally St. Thomas and Elgin County experienced greater ‘Potential Years of Life Lost’ for many of the leading causes of death than the province. This indicates that there was greater premature mortality locally from the biggest provincial killer, ischaemic heart disease, and also other causes. Relative to the province, mortality rates for lung diseases such as cancer and COPD were higher. Diabetes was also ranked near the top.

The impact seen by chronic disease in St. Thomas and Elgin County is likely related to socio‐ economic factors and poor health behaviours such as higher than average smoking rates.

While injuries and infectious diseases were experienced by residents in St. Thomas and Elgin County they did not impact premature mortality in the way that chronic conditions did. For instance motor vehicle collisions were the 12th leading cause of death in males and the 21st leading cause of death in females.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: ii) Mortality, including death by cause;

Mortality Introduction Mortality is commonly used to measure the overall health of a population. Trends seen from different death‐related indicators paint a picture of the burden of premature death. Rates of leading causes of death indicate which diseases impact a community in the biggest way. Looking at the age and sex of people who die from each disease gives an idea of who is affected most by each cause of death.

This chapter examines mortality from all causes as well as the leading causes of death in St. Thomas and Elgin County. Indicators such as life expectancy, crude mortality rates, standardized mortality rates and ratios and potential years of life lost can be used to get a sense of the causes of death in the community and whether they happened prematurely, relative to other populations such as Ontario as a whole.

Life Expectancy

Key Findings: • In St. Thomas and Elgin County the life expectancy at birth for females was 80.9 years and for males it DEFINITION: was 75.9 years. This was calculated using the most recently available data (2003 – 2005 average). Life expectancy is an overall measure • These were both lower than the life expectancy of of mortality in a population that Ontarians in the same time period (for females it was 82.5 and for males it was 78.1 years). summarizes mortality across all age • At age 65, the life expectancy for females in St. groups. It is the average number of Thomas and Elgin County was 19.5 years and 15.9 years an individual is expected to live for males, both of which were lower than that of from a certain age, in most cases from Ontarians. birth. Life expectancy at birth can be • While women live longer than men in St. Thomas interpreted as the number of years a and Elgin County, people of both sexes die sooner baby born today would be expected to than the average Ontarian. The premature death happens both in youth and late in life. live if mortality rates stay the same • Higher life expectancy is associated with less throughout her life. premature mortality related to disease. (World Health Organization, 2010a)

All Cause Mortality Figure 3.1: Number of deaths and crude mortality rates for all causes, by sex, St. Thomas and Elgin County, 2000 to 2005 Deaths Crude Mortality Rate Year (#) (per 100,000) Male Female Total Male Female Total 2000 362 364 726 865 860 863 2001 321 345 666 762 810 786 2002 361 360 721 852 840 846 2003 406 389 795 952 903 927 2004 361 344 705 836 790 813 2005 364 393 757 835 896 866 Average 363 366 728 851 850 850 Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • Both the number and rate of deaths in males and DEFINITION: females have been consistent over time. • The annual number of deaths in men was similar to The crude death rate is the number of that in women. deaths divided by the number of • Total number of deaths ranged from 666 per year people in the population. This rate to 795 per year. depicts the "true" picture of death in a community although it is greatly influenced by the age structure of the population. An older population would likely have a higher crude death rate whereas a younger population may have a higher crude birth rate.

(APHEO, 2009)

Figure 3.2: Age‐specific mortality rates for all causes, by age group, St. Thomas and Elgin County, 2003 to 2005 average 100.0

90.0

80.0

70.0

60.0 1,000

50.0 per

40.0 Rate

30.0

20.0

10.0

0.0 0‐67‐19 20‐44 45‐64 65‐74 75+ Males 1.4 0.3 1.0 6.4 30.4 92.8 Females 0.9 0.1 0.9 4.0 17.4 74.1 Age Group

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • The younger age groups had lower mortality rates than older age groups. This is what would be expected given that in Canada the majority of deaths occur later in life. • There was slightly higher mortality in the 0‐6 age group compared to the 7‐19 age group because of higher rates of infant mortality in the first year of life compared to the rest of childhood.

Figure 3.3: Age‐standardized mortality rates for all causes, by sex, St. Thomas and Elgin County and Ontario, 1986 to 2005

STE Males STE Females ON Males ON Females

1000

900

800 100,000 700 per

Rate 600

500

400 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009 DEFINITION:

Key Findings: The numbers of deaths per 100,000 • Mortality rates in males in St. Thomas and population are influenced by the age Elgin County decreased over time between distribution of the population. Two 1986 and 2005. populations with the same age‐specific • Mortality in women in St. Thomas and Elgin mortality rates for a particular cause of death County went from being very similar to the will have different overall death rates if the province in the late 1980s to being higher age distributions of their populations are than the province in more recent years. different. Age‐standardized mortality rates • Compared to the province, mortality rates in adjust for differences in the age distribution both males and females in St. Thomas and of the population by applying the observed Elgin County were higher. age‐specific mortality rates for each • The downward trend over time was similar population to a standard population. for both St. Thomas and Elgin County and Ontario. (World Health Organization, 2010b) • The gap between the sexes has closed both locally and provincially in recent times. 42

Leading Causes of Death Figure 3.4: Number, proportion and ranking of leading causes of death, St. Thomas & Elgin County and Ontario, 2003 to 2005 average Average Annual Proportion Number of of total Ontario STE Rank Cause of Death Deaths deaths Rank 1 Ischaemic heart disease 143 19.0 1 2 Residual 85 11.3 2 3 Lung cancer 54 7.1 3 4 Cerebrovascular diseases 47 6.2 4 5 Chronic lower respiratory diseases 47 6.2 6 6 Diabetes 36 4.8 7 7 Dementia and Alzheimer Disease 29 3.9 5 8 Lymphoma and leukemia 25 3.4 9 9 Diseases of urinary system 24 3.2 12 10 Colorectal cancer 23 3.0 8 Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: DEFINITION: • The leading cause of death in St. Thomas and Elgin Causes of death are ranked in order to County was ischemic heart disease – the disease prioritize problems and define policies that causes heart attacks. Nearly 20% of all deaths and health programs. Becker, et al were due to this disease. This was also the leading derived a standard list to identify cause of death in the province. leading causes of death and allow for • Lung cancer, cerebrovascular diseases (stroke) and comparison between regions. The lung diseases such as COPD were within the top five leading causes of death are based on leading causes of death. These diseases with the International statistical ischemic heart disease were attributed to nearly classification of diseases and related 40% of all deaths in St. Thomas and Elgin County health problems tenth revision between 2003 and 2005. (ICD‐10).

(Becker, 2006)

NOTE: Residual category represents all ‘other’ conditions not included in the main leading causes of death categories and can be difficult to interpret.

Figure 3.5: Number, proportion and ranking of leading causes of death, by sex, St. Thomas & Elgin County, 2003 to 2005 average Female Average Annual Number of Proportion of STE Rank Cause of Death Deaths total deaths 1 Ischaemic heart disease 65 17.4 2 Residual 46 13.2 3 Cerebrovascular diseases 29 7.6 4 Lung cancer 24 6.3 5 Chronic lower respiratory diseases 21 5.6 6 Dementia and Alzheimer Disease 20 5.3 7 Diabetes 17 4.6 8 Breast cancer 14 3.7 9 Influenza and pneumonia 13 3.6 10 Diseases of urinary system 12 3.3

Male Average Annual Number of Proportion of STE Rank Cause of Death Deaths total deaths 1 Ischaemic heart disease 78 20.6 2 Residual 40 10.5 3 Lung cancer 30 8.0 4 Chronic lower respiratory diseases 26 6.8 5 Diabetes 19 5.0 6 Cerebrovascular diseases 18 4.9 7 Lymphoma and leukemia 16 4.2 8 Diseases of urinary system 12 3.1 9 Colorectal cancer 11 3.9 10 Prostate cancer 10 3.7 Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • More than 20% of all deaths in males and 17.4% of all deaths in women were due to ischaemic heart disease. • Cerebrovascular disease followed as the 2nd leading cause of death for women – 7.6% of deaths. It was the 6th leading cause of death in men accounting for 4.9% of total male deaths. • Lung cancer and lung disease were both major contributors to mortality in men and women. • Diabetes was ranked as the 7th and 5th leading cause of death in women and men respectively.

• Breast cancer in women and prostate cancer in men were leading causes but only contributed 3.9% and 3.7% respectively to overall mortality.

Figure 3.6: Proportion and ranking of leading causes of death, by sex, by age group, St. Thomas and Elgin County and Ontario, 2003 to 2005 average Age 0‐6 Female (N<=5) Male (N<=5) Rank Cause of Death Percent Cause of Death Percent 1 Too small to report Too small to report

Age 7‐19 Female (N<=5) Male (N<=5) Rank Cause of Death Percent Cause of Death Percent 1 Too small to report Too small to report

Age 20‐44 Female (N=13) Male (N=15) Rank Cause of Death Percent Cause of Death Percent 1 Too small to report Transport collisions 20 2 Residual 20 3 Intentional self harm 11 4 Too small to report

Age 45‐64 Female (N=44) Male (N=70) Rank Cause of Death Percent Cause of Death Percent 1 Lung cancer 19 Ischaemic heart disease 17 2 Residual 13 Residual 15 3 Ischaemic heart disease 12 Lung cancer 11 4 Breast cancer 9 Lymphoma and leukemia 7 5 Lymphoma and leukemia 5 Diabetes 6 6 Cerebrovascular diseases 5 Cerebrovascular diseases 4 7 Colorectal cancer 4 Cirrhosis and other liver diseases 3 8 Diabetes 4 Transport collisions 3 9 Too small to report 3 Chronic lower respiratory diseases 2 10 Too small to report 2

Age 65 ‐ 74 Female (N=55) Male (N=87) Rank Cause of Death Percent Cause of Death Percent 1 Lung cancer 15 Ischaemic heart disease 22 2 Residual 13 Lung cancer 12 3 Ischaemic heart disease 10 Chronic lower respiratory diseases 8 4 Diabetes 7 Residual 8 5 Chronic lower respiratory diseases 7 Diabetes 6 6 Colorectal cancer 5 Lymphoma and leukemia 6 7 Pancreatic cancer 4 Colorectal cancer 5 8 Dementia and Alzheimer Disease 4 Diseases of urinary system 4 9 Cerebrovascular diseases 4 Cirrhosis and other liver diseases 3 10 Cirrhosis and other liver diseases 3 Cerebrovascular diseases 2

Age 75 + Female (N=260) Male (N=197) Rank Cause of Death Percent Cause of Death Percent 1 Ischaemic heart disease 21 Ischaemic heart disease 23 2 Residual 13 Residual 9 3 Cerebrovascular diseases 9 Chronic lower respiratory diseases 9 4 Dementia and Alzheimer Disease 7 Cerebrovascular diseases 7 5 Chronic lower respiratory diseases 6 Lung cancer 6 6 Influenza and pneumonia 5 Diabetes 4 7 Diabetes 4 Prostate cancer 4 8 Diseases of urinary system 4 Dementia and Alzheimer Disease 4 9 Breast cancer 3 Diseases of urinary system 4 10 Colorectal cancer 3 Influenza and pneumonia 3 Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009 (N= average annual number of deaths)

Key Findings: • Age group‐specific leading causes of death can shed light on the most important causes of death for a certain age groups. • The overall impact on death in the whole population is driven by the causes of death in the older age groups. • Almost all categories of mortality under the age of 45 were too small to report – meaning that in the time frame from 2003 to 2005 less than five deaths were reported in each leading cause category. The average annual number of deaths in each age group is also quite small (see N= in brackets). • Circulatory and lung diseases were the overall leading causes of death because the age groups for which they are leading causes also have the greatest age‐specific mortality rates. 46

Standardized Mortality Ratios

INTERPRETATION NOTE:

DEFINITION: An SMR of 1 indicates that the standardized mortality rate for a The standardized mortality ratio specific disease in St. Thomas and (SMR) is the ratio of the number of Elgin County is the same as in deaths in Elgin St. Thomas population Ontario. An SMR that is higher than to the number expected if the 1 indicates higher mortality in St. population had the same age and sex Thomas and Elgin County. The black specific death rates as the Ontario line above and below the dot population. This is a useful tool when indicates the upper and lower rates of disease in each individual confidence interval (UCI, LCI). age/sex category are unstable due to When the confidence interval does low numbers. not cross 1, the difference between the rate for Elgin St. Thomas and (Bains, 2009) the provincial rate is statistically significant.

Figure 3.7: Standardized mortality ratios for leading causes of death in males, St. Thomas and Elgin County, 2003 to 2005 average 3.5

3.0

Ratio 2.5

2.0 Mortality 1.5

1.0 Standardized 0.5

0.0 Chronic Ischae‐ lower Cerebro‐ Lymph‐ Diseases Colo‐ Lung Prostate mic heart Residual respir‐ Diabetes vascular oma and of urinary rectal cancer cancer disease atory diseases leukemia system cancer diseases UCI 1.5 1.6 1.6 2.8 2.3 1.5 2.4 2.9 1.5 1.6 LCI 1.0 0.8 0.8 1.2 0.8 0.6 0.8 0.8 0.4 0.4 SMR 1.2 1.2 1.2 2.0 1.6 1.0 1.6 1.8 0.9 1.0 Leading Cause of Death

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • Compared to the province, all 10 leading causes were either higher or on par with the provincial mortality rates, except colorectal cancer which was 10% lower (SMR=0.9). • The mortality rate for chronic lung disease in men was two times higher in St. Thomas and Elgin County compared to Ontario. This result was statistically significant. • Ischaemic heart disease, lung cancer, diabetes, blood cancer and urinary diseases all had higher SMRs in St. Thomas and Elgin County compared to Ontario, although the difference was not statistically significant.

Figure 3.8: Standardized mortality ratios for leading causes of death in females, St. Thomas and Elgin County, 2003 to 2005 average 3.0

2.5 Ratio 2.0

Mortality 1.5

1.0

Standardized 0.5

0.0 Chronic Dementia Influenza Ischae‐ Cerebro‐ lower Diseases Lung & Alz‐ Breast and mic heart Residual vascular respir‐ Diabetes of urinary cancer heimer cancer pneu‐ disease diseases atory system Disease monia diseases UCI 1.4 1.7 1.4 1.7 2.4 1.3 2.2 1.5 2.3 2.5 LCI 0.9 0.9 0.7 0.7 1.0 0.5 0.8 0.5 0.7 0.7 SMR 1.2 1.3 1.1 1.2 1.7 0.9 1.5 1.0 1.5 1.6 Leading Cause of Death

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, intelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • Compared to the province, rates in 9 of the 10 leading causes of mortality were either higher or on par with the provincial mortality rates. This indicates that St. Thomas and Elgin County experienced more premature mortality in the 9 of the 10 leading causes of death compared the province. • The mortality rate for chronic lung disease in women was 70% higher in St. Thomas and Elgin County compared to Ontario. • Ischaemic heart disease, cerebrovascular disease, lung cancer, diabetes, influenza and pneumonia, and urinary diseases all had higher SMRs in St. Thomas and Elgin County compared to Ontario, although the difference was not statistically significant. • The SMR for dementia and Alzheimer’s disease was 10% lower in St. Thomas and Elgin County than the province, although the difference was not statistically significant.

Potential Years of Life Lost

INTERPRETATION NOTE:

The younger a person dies, the greater potential years of life lost. For instance, if a 73 year old person dies DEFINITION: of ischaemic heart disease this would count as 2 potential years of life lost in The Potential Years of Life Lost the heart disease category. Compared indicator describes premature to if a 12 year old dies in a motor mortality in the population. It is vehicle collision where there are 63 calculated by subtracting the age at potential years of life lost. This death from age 75. indicator more heavily weights conditions or situations where death (APHEO, 2006) occurs at younger ages. Large PYLL can result from situations or diseases where few people die at very young ages or can also result from many people dying slightly prematurely.

Figure 3.9: Potential Years of Life Lost for leading causes of death in males, St. Thomas and Elgin County, 2003 to 2005 average

STE Ontario

Ischaemic heart disease

Residual

Lung cancer

Chronic lower respiratory diseases death of Diabetes causes

Cerebrovascular diseases

Lymphoma and leukemia Leading Diseases of urinary system

Colon cancer

Prostate cancer

012345678 Rate per 1,000

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Figure 3.10: Potential Years of Life Lost for leading causes of death in females, St. Thomas and Elgin County, 2003 to 2005 average

STE Ontario

Ischaemic heart disease

Residual

Cerebrovascular diseases

Lung cancer Death of Chronic lower respiratory diseases Cause

Dementia and Alzheimer Disease

Diabetes Leading Breast cancer

Influenza and pneumonia

Diseases of urinary system

012345678 Rate per 1,000

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted September 10, 2009

Key Findings: • Ischaemic heart disease was the greatest cause of potential years of life lost both in St. Thomas and Elgin County and Ontario, for both men and women. • It should be noted that St. Thomas and Elgin County had more than one full year of PYLL than the province for this disease, indicating premature mortality in those with ischaemic heart disease compared to the province. • The residual category represents all ‘other’ conditions not included in the main leading causes of death categories and can be difficult to interpret. • Cancer of the lung was the 2nd highest cause of PYLL in men and the PYLL rate was higher in St. Thomas and Elgin County than Ontario. Cerebrovascular disease was the 2nd highest cause of PYLL in women and also experienced a higher rate of PYLL than in the province. • All other conditions, aside from colorectal cancer, breast cancer and prostate cancer experienced higher PYLL compared to the province. This indicates that there was a higher rate of these diseases in the population, or people died from these diseases at younger ages, or both.

References:

Association of Public Health Epidemiologists of Ontario (APHEO). (2009). All Cause Mortality in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/index.php?pid=89

Association of Public Health Epidemiologists of Ontario (APHEO). (2006). Calculating Potential Years of Life Lost (PYLL) in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/index.php?pid=190

Bains N. (2009). Standardization of Rates in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/resources/indicators/Standardization%20report_NamBains_FINALMarch16 .pdf.

Becker R, Silvi J, Ma Fat D, L'Hours J, Laurenti R. (2006). A method for deriving leading causes of death. WHO Bulletin, 84(4): 297‐303.

World Health Organization (WHO). (2010a). Life expectancy at birth (years) in WHO Statistical Information System (WHOSIS). Retrieved August, 2010, from http://www.who.int/whosis/indicators/lifeexpectancy/en/index.html

World Health Organization (WHO). (2010b). Age‐standardized mortality rates (per 100 000 population) by cause in WHO Statistical Information System (WHOSIS). Retrieved August, 2010, from http://www.who.int/whosis/indicators/mortagestandardized/en/index.html

Chapter 4: Morbidity

Overview The burden of illness in St. Thomas and Elgin County was significantly higher than that of the province. As seen in the standardized rates of hospitalization and diease‐specific Standardized Hospitalization Ratios (SHRs), residents of St. Thomas and Elgin County were hospitalized more often for most of the common illnesses. This indictes that all things considered equal, such as age and gender structure in the population, St. Thomas and Elgin County has a population with higher morbidity and was more likely to use the hospital than Ontario.

Circulatory diseases were both the leading cause of death and leading cause of morbidity in St. Thomas and Elgin County. Lung diseases were less prominent in the hospitalization estimates. This is not consistent with the high mortality burden of respiratory diseases but may be the result of the fact that respiratory conditions are less likely to be treated in hospital compared to other illnesses.

Higher rates of hopsitalizations for conditions such as cardiovascular disease and lung disease are consistent with higher rates of premature mortality indicating sicker people who die earlier of these chronic conditions. Review of health behaviours such as smoking rates and obesity rates indicates that poor health behaviours were prevelant and the chronic diseases associated with these behaviours were also prevalent.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: ii) Morbidity, including…incidence of injury as assessed by in‐patient hospitalizations and emergency department visits, and prevalence of chronic conditions;

Morbidity Introduction Morbidity is described as a departure from a state of physiological or psychological well‐being (Last, 2001). It can also be described as the incidence of ill health. Illness or morbidity can be challenging to measure directly so hospitalizations are often used as a proxy measure. They are a good measure because they comprehensively capture all diseases that people are suffering from in St. Thomas and Elgin County. Hospitalizations, however, represent illness only when it is severe enough for a hospital admission. In other words, it may represent the ‘tip of the iceberg’ for many conditions that do not normally require a hospital stay.

This chapter examines morbidity from all causes as well as the leading causes of illness in St. Thomas and Elgin County. Indicators such as crude morbidity rates, standardized morbidity rates and ratios and length of stay in hospital can be used to get a sense of the causes of illness in the community and whether they are happening at a greater rate, relative to other populations such as Ontario as a whole.

All Cause Hospitalizations Figure 4.1: Number of hospitalizations and crude hospitalization rates for all causes, by sex, St. Thomas and Elgin County and Ontario, 2003 to 2008 average Year Hospitalizations Crude Hospitalization Rate (#) (per 100,000) Male Female Total Male Female Total Ontario 2003 3,275 4,612 7,887 7,681 10,705 9,200 7,548 2004 3,176 4,528 7,704 7,358 10,400 8,886 7,641 2005 3,161 4,633 7,794 7,253 10,568 8,916 7,554 2006 3,174 4,528 7,702 7,186 10,177 8,687 7,391 2007 3,253 4,656 7,909 7,300 10,389 8,849 7,284 2008 3,182 4,459 7,641 7,080 9,880 8,483 7,186 Average 3,204 4,569 7,773 7,310 10,353 8,837 7,434 Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH DEFINITION: ONTARIO Extracted January 13, 2010 The crude hospitalization rate is the Key Findings: number of hospitalizations divided by • The crude number and rate of hospitalizations the number of people in the has remained stable from 2003 and 2008 but population. This rate depicts the was higher in St. Thomas and Elgin County "true" picture of hospitalization in a compared to the province. community although it is greatly • The rate of hospitalization in females is nearly influenced by the age structure of the 30% higher than that of males. This is often population. influenced by the high rate of hospitalization during pregnancy and childbirth. (APHEO, 2009)

Figure 4.2: Age‐specific hospitalization rates for all causes, by age group, St. Thomas and Elgin County, 2006 to 2008 average 450.0

400.0

350.0

300.0

250.0 1,000

per 200.0 Rate 150.0

100.0

50.0

0.0 0‐67‐19 20‐44 45‐64 65‐74 75+ Males 64.0 17.8 26.4 79.1 193.0 392.5 Females 44.7 24.1 112.4 79.1 169.3 300.6 Age Group

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2010

Key Findings: • Hospitalizations generally increased as age increases. • Higher rates of hospitalizations in the youngest age group are affected by higher rates of sickness in the first years of life. • The relatively high rate of hospitalizations in women aged 20‐44 is a reflection of the large number of hospitalizations associated with childbirth and pregnancy. • After age 45, hospitalizations reflect the pattern seen with increased rates of chronic disease later in life, similar to the trend in age specific mortality rates.

Figure 4.3: Age‐standardized hospitalization rates for all causes, by sex, St. Thomas and Elgin County and Ontario, 2002 to 2008

EST Males EST Females ON Males ON Females

12400

10400

8400 100,000 6400 per

Rate 4400

2400

400 2002 2003 2004 2005 2006 2007 2008 Year Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2010

Key Findings: • Age standardized hospitalizations declined in males and females in St. Thomas and Elgin County between 2002 and 2008 by 16%. • Age standardized hospitalizations were nearly 20% lower for females in the province compared St. Thomas and Elgin County and 10% lower for males in the province.

Leading Causes of Hospitalizations

Figure 4.4: Number, proportion and ranking of leading causes of hospitalization, St. Thomas and Elgin County and Ontario, 2006 to 2008 average

Number of Hospital Ontario STE Rank Cause of Hospitalization Separations Percent Rank 1 Diseases of the Circulatory System 1034 13 2 2 Pregnancy, childbirth & the puerperium 975 13 1 3 Diseases of the Digestive System 964 12 3 Injury, poisoning & certain other consequences of 4 external causes 707 9 4 5 Diseases of the Respiratory System 643 8 5 Factors influencing health status & contact with health 6 services 621 8 9 7 Neoplasms 552 7 6 8 Diseases of the Genitourinary System 545 7 10 Symptoms, signs & abnormal clinical & lab findings 9 (not classified elsewhere) 472 6 7 Diseases of the musculoskeletal system & connective 10 tissue 462 6 8 Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009

Key Findings: INTREPRETATION NOTE: • The number one leading cause of hospitalizations in St. Thomas and Elgin County was diseases of the Causes are based on the most circulatory system, amounting to 13% of all responsible diagnosis (diagnosis hospitalizations. This cause was ranked number two in associated with the longest duration the province behind pregnancy and childbirth. of treatment) during a given hospital nd • Pregnancy and Childbirth was the 2 leading cause of stay. Diagnoses are classified using hospitalization, also responsible for 13% of all the International statistical hospitalizations in St. Thomas and Elgin County. classification of diseases and related • Diseases of the digestive system, injury and poisoning health problems tenth revision rd th and diseases of the respiratory system ranked 3 , 4 (ICD‐10). th and 5 , respectively and together comprised 29% of all hospitalizations. (APHEO, 2009)

Figure 4.5: Number, proportion and ranking of leading causes of hospitalization, by sex, St. Thomas and Elgin County, 2006 to 2008 average Female Male Hospital Hospital STE Separa‐ Separa‐ Rank Cause of Hospitalization tions (#) % Cause of Hospitalization tions (#) % Pregnancy, childbirth & the Diseases of the 1 puerperium 975 21 Circulatory System 576 18 Diseases of the Digestive Diseases of the Digestive 2 System 522 11 System 442 14 Injury, poisoning & certain Diseases of the Circulatory other consequences of 3 System 458 10 external causes 337 11 Factors influencing health status & contact with health Diseases of the 4 services 390 9 Respiratory System 334 10 Diseases of the 5 Genitourinary System 371 8 Neoplasms 282 9 Injury, poisoning & certain Factors influencing health other consequences of status & contact with 6 external causes 370 8 health services 231 7 Symptoms, signs & abnormal clinical & lab Diseases of the Respiratory findings (not classified 7 System 309 7 elsewhere) 218 7 Diseases of the musculoskeletal system & 8 Neoplasms 270 6 connective tissue 202 6 Diseases of the musculoskeletal system & Diseases of the 9 connective tissue 259 6 Genitourinary System 174 5 Symptoms, signs & abnormal clinical & lab findings (not classified Endocrine, nutritional & 10 elsewhere) 254 6 metabolic diseases 102 3 Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009

Key Findings: • Pregnancy and childbirth was the leading cause of hospitalizations in all women, representing 21% of all female hospitalizations. • In males, the leading cause was circulatory diseases, followed by digestive system diseases. • Injury & poisoning, respiratory diseases and neoplasms made up the next three leading causes for men. • Diseases of genitourinary system and circulatory diseases were within the top 5 leading causes of hospitalizations for women. 60

Figure 4.6: Proportion and ranking of leading causes of hospitalization, by sex, by age group, St. Thomas and Elgin County and Ontario, 2006 to 2008 average Age 0‐6 Female (N=161) Male (N=242) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent 1 Diseases of the Respiratory System 27 Diseases of the Respiratory System 31 Certain conditions originating in the Certain conditions originating in the 2 perinatal period 15 perinatal period 10 Symptoms, signs & abnormal clinical & lab Symptoms, signs & abnormal clinical & lab 3 findings (not classified elsewhere) 10 findings (not classified elsewhere) 10 Injury, poisoning & certain other Injury, poisoning & certain other 4 consequences of external causes 8 consequences of external causes 9 5 Diseases of the Digestive System 8 Diseases of the Digestive System 7 Congenital malformations, deformation & 6 Certain infectious & parasitic diseases 7 chromosomal anomalies 7 Factors influencing health status & contact Factors influencing health status & contact 7 with health services 6 with health services 7 Congenital malformations, deformation & 8 chromosomal anomalies 5 Certain infectious & parasitic diseases 6 9 Disaeses of skin & subcutaneous tissue 3 Diseases of the Genitourinary System 3 10 Diseases of the Genitourinary System 3 Diseases of the Nervous System 2 Age 7‐19 Female (N=195) Male (N=147) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent Injury, poisoning & certain other 1 Pregnancy, childbirth & the puerperium 29 consequences of external causes 29 2 Diseases of the Digestive System 15 Diseases of the Digestive System 19 Injury, poisoning & certain other 3 consequences of external causes 13 Diseases of the Respiratory System 9 Factors influencing health status & contact Factors influencing health status & contact 4 with health services 9 with health services 8 Symptoms, signs & abnormal clinical & lab 5 Diseases of the Respiratory System 9 findings (not classified elsewhere) 6 Symptoms, signs & abnormal clinical & lab Diseases of the musculoskeletal system & 6 findings (not classified elsewhere) 6 connective tissue 5 Endocrine, nutritional & metabolic Endocrine, nutritional & metabolic 7 diseases 5 diseases 4 Congenital malformations, deformation & 8 Diseases of the Genitourinary System 5 chromosomal anomalies 4 Diseases of blood & blood‐forming organs Diseases of the musculoskeletal system & & certain disorders involving the Immune 9 connective tissue 3 Mechanism 3 10 Certain infectious & parasitic diseases 1 Diseases of the Nervous System 3

Age 20‐44 Female (N=1613) Male (N=400) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent Injury, poisoning & certain other 1 Pregnancy, childbirth & the puerperium 57 consequences of external causes 24 Factors influencing health status & 2 contact with health services 11 Diseases of the Digestive System 24 3 Diseases of the Genitourinary System 9 Diseases of the Respiratory System 8 Diseases of the musculoskeletal system 4 Diseases of the Digestive System 8 & connective tissue 7 Injury, poisoning & certain other 5 consequences of external causes 3 Diseases of the Circulatory System 6 Symptoms, signs & abnormal clinical & Symptoms, signs & abnormal clinical & 6 lab findings (not classified elsewhere) 2 lab findings (not classified elsewhere) 5 Factors influencing health status & 7 Diseases of the Respiratory System 2 contact with health services 5 8 Neoplasms 2 Neoplasms 4 Diseases of the musculoskeletal system Endocrine, nutritional & metabolic 9 & connective tissue 1 diseases 4 Endocrine, nutritional & metabolic 10 diseases 1 Disaeses of skin & subcutaneous tissue 3 Age 45‐64 Female (N=943) Male (N=948) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent 1 Diseases of the Digestive System 18 Diseases of the Circulatory System 21 2 Diseases of the Genitourinary System 12 Diseases of the Digestive System 15 3 Neoplasms 11 Neoplasms 11 Injury, poisoning & certain other 4 Diseases of the Circulatory System 10 consequences of external causes 9 Injury, poisoning & certain other Diseases of the musculoskeletal system 5 consequences of external causes 10 & connective tissue 8 Diseases of the musculoskeletal system Factors influencing health status & 6 & connective tissue 10 contact with health services 7 Symptoms, signs & abnormal clinical & 7 lab findings (not classified elsewhere) 7 Diseases of the Respiratory System 7 Symptoms, signs & abnormal clinical & 8 Diseases of the Respiratory System 7 lab findings (not classified elsewhere) 6 Factors influencing health status & 9 contact with health services 7 Diseases of the Genitourinary System 6 Endocrine, nutritional & metabolic Endocrine, nutritional & metabolic 10 diseases 3 diseases 3

Age 65 – 74 Female (N=567) Male (N=612) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent 1 Diseases of the Circulatory System 17 Diseases of the Circulatory System 22 2 Diseases of the Digestive System 14 Diseases of the Digestive System 13 Diseases of the musculoskeletal system & 3 connective tissue 12 Neoplasms 12 Diseases of the musculoskeletal system & 4 Neoplasms 10 connective tissue 9 5 Diseases of the Respiratory System 10 Diseases of the Respiratory System 8 Injury, poisoning & certain other Factors influencing health status & 6 consequences of external causes 8 contact with health services 8 Factors influencing health status & 7 contact with health services 8 Diseases of the Genitourinary System 7 Symptoms, signs & abnormal clinical & Symptoms, signs & abnormal clinical & 8 lab findings (not classified elsewhere) 6 lab findings (not classified elsewhere) 6 Injury, poisoning & certain other 9 Diseases of the Genitourinary System 6 consequences of external causes 6 Endocrine, nutritional & metabolic Endocrine, nutritional & metabolic 10 diseases 3 diseases 3 Age 75 + Female (N=1060) Male (N=844) EST Rank Cause of Hospitalization Percent Cause of Hospitalization Percent 1 Diseases of the Circulatory System 24 Diseases of the Circulatory System 25 Injury, poisoning & certain other 2 consequences of external causes 13 Diseases of the Respiratory System 12 3 Diseases of the Digestive System 10 Diseases of the Digestive System 10 4 Diseases of the Respiratory System 9 Neoplasms 9 Symptoms, signs & abnormal clinical & Factors influencing health status & 5 lab findings (not classified elsewhere) 8 contact with health services 8 Factors influencing health status & Symptoms, signs & abnormal clinical & 6 contact with health services 7 lab findings (not classified elsewhere) 8 7 Neoplasms 7 Diseases of the Genitourinary System 7 Diseases of the musculoskeletal system & Injury, poisoning & certain other 8 connective tissue 6 consequences of external causes 7 Diseases of the musculoskeletal system & 9 Diseases of the Genitourinary System 6 connective tissue 5 Endocrine, nutritional & metabolic Endocrine, nutritional & metabolic 10 diseases 3 diseases 3 Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009 63

Key Findings: • Respiratory diseases were the leading cause of INTERPRETATION NOTE: hospitalizations in boys and girls aged 0 to 6 years. • Pregnancy and childbirth was the leading cause for ‘Factors influencing health status & the female age groups 7 to 19 and 20 to 44. contact with health services’, ‘Contact Whereas injury, poisoning and other external with health services’ and ‘Symptoms, causes was the leading cause of hospitalizations for signs & abnormal clinical & lab males age 7 to 44. findings (not classified elsewhere)’ • From ages 45 to 64 women were most often categories represent generalized hospitalized for diseases of the digestive system hospitalization use or ‘other’ and men for diseases of the circulatory system. conditions not included in the main • After age 65 diseases of the circulatory system were leading causes. They can be difficult to the leading cause of hospitalizations for men and interpret. women.

Standardized Hospitalization Ratios Figure 4.7: Standardized hospitalization ratios for leading causes of hospitalization in males, St. Thomas and Elgin County, 2006 to 2008 average 2.0

1.8 Ratio 1.6

1.4

Hospitalization 1.2

1.0

Standardized 0.8

0.6 Contact Not Injury/ Resp‐ with Musculo‐ Genito‐ Circulatory Digestive Neoplasms classified Endocrine Poisoning iratory health skeletal urinary elsewhere services UCI 1.1 1.2 1.4 1.4 1.3 1.8 1.3 1.3 1.4 1.5 LCI 1.0 1.0 1.1 1.1 1.0 1.4 1.0 1.0 1.0 1.0 SMR 1.0 1.1 1.2 1.2 1.2 1.6 1.1 1.1 1.2 1.3 Leading Cause of Hospitalization

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009 DEFINITION: Key Findings: • All of the 10 leading causes of hospitalization in St. The standardized hospitalization ratio Thomas and Elgin County had higher SHRs than (SHR) is the ratio of the number of Ontario. This means that there was a greater hospitalizations in Elgin St. Thomas contribution to morbidity in St. Thomas and Elgin population to the number expected if County males than for Ontario males for these the population had the same age and conditions sex specific hospitalization rates as the • For diseases of the digestive system, respiratory Ontario population. This is a useful system, genitourinary system, neoplasms, injury & tool when rates of disease in each poisoning and endocrine and nutrition diseases, the individual age/sex category are standardized hospitalization ratios were higher in unstable due to low numbers. males in St. Thomas and Elgin County than for males in Ontario. (Bains, 2009) • In the cases of injury & poisoning and respiratory diseases the differences were statistically significant. 65

Figure 4.8: Standardized hospitalization ratios for leading causes of hospitalization in females, St. Thomas and Elgin County, 2006 to 2008 average 2.0

1.8 Ratio 1.6

1.4

Hospitalization 1.2

1.0

Standardized 0.8

0.6 Contact Not Pregnancy with Genito‐ Injury/ Respir‐ Musculo‐ Digestive Circulatory Neoplasms classifed /Childbirth health urinary Poisoning atory skeletal elsewhere services UCI 1.2 1.6 1.3 1.8 1.7 1.4 1.4 1.1 1.3 1.3 LCI 1.0 1.3 1.0 1.5 1.4 1.2 1.1 0.9 1.0 1.0 SMR 1.1 1.4 1.2 1.6 1.5 1.3 1.2 1.0 1.1 1.2 Leading Cause of Hospitalization

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH INTERPRETATION NOTE: ONTARIO Extracted January 13, 2009 An SHR of 1 indicates that the Key Findings: hospitalization rate for a specific • Nine of the 10 leading causes of hospitalization in disease in St. Thomas and Elgin St. Thomas and Elgin County had higher SHRs than County is the same as in Ontario, Ontario. This means that there was a greater given the same age/sex structure in contribution to morbidity in St. Thomas and Elgin both. An SHR that is higher than 1 County females than for Ontario females for these indicates higher hospitalization in St. conditions. Thomas and Elgin County. • Age standardized rates of diseases such as those The black line above and below the related to the digestive system and genitourinary dot indicates the confidence interval system are nearly 50% higher than the province. of the SHR. When the confidence • Diseases of the digestive system, genitourinary interval does not cross 1, the rate for system, injuries & poisonings and respiratory Elgin St. Thomas is interpreted to be system higher than the province. The differences statistically significantly higher, or were statistically significant. lower, than the provincial rate.

Length of Stay

Figure 4.9: Average length of stay of in‐patient hospitalization for leading causes of hospitalization in males, St. Thomas and Elgin County, 2006 to 2008 average

ON STE

Diseases of the Circulatory System

Diseases of the Digestive System

Injury, poisoning & certain other consequences of external causes Diseases of the Respiratory System

Neoplasms Hospitalization of Factors influencing health status & contact with health services Cause

Symptoms, signs & abnormal clinical & lab findings (not classified elsewhere) Diseases of the musculoskeletal system & Leading connective tissue Diseases of the Genitourinary System

Endocrine, nutritional & metabolic diseases

012345678 Days

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009

Figure 4.10: Average length of stay of in‐patient hospitalization for leading causes of hospitalization in females, St. Thomas and Elgin County, 2006 to 2008 average

ON STE

Pregnancy, childbirth & the puerperium

Diseases of the Digestive System

Diseases of the Circulatory System

Factors influencing health status & contact with health services Diseases of the Genitourinary System Hospitalization of Injury, poisoning & certain other consequences of external causes Cause

Diseases of the Respiratory System

Neoplasms Leading Diseases of the musculoskeletal system & connective tissue Symptoms, signs & abnormal clinical & lab findings (not classified elsewhere)

012345678 Days

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted January 13, 2009

Key Findings: INTERPRETATION NOTE: • The longest lengths of stay were for diseases of the circulatory, endocrine and respiratory systems It should also be noted that Length of as well as injuries and neoplasms. These diseases Stay may also reflect differences in represent those that may be most severe given the health care practices between Elgin St length of time needed to treat while hospitalized. Thomas and Ontario as a whole. • Average length of stay in hospital for the leading Length of stay is highly dependent on causes of hospitalizations in both men and women the number of available hospital beds were shorter in St. Thomas and Elgin County and is also affected by other factors compared to Ontario. not related to health status such as • These findings could be attributed to the fact the availability of home care services or severity of the illness wass slightly less in St. characteristics of physician or Thomas and Elgin County compared to Ontario, hospital. therefore needing less time in hospital to be treated.

References:

Association of Public Health Epidemiologists of Ontario (APHEO). (2009). All Cause Hospitalization in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/index.php?pid=93

Last JM, Spasoff RA, International Epidemiological Association. A dictionary of epidemiology. 4th ed ed. Oxford: Oxford University Press, 2001.

Chapter 5: Chronic Health Conditions

Overview Chronic diseases were the biggest contributor to illness and death in St. Thomas and Elgin County. Cardiovascular disease was responsible for most chronic disease hospitalizations followed closely by respiratory diseases. Although males suffered a greater burden from cardiovascular diseases, reductions over time in mortality and hospitalizations were more apparent for males than females. Death and hospitalization rates of respiratory diseases were consistently higher in St. Thomas and Elgin County for both sexes between 2003 and 2008 compared to the province. Local residents also experienced greater diabetes‐related hospitalization rates than the province.

Cancer rates (incidence and death), were comparable between St. Thomas and Elgin County and the province. Prostate cancer was the most commonly diagnosed cancer in men and breast cancer the most commonly diagnosed in women; however, the greatest number of cancer deaths for both sexes was attributed to lung cancer.

Males in St. Thomas and Elgin County appeared to have higher rates of self‐reported chronic illness compared to the province. Back problems, arthritis and high blood pressure were commonly reported chronic health problems.

Generally, cancer screening rates were slightly lower in St. Thomas and Elgin County compared to Ontario; however, the differences were not statistically significant. Colorectal screening appeared to be the least practiced in the County and the province.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

Chronic Health Conditions Introduction Chronic diseases are defined broadly by the US Centers for Disease Control and Prevention as "illnesses that are prolonged, do not resolve spontaneously and are rarely cured completely" (Haydon, 2006). In Canada, chronic diseases are the leading cause of premature mortality and a major contributor to morbidity (Ontario Ministry of Health Promotion, 2010). In fact, chronic diseases, such as cardiovascular disease (CVD), cancer, chronic respiratory diseases and diabetes represent approximately 60% of all deaths worldwide (WHO, 2010). The primary prevention efforts of public health address the major risk factors for chronic disease, including physical inactivity, poor diet, tobacco smoking, alcohol and substance misuse as well as more distal socio‐environmental factors – information on many of these risk factors is presented in the Lifestyle Behaviours chapter of this report.

Cardiovascular diseases, including heart disease and stroke, are responsible for a large portion of chronic disease‐related hospitalizations and deaths. It is estimated that at least 1.6 million Canadians either have heart disease or are living with the effects of stroke (PHAC, 2009b). A 2010 report from the Heart and Stroke Foundation warned a “perfect storm” for heart disease is looming given the dangerous combination of risk factors evident in the population. This report also highlighted the “changing face of heart disease” – a condition once mainly faced by older Caucasian males is now faced more broadly by young adults, baby boomers, aboriginal peoples, ethnic populations and women (Heart & Stroke Foundation, 2010).

In 2004, respiratory diseases, including influenza and pneumonia as well as chronic conditions like asthma and chronic obstructive pulmonary disease (COPD), were the third leading cause of hospitalization for both men and women in Canada (PHAC, 2007). Tobacco smoke and air quality remain the most important preventable risk factors for chronic respiratory diseases (PHAC, 2007).

Diabetes has grown to be a colossal public health concern with an estimate of 2 million Canadians (1 in 16) having diagnosed disease as of 2007 (PHAC, 2009a). While there are several forms of diabetes, Type II is the main target for preventive action, as risk can be greatly modified with healthy lifestyle choices. Although usually diagnosed after age 40, it is becoming more common to see Type II diabetes in younger adults and even children and adolescents (PHAC, 2009a). Unmanaged diabetes can lead to severe long‐ term complications including CVD, kidney failure, blindness, nerve damage, heart attack, and stroke.

Worldwide, cancer is responsible for at least 7 million deaths annually, and it is estimated that up to 40% of all cancer deaths can be prevented through healthy lifestyle practices (WHO, 2007). There continues to be an increase in number of people diagnosed and dying from cancer. Prostate cancer and breast cancer are the most commonly diagnosed cancers for men and women, respectively – lung cancer continues to be the leading cause of cancer death for both sexes (CCSSC, 2010).

To fully assess the burden of various chronic diseases in the population, this chapter will focus on the prevalence of self‐reported chronic health problems (as diagnosed by a health professional); morbidity and mortality for the major chronic conditions (as assessed by hospitalization and mortality rates); as well as cancer incidence and mortality rates and self‐reported cancer screening practices.

Prevalence of SelfReported Chronic Health Problems

Figure 5.1 Prevalence of at least one chronic health problem, by sex, by age group, St. Thomas & Elgin County, 2007/08 STE ON % (95% CI) % (95% CI) Age Under 65 61.8 (55.6, 68.0) 59.5 (58.6, 60.4) Group 65 and older 88.6 (82.1, 95.1) 88.7 (87.7, 89.8) Male 65.6 (57.1, 74.0) 60.6 (59.4, 61.7) Sex Female 67.1 (60.0, 74.1) 67.8 (66.8, 68.7) Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Figure 5.2: Prevalence of selected chronic health problems (age 12 yrs +), St. Thomas & Elgin County and Ontario, 2007/08 30.0%

25.0%

20.0%

15.0% Percent

10.0%

5.0%

0.0% High Back Heart Mood Asthma Arthritis Blood Migraines Diabetes Problems Disease disorder Pressure STE 6.9%* 21.7% 23.1% 17.9% 10.2% 5.6% 6.7% 10.7% ON 8.3% 16.7% 20.5% 16.6% 11.4% 5.0% 6.2% 7.2% Chronic Health Problem

Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability.

Figure 5.3 Prevalence of selected chronic health problems by sex (age 12 yrs +), St. Thomas & Elgin County, 2007/08 40

20 Percent 15

0 High Back Heart Mood Asthma Arthritis Blood Migraines Diabetes Problems Disease disorder Pressure Males N.R. 20.7 28.4 20.2 9.6* 6.2* 6.1* 9.6 * Females 9.7* 22.8 17.8 15.6 10.7* 5.0* 7.2* 11.8 * Chronic Health Problem

Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, DID YOU KNOW? Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high Prevalence of self‐reported variability. N.R.: Not reportable (estimate suppressed due to extreme chronic health problems variability). was estimated using the Canadian Community Heath Key Findings: Survey (CCHS). Since this • Nearly 90% of seniors (age 65+) in the province, and locally, survey relies on self‐report reported having at least one chronic condition as diagnosed of conditions that have by a health professional. been diagnosed by a health • Compared to Ontario, a higher proportion of males in St. professional, we can Thomas and Elgin County reported having at least one chronic assume that true condition; however, this difference was not statistically prevalence rates for these significant. conditions could actually be • Local rates for most chronic conditions were comparable with much higher. the province; however arthritis and mood disorders were more prevalent in St. Thomas and Elgin County – the difference for arthritis was statistically significant. 74

• The most prevalent self‐reported chronic condition in St. Thomas and Elgin County was back problems, followed by arthritis and high blood pressure. • Differences between sexes (although not statistically significant) were largest for back problems and high blood pressure, with males more likely to report these conditions.

Chronic Disease Morbidity & Mortality

Cardiovascular Disease Figure 5.4: Age‐standardized hospitalization rates for cardiovascular disease, by sex, St. Thomas & Elgin County and Ontario, 2003 to 2008 1600.0

1400.0

1200.0

1000.0 100,000 800.0 per

600.0 Rate

400.0

200.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 1487.1 1198.7 1155.7 1231.5 1120.5 1071.8 ON Males 1341.3 1313.5 1232.8 1151.8 1096.5 1064.6 STE Females 775.7 771.1 659.2 726.6 683.1 696.5 ON Females 749.0 732.9 695.6 655.4 612.2 596.6 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: DEFINITION: • There was an average of 1041 hospitalizations per year from 2003 to Cardiovascular disease (CVD) refers to all 2008 (data not shown). diseases of the circulatory system including • Male hospitalization rates largely the heart and blood vessels. The six types exceeded those of females in St. Thomas of CVD include ischemic heart disease, and Elgin County with a similar trend seen cerebrovascular disease, peripheral for the province as a whole. • Hospitalization rates have remained vascular disease, heart failure, rheumatic relatively stable for females and have heart disease, and congenital heart disease slightly declined for males in St. Thomas and Elgin County and Ontario. (PHAC 2008) 76

Figure 5.5: Age‐specific hospitalization rates for cardiovascular disease, by sex, St. Thomas & Elgin County, 2003 to 2008 average 12000.0

10000.0

8000.0 100,000 6000.0 per

Rate 4000.0

2000.0

0.0 <20 20‐44 45‐64 65‐74 75+ Males 40.0 187.8 1766.3 4793.4 9880.6 Females 21.5 103.3 824.0 3174.4 6693.5 Age Group

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • Hospitalization rates for cardiovascular disease increased markedly with age, with those aged 75 and older accounting for over 40% of all cardiovascular disease hospitalizations in the 2003 to 2008 time period. • Male hospitalization rates exceeded those of females in all age groups by at least 30%.

Figure 5.6: Age‐standardized mortality rates for cardiovascular disease, by sex, St. Thomas & Elgin County and Ontario, 2000 to 2005 350.0

300.0

250.0

200.0 100,000

per 150.0 Rate 100.0

50.0

0.0 2000 2001 2002 2003 2004 2005 STE Males 305.8 290.2 276.9 311.1 234.0 214.2 ON Males 277.4 256.7 243.2 241.8 223.9 212.3 STE Females 185.7 191.8 171.8 173.6 142.6 153.0 ON Females 171.0 162.1 156.0 147.7 138.7 136.8 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • An average of 248 deaths per year (data not shown) in St. Thomas and Elgin County was seen from 2000 to 2005 with mortality rates in males exceeding those in females. • The mortality gap between males and females in St. Thomas and Elgin County appears to have decreased, so too did that between St. Thomas and Elgin County and Ontario males.

Figure 5.7: Age‐specific mortality rates for cardiovascular disease, by sex, St. Thomas & Elgin County, 2000 to 2005 average 4000.0

3500.0

3000.0

2500.0 100,000 2000.0 per

Rate 1500.0

1000.0

500.0

0.0 20‐44 45‐64 65‐74 75+ Males 12.1 184.6 862.9 3523.3 Females 13.9 75.5 364.7 3086.7 Age Group

Source: Ontario Mortality Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • Mortality rates for cardiovascular disease increased dramatically with age, especially for the 75 and older age group. • The oldest age group experienced more than five times the crude number of deaths than those aged 65‐74. • The largest difference between males and females was for the 65 – 74 age group where the mortality rate for males was over twice that for females.

Ischemic Heart Disease Figure 5.8: Age‐standardized hospitalization rates for ischemic heart disease, by sex, St. Thomas & Elgin County and Ontario, 2003 to 2008 900.0

800.0

700.0

600.0

500.0 100,000

per

400.0

Rate 300.0

200.0

100.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 767.5 621.2 551.4 593.8 455.5 511.4 ON Males 668.7 648.2 589.8 536.4 499.2 479.1 STE Females 340.2 344.8 249.6 237.9 239.0 292.1 ON Females 288.0 276.3 252.1 228.7 206.6 198.7 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • An average of 466 hospitalizations was seen per year DEFINITION: in St. Thomas and Elgin County from 2003 to 2008, accounting for nearly half of all hospitalizations due Ischemic heart disease refers to to cardiovascular diseases (data not shown). conditions involving deficient • St. Thomas and Elgin County hospitalization rates circulation of blood to the heart were comparable to those of the province. muscle, such as angina pectoris and • The hospitalization rate for Ontario males remained myocardial infarction (heart attack). well over twice that of Ontario females from 2003 to 2008. (PHAC, 2008)

Figure 5.9: Age‐standardized mortality rates for ischemic heart disease, by sex, St. Thomas & Elgin County and Ontario, 2000 to 2005 250.0

200.0

150.0 100,000

per

100.0 Rate

50.0

0.0 2000 2001 2002 2003 2004 2005 STE Males 213.1 215.1 190.9 217.2 158.4 138.9 ON Males 171.5 158.9 150.2 150.4 137.9 130.1 STE Females 112.6 117.2 98.9 88.3 86.3 84.8 ON Females 90.6 85.6 81.5 76.7 71.0 70.1 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • On average, there were 157 deaths per year (data not shown) in St. Thomas and Elgin County which experienced slightly higher mortality rates compared to the province. • Mortality rates were relatively stable for females in St. Thomas and Elgin County and the province, with a greater reduction in mortality over time apparent for St. Thomas and Elgin County males.

Cerebrovascular Disease Figure 5.10: Age‐standardized hospitalization rates for cerebrovascular disease, by sex St. Thomas & Elgin County and Ontario, 2003 to 2008 200.0

180.0

160.0

140.0

120.0 100,000 100.0 per

80.0 Rate 60.0

40.0

20.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 184.4 111.6 142.9 172.7 168.0 143.7 ON Males 151.7 145.0 140.9 137.2 132.9 129.1 STE Females 104.8 121.4 121.4 137.7 94.1 89.1 ON Females 106.4 103.6 102.4 99.2 92.3 91.1 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • An average of 144 hospitalizations was seen per year in St. DEFINITION: Thomas and Elgin County from 2003 to 2008 (data not shown). • Hospitalization rates have fluctuated over time for St. Thomas Cerebrovascular disease and Elgin County males and females, but tended towards the refers to conditions same relative stability of the provincial rates over the time involving deficient period. circulation of blood within • Stroke, a more specific diagnosis within the category of the blood vessels of the cerebrovascular disease, accounted for approximately 90% of brain, such as stroke. total cerebrovascular disease hospitalizations during the 6 year period. (PHAC, 2008) • The gap between males and females for both hospitalization and mortality (data not shown) was far less evident than for cardiovascular disease.

• In terms of mortality, there were 266 deaths due to cerebrovascular disease (over 80% of which occurred in the 75+ age group) between 2000 and 2005 in St. Thomas and Elgin County (data not shown). • Between 2000 and 2005, more St. Thomas and Elgin County females than males died of cerebrovascular disease – the average age‐specific mortality rate for the 75+ age group was 690 versus 594 per 100,000 population in females and males, respectively, for this time period (data not shown).

Respiratory Disease Figure 5.11: Age‐standardized hospitalization rates for respiratory disease, by sex, St. Thomas & Elgin County and Ontario, 2003 to 2008 1200.0

1000.0

800.0 100,000 600.0 per

Rate 400.0

200.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 1003.3 907.9 906.4 797.5 715.7 724.4 ON Males 722.7 699.6 724.7 643.7 603.7 587.2 STE Females 847.4 773.3 830.2 623.9 602.6 560.8 ON Females 535.5 520.1 545.1 478.2 448.9 445.8 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

DEFINITION: Key Findings: • Crude number of hospitalizations for respiratory Diseases of the respiratory system refer disease ranged from 834 in 2003 to 615 in 2008 for to all respiratory conditions, mostly St. Thomas and Elgin County. chronic in nature – such as chronic • Hospitalization rates for respiratory disease in St. obstructive pulmonary disease (COPD) Thomas and Elgin County remained consistently and asthma – as well as some acute higher than provincial rates for both males and conditions, such as influenza and females; however, rates appeared to decline over pneumonia. Lung cancer is not included time for both sexes, provincially and locally. in this category.

(APHEO, 2009)

Figure 5.12: Age‐specific hospitalization rates for respiratory disease, by sex, St. Thomas & Elgin County, 2003 to 2008 average 5000.0

4500.0

4000.0

3500.0

3000.0 100,000 2500.0 per

2000.0 Rate

1500.0

1000.0

500.0

0.0 <20 20‐44 45‐64 65‐74 75+ Males 946.0 242.7 526.1 1889.8 4651.5 Females 696.9 257.7 593.2 1926.2 3102.8 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: • Hospitalization rates for respiratory disease for St. Thomas and Elgin County males were higher than females, most notably in the youngest (<20) and oldest (75+) age groups. These age groups also experienced the highest crude number of hospitalizations accounting for over half of all respiratory‐related hospitalizations between 2003 and 2008. • Just over 400 deaths were due to respiratory illness from 2000 to 2005, of which, over 70% were in the 75+ age group (data not shown). • Mortality rates due to respiratory illness were stable over time in the province and were comparatively lower than the rates experienced by St. Thomas and Elgin County; for 2005 the age‐standardized mortality rate was 72 versus 45 per 100,000 for St. Thomas and Elgin County and the province, respectively (data not shown).

Chronic Obstructive Pulmonary Disease (COPD) Figure 5.13: Age‐standardized hospitalization rates for chronic obstructive pulmonary disease (COPD), by sex, St. Thomas & Elgin County and Ontario, 2003 to 2008 300.0

250.0

200.0 100,000 150.0 per

Rate 100.0

50.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 263.2 243.7 241.8 224.7 203.8 235.4 ON Males 172.3 184.5 197.3 178.1 170.4 165.1 STE Females 223.2 244.9 268.6 182.1 192.4 197.3 ON Females 125.0 134.8 147.9 130.3 128.9 126.4 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: DEFINITION: • In St. Thomas and Elgin County, hospitalizations for COPD Chronic obstructive accounted for just over 30% of all hospitalizations due to pulmonary disease (COPD) is respiratory disease from 2003 to 2008. a category of respiratory • Hospitalization rates in St. Thomas and Elgin County were disease that includes chronic higher than those experienced by the province as a whole, bronchitis, emphysema and for both males and females. other unspecified chronic

• Overall, hospitalization rates remained relatively stable over airways obstruction. time. • There was a larger difference in hospitalization rates (APHEO, 2009) between sexes for Ontario (males having the higher rates) than for St. Thomas and Elgin County, where the rates between sexes were more comparable.

• On average, the age‐specific hospitalization rates DID YOU KNOW? for females slightly exceeded those of males in the 45 to 74 age groups between 2003 and 2008 COPD is a progressive disease that can (data not shown). greatly impact quality of life as activity • There were 235 deaths due to COPD between levels become very restricted in 2000 and 2005, of which, 70% were in the 75+ advanced stages. It is estimated that age group (data not shown). nearly 755,000 Canadians over the age • The age‐standardized mortality rate for COPD of 35 have been diagnosed with COPD. was higher in St. Thomas and Elgin County National prevalence estimates show compared to the province – for 2005, the rates higher rates of COPD among women were 42 versus 21 per 100,000 population for St. than men under age 75. Thomas and Elgin County and Ontario, respectively (data not shown). (PHAC, 2007)

Asthma Key Findings (data not shown): • From 2003 to 2008, a total of 374 hospitalizations were due to asthma – over 70% of these were in the under 20 age group (mostly in the <10 age group). • The age‐standardized hospitalization rate for asthma decreased in St. Thomas and Elgin County from 2003 to 2008 from 118 to 69 per 100,000 population, and rates were comparable between males and females. • Hospitalization rates for the province were lower than those experienced in St. Thomas and Elgin County with an age‐standardized rate of 49 per 100,000 in 2008. • On average, there were just over 100 deaths per year due to asthma in the province as a whole between 2000 and 2005.

DEFINITION: DID YOU KNOW?

Asthma is a common childhood and adult Estimates show that over 15% of respiratory disease characterized by cough, Canadian children age 4‐11 have ever shortness of breath, chest tightness and been diagnosed with asthma. And wheeze. Symptoms occur when exercise or while children and teens do an exposure (allergen, virus or other experience the highest asthma irritant) causes an inflammation of the prevalence and hospitalization rates, airway wall and an abnormal narrowing of the disease actually affects a larger the airways. number of adults – and the prevalence among this group is increasing. (PHAC, 2007) (PHAC, 2007)

Diabetes Figure 5.14: Age‐standardized hospitalization rates for diabetes, by sex, St. Thomas & Elgin County and Ontario, 2003 to 2008 180.0

160.0

140.0

120.0

100.0 100,000

per

80.0

Rate 60.0

40.0

20.0

0.0 2003 2004 2005 2006 2007 2008 STE Males 137.5 96.7 169.3 162.0 121.4 124.1 ON Males 100.8 103.7 106.3 111.5 111.3 105.2 STE Females 151.5 124.6 101.4 124.1 82.2 83.0 ON Females 72.5 76.4 73.9 76.2 75.5 73.3 Year

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

Key Findings: DEFINITION: • From 2003 to 2008, there was an average of 120 diabetes‐related hospitalizations per year in St. Thomas Diabetes is a condition that and Elgin County (data not shown). results from the body's inability • Generally, age‐standardized hospitalization rates for to produce a sufficient amount of males were higher than those of females in St. Thomas and/or properly use insulin – a and Elgin County and the province. protein the body requires to • Hospitalization rates for the province showed a stable convert sugar into energy. trend. (PHAC, 2009a)

Figure 5.15: Age‐specific hospitalization rates for diabetes, by sex, St. Thomas & Elgin County, 2003 to 2008 average 800.0

700.0

600.0

500.0 100,000 400.0 per

Rate 300.0

200.0

100.0

0.0 <20 20‐44 45‐64 65‐74 75+ Males 47.0 72.5 154.5 462.8 710.2 Females 55.9 73.1 163.6 313.3 307.9 Age Group

Source: Ontario Inpatient Discharges Data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted March 3, 2010

DID YOU KNOW? Key Findings:

• Age‐specific hospitalization rates for St. Thomas The national incidence of diabetes in and Elgin County increased with age, most 2007 was estimated to be 6.7 per dramatically for males. 1000 population, based on over • In the 75+ age group the rate in males was double 211,000 new diabetes diagnoses. the female rate for the 2003 to 2008 time period. Projections show that by 2012, there • 30% of all diabetes‐related hospitalizations during will be 2.8 million Canadians with 2003 to 2008 were in the 45‐64 age group. diagnosed disease (a 25% increase • There were 216 deaths due to diabetes in St. from 2007) and 28,000 Canadian Thomas and Elgin County from 2000 to 2005 children and adolescents with Type I (average of 37 per year) – nearly 60% were in the or II diabetes. 75+ age group (data not shown). • Age standardized mortality rates were relatively (PHAC, 2009a) similar between St. Thomas and Elgin County and the province (data not shown).

Cancer Incidence, Mortality, and Screening

Cancer Incidence and Mortality

All Cancers Figure 5.16: Number of cases of most commonly diagnosed cancers, by sex, St. Thomas & Elgin County, 2000 to 2005 combined Male Female # # Site Cases Site Cases All Sites 1326 All Sites 1212 Prostate Cancer 343 Breast Cancer 325 Lung Cancer 206 Colorectal Cancer 151 Colorectal Cancer 164 Lung Cancer 143 Bladder Cancer 71 Uterine Cancer 78 Non‐Hodgkin Lymphoma 70 Non‐Hodgkin Lymphoma 57 Melanoma of the Skin 62 Melanoma of the Skin 43 Leukemia 57 Thyroid Cancer 39 Oral Cancer 35 Pancreatic Cancer 36 Kidney Cancer 34 Ovarian Cancer 32 Pancreatic Cancer 25 Leukemia 32 Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • Looking at cancer diagnoses from 2000 to 2005, the most commonly diagnosed cancer type was prostate for St. DID YOU KNOW? Thomas and Elgin County males and breast for St. Thomas and Elgin County females. All cancers involve • Lung cancer and colorectal cancer resided in the top 3 for uncontrolled growth and both sexes. spread of abnormal cells in some part of the body Cancers are named according to the body part where the cancer originated.

(Health Canada, 2010)

Figure 5.17: Number of deaths of most commonly diagnosed cancers, by sex, St. Thomas & Elgin County, 2000 to 2005 combined Male Female Site # Deaths Site # Deaths All Malignant Cancers 631 All Malignant Cancers 572 Lung Cancer 172 Lung Cancer 124 Colorectal Cancer 70 Breast Cancer 90 Prostate Cancer 63 Colorectal Cancer 76 Non‐Hodgkin Lymphoma 37 Pancreatic Cancer 36 Pancreatic Cancer 30 Non‐Hodgkin Lymphoma 27 Leukemia 26 Ovarian Cancer 26 Esophageal Cancer 25 Uterine Cancer 17 Bladder Cancer 20 Myeloma 13 Kidney Cancer 19 Stomach Cancer 12 Melanoma of the Skin 18 Leukemia 12 Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • Lung cancer was the leading cause of cancer deaths for both sexes with a total of 296 deaths during 2000 to 2005 – proportionately, this represents about one quarter of all cancer deaths in St. Thomas and Elgin County. • Colorectal cancer was another leading cause of cancer death, ranked second for males and third for females, behind breast cancer.

INTERPRETATION NOTE:

Cancer incidence refers to the number of new cancer cases in a given population over a specific time period. Incidence differs from prevalence in that it does not capture the total number of persons currently living with the condition, if they were diagnosed prior to the time period of interest. The other chronic conditions discussed earlier in this chapter were assessed using hospitalization rates, which is essentially a proxy indicator for prevalence.

Figure 5.18: Age‐standardized incidence rates for all cancers, by sex, St. Thomas & Elgin County and Ontario, 1995 to 2005 600.0

500.0

400.0 100,000 300.0 per

Rate 200.0

100.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE Males 488.6 544.9 442.6 420.0 506.1 496.3 469.7 483.7 452.1 518.1 449.9 ON Males 452.8 460.6 468 464.2 470.8 478.7 487.1 467.2 462 466.8 470.4 STE Females 398.4 302.9 404.9 445.5 406.1 362.9 325.8 359.6 372.6 416.5 423.6 ON Females 346.7 345.2 351 361.1 364 362.1 360.8 369.8 361.4 366 369.9 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

DID YOU KNOW?

“Canada is one of the few nations in the world with a cancer registry system that allows cancer patterns to be monitored and compared across the entire population.”

(CCSSC, 2010)

Figure 5.19: Age‐standardized mortality rates for all cancers, by sex, St. Thomas & Elgin County and Ontario, 1995 to 2005 350.0

300.0

250.0

200.0 100,000

per 150.0 Rate 100.0

50.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE Males 299.0 242.9 174.1 206.5 250.1 240.5 210.7 228.4 256.2 223.2 227.4 ON Males 230.7 226.8 225.4 219.2 220 217.4 215.5 211.7 206.8 202.4 196.2 STE Females 163.1 173.2 158.6 165.1 204.8 172.3 154.9 169.4 155.7 155.5 169.0 ON Females 153.3 152.4 145.8 147.1 148 149.8 148.4 146.4 145 144.7 143 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • On average, there were 410 new (incident) cases of cancer and 195 cancer‐related deaths per year in St. Thomas and Elgin County, from 1995 to 2005 (data not shown). • Age‐standardized incidence and mortality rates for all cancers remained relatively stable for both sexes in the province, with male rates higher than those of females • St. Thomas and Elgin County rates were more variable but appear to have followed the same general trend as that of Ontario.

Lung Cancer Figure 5.20: Age‐standardized lung cancer incidence rates, St. Thomas & Elgin County and Ontario, 1995 to 2005 80.0

70.0

60.0

50.0 100,000 40.0 per

Rate 30.0

20.0

10.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 53.9 51.8 58.6 56.3 69.7 64.5 57.0 61.7 57.1 52.2 57.6 ON 55.8 56.7 54.9 56.3 55.4 55.5 55.2 53.2 51.7 52.1 53.5 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • An average of 56 new cases of lung cancer and 47 lung cancer deaths were seen per year in St. Thomas and Elgin County from 1995 to 2005. • Overall, lung cancer incidence rates remained relatively stable over time and St. Thomas and Elgin County rates were similar to those of the province. • Looking into provincial trends by sex, the age‐standardized incidence rate for males slightly decreased while the rate for females slightly increased over time – suggesting the gap between the sexes is getting smaller (data not shown). Males, however, still have higher incidence rates of lung cancer than females (for Ontario, age‐standardized rate of 64 versus 45 per 100,000 for males and females, respectively in 2005) (data not shown). • In 2005 the age‐standardized mortality rate for lung cancer was slightly higher in St. Thomas and Elgin County compared to the province at 53 versus 41 per 100,000 for St. Thomas and Elgin County and Ontario, respectively (data not shown).

• Age‐standardized mortality rates by sex for the province followed a similar trend as the incidence rates – in 2005, the age‐standardized rate was 53 vs. 33 per 100,000 for males and females, respectively (data not shown).

Female Breast Cancer Figure 5.21: Age‐standardized breast cancer incidence rates, females, St. Thomas & Elgin County and Ontario, 1995 to 2005 140.0

120.0

100.0

80.0 100,000

per 60.0 Rate

40.0

20.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 85.8 84.1 110.2 123.0 113.0 96.6 88.9 80.2 108.0 121.1 116.9 ON 100.5 100 104.6 104.6 106.7 102.5 102.3 105 99.3 100.1 101.3 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • The yearly number of new breast cancer cases in St. Thomas and Elgin County ranged from 40 to 67 with an average of 15 deaths per year from 1995 to 2005 (data not shown). • The age‐standardized incidence rate for St. Thomas and Elgin County fluctuated around the provincial rate, which remained relatively unchanged from 1995 to 2005. • According to provincial trends, the age‐standardized mortality rate for breast cancer went from 30.2 per 100,000 in 1995 to 23.5 per 100,000 in 2005.

Prostate Cancer Figure 5.22: Age‐standardized prostate cancer incidence rates, males, St. Thomas & Elgin County and Ontario, 1995 to 2005 160.0

140.0

120.0

100.0 100,000 80.0 per

Rate 60.0

40.0

20.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 130.2 139.2 127.9 99.9 150.6 111.0 126.8 126.3 102.0 148.1 124.8 ON 111.5 117.2 127.4 125.3 125.7 133 144.2 134 126.7 134.2 138.8 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • The yearly number of new prostate cancer cases in St. Thomas and Elgin County ranged from 41 to 71 and yearly deaths ranged from 7 to 23 between 1995 and 2005 (data not shown). • The age‐standardized incidence rate for St. Thomas and Elgin County fluctuated around the provincial rate, which generally increased over time from 1995 to 2005. • According to provincial trends, the age‐standardized mortality rate for prostate cancer went from 30.2 per 100,000 in 1995 to 20.6 per 100,000 in 2005 (data not shown).

Colorectal Cancer

Figure 5.23: Age‐standardized colorectal cancer incidence rates, St. Thomas & Elgin County and Ontario, 1995 to 2005 70.0

60.0

50.0

40.0 100,000

per 30.0 Rate

20.0

10.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 44.1 48.0 37.0 58.0 61.8 50.3 56.8 50.2 47.4 43.5 58.8 ON 49.5 49.3 48.5 51.4 51.8 52.6 52.3 50.9 49.1 50.1 49.5 Year

Data Source: Cancer Care Ontario (Ontario Cancer Registry), SEER*Stat Release [7] ‐ OCRIS [March, 2009]

Key Findings: • Yearly number of new colorectal cancer cases ranged from 36 to 65 with an average of 24 colorectal cancer deaths per year in St. Thomas and Elgin County from 1995 to 2005 (data not shown). • The age‐standardized incidence rate for St. Thomas and Elgin County fluctuated around the provincial rate, which remained relatively unchanged from 1995 to 2005. • Incidence and mortality rates were higher for males than for females in the province (data not shown). o Provincial age‐standardized incidence rates in 2005 were 60 and 41 per 100,000 for males and females, respectively (data not shown). o Provincial age‐standardized mortality rates in 2005 were 26 and 16 per 100,000 for males and females, respectively (data not shown). • Provincial mortality rates decreased slightly from 1995 to 2005 (data not shown).

Other Types of Cancer

Key Findings (data not shown): • In St. Thomas and Elgin County, there were 23 new cases of cervical cancer and 7 cervical cancer deaths between 2000 and 2005. • In St. Thomas and Elgin County, there were 56 new cases of oral cancer (35 in males and 21 in females) and 15 oral cancer deaths between 2000 and 2005. • In St. Thomas and Elgin County, there were 105 new cases of melanoma of the skin (62 in males and 43 in females) and 23 melanoma deaths between 2000 and 2005. The age‐standardized incidence rate in 2005 was higher for St. Thomas and Elgin County than the province (24 versus 14 per 100,000). • Looking to provincial trends, age standardized incidence rates for oral cancer remained relatively stable over time – in 2005 the rate was 9.5 per 100,000. For melanoma, the rate in 2005 was 14 per 100,000 and rates slightly increased over time. And for cervical cancer, the rate slightly decreased over time – in 2005 the rate was 7.5 per 100,000. • Age‐standardized annual death rates for oral and cervical cancer and melanoma of the skin were all under 5 per 100,000 according to provincial estimates.

Cancer Screening Figure 5.24: Prevalence of cancer screening (ever and according to recommended intervals) by type of cancer, St. Thomas & Elgin County and Ontario, 2007/08 STE ON Type of Cancer Indicator % (95% CI) % (95% CI)

Women (50‐69) who have EVER had a 85.3 (76.0, 94.6) 89.6 (88.3, 90.9) mammogram Breast Women (50‐69) who have had a screening mammogram in past 2 62.9 (51.8, 74.0) 63.8 (61.8, 65.8) years

Women (20‐69) who have EVER had a 94.1 (88.9, 99.4) 91.0 (90.2, 91.8) pap test2 Cervical Women (20‐69) who have had a pap 70.2 (62.6, 77.8) 76.7 (75.7, 77.8) test in past 3 years1

People (50‐74) who have EVER had a 37.7 (28.8, 46.6) 42.8 (41.4, 44.1) fecal occult blood test (FOBT) Colorectal People (50‐74) who have had a FOBT 19.7 (13.3, 26.1)* 23.8 (22.6, 24.9) in past 2 years Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share DID YOU KNOW? File, Knowledge Management and Reporting Branch, Ministry of Health and Ontario offers three cancer screening programs: Long‐Term Care 1) Ontario Breast Screening Program, 2) Ontario Data Notes: *Estimate should be Cervical Screening Program and 3) ColonCancerCheck interpreted with caution due to high (CCO, 2009b) 1 variability. Women who have received a hysterectomy have NOT been excluded. Cancer Care Ontario recommendations: Screening Mammogram (breast cancer) Key Findings: Every 2 years for women 50 and older (especially 50‐ • Estimates from 2007/08 show that 69) (CCO, 2010b) 63.8% of women 50‐69 in St. Thomas and Elgin County have had Pap Test (cervical cancer) a mammogram and 70% of Every year once sexually active, and if normal tests for women 20‐69 in St. Thomas and 3 years in a row, every 2‐3 years, for women up to age Elgin County have had a pap test 70 (CCO, 2009a) according to the intervals recommended by Cancer Care Fecal Occult Blood Test (FOBT) (colorectal cancer) Ontario. Every 2 years for men and women over the age of 50 • Nearly 20% of 50‐74 year olds had (CCO, 2010a) a FOBT in the previous 2 years at the time of the survey. • Screening estimates for St. Thomas and Elgin County were not statistically different from those of the province.

References:

Association of Public Health Epidemiologists of Ontario (APHEO). (2009). Chronic Disease Hospitalization in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/index.php?pid=100

Canadian Cancer Society’s Steering Committee (CCSSC). (2010). Canadian Cancer Statistics. Toronto: Canadian Cancer Society. Retrieved August, 2010, from: http://www.cancer.ca/Canada‐ wide/About%20cancer/Cancer%20statistics/Canadian%20Cancer%20Statistics.aspx?sc_lang=en

Cancer Care Ontario (CCO). (2009a). Cervical Cancer Screening ‐ Frequently Asked Questions. Retrieved August, 2010, from http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9550#cerv‐link3

Cancer Care Ontario (CCO). (2009b). Screening. Retrieved August, 2010, from: http://www.cancercare.on.ca/pcs/screening/

Cancer Care Ontario (CCO). (2010a). About Colorectal Cancer Screening. Retrieved August, 2010, from: http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9858

Cancer Care Ontario (CCO). (2010b). Mammograms. Retrieved August, 2010, from: http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9437

Haydon E, Roerecke M, Giesbrecht N, Rehm J, Kobus‐Matthews M. (2006). Chronic disease in Ontario and Canada: Determinants, Risk Factors and Prevention Priorities. Toronto: Ontario Chronic Disease Prevention Association. Retrieved August, 2010 from: http://www.ocdpa.on.ca/OCDPA/docs/CDP‐FullReport‐Mar06.pdf

Health Canada. (2010). Cancer. Retrieved August, 2010, from: http://www.hc‐sc.gc.ca/hc‐ps/dc‐ ma/cancer‐eng.php

Heart & Stroke Foundation. (2010). 2010 Heart and Stroke Foundation Annual Report on Canadians’ Health: A perfect storm of heart disease looming on our horizon. Retrieved August, 2010, from: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5761931/k.8118/2010_Report__A_Perfec t_Storm.htm

Ontario Ministry of Health Promotion. (2010). Healthy Eating, Physical Activity and Healthy Weights Guidance Document. Retrieved August, 2010, from: http://www.mhp.gov.on.ca/en/healthy‐ communities/public‐health/guidance‐documents.asp

Public Health Agency of Canada (PHAC). (2007). Life and Breath: Respiratory Disease in Canada. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/publicat/2007/lbrdc‐vsmrc/index‐ eng.php

Public Health Agency of Canada (PHAC). (2008). Six Types of cardiovascular Disease. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/cd‐mc/cvd‐mcv/cvd‐mcv‐eng.php 100

Public Health Agency of Canada (PHAC). (2009a). Report from the National Diabetes Surveillance System: Diabetes in Canada, 2009. Retrieved August, 2010, from: http://www.phac‐ aspc.gc.ca/publicat/2009/ndssdic‐snsddac‐09/index‐eng.php

Public Health Agency of Canada (PHAC). (2009b). Tracking Heart Disease and Stroke in Canada. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/publicat/2009/cvd‐avc/index‐eng.php

World Health organization (WHO). (2010). Chronic Diseases and Health Promotion. Retrieved August, 2010, from: http://www.who.int/chp/en/

World Health organization (WHO). (2007). The World Health Organization’s Fight Against Cancer: Strategies That Prevent, Cure and Care. Retrieved August, 2010, from: http://www.who.int/cancer/publicat/WHOCancerBrochure2007.FINALweb.pdf

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Chapter 6: Lifestyle Behaviours

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Overview Compared to the province there were higher rates of smoking, obesity and poor nutrition in St. Thomas and Elgin County which is in line with the higher rates of illness and death seen from chronic diseases such as cardiovascular disease and lung disease.

Smoking continued to be a major health issue in St. Thomas and Elgin County where the rate of smoking was significantly higher than that of the province. In addition, the proportion of current smokers appears to have increased between 2003 and 2008. While the change was not significant, the trend is troubling. With persistently high rates of smoking and exposure to second hand smoke it is not surprising that lung and cardiovascular diseases were the leading causes of illness and death in St. Thomas and Elgin County. Fortunately the rate of smoking initiation in teenagers went down over the timeframe but the most recent data still show higher rates than that of Ontario teens.

Overweight and obesity were more prevalent in men in St. Thomas and Elgin County compared to women, as were binge and high risk drinking behaviours. Compared to the province there was a greater proportion of overweight people but a lower proportion of obese people in St. Thomas and Elgin County. The trend towards a decreased proportion of teens of normal weight indicates that more teens were overweight and obese and that the proportion of overweight/obese teens increased disproportionately faster than in the province. In adults, drinking rates were more in line with provincial rates but still high. Rates of adolescent drinking, while somewhat unstable, indicate that binge drinking was higher in St. Thomas and Elgin County compared to Ontario.

The rate of people reporting active or moderately active lifestyles was similar to that of the province; however, examination of obesity rates indicated that physical activity may not be sufficient. Additionally, the proportion of people not getting enough fruits and vegetables in a day was significantly higher in St. Thomas and Elgin County than the province. On the positive side, work and life stress levels were lower than the provincial rates and the proportion of people that reported having a family doctor was higher as well. A considerate proportion of smokers in St. Thomas and Elgin County indicated they were seriously considering or trying to stop smoking.

Local data on exposure to ultraviolet radiation and related preventive behaviours in not available as is not included in this report.

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Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: vi) Risk factors including tobacco use…use of alcohol and other substances, work stress, vii) Preventive health practices including…physical activity, healthy eating, healthy weights…;

104

Lifestyle Behaviours Introduction The behaviours of individuals within the contexts that they live, work and play, have substantial impacts on both individual and population health. Public health has a mandate to address the major modifiable risk factors for chronic disease, including tobacco and alcohol use, physical inactivity, and unhealthy eating. The promotion of healthy behaviours is targeted to individuals, through skill‐building, education and awareness, and to communities, through capacity‐building, and the creation of healthy public policy and environments that support healthy lifestyles.

The achievement and maintenance of a healthy body weight is a high priority for reducing risk of chronic disease in the population. The health risks associated with overweight and obesity are well established and include heart disease, diabetes, high blood pressure, arthritis, several types of cancer and gallbladder disease (Ontario Ministry of Health Promotion, 2010b). The causes of overweight and obesity are complicated, and involve factors such as genetic composition as well as the individual choices made regarding eating and physical activity – choices which are heavily influenced by our social, cultural, physical and economic environments (CIHI, 2006).

Although there has been a trend towards reduced tobacco use in the province, it remains the leading public health problem in Ontario (Ontario Ministry of Health Promotion, 2010a). Tobacco contributes to premature death from cancer, cardiovascular disease and chronic respiratory disease, with the number of tobacco‐caused diseases continuing to increase. An analysis of the cost of substance abuse in Canada estimated the economic cost associated with tobacco use to be $17 billion in 2002, representing nearly half of the total cost of substance abuse that year (Rehm et al, 2006). Furthermore, second hand smoke, a known human carcinogen (cancer‐causing agent), contributes to disease and death in children and adults who do not smoke, and is also associated with sudden infant death syndrome (SIDS) and childhood respiratory conditions (U.S. Department of Health and Human Services, 2006).

Alcohol use has also been identified as a risk factor of public health importance due to the range of health and social consequences to which it contributes (WHO, 2006). Some evidence suggests that regular light drinking is protective against heart disease; however, the range of harmful effects associated with alcohol use is much more substantive, including increased risk‐taking behaviours, unintentional injuries, and violence; poor infant outcomes such as fetal alcohol syndrome (FAS); cancers, liver damage, heart disease and other chronic conditions; and mental health and neurological conditions. Furthermore, the economic cost associated with alcohol abuse was estimated to be $14.6 billion in 2002, lower than tobacco, but nearly 40% of the total cost of substance abuse (Rehm et al, 2006).

To examine some of the important lifestyle behaviours that contribute to overall population health, this chapter examines indicators related to healthy eating, healthy weights and physical activity as well as tobacco and alcohol use. Information around stress and health service use is also presented in this chapter to provide further context to the assessment of health‐related behaviors in St. Thomas and Elgin County.

105

Healthy Eating Figure 6.1: Recommended number of vegetable and fruit servings per day, by sex, by age group Daily Servings of Fruit Age Sex and Vegetables 2‐3 Both Sexes 4 4‐8 Both Sexes 5 9‐13 Both Sexes 6 Male 8 14‐18 Female 7 Male 8‐10 19‐50 Female 7‐8 Male 7 51+ Female 7 Source: Eating Well with Canada’s Food Guide. Health Canada (2007)

DID YOU KNOW?

Adequate consumption of fruit and vegetables is important for a healthy diet and could help prevent major chronic diseases.

It is estimated that as many as 2.7 million lives could be saved worldwide each year if fruit and vegetable consumption were sufficiently increased.

(WHO, 2010)

106

Figure 6.2: Proportion of people (age 12 yrs +) reporting number of daily fruit and vegetable servings, by sex, St. Thomas and Elgin County, 2003, 2005, 2007/8 90.0%

80.0%

70.0%

60.0%

50.0%

Percent 40.0%

30.0%

20.0%

10.0%

0.0% More than More than Less than 55 to 10 Less than 55 to 10 10 10 Males Females 2003 65.9% 32.2% 0.0%N.R. 48.8% 47.2% 4.0% 2005 69.4% 28.1% 0.0%N.R. 55.2% 43.1%N.R. 0.0% 2007/08 72.2% 22.2%N.R. 0.0% 49.2% 47.3%N.R. 0.0% # of Daily Servings of Fruit and Vegetables by Sex

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: N.R.: Not reportable (estimate suppressed due to extreme variability)

Key Findings: • The proportion of males who ate fewer than five fruits and vegetables a day increased between 2003 and 2007/8 from 65.9% (95%CI 56.8, 75.0) to 72.2% (95%CI 66.2, 78.2). This change was not seen in females. • In St. Thomas and Elgin County in 2007/8, the proportion of males who ate 5 to 10 vegetables a day was low at 22.2% (95%CI 16.1, 28.2) compared to the females 47.3% of females (95%CI 39.3, 55.3). This difference is statistically significant (data not shown). • There weren’t enough respondents who ate more than 10 fruits and vegetables day to generate an estimate. • Compared to the province, the proportion of males who ate 5 to 10 fruit and vegetable servings a day was significantly lower in St. Thomas and Elgin County (ON males 31.5% (95%CI 30.4, 32.6)) and significantly higher (ON females 42. 7 (95%CI 41.6, 43.8)) for females (data not shown).

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Healthy Weights Figure 6.3: Proportion of adults (age 18 yrs +) in each body mass index category, by sex, St. Thomas and Elgin County, 2003, 2005, 2007/8 70.0%

60.0%

50.0%

40.0%

Percent 30.0%

20.0%

10.0%

0.0% Normal Overweight Obese Normal Overweight Obese Males Females 2003 30.5% 49.5% 18.7% 48.9% 30.2% 19.1% * 2005 35.7% 39.4% 23.1% 52.5% 27.4% 13.1% * 2007/08 37.1% 46.9% 15.6%* 50.0% 25.9% 22.2% Sex and BMI Category

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability

Key Findings: DEFINITION: • No statistically significant changes in the proportion of overweight and obese population The Body Mass Index (BMI) is a ratio of 2 were seen between 2003 and 2008. weight to height (kg/m ) and is • The provincial rates showed a higher rate of considered the most useful indicator of overweight women and a lower rate of obese population health risk associated with women with similar rate of women at a normal both overweight and underweight. weight (data not shown). • In men the provincial rate of obesity was higher Normal weight – BMI 18.5‐24.9 than in St. Thomas and Elgin County but the rate Overweight – BMI 25.0‐29.9 of overweight was higher in St. Thomas and Elgin Obese – 30.0 and above County than Ontario (data not shown). (Health Canada, 2003) 108

Figure 6.4: Proportion of adolescents (age 12 to 17 yrs) of normal weight, by sex, St. Thomas and Elgin County, 2005, 2007/8 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% EST ON EST ON Males Females 2005 79.0% 76.1% 92.4% 85.1% 2007/08 59.7% * 74.7% 79.8% 85.1% Sex and BMI Category

Data Source: Canadian Community Health Survey 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability

Key Findings: • The proportion of adolescents at a normal weight went down between 2005 and 2007/8, although this difference was not statistically significant. • In 2005, a greater proportion of teens in St. Thomas and Elgin County were at a normal weight compared to the province, the opposite was true in 2007/8. • There was a higher proportion of girls 79.8% (95%CI 61.2, 98.3) than boys 59.7% (95%CI 33.3, 86.0) at a normal weight in St. Thomas and Elgin County in 2007/8.

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Comprehensive Tobacco Control Figure 6.5: Proportion of adults (age 20 yrs +) who were current, former and never smokers, St. Thomas and Elgin County and Ontario, 2003, 2005, 2007/8 60.0%

50.0%

40.0%

30.0% Percent

20.0%

10.0%

0.0% 2003 2005 2007/08 2007/08 EST ON Current 25.0% 29.2% 28.5% 21.9% Former 47.2% 42.8% 40.7% 38.5% Never 27.8% 27.9% 30.8% 39.6% Year and Geography

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings: • The proportion of current smokers in St. Thomas and Elgin County in 2007/8 was 28.5% (95%CI 23.4, DID YOU KNOW? 33.5) compared to 21.9% (95%CI 21.2, 22.6) in Ontario. The difference between the two rates was An estimated total of 37,209 statistically significant. Canadians died from tobacco use in • The proportion of former smokers in St. Thomas 2002, accounting for 16.6% of all and Elgin County went down between 2003 and deaths in Canada that year. 2007/8, partly because the proportion of never smokers increased but also because the proportion (Rehm et al, 2006) of current smokers went up.

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Figure 6.6: Proportion of adolescent (age 12‐ 19 yrs) never smokers, St. Thomas and Elgin County and Ontario, 2003, 2005, 2007/8 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% 2003 2005 2007/08 EST 68.1% 69.1% 73.3% ON 73.9% 78.8% 80.8% Year

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings • The proportion of adolescents in St. Thomas and Elgin County who have never smoked went up from 68.1% (95%CI 53.1, 83.1) to 73.3% (95%CI 58.3, 88.4) between 2003 and 2007/8. This change was not statistically significant. • The proportion of Ontario adolescents aged 12 to 19 who have never smoked was 10% higher than that of St. Thomas and Elgin County.

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Key Findings in Second Hand Smoke Exposure (data not shown): • The proportion of people in St. Thomas and Elgin County who indicated that someone smokes inside their home, every day or almost every day was 22.7 % (95%CI 18.1, 27.6) in 2003 compared to 16.4% (95%CI 13.0, 19.8) in 2007/08. This compares to 10.9% (95%CI 10.4, 11.4) of Ontarians in 2007/08. • The proportion of people in St. Thomas and Elgin County who indicated that in the past month, they were exposed to second‐hand smoke, every day or almost every day, in a car or other private vehicle was 9.5% (95%CI 6.7, 12.4) in 2003 compared to 16.0% (95%CI 12.6, 19.4) in 2007/08. • This compares to 7.4% (95%CI 6.9, 7.9) of Ontarians who indicated the same in 2007/08. The exposure to second hand smoke in a vehicle was statistically significantly higher in St. Thomas and Elgin County compared to Ontario. • The proportion of people in St. Thomas and Elgin County who indicated that in the past month, they were exposed to second‐hand smoke, every day or almost every day, in public places (such as bars, restaurants, shopping malls, arenas, bingo halls, bowling alleys) was 17.4 % (95%CI 11.8, 23.1) in 2003 compared to 15.9% (95%CI 11.2, 20.7) in 2007/08. This compares to 11.4% (95%CI 10.8, 12.1) of Ontarians indicating the same in 2007/08.

DID YOU KNOW?

The Smoke‐Free Ontario Act is legislation enacted in 2006 that bans smoking from enclosed workplaces and public places in Ontario. In 2009, smokers were banned from smoking in cars with children under the age of 16.

(Ontario Ministry of Health Promotion, 2010c)

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Figure 6.7: Minors’ Access to Tobacco, St. Thomas and Elgin County, 2008 and 2009 2008 2009 # Number of tobacco vendors 89 82 Number of youth access compliance checks 193 154 Average number of annual checks per vendor 2.1 1.8 Number of vendors selling to minors 25 15

Key Findings: • The number of tobacco vendors decreased between 2008 and 2009. This was partly due to retailers closing, however some retailers chose to stop selling cigarettes due to the amount of work involved in implementing the display bans. • The Ministry of Health and Long Term Care requires two checks per premise per year with 15‐17 year old test shoppers. • St. Thomas and Elgin County met the 90% compliance for vendors in 2009.

Key Findings in Smoking Cessation (data not shown): • In the 2007/8 cycle of the Canadian Community Health Survey current smokers were asked ‘In the past 12 months, did you stop smoking for at least 24 hours because you were trying to quit?’ • In St. Thomas and Elgin County 47.0% (95%CI 36.4, 57.6) indicated yes to this question. This result was similar to the Ontario rate. • Current smokers were also asked ‘Are you seriously considering quitting smoking within the next 6 months?’ of which 68% (57.7, 78.4) indicated that they were seriously considering quitting smoking in St. Thomas and Elgin County compared to 62.8% (95%CI 61.1, 64.5) in Ontario.

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Physical Activity Figure 6.8: Proportion of people (age 12 yrs +) reporting level of physical activity in leisure time as active or moderately active, St. Thomas and Elgin County and Ontario, 2003, 2005, 2007/8 40.0%

35.0%

30.0%

25.0%

20.0% Percent 15.0%

10.0%

5.0%

0.0% Moderately Active Active Moderately Active Active EST ON 2003 22.6% 26.2% 24.9% 26.8% 2005 21.7% 30.8% 24.7% 28.2% 2007/08 25.8% 28.1% 24.0% 25.7% Sex and Activity Category

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings: • The proportion of people in St. Thomas and DID YOU KNOW? Elgin County who reported that they were active [28.1% (95%CI 21.2, 30.5)] or Canada’s Physical Activity Guide moderately active [25.8% (27.5, 30.5)] in recommends accumulating 60 minutes of their leisure time in 2007/8 was higher than physical activity (PA) every day. Progressing in the province, though the difference was to more moderate (eg. biking, swimming, not statistically significant. brisk walking) or vigorous (eg. jogging, aerobics, hockey) forms of PA, one needs to • It appears that the proportion of people in accumulate less total activity on a daily basis St. Thomas and Elgin County who were to stay in the healthy range. moderately active went up over time while

the proportion that was active went down. (PHAC, 2007)

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Alcohol Use Figure 6.9: Proportion of males (age 19 yrs +) considered low risk drinkers, St. Thomas and Elgin County, 2003, 2005, 2007/8 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% 2003 2005 2007/08 EST Males 75.2% 70.3% 70.6% ON Males 70.0% 68.9% 70.2% Year

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

115

Figure 6.10: Proportion of females (age 19 yrs +) considered low risk drinkers, St. Thomas and Elgin County, 2003, 2005, 2007/8 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% 2003 2005 2007/08 EST Females 88.3% 87.3% 84.7% ON Females 85.4% 85.1% 85.3% Year

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics DEFINITION: Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and The Low Risk Drinking Guidelines indicate no more Long‐Term Care than 2 standard drinks on any one day with a

maximum of 9 and 14 standard drinks a week for Key Findings: women and men, respectively. • The proportion of people considered A standard drink is 13.6 g of alcohol, which low risk drinkers was consistent over translates into 5 oz of wine, 1.5 oz of spirits, or 12 time and was similar to the provincial oz of regular strength beer. rate. • In 2007/8, 84.7% (95%CI 80.2, 89.2) of women were low risk drinkers compared to 70.6% (95%CI 64.5, 76.6) of men. The difference between the two was statistically significant.

(CAMH, 2009) 116

Figure 6.11: Proportion of adults (age 19 yrs +) who reported drinking 5 or more drinks at least once a month in the past year, by sex, St. Thomas and Elgin County & Ontario, 2003, 3005, 2007/8 40.0%

35.0%

30.0%

25.0%

20.0% Percent 15.0%

10.0%

5.0%

0.0% 2003 2005 2007/08 EST Males 25.8% * 28.1% 28.8% ON Males 26.0% 26.9% 25.1% EST Females 10.3% * 10.8% * 9.0% * ON Females 8.9% 9.1% 9.2% Year

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability

Key Findings: • In 2007/8 the rate of men who reported heavy drinking was 3 times higher than in women in St. Thomas and Elgin County. • The rates in women were consistent between St. Thomas and Elgin County and the province, as were the rates in men. • The trend indicated that the proportion of men who were heavy drinkers in 2008 went up from 2003 compared to women where the proportion went down in St. Thomas and Elgin County. These changes were not statistically significant.

Key Findings in Adolescent Drinking (data not shown): • The proportion of the female adolescent population, under age 19, that drank at least once in the year prior to answering the survey question was 54.7% (95%CI 32.1, 77.4) compared to 38.8% (95%CI 35.8, 41.8) of Ontario female adolescents in 2007/8. • In 2005, 70.3% (95%CI 50.3, 90.3) of male adolescents drank alcohol in the past 12 months compared to 42.6% (95%CI 39.9, 45.3) of males.

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• The St. Thomas and Elgin County rates are higher than what was seen in Ontario, and the difference was statistically significant for males. • These data should be interpreted with caution due to high sampling variability.

Stress Figure 6.12: Proportion of people (age 15 yrs +) who report life and work as quite stressful or extremely stressful, by sex, St. Thomas and Elgin County, 2007/8 40.0%

35.0%

30.0%

25.0%

20.0% Percent 15.0%

10.0%

5.0%

0.0% Life quite or Work quite or Life quite or Work quite or extremely stressful extremely stressful extremely stressful extremely stressful Males Females EST 17.9% 19.4% * 24.9% 27.4% * ON 20.6% 29.0% 23.8% 30.7% Sex and Stress Level

Key Findings: • In St. Thomas and Elgin County in 2007/8, 27.4% (95%CI 18.2, 36.6) of women found work to be quite or extremely stressful. 24.9% (95%CI 19.5, 30.4) found life to be quite or extremely stressful. Neither of these rates was significantly different from the provincial rates. • Men in St. Thomas and Elgin County experienced lower levels of work stress [19.4% (95%CI10.9, 27.9)] and life stress [17.9 (95%CI 11.8, 23.9)] than St. Thomas and Elgin County women and their Ontario counterparts. These differences were not statistically significant.

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Health Service Use Figure 6.13: Proportion of population (age 12 yrs +) who reported having a family physician, by sex, St. Thomas and Elgin County and Ontario, 2003, 2005, 2007/8 100.0%

98.0%

96.0%

94.0%

92.0%

90.0% Percent 88.0%

86.0%

84.0%

82.0%

80.0% Males Females Males Females EST ON 2003 97.5% 99.6% 89.5% 94.0% 2005 94.8% 98.5% 89.1% 93.2% 2007/08 92.2% 96.1% 88.4% 92.9% Sex and Geography

Data Source: Canadian Community Health Survey 2003, 2005 & 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings: • The proportion of males and females with a family doctor decreased from 2003 to 2007/8. This decrease was not statistically significant. • In 2008, 96.0% (95%CI 93.5, 98.7) of women and 92.2% (95%CI 88.1, 96.3) of men had a family doctor. • The proportion of people with a family doctor in St. Thomas and Elgin County was higher than that of the province. This difference was not statistically significant.

119

References:

Rehm J, Baliunas D, Brochu S, Fischer B, et al. (2006). The costs of substance abuse in Canada 2002: Highlights. Ottawa, Ontario: Canadian Centre on Substance Abuse. Available from: http://www.ccsa.ca/2006%20CCSA%20Documents/ccsa‐011332‐2006.pdf

Canadian Institute for Health Information. (2006). Improving the Health of Canadians: Promoting Healthy Weights. Ottawa, Ontario: Canadian Institute fro Health Information. Available from: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_470_E&cw_topic=470&cw_rel=AR_1217 _E

Centre for Addiction and Mental Health (CAMH). (2009). Low‐Risk Drinking Guidelines in Information about drugs and addiction. Retrieved January, 2010, from: http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction_Information/low_ri sk_drinking_guidelines.html

Health Canada. (2007). Eating Well with Canada’s Food Guide. Retrieved July, 2010, from: http://www.hc‐sc.gc.ca/fn‐an/food‐guide‐aliment/order‐commander/index‐eng.php

Health Canada. (2004). Canadian Guidelines for Body Weight Classification in Adults in Food and Nutrition. Retrieved August, 2010. http://www.hc‐sc.gc.ca/fn‐an/nutrition/weights‐poids/guide‐ ld‐adult/index‐eng.php

Ontario Ministry of Health Promotion. (2010a). Comprehensive Tobacco Control Guidance Document. Retrieved August, 2010, from: http://www.mhp.gov.on.ca/en/healthy‐communities/public‐ health/guidance‐documents.asp

Ontario Ministry of Health Promotion. (2010b). Healthy Eating, Physical Activity and Healthy Weights Guidance Document. Retrieved August, 2010, from: http://www.mhp.gov.on.ca/en/healthy‐ communities/public‐health/guidance‐documents.asp

Ontario Ministry of Health Promotion. (2010c). Smoke‐Free Ontario. Retrieved August, 2010. http://www.mhp.gov.on.ca/en/smoke‐free/default.asp

Public Health Agency of Canada (PHAC). (2007). Canada’s Physical Activity Guide to Healthy and Active Living. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/hp‐ps/hl‐mvs/pag‐ gap/downloads‐eng.php

U.S. Department of Health and Human Services. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available from: http://www.surgeongeneral.gov/library/secondhandsmoke/

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World Health Organization. (2010). Promoting fruit and vegetable consumption around the world in Global Strategy on Diet, Physical Activity and Health. Retrieved August, 2010, from: http://www.who.int/dietphysicalactivity/fruit/en/index.html

WHO Expert Committee on Problems Related to Alcohol Consumption. (2006). Second report: WHO Expert Committee on Problems Related to Alcohol Consumption. Geneva, Switzerland: WHO Expert Committee on Problems Related to Alcohol Consumption. Available from: http://www.who.int/substance_abuse/expert_committee_alcohol_trs944.pdf

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Chapter 7: Injuries and Injury Prevention

122

Overview Injury rates in St. Thomas and Elgin County were higher than those seen in the province and in some cases substantially higher. Generally, however, rates of hospitalizations and deaths from injuries decreased over the time period reviewed, even if only slightly. Top priorities for injury prevention were established using a method incorporating frequency, severity and fatality related to each injury category. The top priority for the population was motor vehicle collisions. Motor vehicle collisions were the most important in the younger age groups and falls were most important in the older age groups.

According to data from the Ministry of Transport, the total collision rates related to motor vehicle collisions were slightly lower in St. Thomas and Elgin County than that of the province. However, rates of hospitalizations due to motor collisions were much higher. Death rates due to motor vehicle collisions were also higher. While there was a lower rate of collisions in St. Thomas and Elgin County, the collisions were more likely to cause severe injury or to be fatal. Men were much more likely to be involved in motor vehicle collisions while intoxicated compared to women. Those aged 25 to 44 had the highest number of collisions where the driver was intoxicated.

Injury prevention behaviours were practiced less in St. Thomas and Elgin County compared to the province. Seatbelt use, both by drivers and passengers, and helmet use represent areas where more work can be done.

Injuries constitute the fourth highest cause of morbidity in St. Thomas and Elgin County and the rates are higher than those in the province. There are lower rates of injury prevention behaviours in St. Thomas and Elgin County.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: iii) Morbidity, including… incidence of injury as assessed by in‐patient hospitalizations and emergency department visits… vii) Preventive health practices including … road and off‐road safety…

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Injuries and Injury Prevention Introduction

Every hour of every day, 65 people in Ontario are injured and roughly 11 people die each day from their injuries. Injuries, both intentional and unintentional, are the fourth leading cause of death for Ontarians of all ages, and the leading cause of death for those aged one to 44 years. (SMARTRISK, 2006) Injuries are also an important cause of morbidity and mortality in St. Thomas and Elgin County. According to the Morbidity chapter, injuries were the fourth leading cause of hospitalizations between 2006 and 2008 and accounted for nearly 10% of all hospitalizations. The age groups most affected were young men age seven to 19 and 20 to 44. In boys and men in these age groups injuries were the leading cause of hospitalizations.

This chapter examines the rates of injury, top priorities in injury prevention and injury prevention behaviours. Utilizing data from deaths, emergency room visits, hospitalizations provide a perspective on the most common and the most severe injuries and, most importantly, the injuries of the highest priority for the community. Survey data provides the perspective of injury prevention behaviours both on and off the road. The Ontario Road Safety Annual Report (ORSAR, 2006) provides valuable information about motor vehicle collision that involve fatalities as injuries as well as the demographic characteristics of drivers found to be intoxicated at the time of the collision. Review of the most common injuries and those with the greatest severity as well as behaviour patterns in St. Thomas and Elgin County can be helpful in establishing priorities for program planning in injury prevention.

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Injury Priority Setting

Figure 7.1: Injury prevention priorities, St. Thomas and Elgin County and Ontario Age Group STE Rank All Ages 0‐4 5‐14 15‐24 25‐59 60‐79 80+ Motor Motor Motor Motor 1 vehicle Burns vehicle vehicle vehicle Falls Falls Motor Motor Motor 2 Falls vehicle Falls Falls Falls vehicle vehicle 3 Self‐harm Falls Poisoning Self‐harm Self‐harm Self‐harm Suffocation Vehicle related 4 Poisoning Poisoning Sports Cycling Poisoning Suffocation pedestrian Assault & Assault & Assault & Assault & 5 Abuse Abuse Cycling Abuse Abuse Poisoning Poisoning Data Source: Mortality Data, IP Diagnosis & External Cause, Ambulatory All Visit External Cause, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: January 13, 2009 DID YOU KNOW?

Key Findings Using a method developed in • There were commonalities in the top injuries seen in Manitoba by Harlos in 2008, these each age group. priorities were identified by • Motor vehicle collisions were the main priority for all comprehensively reviewing many ages and were most important in those aged five to sources of injury data to identify the 59. areas that have the greatest impact on • Above age 60 falls was the highest priority for each age group. prevention. Sources of information included • Burns were the greatest priority in those under age hospitalizations, emergency room five. This may be due to the severity of burns and visits, deaths, potential years of life number of deaths due to burns in this age group lost and the length of time spent in during the timeframe examined. hospital with an injury. In essence this • Self‐harm, poisoning, sports‐related and assault and method accounts for the frequency abuse also ranked in the top five priority spots for that an injury occurs, the severity of most age groups. the injury and the age group most • Further information is provided below about each of often affected. The method provides a these areas. simple framework from which priorities can be set for injury prevention efforts.

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Selfreported injury Figure 7.2: Type of activity resulting in serious injury (12+ years of age), St. Thomas and Elgin County, 2003

Sports or physical exercise (include school 30.7% activities)

Working at a job or business (exclude travel to or 20.0% from work)

19.2% Leisure or hobby (include volunteering) Activity of

Household chores, other unpaid work or education N.R. Type

Travel to or from work 0

Sleeping, eating, personal care 0

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Percent

Data Source: Canadian Community Health Survey 2003, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: N.R.: Not reportable (estimate suppressed due to extreme variability).

Key Findings: • In 2003, 12.6% of people in St. Thomas and Elgin County reported having an injury (95%CI 9.3, 15.9) There was no significant difference between St. Thomas and Elgin County and the province. (data not shown) • 30.7% (95%CI 19.1, 42.4) indicated that sports or physical exercise was the type of activity they were doing at the time of the injury. • Work [20.0% (95%CI 94.4, 30.1)] and then hobbies [19.1% (95%CI 9.1, 29.2)] were the next two activities that resulted in serious injury.

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Key Findings about Types of Injuries (data not shown): • Injuries occurred throughout the year but the greatest proportion, 30.4% (95%CI 18.3, 42.4) occurred in the summer in St. Thomas and Elgin County. Autumn was the next most common time for injuries followed by spring and finally winter. • The home was the location where the greatest proportion of injuries occurred; 36.0% (95%CI 22.5, 49.6) of all injuries occurred in the home in St. Thomas and Elgin County. A similar proportion of injuries occurred in home in all of Ontario. • The most common type of injury in St. Thomas and Elgin County [31.8% (95%CI 19.2, 44.4)] was of the bone, compared to only 20.9% (95%CI 19.5, 22.4) in Ontario. The next most common type of injury in St. Thomas and Elgin County was a sprain at 26.7% (95%CI 15.2, 38.3) compared to 39.3% (95%CI 37.5, 41.1) in Ontario.

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Injury Hospitalizations and Deaths

Figure 7.3: Age standardized hospitalization rates for all unintended injuries, St. Thomas and Elgin County and Ontario, 2002 ‐2008 700

600

500

400 100,000

per 300 Rate

200

100

0 2003 2004 2005 2006 2007 2008 STE 655 625 630 580 602 627 ON 492 489 473 453 444 442 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, DID YOU KNOW? IntelliHEALTH ONTARIO Extracted: February 23, 2010 Hospitalization and death data are used to get Key Findings: a picture of the injuries that are identified as • Hospitalizations for all unintenitional injuries priorities in St. Thomas and Elgin County. Since decreased slightly from 2003 to 2008 by about injuries can be challenging to measure directly, 5% in St. Thomas and Elgin County compared to hospitalizations are often used as a proxy a 10% decrease in the province. measure. Hospitalizations represent only a • Rates of unintentional injury were higher in St. fraction of the injuries, however, since the Thomas and Elgin County, nearly 30% higher injury must be severe enough for than the province in 2008. hospitalization to be recorded. Deaths due to • Not only were rates nearly 30% higher in St. injury, while much less common than Thomas and Elgin County, they declined at a hospitalizations, present a picture of the most slower rate than that of the province. severe injuries and those that are most often fatal. 128

Figure 7.4: Age standardized mortality rates for all unintended injuries, St. Thomas and Elgin County and Ontario, 2000 to 2005 35

20 100,000

per 15 Rate

0 2003 2004 2005 2006 2007 2008 STE 24 23 29 30 28 27 ON 22 21 22 23 22 23 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH INTERPRETATION NOTE: ONTARIO Extracted: February 23, 2010 Rates are generated as a way to Key Findings: compare the frequency that an event • Rates of death from unintended injury rose and occurs in different populations. In declined in the time period between 2003 and order to compare Ontario information 2008. This is likely due to the small population size to that in St. Thomas and Elgin in St. Thomas and Elgin County. County, numbers cannot simply be • St. Thomas and Elgin County had consistently used. This is because there are far higher rates of death due to all unintended fewer people in St. Thomas and Elgin injuries compared to the province. In 2008 the County than Ontario. In this chapter a rate of deaths due to injury in St. Thomas and rate is calculated as the number of Elgin County was almost 15% higher than Ontario. events per 100,000 people. Placing a • This is not surprising given the findings in Figure common denominator (i.e. 100,000 7.3 show that rates of hospitalization for injuries people) allows for an ‘apples to were 30% higher in St. Thomas and Elgin County apples’ comparison of the frequency than Ontario. that an event happens.

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Figure 7.5: Rates of age‐standardized hospitalizations and deaths for selected injuries, St. Thomas and Elgin County and Ontario, 2006 to 2008 average (hospitalizations) and 2003 to 2005 average (mortality) Hospitalization Rate (per 100,000) Mortality Rate (per 100,000) Female Male Female Male STE ON STE ON STE ON STE ON All unintentional injuries* 570.8 436.6 635.9 456.8 21.7 18.4 35.4 27.1 Falls 362.5 296.2 250.4 207.0 4.3 6.9 4.9 6.4 Self‐harm/Suicide 68.1 58.7 48.9 40.0 1.2 3.9 8.0 12.2 Motor vehicle collisions 44.3 37.0 118.6 67.2 5.7 2.7 12.8 7.4 Poisonings 38.4 21.2 42.1 20.8 1.5 1.6 3.0 3.8 Sports 7.3 3.0 17.5 15.5 0.4 0.0 0.4 0.0 Suffocation 6.8 3.0 8.1 3.5 1.8 0.9 1.5 1.2 Assault and Abuse 5.3 5.8 32.8 31.2 0.4 0.8 1.5 2.1 Burns 4.9 4.5 13.2 9.1 0.4 0.5 2.3 0.7 All Terrain Vehicle‐related 2.3 1.8 24.2 8.4 0.4 0.0 0.4 0.0 Drowning 1.9 0.5 1.8 1.0 1.0 0.3 1.2 1.3 Pedestrian, Traffic‐related 1.0 5.2 6.6 5.8 1.6 0.6 1.4 0.9 Boating 0.9 0.3 1.0 0.8 1.0 0.0 0.4 0.2 Farming 0.9 0.1 4.5 0.8 0.4 0.0 1.0 0.1 Snowmobiling 0.4 0.7 5.0 3.9 0.4 0.0 0.4 0.0 Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, 2010 Data Notes: *excludes self‐harm, assault and abuse

Key Findings: • The most common reason for hospitalization due to injury was falls. • Females had a higher rate of hospitalization than males for falls but rates in both sexes were higher in St. Thomas and Elgin County than in Ontario. • Hospitalizations for self‐harm were the next most common for females and motor vehicle collisions for males in St. Thomas and Elgin County. Again, both were higher than what was seen in the province overall. • Rates of death due to self‐harm, however, were lower. This indicates that more people attempted but did not complete suicide in St. Thomas and Elgin County. • Motor vehicle collision hospitalizations were higher for both males and females in St. Thomas and Elgin County compared to Ontario – nearly double for males. The mortality rate for collisions was also higher – double for females and 73% higher for males. • Poisonings were the forth most common injury for hospitalization. The rate was nearly double that of what was seen in the province. • Of particular note, hospitalizations for sports and violence related to assault and abuse were much higher in males compared to females. These rates were more in line with what was seen in the province. • The rate of deaths due to poisonings, sports‐related injuries, suffocation, burns and assault and abuse were low.

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• St. Thomas and Elgin County is has both urban and rural areas and it borders Lake Erie. It is important to consider injuries such as those related to farming, boating, drowning, All Terrain Vehicle use and pedestrians in traffic. • While the rate of hospitalizations and deaths due in these categories is only higher in St. Thomas and Elgin County compared to Ontario, the rate of these injuries relative to other types of injuries is quite low.

INTREPRETATION NOTE:

Figures 7.6 through 7.11 show hospitalizations for the categories of injury that were identified as priorities in Figure 7.5.

Note that the graphs are ordered from the highest to lowest rates of injury hospitalizations.

They can be used to interpret which types of injuries have the largest impact on the population in terms of highest frequency of injuries. Note that they do not indicate the severity of injury.

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Figure 7.6: Age standardized hospitalization rates for falls, St. Thomas and Elgin County and Ontario, 2003 ‐2008 400.0

350.0

300.0

250.0 100,000 200.0 per

Rate 150.0

100.0

50.0

0.0 2003 2004 2005 2006 2007 2008 STE 350.4 308.5 331.0 304.7 294.9 321.1 Ontario 279.6 271.6 264.1 250.8 249.5 255.7 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, INTERPRETATION NOTE: IntelliHEALTH ONTARIO Extracted: February 23, 2010 When the age and sex structure of populations are very different age Key Findings: standardization is used. • Rates of hospitalizations for falls in St. For instance since St. Thomas and Elgin Thomas and Elgin County were higher than County has a greater proportion of elderly that of Ontario by approximately 20% in people than Ontario and elderly people are 2008. more likely to be hospitalized for falls than • Rates in St. Thomas and Elgin County and younger people, simply comparing the rate Ontario declined between 2003 and 2008. of falls in both populations would surely • Rates of hospitalizations for falls were the show that St. Thomas and Elgin County had highest of all types of injury. a higher rate. Adjusting for the difference in age distribution, or ‘age standardizing’, allows for an assessment of whether falls in the population are higher if the same age structure existed in both populations.

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Figure 7.7: Age standardized hospitalization rates for motor vehicle collisions, St. Thomas and Elgin County and Ontario, 2003 to 2008 120.0

100.0

80.0 100,000 60.0 per

Rate 40.0

20.0

0.0 2003 2004 2005 2006 2007 2008 STE 101.0 99.3 98.1 89.3 93.3 60.7 Ontario 60.1 58.5 55.7 55.2 53.3 47.3 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, INTERPRETATION NOTE: 2010 Rates in small populations are often unstable due Key Findings: to the relatively small number of events that • Rates of hospitalizations declined occur each year. As can be seen in the rates in between 2003 and 2008 – there was a Ontario, the time trends were fairly smooth from substantial decrease between 2007 and one year to the next. This is different from what is 2008. seen for time trends in St. Thomas and Elgin • This could be due to the small population County. Since there are small numbers of events size and yearly fluctuations in number of occurring in St. Thomas and Elgin County, small injuries each year. changes in the number of events from year to year represent a bigger change in the rate from • Even with the decline, however, the rates year to year. As a result the time trends tend to seen in St. Thomas and Elgin County were jump up and down. In order to get a good idea of higher than those seen at the provincial the ’average’ rate imagine a line drawn through level. the centre of all the time points.

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Figure 7.8: Age standardized hospitalization rates for self‐harm, St. Thomas and Elgin County and Ontario, 2003 to 2008 120.0

100.0

80.0 100,000 60.0 per

Rate 40.0

20.0

0.0 2003 2004 2005 2006 2007 2008 STE 95.9 75.6 68.6 38.1 77.8 59.9 Ontario 79.5 75.9 67.5 52.8 47.8 47.8 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, 2010

Key Findings: • Hospitalization rates for self‐harm were similar in St. Thomas and Elgin County and Ontario. • A decline in rates was seen between 2003 and 2008 for both the St. Thomas and Elgin County and the province.

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Figure 7.9: Age standardized hospitalization rates for unintentional poisonings, St. Thomas and Elgin County and Ontario, 2003 to 2008 70.0

60.0

50.0

40.0 100,000

per 30.0 Rate

20.0

10.0

0.0 2003 2004 2005 2006 2007 2008 STE 34.2 37.8 42.9 25.3 30.6 64.7 Ontario 21.3 24.1 23.1 20.9 21.0 21.1 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, 2010

Key Findings: • Rates of hospitalization for poisonings were higher in St. Thomas and Elgin County compared to the province. • The increase seen in 2008 was likely due to the small population size of St. Thomas and Elgin County.

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Figure 7.10: Age standardized hospitalization rates for sports‐related injuries, St. Thomas and Elgin County and Ontario, 2003 to 2008 16.0

14.0

12.0

10.0 100,000 8.0 per

Rate 6.0

4.0

2.0

0.0 2003 2004 2005 2006 2007 2008 STE 12.3 13.9 13.0 14.5 10.9 11.7 Ontario 9.3 10.2 10.4 9.4 9.3 8.9 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, 2010

Key Findings: • As is seen in nearly all other injury categories, rates of hospitalization for sports‐related injuries were higher in St. Thomas and Elgin County compared Ontario. • There was no meaningful decline seen the rate of sports‐related injuries in St. Thomas and Elgin County between 2003 and 2008.

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Figure 7.11: Age standardized hospitalization rates for assault and abuse, St. Thomas and Elgin County and Ontario, 2003 to 2008 25.0

20.0

15.0 100,000

per

10.0 Rate

5.0

0.0 2003 2004 2005 2006 2007 2008 STE 21.7 21.0 22.4 19.1 21.9 15.7 Ontario 19.3 18.4 19.6 18.7 18.5 18.0 Year

Data Source: IP Diagnosis & External Cause data, Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted: February 23, 2010

Key Findings: • Hospitalizations related to injuries from assault and abuse decreased between 2003 and 2008 by nearly 28% in St. Thomas and Elgin County. • The decrease seen in Ontario over the time frame was only by 7%. • Due the small population size in St. Thomas and Elgin County these numbers fluctuated from year to year and may increase in following years.

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Motor Vehicle Collisions

Figure 7.12: Crude rate of total motor vehicle collisions, St. Thomas and Elgin County and Ontario, 2002 to 2006 2500.0

2000.0

1500.0 100,000

per

1000.0 Rate

500.0

0.0 2002 2003 2004 2005 2006 STE 1436.8 1629.6 1573.2 1616.3 1474.2 Ontario 2023.3 2013.2 1868.7 1837.9 1707.4 Year

Data Source: Ontario Road Safety Data. Ministry of Transportation. DID YOU KNOW? Key Findings: • The crude rate of motor vehicle collisions in St. Data from the Ministry of Transportation of Thomas and Elgin County was lower than that of Ontario (MTO) provides information about Ontario in 2006 by nearly 15%. collisions that occur on roads in St. Thomas and Elgin County. Information about the • There was a decline in the rate of collisions number and types of collisions is available. between 2002 and 2006 seen in Ontario, In order to compare the collisions, rates are however the rate remained fairly constant in St. generated for both St. Thomas and Elgin Thomas and Elgin County over the time period. County and Ontario.

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Figure 7.13: Crude rate of motor vehicle collisions involving an injury, St. Thomas and Elgin County and Ontario, 2002 to 2006 800.0

700.0

600.0

500.0 100,000 400.0 pe

Rate 300.0

200.0

100.0

0.0 2002 2003 2004 2005 2006 STE 449.6 608.9 561.7 521.6 481.6 Ontario 696.3 636.1 589.2 573.5 543.2 Year

Data Source: Ontario Road Safety Data. Ministry of Transportation.

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Figure 7.14: Crude rate of motor vehicle collisions involving a fatality, St. Thomas and Elgin County and Ontario, 2002 to 2006 20.0

18.0

16.0

14.0

12.0 100,000 10.0 per

8.0 Rate

6.0

4.0

2.0

0.0 2002 2003 2004 2005 2006 STE 9.4 11.7 16.1 18.3 9.0 Ontario 7.2 6.8 6.4 6.1 6.1 Year

Data Source: Ontario Road Safety Data. Ministry of Transportation.

Key Findings: • The rate of people injured in motor vehicle collisions between 2002 and 2006 was lower in St. Thomas and Elgin County compared to Ontario, however the rate of people killed in collisions during the time period was higher. • Both injury and death rates in the population increased during the time period and declined again in 2006. This may be due to fluctuations in yearly numbers of events due to small population size.

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Figure 7.15: Proportion of motor vehicle collisions involving an intoxicated driver, by age group, St. Thomas and Elgin County, 1995 to 2006 combined 16.0%

14.0%

12.0%

10.0%

8.0% Percent 6.0%

4.0%

2.0%

0.0% <16 16‐24 25‐34 35‐44 45‐54 55‐59 60‐64 65‐69 70‐79 Fatal Injury 0.1% 1.2% 0.9% 1.1% 0.8% 0.0% 0.0% 0.0% 0.0% Non Fatal Injury 0.6% 11.6% 11.1% 9.4% 4.2% 0.8% 0.9% 0.2% 0.5% Property Damage Only 0.2% 15.2% 14.1% 14.6% 7.1% 1.6% 1.2% 0.8% 0.8% Age Group

Data Source: Ontario Road Safety Data. Ministry of Transportation.

Key Findings: • The highest proportion of collisions involving DID YOU KNOW? intoxicated drivers that involved a non‐fatal injury was in the 16‐24 age group. The 25‐34 and 35‐44 Data from the Ministry of Transportation of age groups were similar. This was also true for fatal Ontario (MTO) provides information about injuries. whether collisions involved an intoxicated • All types of collisions such as fatal, injury and driver. The age and sex distribution of property damage are displayed here. collisions involving intoxicated drivers indicates what the highest risk groups are for driving while intoxicated.

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Figure 7.16: Proportion of motor vehicle collisions involving an intoxicated driver, by type of collisions, by sex, St. Thomas and Elgin County, 1995 to 2006 combined 60.0%

50.0%

Drivers 40.0%

30.0% Intoxicated of

20.0% Proportion 10.0%

0.0% Females Males Total Fatal Injury 0.7% 3.6% Total Non Fatal Injury 5.2% 34.1% Total Property Damage Only 7.7% 48.5% Sex

Data Source: Ontario Road Safety Data. Ministry of Transportation.

Key Findings: • The highest proportion of collisions occurred in men ‐ 87% of all collisions in St. Thomas and Elgin County between 1995 and 2006. • Less severe collisions involving only property damage are more common than those involving injury or death.

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Injury Prevention Figure 7.17: Proportion of drivers, by frequency of reported seat belt use, St. Thomas and Elgin County, 2003 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% Always Most of the time Rarely or never STE 83.3% 13.9% * 0.0%N.R. ON 91.6% 6.0% 2.3% Frequency of Seat Belt Use

Data Source: Canadian Community Health Survey 2003, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability. N.R.: Not reportable (estimate suppressed due to extreme variability).

Key Findings: • A greater proportion of drivers in Ontario reported always wearing their seat belt 91.6% compared to in St. Thomas and Elgin County 83.3%. The difference between the two was statistically significant. • The majority of the rest of drivers report wearing their seatbelt most of the time.

Key Findings about Passenger Seat Belt Use (data not shown): • In St. Thomas and Elgin County, 84.5% (95%CI 79.4%, 89.6%) of front seat passengers reported ‘always’ wearing their seat beat. This rate was significantly lower than that of the province.

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Figure 7.18: Proportion of drivers, by reported cell phone use, St. Thomas and Elgin County, 2003 80.0%

70.0%

60.0%

50.0%

40.0% Percent

30.0%

20.0%

10.0%

0.0% Often Most of the time Rarely Never STE 3.7% * 13.0% * 18.3% 65.0% ON 7.5% 12.3% 21.7% 58.6% Frequency of Cell Phone Use

Data Source: Canadian Community Health Survey 2003, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability.

Key Findings: • Note: This data is from 2003 and cell phone use patterns may have changed dramatically since then. The data from the survey is the only local data available on the topic. • Only 3.7% of people in St. Thomas and Elgin County reported using a cell phone while driving often and 13.0% reported using a cell phone most of the time. • The proportion of people often using a cell phone while driving in the province overall was more than double.

Key Findings about Driving Speed and Aggression (data not shown): • In St. Thomas and Elgin County, 57.0% of drivers (95%CI 51.5%, 63.5%) reported their driving speed to be about the same as others. • There was a higher proportion of people who reported driving a little slower than others in St. Thomas and Elgin County compared to Ontario as a whole. • 11.0% of drivers reported driving a little more aggressively compared to others (estimate should be interpreted with caution due to high variability), 42.7% reported about the same level of

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Figure 7.19: Proportion of people who answered NO to 'Did driver have 2 + drinks in the hour before driving in the past 12 months?’, by type of vehicle, St. Thomas & Elgin County and Ontario, 2003 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% Driver of motor Passenger of motor Driver of ATV Passenger of ATV vehicle vehicle STE 87.2% 89.5% 87.3% 91.8% ON 92.5% 89.0% 95.2% 94.1% Type of Vehicle

Data Source: Canadian Community Health Survey 2003, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings: • About 90% of drivers and passengers of vehicles said they did not get into a vehicle if the driver had two or more drinks in the hour before driving. • There was no statistical difference between St. Thomas and Elgin County and Ontario. • The results were very similar between on and off road motor vehicles.

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Figure 7.20: Proportion of people (age 12 yrs +) who reported rarely or never wearing a helmet , by activity, St. Thomas and Elgin County and Ontario, 2005 (ATV data, 2003) 120

100

60 Percent

0 Biking In line skating Skateboarding ATV STE 77.5 88.0 93.9 35.0 ON 59.2 72.0 74.4 28.5 Activity

Data Source: Canadian Community Health Survey 2003 & 2005, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

Key Findings: • The proportion of people who reported rarely or never wearing a helmet while biking was 77.5% compared to 59.2% in Ontario. The results were statistically different from each other. • The proportion of people who rarely or never wore a helmet when in‐line skating was higher than for biking. This result was also significantly higher than in the province overall. • 93.9% of people reported rarely or never wearing a helmet when skateboarding. This was statistically different from the proportion in the provincial. • The proportion of people indicating that they never or rarely wear a helmet when riding an ATV was much lower than for biking, in‐line skating and skateboarding and not significantly different from the province.

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References: SMARTRISK. (2006). The Economic Burden of Injury in Ontario. Toronto: SMARTRISK, 2006.

Harlos S. (2007). Setting injury priorities: SMARTRISK Learning Series. Retrieved January, 2009, from: http://pipl.com/directory/people/Sande/Harlos

Ministry of Transportation. (2006). Ontario Road Safety Annual Report. Retrieved July, 2010, from: http://www.mto.gov.on.ca/english/safety/orsar/orsar06/.

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Chapter 8: Reproductive Health and Early Development

148

Overview A large proportion of teens are sexually active, both locally and provincially. This trend, in combination with a much higher teen pregnancy rate in St. Thomas and Elgin County compared to the province, presents a pertinent public health issue, considering the adverse effects of teen pregnancy on adolescent mothers, infants and the community. Generally, women in St. Thomas and Elgin County are having children at younger ages than in the province as a whole. Furthermore, overall therapeutic abortion rates have been historically lower than the province.

The benefits of folic acid supplementation during the preconception period are well‐ known; however, increased awareness and uptake among women in the reproductive age is still warranted. A large majority of women reportedly abstain from cigarette and alcohol use during pregnancy; however, at least a quarter of births are to mothers lacking prenatal education and around the same proportion of births are identified to be at high risk for developmental difficulties. Being such a strong determinant of infant morbidity and mortality, birth weight in the normal range remains an important target for public health promotion efforts. Furthermore, the continued support and promotion of breastfeeding practices to improve successful initiation and increase duration is necessary to ensure optimal infant health and development.

Local data on positive parenting, healthy family dynamics, child healthy eating, child healthy weights, child physical activity and child oral health is not available and will not be presented in this report.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: iv) Reproductive outcomes including live births, stillbirths, pregnancy, birth weight, multiple births, gestational age; v) Growth and development; vii) Preventive health practices including … sexual practices, breastfeeding, preconception health, healthy pregnancies, preparation for parenting

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Reproductive Health and Early Development Introduction A large part of the work done in public health is around reproductive health and healthy child development. Ontario public health units provide the Healthy Babies Healthy Children Program (HBHC), an early intervention initiative aimed to help children get a healthy start to life. This program promotes prenatal, infant and maternal health by offering prenatal and parenting education; prenatal and postpartum screening and assessments; and family home visiting and counseling, among other services. The ultimate goal set by the reproductive health program standard is “[t]o enable individuals and families to achieve optimal preconception health, experience a healthy pregnancy, have the healthiest newborn(s) possible, and be prepared for parenthood” (MOHLTC, 2008).

Sexual health is an important element of reproductive health. It integrates the emotional, physical, cognitive and social aspects of sexuality and is a fundamental component of overall health and well‐ being throughout the lifespan (Health Canada, 2006). Public health promotes sexual health in many ways, from education on healthy sexuality, self‐esteem and relationships, to STI risk reduction and prevention of unplanned pregnancies.

During the prenatal period, it is important for women to achieve their optimal health potential and receive the education and skills required to bring a healthy pregnancy to term. Folic acid supplementation and abstinence from harmful substances, such as tobacco and alcohol, among other preventative practices, are widely promoted to reduce the risk of adverse birth outcomes such as neural tube defects, low birth weight and premature birth. Health professionals can identify and mitigate these risks early on when expectant mothers access appropriate prenatal care and attend prenatal classes. Initially focused narrowly on pain management during labour and preparation for in‐hospital birth – prenatal classes have expanded to address preparation for pregnancy, labour and birth, newborn care and adjustment to family life (PHAC, 2009).

To broadly assess reproductive health and early development in St. Thomas and Elgin County, this chapter focuses on various indicators related to sexual health, prenatal health, pregnancy and fertility, birth outcomes, and early development.

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Sexual Health

Sexual Activity among Youth

Figure 8.1: Self‐reported prevalence of early sexual debut (before 19 years of age) among 15 to 49 year olds and proportion of youth (age 15‐19 yrs) that are sexually active, St. Thomas and Elgin County and Ontario, 2007/08 STE ON 1 % (95%CI ) % (95%CI) Early Sexual Debut (< 19 Years of Age) 71.1 (64.8, 77.5) 66.2 (65.1, 67.3) in 15 to 49 year olds Youth Sexual Activity in 15 to 19 year 51.3 (24.0, 78.3)* 36.8 (34.1, 39.4) olds Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: *Estimate should be interpreted with caution due to high variability; 195% confidence interval for the estimated proportion

Key Findings: • Approximately 71% of St. Thomas and Elgin County residents 15 to 49 reported having sexual intercourse for the first time before the age of 19 – this estimate was not statistically different from the province (66%). • Furthermore, one‐third [32.8% (95%CI 25.4‐40.2)] of 15 to 49 year olds in St. Thomas and Elgin County reported having their sexual debut before the age of 17 – this estimate was also comparable to the province (data not shown). • Regarding sexual activity among youth age 15 to 19, the estimate for St. Thomas and Elgin County was highly variable making it difficult to conclude the proportion that were sexually active; however, the provincial estimate suggests that approximately 37% of this population were sexually active (reported ever having sex).

Protective Practices

Key Findings (data not shown): • Reported condom use among 15 to 49 year olds at risk for STIs was assessed. An individual was deemed at‐risk if they reported having two or more sexual partners in the past year. • For St. Thomas and Elgin County, the proportion of this group that reported using a condom the last time they had sexual intercourse was 42.2% (95%CI 20.8, 63.6) (an estimate that should be interpreted with caution due to high variability). • For Ontario, over 60% of this group reported using a condom the last time they had sexual intercourse [63.6% (95%CI 60.7, 66.6)].

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Prenatal Health

Prenatal Class Attendance

Key Findings (data not shown): • According to the postpartum screening instrument (Parkyn) that is used to assess all births reported in the health unit jurisdiction, 241 births or 26% of all births screened in 2008 indicated that the mother did not attend prenatal class. • In 2008, 312 expectant mothers attended prenatal classes offered by the Elgin St. Thomas Public Health Unit/St. Thomas Elgin General Hospital.

Folic Acid Supplementation

Key Findings (data not shown): • Rates of reported folic acid supplementation were also comparable between St. Thomas and Elgin County and the province according to the 2007/08 CCHS. • Approximately 61% of women age 15 to 55, who reported having had a baby in the past 5 years, reported taking a vitamin supplement containing folic acid prior to getting pregnant [St. Thomas and Elgin County, 60.9% (95%CI 39.9‐82.0)* and Ontario, 61.8% (95%CI 58.8‐64.7)]. *The estimate for St. Thomas and Elgin County should be interpreted with caution due to high variability.

DID YOU KNOW?

Folic acid, or folate, is a B‐vitamin that is essential to the normal development of an unborn baby's spine, brain and skull, especially during the first four weeks of pregnancy. It is recommended that all women who could become pregnant should take a multivitamin containing 0.4 mg of folic acid every day to reduce the risk of neural tube defects

(PHAC, 2008b)

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Substance Use during Pregnancy

Figure 8.2: Prevalence of self‐reported not using tobacco and alcohol during pregnancy (among 15 to 55 year olds who had a baby in the last 5 years), St. Thomas and Elgin County and Ontario, 2007/08 STE ON

% (95%CI) % (95%CI) No Tobacco 90.5 (79.4, 101.7) 89.4 (87.9, 90.9) No Alcohol 96.3 (89.7, 102.8) 94.5 (93.4, 95.7) Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care Data Notes: 195% confidence interval for the estimated proportion DID YOU KNOW?

Key Findings: Maternal cigarette smoking leads to • For the 2007/08 CCHS, women age 15 to 55, who an overall increased risk of infant reported having had a baby in the past 5 years, were morbidity and mortality – it is surveyed about maternal experiences, including associated with increased risk of substance use. intrauterine growth restriction, • Estimates for non‐use of substances during pregnancy preterm birth, spontaneous abortion, for this group were comparable between St. Thomas and placental complications, stillbirth and Elgin County and the province. sudden infant death syndrome. • Approximately 90% and 95% of women reported not smoking and not drinking alcohol, respectively, during (PHAC, 2008a) their last pregnancy. • According to the Parkyn tool, a postpartum screening instrument that is used to assess all births reported in the health unit jurisdiction, 127 births or 14% of all births screened in 2008 indicated that the mother smoked during her pregnancy (data not shown).

DID YOU KNOW?

One of the consequences of maternal alcohol consumption is fetal alcohol spectrum disorder (FASD). This disorder can result in cognitive, behavioural, neurodevelopmental, physiological and/or physical impairments – the effects of which can last a lifetime.

No safe amount of alcohol consumption during pregnancy has been established.

(PHAC, 2008a)

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Age of Mother at Infant’s Birth Figure 8.3: Proportion of births by mother’s age group, St. Thomas and Elgin County, 2001‐2005 average 40‐44 45‐49 2.2% 0.1% 15‐19 35‐39 6.8% 9.7%

20‐24 21.0%

30‐34 26.2%

25‐29 34.0%

Data Source: Ontario Live Birth/Stillbirth/Therapeutic Abortions Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO Extracted June 7, 2010

Key Findings: • Figure 8.3 displays the proportion of all births (live and still) by mother’s age group. • The largest proportion of births (34.0%) were born to women age 25 to 29 followed by women age 30 to 34. • Less than 1% of births were born to mothers between 45 and 49 years old.

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Pregnancy and Fertility

Pregnancy Figure 8.4: Overall and teen pregnancy rate, St. Thomas and Elgin County and Ontario, 2001‐2005 STE ON Overall Teen Overall Teen Year pregnancy rate pregnancy rate pregnancy rate pregnancy rate (per 1,000 (per 1,000 (per 1,000 (per 1,000 women 15‐49) teens 15‐19) women 15‐49) teens 15‐19) 2001 52.1 33.4 55.5 30.4 2002 50.8 32.0 53.8 28.8 2003 55.6 30.4 53.7 27.6 2004 51.2 32.3 52.9 24.9 2005 54.5 32.7 52.8 23.9 Data Source: Ontario Live Birth/Stillbirth/Therapeutic Abortions Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • In Ontario, the overall pregnancy rate decreased only slightly from 2001 to 2005; however, the teen pregnancy rate dropped substantially in this time period. • The situation for St. Thomas and Elgin County appears more stable, with overall pregnancy rates slightly exceeding those of the province in most years between 2001 and 2005 – the St. Thomas and Elgin County teen pregnancy rate was higher than that of Ontario and the difference grew larger over time. • There was a yearly average of 1085 pregnancies overall and 97 teen pregnancies from 2001 to 2005 in St. Thomas and Elgin County (data not shown).

DEFINITION:

A pregnancy rate is calculated by taking the number of live births, stillbirths, and therapeutic abortions and dividing by the number of women of reproductive age or in a specific age group.

(APHEO, 2008)

155

Figure 8.5: Age‐specific pregnancy rates, St. Thomas and Elgin County and Ontario, 2001‐2005 160.0

140.0

120.0

100.0 women

80.0 1,000

per 60.0 Rate

40.0

20.0

0.0 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 STE 32.1 96.6 144.2 95.8 31.0 6.8 ON 27.1 72.0 113.6 114.9 52.5 10.8 Age Group

Data Source: Ontario Live Birth/Stillbirth/Therapeutic Abortions Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • In St. Thomas and Elgin County, the highest age‐specific pregnancy rate was for the 25 to 29 age group. • For the province, pregnancy rates were similar for the 25 to 29 and 30 to 34 age groups. The pregnancy rates were highest in these two age groups. • St. Thomas and Elgin County age‐specific pregnancy rates exceeded those of the province in the younger age groups – for the 30 to 34 age group and beyond, the reverse is true. • For St. Thomas and Elgin County there were six or fewer pregnancies in each of the 10 to 14 and 45 to 49 age groups, between 2001 and 2005 (data not shown).

156

Therapeutic Abortions Figure 8.6: Overall and teen therapeutic abortion rates, St. Thomas and Elgin County and Ontario, 2001‐ 2005 STE ON Overall TA Overall TA Year rate (per Teen TA rate rate (per Teen TA rate 1,000 women (per 1,000 1,000 women (per 1,000 15‐49) teens 15‐19) 15‐49) teens 15‐19) 2001 5.8 12.1 12.3 17.4 2002 6.9 11.7 12.2 16.8 2003 7.9 11.3 11.6 15.8 2004 5.9 7.0 10.6 14.2 2005 7.2 12.0 10.4 13.4 Data Source: Ontario Live Birth/Stillbirth/Therapeutic Abortions Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • The overall therapeutic abortion rate for St. Thomas and Elgin County was substantially lower than the province from 2001 to 2005. • Rates of therapeutic abortions (both overall and teen‐specific) remained relatively stable from 2001 to 2005 in St. Thomas and Elgin County, whereas a more consistent decrease in rates was evident for the province as a whole. • The teen‐specific therapeutic abortion rate for the province reached a level similar to that of St. Thomas and Elgin County, as of 2005. • There was a yearly average of 139 TAs overall and 33 teen TAs from 2001 to 2005 in St. Thomas and Elgin County (data not shown).

DID YOU KNOW?

Therapeutic abortions are performed to terminate pregnancies with abnormal genetic screening results, but they may also be an indicator of unwanted or unplanned pregnancy

(APHEO, 2003b)

157

Figure 8.7: Age‐specific therapeutic abortion rates, St. Thomas and Elgin County and Ontario, 2001‐2005 average 30.0

25.0

20.0 women

15.0 1,000

per

Rate 10.0

5.0

0.0 10‐14 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 45‐49 STE 0.4 10.8 19.0 11.8 5.8 2.7 0.8 0.0 ON 0.3 15.5 27.0 18.6 12.7 8.0 2.8 0.2 Age Group

Data Source: Ontario Therapeutic Abortions Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • Therapeutic abortion rates were highest, in the province and locally, for the 20 to 24 year old age group and decreased consistently in subsequent age groups. • Rates of therapeutic abortion were lower in St. Thomas and Elgin County than the province in every age group.

158

Fertility Figure 8.8: General fertility rates, St. Thomas and Elgin County and Ontario, 2001‐2005 Rate per 1,000 women 15‐49 Year STE ON 2001 46.2 42.9 2002 43.7 41.3 2003 47.4 41.8 2004 45.1 42.0 2005 46.9 42.1 Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • There was an average of 941 live births per year in St. Thomas and Elgin County, between 2001 and 2005 (data not shown). • General fertility rates have remained relatively unchanged, in St. Thomas and Elgin County and the province, between 2001 and 2005.

DEFINITIONS:

The General Fertility Rate (GFR) is the number of live births during a given period as a proportion of the female population aged 15‐49.

An age‐specific fertility rate is the number of live births to women in a given age group as a proportion of the total number of women in that age group.

(APHEO, 2003a)

159

Figure 8.9: Age‐specific fertility rates, St. Thomas and Elgin County and Ontario, 2001‐2005 140.0

120.0

100.0

women 80.0 1,000

60.0 per

Rate 40.0

20.0

0.0 10‐14 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 STE 0.0 21.2 77.3 131.3 89.8 28.3 5.9 ON 0.1 11.5 44.7 94.5 101.5 44.1 7.9 Age Group

Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • Whereas TA rates were highest for the 20 to 24 age group, fertility rates were highest for the 25 to 29 and 30 to 34 age groups, for St. Thomas and Elgin County and the province, respectively, between 2001 and 2005. • There were fewer than six live births born to women in the 45 to 49 age group between 2001 and 2005 (data not shown). • Age‐specific fertility rates for St. Thomas and Elgin County were substantially higher than the province in age groups under 30, after which rates were more comparable (although higher for the province as a whole). • The rate of live births to teens (15 to 19) is about twice that of the province.

160

Crude Birth Rate Figure 8.10: Crude birth rate, St. Thomas and Elgin County and Ontario, 1995 to 2005 16.0

14.0

12.0

10.0 1,000

8.0 per

Rate 6.0

4.0

2.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 14.3 12.5 12.1 12.7 11.6 11.0 11.1 10.5 11.4 10.7 11.1 ON 13.4 12.7 12.0 11.7 11.5 11.0 11.1 10.7 10.8 10.8 10.8 Year

Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • The crude birth rate for St. Thomas and Elgin County was on par with province, and experienced a gradual decline from 1995 to 2005. During the most recent years, the rate leveled out, provincially and locally.

Multiple Births Key Findings (data not shown): • In 2005, multiple births (quadruplets, triplets, and twins) accounted for about 2% of all births in the county. • Between 2001 and 2005, multiples accounted for 2.6% of all live births in St. Thomas and Elgin County, with the number of live multiples ranging from 12 to 48 (annual average, 24). • Between 2001 and 2005, there was an average of 4164 multiple live births per year in Ontario, accounting for 3.1% of all live births in the province for that time period.

161

Birth Outcomes

Birth Weight Figure 8.11: Low and high birth weight rates, by type of live birth, St. Thomas and Elgin County and Ontario, 2001‐2005 average

Birth Weight Type of Live Birth Rate per 100 live births STE ON All 4.7 5.9 Low Singleton Only 3.5 4.5 Multiple Only 50.4 51.7 High All 15.6 12.5 Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • Between 2001 and 2005 there was an average of 44 low birth weight and 147 high birth weight live births per year (data not shown). • Approximately half of all multiple live births between 2001 and 2005 were low birth weight, in St. Thomas and Elgin County and the province as a whole. • For singleton live births, the low birth weight rate was only slightly lower for St. Thomas and Elgin County than the province (3.5 versus 4.5 per 100 live births) for the 2001 to 2005 time period. • The rate of high birth weight for St. Thomas and Elgin County was higher than the province (15.6 versus 12.5 per 100 live births for St. Thomas and Elgin County and Ontario, respectively) for the same period.

DEFINITIONS:

Low birth weight: less than 2500g

Normal birth weight: 2500 to 4000g

High birth weight: more than 4000g

(APHEO, 2004)

162

Figure 8.12: Low birth weight rate, St. Thomas and Elgin County and Ontario, 1995 to 2005 8.0

7.0

6.0

5.0 births

live

4.0 100

per 3.0 Rate 2.0

1.0

0.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 STE 7.2 7.0 5.2 7.3 5.4 4.1 4.1 4.0 5.7 5.8 4.0 ON 6.1 6.0 5.9 5.8 5.8 5.7 5.6 5.9 6.1 5.9 6.2 Year

Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings:

• The rate of low birth weight has remained relatively DID YOU KNOW? unchanged for the province from 1995 to 2005, hovering around 6 per 100 live births. Low birth weight is a main • The low birth weight rate for St. Thomas and Elgin determinant of infant survival, County has fluctuated around the provincial rate, health and development. ranging from 7.2 per 100 live births in 1995 to 4.0 per 100 live births in 2005. (Statistics Canada, 2010)

163

Figure 8.13: Birth weight rates by mother’s age group, St. Thomas and Elgin County, 1995 to 2005 average 25.0

20.0 births

15.0 live 100

per

10.0 Rate

5.0

0.0 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 Low Birth Weight 6.4 5.8 4.8 5.5 6.4 5.7 High Birth Weight 10.4 12.4 13.9 16.6 17.2 19.4 Mother's Age Group

Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: DID YOU KNOW? • Rates of low birth weight in St. Thomas and Elgin County appeared to be lowest for the 25 to 29 age group, with High birth weight can lead to the younger and older maternal age groups having complications during birth for both higher rates. infant and mother and may be • This was a similar trend to that of the province (data not associated with an increased risk of shown). diabetes. • Rates of high birth weight for St. Thomas and Elgin County from 1995 to 2005 appeared to gradually (Statistics Canada, 2010) increase with increasing maternal age. • This trend was evident, but not as dramatic, when looking to provincial data – for the province, rates increased to their highest level in the 35 to 39 age groups and decreased thereafter (data not shown).

164

Preterm Births Figure 8.14: Preterm birth rates, by type of live birth, St. Thomas and Elgin County and Ontario, 2001‐ 2005 average Rate per 100 live births Type of Live Birth STE ON All 6.2 7.4 Singleton Only 4.9 5.9 Multiple Only 53.7 54.1 Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010

Key Findings: • The overall preterm live birth rate for the province for 2001 to 2005 was 7.4 per 100 live births, only slightly higher than St. Thomas and Elgin County at 6.2 per 100 live births. • On average, 58 live births per year were delivered preterm in St. Thomas and Elgin County between 2001 and 2005 (data not shown). • Just over half of all multiple live births between 2001 and 2005 were preterm births, in both St. Thomas and Elgin County and the province.

DID YOU KNOW?

Preterm birth is the leading cause of neonatal (newborn) and infant mortality in developed nations.

(PHAC, 2008a)

165

Figure 8.15: Preterm live birth rates, by mother’s age group, St. Thomas and Elgin County and Ontario, 1995 to 2005 average 18

12 births

10 live 100 8 per

6 Rate

0 10‐14 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 45‐49 STE N.R. 5.9 7.2 7.1 7.2 8.4 10.3 N.R. ON 8.6 8.7 7.7 7.3 7.5 8.7 10.4 17.0 Mother's Age Group

Data Source: Ontario Live Birth Data. Ontario Ministry of Health and Long‐Term Care, IntelliHEALTH ONTARIO. Extracted June 7, 2010 Data Notes: N.R.: Not reportable (estimate suppressed due to low counts).

Key Findings:

• The very low number of births in general for the youngest and oldest age groups, does not allow for a preterm birth rate calculation for St. Thomas and Elgin County mothers in these age groups. • Looking to provincial trends though, it appears that preterm birth rates are slightly lower in the middle reproductive years, than in the youngest age groups, and is most high for the 45 to 49 age group.

166

Stillbirths and Infant Mortality

Key Findings (data not shown): • In St. Thomas and Elgin County between 2001 and 2005 there were a total of 23 stillbirths DEFINITION: (range: 2 to 8; annual average: 4.6). • The overall stillbirth rate for St. Thomas and A stillbirth is defined as a fetal death Elgin County between 2001 and 2005 was 4.9 with a gestation of 20 or more weeks per 1000 births – for Ontario the rate was or a birth weight of at least 500 grams. slightly higher at 6.5 per 1000 births. • There was a total of 39 deaths of live born (PHAC, 2008a) infants under 1 year of age in St. Thomas and Elgin County between 2001 and 2005 (annual average: 7.8) • The average annual infant mortality rate for 2001 to 2005 was 8.3 deaths per 1000 live births, exceeding that of the province, at 5.3 deaths per 1000 live births.

DID YOU KNOW?

The infant mortality rate (IMR) is a long‐established indicator, not only of child health, but also of a society’s well‐being. The IMR reflects the level of mortality, health status, and health care of a population, and the effectiveness of preventive care and the attention paid to maternal and child health.

(Statistics Canada, 2010)

167

Early Development

High‐Risk Births Figure 8.16: Number and proportion of births identified as high‐risk for developmental difficulties (scored 9 or greater on the postpartum Parkyn screen), St. Thomas and Elgin County, 2001‐2008 Births scoring ≥9 (high‐risk) on the Parkyn screen Year # births % of all births screened 2006 229 25.2% 2007 246 24.7% 2008 210 23.8% Data Source: Integrated Services for Children Information System. Ontario Ministry of Health and Long‐ Term Care. Extracted July14, 2010

Key Findings: • The percentage of high‐risk births in St. Thomas and Elgin County remained relatively stable from 2001 to 2008, ranging between 23% and 26% of all births screened with a Parkyn.

DEFINITION:

The Parkyn is a universal postpartum screening tool implemented by the Healthy Babies Healthy Children (HBHC) program in Ontario public health units to identify newborns at risk of poor development.

It includes items such as birth weight, pregnancy/delivery complications, maternal smoking, prenatal care and education, bonding, family history, maternal education, and other social factors. A high‐risk birth is indicated when the screen results in a score of 9 or higher.

168

Breastfeeding

Figure 8.17: Self‐reported breastfeeding initiation rates (among 15 to 49 year olds who had a baby in the last 5 years), St. Thomas and Elgin County and Ontario, 2001‐2008 100.0%

90.0%

80.0%

70.0%

60.0%

50.0% Percent 40.0%

30.0%

20.0%

10.0%

0.0% 2001 2003 2005 2007/08 STE 82.2% 88.8% 88.5% 81.4% ON 82.8% 87.2% 88.0% 89.4% Year

Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care

DID YOU KNOW?

The World Health Organization (WHO) globally recommends that infants be exclusively breastfed for the first six months of life to achieve optimal growth, development and health.

(WHO, 2010)

169

Key Findings: • It appears that breastfeeding initiation rates remained fairly stable from 2001 to 2008. • For St. Thomas and Elgin County the rate was slightly lower than the province in 2007/08; however, this difference was not statistically significant. • Overall, the majority of women initiated breastfeeding or at least attempted to breastfeed their newborn infants. • Regarding duration of breastfeeding, both any and exclusive, local estimates from the CCHS need to be interpreted with caution or suppressed completely due to high variability, therefore it is most useful to look to provincial estimates. • According to the 2007/08 CCHS, approximately 46% (95%CI 42.5‐49.5) of women 15 to 49 years old who had a baby in the last 5 years reported breastfeeding duration of at least 6 months (data not shown). • When looking at exclusive breastfeeding only, this proportion dropped to 22% (95%CI 19.1‐24.9) (data not shown).

School Readiness

Key Findings: • According to the 2005 to 2006 Early Development Index, 238 children (29.3%) were classified as developmentally vulnerable (i.e. scored low on one or more of the 5 developmental domains). • For the 2008‐2009 school year, this estimate decreased to 185 (23.1%) children – the provincial estimate for this time period was higher at 27.0%.

DEFINITION: DID YOU KNOW?

The Early Development Index (EDI) is a Children who are not ready to learn population level measure of children’s upon school entry are at a development at kindergarten across 5 disadvantage, and often never catch up. domains: physical health and well‐being, About 1 in 20 children enter social competence, emotional maturity, kindergarten without the skills needed language and cognitive development, and to learn. communication skills. (Offord Centre, 2010) (HELP, 2010)

170

References: Association of Public Health Epidemiologists of Ontario (APHEO). (2008). Pregnancy rate in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from: http://www.apheo.ca/index.php?pid=139

Association of Public Health Epidemiologists of Ontario (APHEO). (2004). Birth Weights in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from: http://www.apheo.ca/index.php?pid=142

Association of Public Health Epidemiologists of Ontario (APHEO). (2003a). Fertility Rates in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from: http://www.apheo.ca/index.php?pid=136

Association of Public Health Epidemiologists of Ontario (APHEO). (2003b). Therapeutic Abortions in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from: http://www.apheo.ca/index.php?pid=138

Health Canada. (2006). Sexual Health and Promotion. Retrieved August, 2010, from: http://www.hc‐ sc.gc.ca/hl‐versus/sex/index‐eng.php

Human Early Learning Partnership (HELP). (2010). Early Development Instrument. Retrieved August, 2010, from: http://www.earlylearning.ubc.ca/research/initiatives/early‐development‐instrument/

Offord Centre for Child Studies. (2010). School Readiness to Learn (SRL) Project. Retrieved August, 2010, from: http://www.offordcentre.com/readiness/

Ontario Ministry of Health and Long‐Term Care (MOHLTC). (2008). Ontario Public Health Standards. Retrieved August, 2010, from: http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/ophspr otocols.html

Public Health Agency of Canada (PHAC). (2008a). Canadian Perinatal Health Report, 2008 Edition. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/publicat/2008/cphr‐rspc/index‐ eng.php

Public Health Agency of Canada (PHAC). (2008b). Folic Acid. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/fa‐af/index‐eng.php

Public Health Agency of Canada (PHAC). (2009). What Mothers Say: The Canadian Maternity Experiences Survey. Retrieved August, 2010, from: http://www.phac‐aspc.gc.ca/rhs‐ssg/survey‐eng.php

Statistics Canada. (2010). Health Status Definitions and Data Sources in Health Indicators. Retrieved August, 2010, from: http://www.statcan.gc.ca/pub/82‐221‐x/2010001/def/def1‐eng.htm#de1imx

171

World Health Organization (WHO). (2010). The World Health Organization's infant feeding recommendation. Retrieved August, 2010, from: http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/index.html

172

Chapter 9: Communicable Diseases

173

Overview Infectious diseases are important to monitor in the community. The rate of sickness and death from these diseases is much lower than that of chronic disease. A tremendous amount of work is done, however, to prevent infection and transmission of infectious diseases through control practices such as inspection of food premises and immunization.

The biggest burdens of infectious disease in St. Thomas and Elgin County were Chlamydia and Hepatitis C infections which represented over half of the total number of cases of communicable disease over the past 10 years. Other food borne, blood borne or sexually transmitted infections occur but their rates were low. In most cases, stable rates cannot be generated due to low numbers of incident cases. As a result, age standardized comparison to provincial rates is not possible. Due to their low number, generally these diseases are not of particular concern in St. Thomas and Elgin County. A seasonal trend can be seen in enteric diseases with the increase in the number of cases seen in the summer months.

There were high rates of vaccination in both childhood diseases and those diseases that occur later in life. In almost all cases of childhood immunization there was 90% coverage and in some cases coverage was over 99%. Vaccination rates for influenza and pneumococcal diseases among residents of long term care homes were high, however, influenza vaccination coverage rates among staff at institutions such as hospitals and long term care homes was less than 50%.

The majority of outbreaks occur in long term care homes and most of the time the causative organism is never identified. Deaths did occur from these outbreaks and appropriate infection prevention and control measure and immunization are important factors in lessening the impact of these outbreaks.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: iii) Morbidity, including incidence of reportable diseases, surveillance of other infectious diseases of public health importance…; vi) Risk factors including… infection prevention and control practices of inspected premises associated with risk of infectious diseases of public health importance; vii) Preventive health practices including immunization…;

174

Communicable Diseases Introduction

Infectious diseases are important to monitor in the community. Many think that death from infectious disease is no longer an issue in present day. The rate of sickness and death from these diseases is lower than that of chronic disease; however a tremendous amount of work is done to prevent infection and transmission of infectious diseases through hygienic and safe practices and immunization. Monitoring information related to infectious diseases in the community helps decide what health programs need to be emphasized.

Reportable diseases are a classification of diseases that must be reported to health authorities under the Health Promotion and Protection Act. All health care providers must report any person who is infected with a reportable disease. The public health unit is responsible for tracking these individuals and, consequently, can tabulate the most commonly occurring infections and the profile of people who are infected by them.

Infectious diseases are reported when a lab test confirms an organism has been found or when a health care provider suspects a disease. However, often people do not seek medical care when they are ill, and so testing isn’t always done. This may cause diseases to be under reported and decrease our ability to detect all cases of disease that are present in the population. What is presented here may only be the ‘tip of the iceberg’ of infectious diseases.

The National Advisory Committee on Immunizations (NACI, 2009) makes recommendations for Influenza vaccination in the Canadian population. NACI recommends priority be given to immunization of those persons at high risk of influenza‐related complications, those capable of transmitting influenza to individuals at high risk of complications, and those who provide essential community services. However, influenza vaccine is encouraged for all Canadians who have no contraindication. The immunization rates in the general community can be ascertained from the Canadian Community Health Survey. Important groups to consider are seniors with and without chronic conditions, people less than 65 years of age with chronic conditions and the whole population. These are consistent with the APHEO indicators for Influenza.

This chapter examines communicable diseases by reviewing rates of reportable diseases in St. Thomas and Elgin County over the past 10 years. Comparisons are made with Ontario. Vaccination rates and number of reported outbreaks are also included to provide a complete picture.

175

Most Common Reportable Diseases Figure 9.1: Number of top 10 most common reportable communicable diseases, by sex, St. Thomas and Elgin County, 2000 to 2009 combined

Number of cases between 2000 and 2009 0 100 200 300 400 500 600 700 800 900

CHLAMYDIAL INFECTIONS

HEPATITIS C

CAMPYLOBACTER ENTERITIS

INFLUENZA Male SALMONELLOSIS Disease Female

GONORRHOEA (ALL TYPES)

Reportable GIARDIASIS

STREPTOCOCCUS PNEUMONIAE, INVASIVE

CRYPTOSPORIDIOSIS

GROUP A STREPTOCOCCAL DISEASE, INVASIVE

Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010

Key Findings: • There were 2040 cases of reportable diseases reported in the 10 year period between 2000 and 2009 (data not shown). • The leading cause of infectious disease in St. Thomas and Elgin County in this timeframe was Chlamydia. A greater proportion of the Chlamydia cases was seen in females (64.3%). • The next most common condition was Hepatitis C. Males (54.9%) were more commonly reported to be infected with Hepatitis C than females. • Chlamydia and Hepatitis C represented more than half of all the infectious diseases reported to Elgin St. Thomas Public Health over the time period. • Following that, the most common reportable diseases were Campylobacteriosis, Influenza, Salmonellosis, Gonorrhea and Giardiasis. • Only the top 10 most common diseases in the 10 year time period are listed here.

176

Sexually Transmitted Infections and Bloodborne Infections

Chlamydia Figure 9.2: Age‐standardized incidence rates of Chlamydia, St. Thomas and Elgin County and Ontario, 2000 to 2009 300

250

200 100,000 150 per

Rate 100

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 EST 68.6 79.1 91.5 131.7 117.7 98.4 101.8 99 154.8 154.7 ON 139.6 151.8 168.3 174.9 185.9 192.1 196.8 204.9 227.1 247 Year

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010

Key Findings: • Chlamydia was the most commonly reported disease between 2000 and 2009 • The rate more than doubled from 68.6 per 100,000 in 2000 to 154.0 per 100,000 in 2009. • This rate was much less than the provincial rate of Chlamydia (247.0/100,000 in 2009)

177

Figure 9.3: Age‐specific incidence of Chlamydia, females, by age group, St. Thomas and Elgin County, 2000 to 2009 average 1600

1400

1200

1000 100,000 800 per

Rate 600

400

200

0 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 EST 676.3 843.2 358.0 123.0 33.8 N.R.0.0 ON 1109.7 1383.8 574.1 244.2 124.1 60.7 Age Group

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010 Data Notes: N.R.: Not reportable (estimate suppressed due to low counts)

178

Figure 9.4: Age‐specific incidence of Chlamydia, males, by age group, St. Thomas and Elgin County, 2000 to 2009 average 1600

1400

1200

1000 100,000 800 per

Rate 600

400

200

0 15‐19 20‐24 25‐29 30‐34 35‐39 40‐44 EST 193.2 463.2 220.3 110.3 37.8 33.4 ON 259.2 716 456.3 229.8 128.9 77 Age Group

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010

Key Findings: • A greater proportion of the Chlamydia cases were females. • The rates in females aged 15‐19 and 20‐24 were the highest of all age groups in both sexes. • The highest rates of Chlamydia in males were seen at ages 20‐24 but were also high in the 15‐19 and 25‐29 age groups. • The age/sex specific rate in St. Thomas and Elgin County was lower for all age groups and both sexes compared to Ontario.

179

Hepatitis C Figure 9.5: Age‐standardized incidence rates of Hepatitis C, St. Thomas and Elgin County and Ontario, 2000 to 2009 50

30 100,000 25 per

20 Rate 15

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 EST 35.3 32.3 36.8 33.1 24.4 18.9 24.1 29 40 33 ON 47.4 44.2 42.7 41.3 40.3 33.8 27.7 32.9 33.1 Year

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010

Key Findings: • Between 2000 and 2009, 277 cases of Hepatitis C were reported in St. Thomas and Elgin County (data not shown). • 54.9% of the cases were reported in males (data not shown). • In the earlier part of the 2000s the rate of Hepatitis C was consistently lower in St. Thomas and Elgin County compared to Ontario. • Both St. Thomas and Elgin County and the province experienced a drop in incidence rates in 2005 and 2006, but rates began to climb at the end of the decade. • The rates in 2009 were similar between St. Thomas and Elgin County and Ontario.

180

Figure 9.6: Age‐specific incidence of Hepatitis C, males, by age, St. Thomas and Elgin County, 2000 to 2009 average 100.0

90.0

80.0

70.0

60.0 100,000 50.0 per

40.0 Rate 30.0

20.0

10.0

0.0 00‐04 05‐14 15‐24 25‐44 45‐59 60‐79 80+ EST 0.0 0.0 19.3 29.3 86.2 18.0 0.0 ON 1.8 0.4 12.3 49.0 68.3 15.0 9.5 Age Group

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010

181

Figure 9.7: Age‐specific incidence of Hepatitis C, females, by age group, St. Thomas and Elgin County, 2000 to 2009 average 100.0

90.0

80.0

70.0

60.0 100,000 50.0 per

40.0 Rate 30.0

20.0

10.0

0.0 00‐04 05‐14 15‐24 25‐44 45‐59 60‐79 80+ EST 0.0 0.0 23.5 51.6 50.7N.R. 0.0 0.0 ON 1.3 0.3 13.8 30.1 31.4 13.8 6.8 Age Group

Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010

Key Findings: • Age specific rates were calculated for males and female. The rate of Hepatitis C incidence in males was highest in the 45‐59 age group. • In females the highest rate of incident infection was in the 25‐44 age group followed closely by the 45‐59 age group. • St. Thomas and Elgin County had higher age‐sex specific rates of Hepatitis C in all people between the ages of 15 and 59 compared to Ontario, except for men aged 25 to 44.

Gonorrhea Key Findings (data not shown): • There were 91 incident cases of gonorrhea in St. Thomas and Elgin County over the time period between 2000 and 2009. • The average number of annual cases was 9 and the average annual crude rate was 10.4 per 100,000 people. • Over the 10 year time period the number of annual cases ranged from 2 per year to 18 per year. There were approximately the same number of cases in both males and females. 182

• In order to compare with the province the average annual rate between 2005 and 2009 was calculated for both St. Thomas and Elgin County and Ontario. The average annual rate in Ontario was 28.8/100,000 compared to 11.2/100,000 in St. Thomas and Elgin County. The local rate was less than half of that of the province.

Other Sexually Transmitted Infections and Bloodborne infections Key Findings (data not shown): • There were only five reported cases of HIV/AIDS and eight reported cases of Syphilis in St. Thomas and Elgin County between the years of 2000 and 2009. • Both HIV/AID and Syphilis cases were distributed evenly throughout the time period, however the total number of cases is too small to provide additional demographic details about those infected. • These numbers are so low that standardized rates for comparison with the province cannot be produced. • Crude rates in St. Thomas and Elgin County are approximately 10 times less than that of the province for the time period of 2005 to 2009.

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Foodborne and Waterborne Enteric Diseases Figure 9.8: Age‐sex specific crude incidence counts and rates of Campylobacteriosis, Salmonellosis and Giardiasis, St. Thomas and Elgin County, 2000 to 2009 average Campylobacteriosis Salmonellosis Giardiasis rate per rate per rate per # 100,00 # 100,00 # 100,00 Female 11 43.7 11 43.7 7 27.8 0‐4 Male 15 56.8 8 30.3 6 22.7 Female 7 11.6 N.R. N.R. N.R. N.R. 5‐14 Male 19 30.6 6 9.7 9 14.5 Female 7 12.2 5 8.7 N.R. N.R. 15‐24 Male 19 31.4 8 13.2 5 8.3 Female 25 21.2 17 14.4 8 6.8 25‐44 Male 26 21.0 12 9.7 12 9.7 Female 17 19.2 8 9.0 5 5.6 45‐59 Male 13 14.6 12 13.5 10 11.2 Female 11 16.2 6 8.8 N.R. N.R. 60‐79 Male 15 24.2 10 16.1 N.R. N.R. Female N.R. N.R. N.R. N.R. 11 43.7 80+ Male N.R. N.R. N.R. N.R. 8 30.3 Total 189 110 72 Data Source: Integrated Public Health Information System. Elgin St. Thomas Public Health. Extracted May 11, 2010 Data Notes: N.R.: Not reportable (estimate suppressed due to low counts).

Key Findings: • Age/sex specific number and rates are presented for each of the most common food and water‐ borne enteric diseases. These represent the count and rate in each age/sex group. • Campylobacteriosis was the most commonly reported enteric disease in St. Thomas and Elgin County between 2000 and 2009, followed by Salmonellosis and then Giardiasis. • The average annual crude rate of Campylobacteriosis in St. Thomas and Elgin County was 17.9 per 100,000 compared to 28.6 in Ontario • The greatest number of cases was reported in the 25‐44 age group, except for Giardiais where it was in the 80+ age group. • The highest age‐specific rates of reported Campylobacteriosis and Salmonellosis infection were in the very youngest age group. The highest age‐specific rate of Giardiasis was in the 80+ age group. • The average annual crude rate of Salmonellosis for 2005 to 2009 in St. Thomas and Elgin County was 14.1 per 100,000 compared to 19.9 in the province. For Giardiasis the rate was 5.2 per 100,000 in St. Thomas and Elgin County compared to 12.0 per 100,000 in Ontario. The rate of Campylobacteriosis was 17.9 per 100,000 in St. Thomas and Elgin County compared to 28.6 per 100,000 in Ontario.

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Figure 9.9: Total count of Campylobacteriosis and Salmonellosis, by month, St. Thomas and Elgin County, 2000 to 2009 35

25 Cases

of 20

15 Number

Total 10

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Campylobacteriosis 8 6 11 10 15 27 27 30 21 17 8 9 Salmonellosis 8 8 8 9 10131214106 8N.R. Month

Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 Data Notes: N.R.: Not reportable (estimate suppressed due to low counts).

Key Findings: • Some food and water borne infectious diseases showed a seasonal pattern – meaning there was an increase in infection seen at certain times every year. • Using monthly data from all the years between 2000 and 2009, peak numbers of incident cases of Campylobacteriosis was reported between June and August. • A similar, but less pronounced, trend was seen for Salmonellosis. • The number of Cryptosporidosis cases peaked in September (data not shown).

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Other Foodborne and Waterborne Enteric Diseases

Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • Other food and water borne diseases such as Cryptosporidiosis have numbers too low to age and sex standardize for comparison with the provincial rates. • However, a comparison of average annual crude rates calculated from the years 2005 to 2009 indicates that St. Thomas and Elgin County had a higher rate of Cryptosporidiosis infection at 7.4 per 100,000 compared to 2.6 in Ontario. In total over the 2000 to 2009 time period, there were 55 cases of Cryptosporidiosis, 60.0% of which were in females. The average annual number of cases was between four and 11 per year. • There were 21 cases of Verotoxin Producing E. Coli in the time period. There was an average annual crude rate from 2005 to 2009 was of 2.2 in St. Thomas and Elgin County, very similar to 2.1 per 100,000 in Ontario. • Six cases of Shigellosis were seen and five incident cases of Amebiasis were reported between 2000 and 2009. Cyclosporiasis, Listeriosis and Yersiniosis all had fewer than five cases reported in the 10 year time period. The average annual crude rate for all of these diseases was much lower than that of the province.

Tuberculosis Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • There were five incident cases of Tuberculosis in St. Thomas and Elgin County during the 2000 to 2009 time period. • The range of incident cases was between 0 and 3 per year. • These numbers were too low to age‐sex standardize for comparison with the provincial rates and the crude rate in St. Thomas and Elgin County was about 4 times less than that of Ontario.

Diseases Prevented by Routine Vaccination

Influenza Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • In the 10 year period between 2000 and 2009, 124 cases of influenza were reported. • There was a range of 3 to 47 cases reported annually in the 2000 to 2009 time period. • There were not enough cases to age standardize the data to compare to province but the average annual crude rate for St. Thomas and Elgin County for Influenza was 18.6 per 100,000 compared to 25.1 for all types of Influenza (A & B) in the province. • 62.9% of the cases were in females. There were cases distributed throughout all age groups from the very youngest to the oldest group.

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Streptococcus pneumoniae Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • There were 66 cases of streptococcus pneumonia reported in the years 2000 to 2009. • In the 2000 to 2009 time frame the range of annual reported cases was between 2 and 15. • Of all the cases reported, 37 or 56.1% were female. • The numbers of incident cases of streptococcus pneumoniae were too low to generate age‐ standardized rates for comparison with the Ontario population. However, the average annual crude rate of Streptococcus pneumoniae for 2005 to 2009 in St. Thomas and Elgin County was 9.2 per 100,000 compared to 7.9 in the province.

Group A Streptococcal Disease Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • There were 35 cases of Group A Streptococcal disease reported in the years 2000 to 2009. • In the 2000 to 2009 time frame the range of annual reported cases was between 1 and 7. • The numbers of incident cases of Group A Streptococcal disease were too low to generate age‐ standardized rates for comparison with the Ontario population, but crude rates can be used for a rough comparison. The average annual crude rate of Group A Streptococcal disease for 2005 to 2009 in St. Thomas and Elgin County was 4.5 per 100,000 compared to 3.6 in the province.

Other Vaccine Preventable Diseases

Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • There were 32 cases of Pertussis in the 2000 to 2009 time period. • Of the total, 18 or 56.2% of cases were in females. • This was a range of 1 to 7 cases per year between 2000 and 2009. • The average annual crude rate of Pertussis for 2005 to 2009 in St. Thomas and Elgin County was 1.3 per 100,000 compared to 6.3 in the province. • In the same time frame there were 10 reported cases of Chicken Pox, 70.0% of which were in males and most occurred in 2005. • Crude rates indicated a slightly higher rate of Chicken Pox in St. Thomas and Elgin County at 2.2 per 100,000 compared to 1.3 in the province. • There were less than five cases of Mumps and Haemophilus influenza B. • There were no reported cases of Measles or Rubella. • For all of these diseases there were not enough cases to create age‐standardized rates for comparison with the province. • Crude rates were similar for the mumps in St. Thomas and Elgin County between 2005 and 2009 and the province.

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Vaccination Coverage Key Findings (data not shown): Data Source: Canadian Community Health Survey 2007/8, Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ministry of Health and Long‐Term Care • In St. Thomas and Elgin County people were asked if they had received a flu shot in the last year. • The overall rate in the general St. Thomas and Elgin County population was 37.9% (95%CI 33.2‐ 42.7) compared to 35.9% (95%CI 35.2‐36.6) in Ontario. • In seniors with a chronic condition, 74.8% (95%CI 63.4 – 86.1) responded that they had received a shot. This compared to 73.5% (95%CI 71.6‐75.4%) in the same group in Ontario. • In seniors with no chronic condition the rate of vaccination in St. Thomas and Elgin County was slightly higher at 70.0% (95%CI 57.7‐82.2) compared to 65.5% (95%CI 63.6‐67.4) in Ontario. • When comparing people aged 12 to 64 with chronic conditions the rate was 47.6% (95%CI 37.2‐ 58.0) in St. Thomas and Elgin County compared to 42.5% (95%CI 40.1 – 44.9) in Ontario. • None of the St. Thomas and Elgin County rates are statistically different from the Ontario rates.

Figure 9.10: Proportion of staff and residents of hospitals and long term care facilities that were immunized for Seasonal Influenza, Pandemic H1N1 Influenza, Streptococcus pneumoniae and during 2007, 2008 and 2009 influenza seasons Seasonal Streptococcus Pandemic Influenza pneumoniae H1N1 Hospital Staff 23.0% NA NA Staff 66.4% NA NA Oct‐Dec 2007 LTCH Residents 92.2% 77.9% NA Hospital Staff 47.5% NA NA Staff 59.6% NA NA Oct‐Dec 2008 LTCH Residents 91.8% 64.5% NA Hospital Staff 35.9% NA 64.5% Staff 65.3% NA 52.4% Oct‐Dec 2009 LTCH Residents 89.6% 85.1% 84.9% Data Source: Internal Vaccination Coverage Database Elgin St.Thomas Public Health Extracted May 15, 2010 Data Notes: NA: Not Applicable

Key Findings: • In 2009 the rate of pandemic H1N1 vaccination was nearly double that of seasonal influenza vaccination in hospital staff. • Seasonal influenza vaccination coverage rates in long term care staff were consistent between 2007 and 2009 and met the target proportion of 90% coverage. • The Pneumococcal vaccination rate in Long Term Care Home residents was highest last year (85% complete) compared to 64% in 2008 and 78% in 2007. • Seasonal influenza and pH1N1 influenza vaccination was at 90% and 85% respectively for the Long Term Care Home residents in 2009. This was similar to seasonal influenza coverage rates seen in this group in 2007 and 2008.

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Figure 9.11: Immunization coverage for children ages 7 to 17, by school year, St. Thomas and Elgin County, 2004/05 to 2008/09 102.0%

100.0%

98.0%

96.0%

94.0%

Percent 92.0%

90.0%

88.0%

86.0%

84.0% 04/05 05/06 06/07 07/08 08/09 DPT, Polio & MMR 91.3% 91.4% 89.8% 90.5% 90.8% DPT 91.1% 91.2% 91.4% 91.7% 91.7% MMR 95.1% 97.5% 96.9% 97.6% 97.3% Polio 96.3% 96.6% 96.7% 97.0% 96.9% Hib 99.7% 99.8% 99.9% 99.9% 99.9% School Year

Data Source: Immunization Records Information System Elgin St. Thomas Public Health Includes coverage estimates for Diptheria/Pertussis/Tetnus (DPT), Polio, Measles/Mumps/Rubella (MMR) and Haemophilus influenzae type B (Hib)

Key Findings: • The coverage rate of vaccination in children aged 7 to 17 between the 2004/05 school year and the 08/09 school year was very consistent in St. Thomas and Elgin County. • All rates of vaccination coverage were higher in St. Thomas and Elgin County compared to the provincial rates. • Diptheria/Pertussis/Tetnus (DPT) coverage in Ontario in 07/08 was 81.7% in Ontario compared to 91.7% in St. Thomas and Elgin County. • Measles/Mumps/Rubella (MMR) coverage in Ontario in 07/08 was 89.4% in Ontario compared to 97.6% in St. Thomas and Elgin County. • Polio coverage in Ontario in 07/08 was 89.4% in Ontario compared to 97.0% in St. Thomas and Elgin County. • Haemophilus influenzae type B (Hib) coverage in Ontario in 07/08 was 97.1% compared to 99.9% in St. Thomas and Elgin County. Hib is easier to achieve a high vaccination coverage rate at ages 7 to 17 because the last booster is at age 5 rather than the other vaccines where the last booster may be in the teenage years.

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Figure 9.12: Immunization coverage for children in grades 7 and 8, by school year, St. Thomas and Elgin County, 2007/08 and 2008/09 Men‐C Hep B HPV School Year Gr. 7 Gr. 7 Gr. 8 % 07/08 87.7 81.5 46.8 08/09 89.7 83.9 52.4 Data Source: Immunization Records Information System Elgin St. Thomas Public Health Includes coverage estimates for Meningococcal C (Men‐C), Hepatitis B (Hep B) and Human Papillomavirus (HPV)

Key Findings: • Coverage rates of Meningococcal C, Hepatitis B and Human Papillomavirus immunization in children in grades 7 and 8 increased from the 2007/08 school year to the 2008/09 school year. • All of these vaccinations are optional and the lower coverage rates were likely due to this. • The HPV vaccine is given to girls only. There was a 5.6% increase between 2007/08 and 2008/09.

Adverse Vaccine Events

Key Findings (data not shown): Data Source: Integrated Public Health Information System Elgin St. Thomas Public Health Extracted May 11, 2010 • Over the 2000 to 2009 time period there were 14 adverse vaccine events recorded. • The events occurred between 2005 and 2008 with an average annual rate of 2.3 per 100,000. • The range of adverse events due to vaccine was between 1 and 4 per year.

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Outbreaks Figure 9.13: Number of outbreaks, by sector, St. Thomas and Elgin County, 2002 to 2008 combined Number of Outbreaks Retire‐ Child‐ Comm‐ Group LTC Hospital ment School Total care unity home Home # Influenza A 18 0 2 2 0 0 0 22 Influenza B 2 0 0 0 0 0 0 2 RSV 3 0 0 0 0 0 0 3 Respir‐ Para‐influenza 7 0 2 0 0 0 0 9 atory Enterovirus/ 8 0 0 0 0 0 0 8 Rhinovirus Not identified 62 1 2 5 0 0 0 70 Total Respiratory 100 1 6 7 0 0 0 114 Norovirus 6 0 1 1 0 0 0 8 E.Coli 0 0 0 0 2 0 0 2 Enteric C. difficile 1 0 0 0 0 0 0 1 Not identified 44 20 10 4 5 3 1 87 Total Enteric 51 20 11 5 7 3 1 98 Total Outbreaks 151 21 17 12 7 3 1 212 Data Source: Internal Outbreak Database Elgin St. Thomas Public Health Extracted May 26, 2010

Key Findings: • During the time period of 2002 to 2008 inclusive there were 212 outbreaks reported in St. Thomas and Elgin County. • The majority of outbreaks occurred in Long Term Care homes (70.8%) followed by childcare facilities, hospitals, retirement homes and then the community. • There were 114 respiratory outbreaks, 87.7% (N=100) of which occurred in LTC homes • Of the 98 enteric outbreaks, 51 or 52.0% occurred in Long Term Care homes and 20.4% (N=20) occurred in Childcare facilities. • Over 60% of respiratory outbreaks and nearly 90% of enteric outbreaks never had the organism identified. • The most commonly identified respiratory organism in outbreaks was Influenza A and the most commonly identified enteric outbreak causing organism was Norovirus. • In Long Term Care homes, over the time period there were 3 deaths during the Norovirus outbreaks and 10 deaths during enteric outbreaks where the organism was not identified (data not shown). • Similarly, in Long Term Care Homes there were nine deaths during Influenza A outbreaks and one death during an Influenza B outbreak. Three deaths occurred during RSV outbreaks, five during Entero/Rhinovirus outbreaks and 17 during respiratory outbreaks where the organism was not identified during the 2002 to 2008 time period.

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References Reportable Diseases. Ontario Regulations 559/91 and amendments under the Health Protection and Promotion Act. (1990). Accessed May, 2010, from: http://www.e‐ laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm.

An Advisory Committee Statement (ACS). National Advisory Committee on Immunization (NACI). (2008). Statement on influenza vaccination for the 2008‐2009 season. Can Commun Dis Rep. 2008;34(ACS‐3):1‐46.

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Chapter 10: Environmental Health

193

Overview The environment can significantly impact the health of St. Thomas and Elgin County residents mostly by affecting mortality and morbidity from chronic and communicable diseases.

Air quality ratings indicate that St. Thomas and Elgin County had almost as many poor air quality days as any other place in Ontario; in fact, Port Stanley had the greatest number of poor air quality days in 2006. Generally, the beaches were open for the entire bathing season with no advisories issued in 2009 and only 5% of days posted with swimming advisories in 2008. Extreme weather is also monitored to protect vulnerable populations. In 2008 and 2009 there were more extreme cold than heat alerts – most cold alerts occurred in the month of February and all heat alerts occurred in July.

Food premise investigation completion rates were higher than previous years and nearly complete for all premise risk levels in 2007 and 2008 – the inspection completion rate fell again in 2009. Regardless, information in the communicable diseases chapter indicated that incidence of food and water borne illnesses were low in St. Thomas and Elgin County, particularly when compared with Ontario.

Although there was very little burden of disease from West Nile Virus and there were no rabies cases in St. Thomas and Elgin County over the time frame studied, a tremendous amount of surveillance was in place to identify potential threats from these diseases.

Data is not currently available on surveillance of drinking‐water systems and is not included in this report.

Ontario Public Health Standards – Related Sections

Population Health Assessment and Surveillance Protocol

1) Data Access, collection and management b) The board of health shall collect or access the following types of population health data and information: vi) Risk factors including … food‐handling practices, and infection prevention and control practices of inspected premises associated with risk of infectious diseases of public health importance; viii) Physical environment factors;

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Environmental Health Introduction The physical environment has important implications for overall health. People are constantly affected by components of the environment including water quality, air quality, agricultural processes, food quality, and animal and insect populations. Public health plays a significant role in monitoring aspects of the environment that can adversely affect health.

Adverse health effects from air pollution are well documented (Toronto Public Health, 2004). Air pollution has health implications for many people, especially the elderly, children, and those with chronic respiratory or heart problems. Smog, comprised of ozone and fine particulate matter, remains an important issue in southern Ontario during the summer (Ministry of the Environment, 2008). Research suggests that the U.S. Midwest and Ohio Valley Region of the U.S. continue to be important contributors to elevated smog concentrations in southern Ontario.

The Elgin St. Thomas Public Health Heat and Cold Alert system was implemented in 2008 with the objective to reduce the health risks associated with extreme hot or cold temperatures, especially for persons at risk such as seniors, those with underlying medical conditions and the homeless, through a coordinated, community response. Community partners in the Elgin County Extreme Temperature Notification System are notified of the alert and respond in ways appropriate to their particular mandate, such as opening a warming or cooling centre, or checking on people at risk (ESTPH, 2009).

St. Thomas and Elgin County residents have access to many recreational opportunities on the waters and beaches of Lake Erie; however, if contaminated, these waters can cause adverse health effects including gastrointestinal illness, and infections of the eyes, ears, nose and throat. Public health units conduct routine beach surveillance throughout the course of the bathing season to ensure that public beaches are suitable for swimming. Beaches are posted with swimming advisories if the samples exceed the acceptable threshold of E‐coli bacteria concentrations or if other health hazards have been identified (APHEO, 2006). Heavy rainfall and strong winds, among other factors, influence the bacterial levels in beach water.

Public health units are mandated to inspect all food premises to ensure that food is safely stored, prepared, served and distributed in a manner that will prevent foodborne illness. Furthermore, the Food Handler Certification Program provides an opportunity for food handlers to learn about food safety including public health legislation, the role of the public health inspector, foodborne illness, safe food handling methods and food premises sanitation.

Animal and insect populations are other aspects of the environment that present health risks to the human population. Local public health units monitor bites and scratches from domestic and wild animals and the distribution of post‐exposure preventive treatment for rabies. West Nile Virus (WNV) is another infectious disease that requires routine surveillance and monitoring. Dead bird surveillance is no longer conducted in some provinces and territories, including Ontario – instead, WNV surveillance efforts are focused on detecting the virus in mosquito and human populations.

This chapter examines components of environmental health including air quality, extreme weather, beach safety, food safety and vector‐borne and zoonotic diseases. The data presented comes from the Ministry of the Environment as well as from internal inspection and surveillance databases.

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Air Quality

Air Quality Index

Figure 10.1: Number of days that air quality was poor or very poor1, Port Stanley and London and the Ontario site with the most poor air quality days, 2004 to 2008 STE Area ON Site with Most poor AQ Days Year # poor AQ days Site # poor AQ days Site Port Stanley London 2004 14 13 Sarnia 18 2005 30 18 Windsor 37 2006 15 4 Port Stanley 15 2007 24 6 Sarnia 28 2008 7 5 Sarnia 15 Data Source: Ontario Air Quality Data. Ministry of the Environment 1As indicated by an air quality index (AQI) > 49 for at least one hour of the day

Key Findings: • The number of poor or very poor air quality days was higher in Port Stanley than London over the timeframe. • In 2006, Port Stanley was the site with the poorest air quality in Ontario. In other years the number of poor AQ days in Port Stanley was similar to the ON site with the most poor air quality days. • In all cases the Ontario site with the highest number of poor or very poor air quality days was located in Southwestern Ontario and on the great lakes.

DEFINITION: DID YOU KNOW?

The Air Quality Index (AQI) is based on six pollutants that Air pollution comes have adverse effects on human health and the environment: from various ozone (O3), fine particulate matter (PM2.5), nitrogen dioxide stationary, mobile and (NO2), carbon monoxide (CO), sulphur dioxide (SO2), and natural sources total reduced sulphur (TRS) compounds. including, factories AQI < 32 = good or very good and power plants; AQI 32‐49 = moderate vehicles and marine AQI 50‐99 = poor vessels; and forest AQI >99 = very poor fires and dust from Air quality in the poor or very poor range can have adverse vegetation. effects on a large portion of the animal/human population and can damage property and vegetation. (Ministry of the Environment, 2008) (Ministry of the Environment, 2008) 196

Smog Advisories

Figure 10.2: Number of annual smog advisories issued and smog advisory days, St. Thomas and Elgin County and DEFINITION: Ontario, 2005 to 2009 The Ministry of the Environment # of smog advisories issued maintains the Smog Alert Program. (# days) Year A Smog Advisory is called when widespread elevated and persistent Elgin County Ontario smog levels are forecast within the next 24 hours. If widespread, 2005 12(45) 15 (53) elevated smog levels occur without 2006 4(13) 6 (17) warning and weather conditions 2007 13(37) 13 (39) conducive to the persistence of such 2008 6(15) 8 (17) levels are forecast to continue for 2009 2(4) 3 (5) several hours, then a Smog Advisory Data Source: Ontario Air Quality Smog Advisory Statistics is issued immediately. Ministry of the Environment

Key Findings: • There have been fewer smog advisories in St. Thomas and Elgin County and Ontario as a whole in recent years compared to 2005 and 2007. • In 2009, three smog advisories were issued for Ontario covering a total of 5 days. St. Thomas and Elgin County had two advisories over four days. • Although lower than the total number advisories, St. Thomas and Elgin County had about an 85% chance of having a smog advisory if an advisory was issued in Ontario.

DID YOU KNOW?

Elevated smog levels during the summer in Ontario are typically due to weather patterns that affect the lower Great Lakes region. These weather patterns are usually associated with slow‐ moving high pressure cells across the region and result in the transport of air pollutants over a long range from neighbouring U.S. industrial and urbanized states during the flow of warm air from the southwest to the northeast.

(Ministry of the Environment, 2008)

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Extreme Weather Conditions

Extreme Heat DID YOU KNOW? • In 2008 there were two heat alerts lasting for a total of six days. • In 2009 there were two heat alerts lasting for a total of five days. Community partners in • All heat alerts occurred in July. the Elgin County Extreme Temperature In the future, data for heat alerts should be examined with smog and air Notification System quality information to help understand if there is a relationship between include municipalities, these two factors in St. Thomas and Elgin County. police, fire, emergency services, health care institutions, social Extreme Cold service agencies, schools and churches.

• During 2008 there were six cold alerts lasting for a total of 14 (ESTPH, 2009) days. • In 2009 there were six cold alerts lasting for total of 22 days. • The majority (60%) of the cold alerts happened in February.

DEFINITION(S):

Elgin St. Thomas Public Health issues a heat alert if at least one of the following conditions exists:

• the forecast is showing a humidex advising of 40° Celsius or higher; • the humidex is forecast to rise to 36° Celsius or higher, combined with an Environment Canada Smog Alert; • Environment Canada issues a humidex warning for outdoor activity for people in the St. Thomas and Elgin County area; or, • the temperature is 38° Celsius or above with no humidex indicated.

Elgin St. Thomas Public Health issues a cold alert if at least one of the following conditions exists:

• the daily predicted low temperature is –15° Celsius without wind chill; • the wind chill reaches the level at which Environment Canada issues a warning for outdoor activity for people in the St. Thomas and Elgin County area; or, • extreme weather conditions, such as a blizzard or ice storm, are occurring.

(ESTPH, 2009)

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Beach Advisories

Figure 10.3: Proportion of days in monitoring season (June to September) that beaches were posted with swimming advisories, St. Thomas and Elgin County, 2005 to 2009 % of monitoring season where beaches were Beach posted with swim advisories 2005 2006 2007 2008 2009 Port Glascow 0% 6% 0% 0% 0% Erie Rest 0% 0% 0% 10% 0% Main Beach 0% 95% 19% 0% 0% Little Beach 0% 24% 8% 11% 0% Port Bruce 0% 8% 0% 8% 0% Springwater 0% 0% 0% 0% 0% Port Burwell ‐ NA NA 0% 13% 0% Village Port Burwell ‐ NA NA 0% 0% 0% Provincial Park Average 0% 22% 3% 5% 0% Data Source: Internal Beach Posting Data Elgin St. Thomas Public Health Extracted July 6, 2010

Key Findings: • In 2009 there were zero swimming advisories posted for beaches in St. Thomas and Elgin County. • In 2007 and 2008, on average only five percent of the bathing season was posted with a swimming advisory. • Little Beach and Main Beach in Port Stanley have had the greatest proportion of days with swimming advisories in St. Thomas and Elgin County between 2005 and 2009. • Swimming advisories were generally seen when samples were taken on hot days with high wave action and high wind.

DID YOU KNOW?

E.coli is an organism that indicates the potential presence of viruses and bacteria that may cause disease. A beach is posted if the collected samples exceed the acceptable threshold of number of E.coli bacteria or if other health hazards have been identified. Beach water E.coli levels are largely affected by factors such as rainfall, current and wind direction, wave action, presence of birds or other animals, as well as management of storm and sanitary sewers.

(APHEO, 2006) 199

Food Safety

Food Premises Inspection

Figure 10.4: Proportion of premises that received required inspections, by risk level, St. Thomas and Elgin County, 2004 – 2009 100.0%

90.0%

80.0%

70.0%

60.0% Complete

50.0%

40.0% Percent 30.0%

20.0%

10.0%

0.0% 2005 2006 2007 2008 2009 High 5.4% 44.8% 92.5% 97.2% 57.0% Medium 32.4% 53.3% 97.6% 82.9% 14.0% Low 37.6% 58.5% 89.5% 90.4% 24.0% Year

Data Source:Food Premise Inspection Data. Hedgehog Database. Elgin St.Thomas Public Health. Extracted March 2, 2010.

Key Findings: • In 2008, 97% of all high risk premises DID YOU KNOW? received the required number of inspections, as did 83% of the medium Using a Risk Categorization Model, food risk and 90% of the low risk. premises are categorized as low, medium or • In 2007 and 2008 completion rate for high risk. The risk level is assigned based on the required inspections were at their complexity of the menu, the type of food highest point, increased from 2005. The served, and the vulnerability of the population rates were lower again in 2009. served. The number of required inspections of a premise is determined by the risk level it has been assigned.

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Food Handler Education

Figure 10.5: Total number of food handling certificates issued, St. Thomas and Elgin County, 2004 to 2009 DID YOU KNOW? Number of Year courses The food handler education provided by public 2004 119 health units allows food handlers to 2005 90 successfully complete an examination to obtain a food handler certificate meeting the 2006 109 Ontario Ministry of Health's food handling 2007 157 training protocol mandatory certification of 2008 143 food handlers. More importantly, the 2009 168 information assists the food handler in storing, Total 786 preparing, cooking and serving food that is Data Souce: Internal Food Handler Certificate Data safe to eat. Elgin St. Thomas Public Health Extracted July 22, 2010.

Key Findings: • The number of food handling certificates issued in 2009 was greater than all the years before that. • The trend indicates that a greater number of food handlers have been trained in recent years compared to the past.

VectorBorne and Zoonotic Diseases

West Nile Virus DEFINITION:

West Nile Virus is a virus that can Key Findings (data not shown): be transmitted to humans through • The number of cases reported in Ontario has been a bite from an infected mosquito. declining in recent years. Mosquitoes become infected after • Surveillance in the past ten years indicated that St. feeding on the blood of birds that Thomas and Elgin County is home to the species of carry the virus. Most infected mosquito associated with West Nile Virus and it has people show no symptoms or may been detected in all parts of St. Thomas and Elgin show flu‐like symptoms; however, County; however, there has not been a significant severe illness is a possibility. burden of illness due to West Nile Virus within the region. (PHAC, 2009) • There have been fewer than five confirmed human cases in St. Thomas and Elgin County – in all of which it was not possible to confirm that the virus was contracted in St. Thomas and Elgin County. 201

Rabies Figure 10.6: Number of animal investigations, and persons receiving rabies prophylaxis treatment, St. Thomas and Elgin County, 2006 to 2009 Persons Animal Year Receiving Investigations Prophylaxis 2006 273 31 2007 254 33 2008 285 38 2009 256 24 Data Source: Rabies Investigation Data. Hedgehog Database Elgin St.Thomas Public Health Extracted March 2, 2010

Key Findings: • There have been no cases of rabies in Ontario since 1967 (data not shown). • There have been a consistent number of rabies investigations due to contact with domestic and wild animals each year for the past several years. • Of the 34 animals tested in 2009 only 4 were confirmed cases of rabies (data not shown). • The number of people receiving prophylaxis was also fairly consistent until the regulations regarding administration of the vaccine changed in 2009. At that point the number of people receiving prophylaxis decreased.

DEFINITION: DID YOU KNOW?

Rabies is a viral infection of the central nervous Rabies is a reportable disease and system that is almost always fatal if left untreated. under Ontario law, dogs and cats Any warm‐blooded animal, including humans, can must be quarantined for a become infected after contact with saliva from an minimum of 10 days after biting a infected animal – usually through a bite, or scratch. person. Public health inspectors Worldwide, rabies is most often transmitted observe the animal for abnormal through dogs; however, foxes, skunks, raccoons, behaviour and signs of rabies. If bats and livestock may be other common carriers. the animal is healthy at the end of the 10 days it can be released. (PHAC, 2009)

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References: Association of Public Health Epidemiologists of Ontario (APHEO). (2006). Posted Bathing Beaches in Core Indicators for Public Health in Ontario. Retrieved August, 2010, from http://www.apheo.ca/index.php?pid=84

Elgin St. Thomas Public Health. (2009). Extreme Temperature Alert System Protocol.

Ministry of the Environment. (2008). Air Quality in Ontario – 2008 Report. Retrieved August, 2010, from http://www.ene.gov.on.ca/en/publications/air/index.php#2

Public Health Agency of Canada. (2009). Rabies in Disease Information. Retrieved August, 2010, from http://www.phac‐aspc.gc.ca/tmp‐pmv/info/rage‐eng.php

Public Health Agency of Canada. (2009). West Nile Virus – Protect Yourself in Infectious Diseases. Retrieved August, 2010, from http://www.phac‐aspc.gc.ca/wn‐no/index‐eng.php

Toronto Public Health. (2004). Air Pollution Burden of Illness in Toronto. Retrieved August, 2010, from http://www.city.toronto.on.ca/health/hphe/air_and_health.htm#1

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Appendix A: Ontario Public Health Standards: Assessment and Surveillance Requirements

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Appendix A: Ontario Public Health Standards: Assessment and Surveillance Requirements

Foundational Standard (Addressed throughout report)

Assessment and Surveillance Requirements:

1. The board of health shall assess current health status, health behaviours, preventive health practices, health care utilization relevant to public health, and demographic indicators in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). 2. The board of health shall assess trends and changes in local population health in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). 3. The board of health shall use population health, determinants of health and health inequities information to assess the needs of the local population, including the identification of populations at risk, to determine those groups that would benefit most from public health programs and services (i.e., priority populations). 4. The board of health shall tailor public health programs and services to meet local population health needs, including those of priority populations to the extent possible based on available resources. 5. The board of health shall provide population health information including determinants of health and health inequities to the public, community partners, and health care providers, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). 6. The board of health shall conduct surveillance, including the ongoing collection, collation, analysis, and periodic reporting of population health indicators, as required by the Health Protection and Promotion Act and in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current). 7. The board of health shall interpret and use surveillance data to communicate information on risks to relevant audiences in accordance with the Identification, Investigation and Management of Health Hazards Protocol, 2008 (or as current); the Infectious Diseases Protocol, 2008 (or as current); the Population Health Assessment and Surveillance Protocol, 2008 (or as current); the Public Health Emergency Preparedness Protocol, 2008 (or as current); and the Risk Assessment and Inspection of Facilities Protocol, 2008 (or as current).

Board of Health Outcomes: 1. Public health programs and services are planned and implemented to address local population health needs. 2. The public, community partners, and health care providers are aware of relevant and current population health information. 3. The board of health identifies public health priorities, including identification of emerging public health issues.

Chronic Disease Prevention (see Chronic Health Conditions Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current), in the areas of: • Healthy eating; • Healthy weights; • Comprehensive tobacco control; • Physical activity; • Alcohol use; and • Exposure to ultraviolet radiation. Data not available

2. The board of health shall monitor food affordability in accordance with the Nutritious Food Basket Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for chronic disease prevention.

Prevention of Injury and Substance Misuse (see Injuries and Injury Prevention and Lifestyle Behaviours Chapters)

Assessment and Surveillance Requirements:

1. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current), in the areas of: • Alcohol and other substances; • Falls across the lifespan; • Road and off‐road safety; and • Other areas of public health importance for the prevention of injuries.

Board of Health Outcomes: The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the prevention of injury and substance misuse. Health Standards: Assessment and Surveillance Requirement

Reproductive Health (see Reproductive Health Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) in the areas of: • Preconception health; • Healthy pregnancies; • Reproductive health outcomes; and • Preparation for parenting.

Board of Health Outcomes: The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the promotion of reproductive health.

Child Health (see Reproductive Health Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current), in the areas of: • Positive parenting; Data not available • Breastfeeding; • Healthy family dynamics; Data not available • Healthy eating, healthy weights, and physical activity; Data not available • Growth and development; and • Oral health. Data not available

2. The board of health shall conduct surveillance of children in schools and refer individuals who may be at risk of poor oral health outcomes in accordance with the Oral Health Assessment and Surveillance Protocol, 2008 (or as current), and the Population Health Assessment and Surveillance Protocol, 2008 (or as current). Data not available

3. The board of health shall report oral health data elements in accordance with the Oral Health Assessment and Surveillance Protocol, 2008 (or as current). Data not available

The board of health achieves timely and effective detection and identification of children at risk of poor oral health outcomes, their associated risk factors, and emerging trends.

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Infectious Diseases Prevention and Control (see Communicable Diseases Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall report infectious disease data elements in accordance with the Health Protection and Promotion Act and the Infectious Diseases Protocol, 2008 (or as current).

2. The board of health shall conduct surveillance of: • Infectious diseases of public health importance, their associated risk factors, and emerging trends; and • Infection prevention and control practices of inspected premises associated with risk of infectious diseases of public health importance in accordance with the Infectious Diseases Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

3. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of cases/outbreaks of infectious diseases of public health importance, their associated risk factors and emerging trends.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to prevent or reduce the burden of infectious diseases of public health importance.

Rabies Prevention and Control (see Environmental Health Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall liaise with the Canadian Food Inspection Agency to identify local cases of rabies in animal species.

2. The board of health shall report rabies data elements in accordance with the Health Protection and Promotion Act and the Rabies Prevention and Control Protocol, 2008 (or as current).

3. The board of health shall conduct surveillance of rabies in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) and the Rabies Prevention and Control Protocol, 2008 (or as current).

4. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of positive reports of rabies in animal species and other emerging risks and trends associated with rabies in humans.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to prevent the occurrence of rabies in humans.

Tuberculosis Prevention and Control (see Communicable Diseases Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall report TB data elements in accordance with the Health Protection and Promotion Act and the Tuberculosis Prevention and Control Protocol, 2008 (or as current).

2. The board of health shall conduct surveillance of active tuberculosis as well as individuals with LTBI in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) and the Tuberculosis Prevention and Control Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of TB trends, emerging risks, and associated risk factors.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to prevent and reduce the burden of TB.

Sexual Health, Sexually Transmitted Infections, and Bloodborne Infections (including HIV) (see Communicable Diseases and Reproductive Health Chapters)

Assessment and Surveillance Requirements:

1. The board of health shall report data elements on sexually transmitted infections and blood‐borne infections in accordance with the Health Protection and Promotion Act and the Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current).

2. The board of health shall conduct surveillance of: • Sexually transmitted infections; • Blood‐borne infections; • Reproductive outcomes; • Risk behaviours; and • Distribution of harm reduction materials/equipment.

in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) and the Sexual Health and Sexually Transmitted Infections Prevention and Control Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of cases of sexually transmitted infections and blood‐borne infections, and their associated risk factors and emerging trends.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to promote healthy sexuality and to prevent or reduce the burden of sexually transmitted infections and blood‐borne infections.

Vaccine Preventable Diseases (see Communicable Diseases Chapter)

Assessment and Surveillance Requirements: 1. The board of health shall assess, maintain records and report, where applicable, on: • The immunization status of children enrolled in licensed child care programs as defined in the Day Nurseries Act; • The immunization status of children attending schools in accordance with the Immunization of School Pupils Act; and • Immunizations administered at board of health‐based clinics as required in accordance with the Immunization Management Protocol, 2008 (or as current) and the Infectious Diseases Protocol, 2008 (or as current).

2. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Infectious Diseases Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of children susceptible to vaccine preventable diseases, their associated risk factors, and emerging trends.

The board of health achieves timely and effective detection and identification of priority populations facing barriers to immunization, their associated risk factors, and emerging trends. The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to reduce or eliminate the burden of vaccine preventable diseases.

Food Safety (see Communicable Diseases and Environmental Health Chapters)

Assessment and Surveillance Requirements:

1. The board of health shall conduct surveillance of: • Suspected and confirmed food‐borne illnesses; and • Food premises in accordance with the Food Safety Protocol, 2008 (or as current) and the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

2. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

3. The board of health shall report Food Safety Program data elements in accordance with the Food Safety Protocol, 2008 (or as current)s: Assessment and Surveillance Requirements

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Board of Health Outcomes: The board of health achieves timely and effective detection and identification of: • Food‐borne illnesses; • Their associated risk factors and emerging trends; and • Unsafe food in food premises.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to reduce the burden of food‐borne illness of public health importance.

Safe Water (see Environmental Health Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall report Safe Water Program data elements in accordance with the Beach Management Protocol, 2008 (or as current); the Drinking Water Protocol, 2008 (or as current); and the Recreational Water Protocol, 2008 (or as current).

2. The board of health shall conduct surveillance of drinking‐water systems and of drinking water illnesses of public health importance, their associated risk factors, and emerging trends in accordance with the Drinking Water Protocol, 2008 (or as current); the Infectious Diseases Protocol, 2008 (or as current); and the Population Health Assessment and Surveillance Protocol, 2008 (or as current). Data not available

3. The board of health shall conduct surveillance of public beaches and public beach water illnesses of public health importance, their associated risk factors, and emerging trends in accordance with the Beach Management Protocol, 2008 (or as current).

5. The board of health shall conduct surveillance of recreational water facilities in accordance with the Recreational Water Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of water contaminants and illnesses, their associated risk factors, and emerging trends.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to reduce the burden of water‐borne illnesses of public health importance.

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Health Hazard Prevention and Management (see Environmental Health Chapter)

Assessment and Surveillance Requirements:

1. The board of health shall conduct surveillance of the environmental health status of the community in accordance with the Identification, Investigation and Management of Health Hazards Protocol, 2008 (or as current); the Infectious Diseases Protocol, 2008 (or as current); the Population Health Assessment and Surveillance Protocol, 2008 (or as current); the Public Health Emergency Preparedness Protocol 2008 (or as current); and the Risk Assessment and Inspection of Facilities Protocol, 2008 (or as current).

2. The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current).

Board of Health Outcomes: The board of health achieves timely and effective detection and identification of exposures of human health concern and associated public health risks, trends and illnesses.

The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services to reduce or eliminate the burden of illness from health hazards in the environment.

Public Health Emergency Preparedness (Data not available)

1. The board of health shall identify and assess the relevant hazards and risks to the public’s health in accordance with the Identification, Investigation and Management of Health Hazards Protocol, 2008 (or as current); the Population Health Assessment and Surveillance Protocol, 2008 (or as current); and the Public Health Emergency Preparedness Protocol, 2008 (or as current).