Carbapenemases producer Gram negative bacilli infections
Surveillance results: 2014-2015

From April 1, 2014, to March 31, 2015, 67 healthcare facilities (participation rate: 75.2%) took part in the surveillance of carbapenemase-producing Gram negative bacilli (CPGNB) infections, for a total of 3,225,934 patient-days (Table 1).

In total, 9 CPGNB infections were reported among patients who acquired their strain during a current or previous hospital stay in the reporting facility (categories 1a + 1b). The incidence rate of healthcare-associated CPGNB infection (cat. 1a + 1b) was 0.028 / 10,000 patient days. The acquisition rate of healthcare-associated CPGNB colonization (cat. 1a + 1b) was 0.16 / 10,000 patient days. Data was extracted on May 20th, 2015 and updated on June 1, 2015 for complications. 

Updated : March 24, 2016

Table 1 – Participation of Healthcare Facilities in the Surveillance of CPGNB Infections, Québec, 2014-2015

 

2014-2015

Participating facilities (N)

67

Admissions (N)

432,363

Inpatient-days (N)

3,225,934

Cases of healthcare-associated CPGNB infection (cat. 1a + 1b) (N)

9

Cases of healthcare-associated CPGNB colonization (cat. 1a + 1b) (N)

52

Infected patients (N)

8

In 2014–2015, the incidence rate of healthcare-associated CPGNB infection (cat. 1a + 1b) was 0.028/10,000 patient-days (table 2).  

Teaching healthcare facilities have a higher incidence rate of healthcare-associated CPGNB infection than non teaching facilities (table 2).

Table 2 – Incidence Rate and Percentile Distribution of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) by Type of Healthcare Facility, Québec, 2014–2015 (Incidence Rate per 10,000 Patient-Days [95% CI])

Type of Facility

Min.

25 %

50 %

75 %

90 %

Max.

Incidence Rate

Non-teaching (N = 45)

0.057

0.057

0.057

0.057

0.057

0.057

0.007 [0-0.027]

Teaching (N = 22)

0.069

0.091

0.122

0.236

0.558

0.558

0.046 [0.020-0.083]¥

Total (N = 67)

0.057

0.069

0.119

0.236

0.558

0.558

0.028 [0.013-0.049]

[I.C. 95 %] : 95% confidence interval.
¥ Significant statistical difference (p < 0.05) between non-teaching and teaching healthcare facilities.

In total, 67 colonizations (including 14 infections) of CPGNB were reported: 54 (80.6%) were identified in patients who acquired their CPGNB during a current hospital stay (9 infections and 51 colonizations), during a previous hospital stay (1 colonization) or in ambulatory care of the reporting facility (1 infection and 2 colonizations) (cat. 1a, 1b and 1c.). A total of 13 colonizations were associated to another facility (2 infections and 6 colonizations), to the community (2 colonizations) or remained unknown (2 infections and 5 colonizations) (cat. 2, 3 and 4) (table 3).

Table 3 – Cases of CPGNB Infections and Colonizations by Presumed Source of Acquisition, Québec, 2014–2015 (N, %)

Category

Source of Acquisition

Infection

Colonization*

1a

Healthcare-associated with a current hospital stay in the reporting facility

9 (64.3 %)

51 (76.1 %)

1b

Healthcare-associated with a previous hospital stay in the reporting facility

0 (0 %)

1 (1.5 %)

1c

Healthcare-associated with ambulatory care in the reporting facility

1 (7.1 %)

2 (3 %)

1d

Healthcare-associated with long-term unit in the reporting facility

0 (0 %)

0 (0 %)

1e

Healthcare-associated with psychiatry unit in the reporting facility

0 (0 %)

0 (0 %)

2

Healthcare-associated with another facility

2 (14.3 %)

6 (9 %)

3

Community

0 (0 %)

2 (3 %)

4

Unknown

2 (14.3 %)

5 (7.5 %)

 

Total

14

67

* Colonizations included infections.

In 2014-2015, among 14 infections, no primary bloodstream infection (BSI) was observed. However, two secondary bloodstream infections have been reported (Table 4).

Table 4 – Number of Cases of CPGNB Infections from All Sources by Type of Infection and Number of Complications (Secondary BSIs), Québec, 2014–2015 (N = 14)

Type of Infection

Infections
(N)

Secondary Bloodstream
Infections (N)

Primary BSI

 

 

   CRBSI-MBI

0

-

   CRBSI

0

-

   Non- CRBSI-MBI

0

-

   Non-CRBSI

0

-

   HD

0

-

 

 

 

Others

 

 

   Surgical site

5

0

   Urinary tract

3

0

   Abdominal

3

1

   Pulmonary

2

1

   Skin and soft tissus

1

0

   Bones and joints

0

0

   Others

0

0

Total

14

2

BSI : bloodstream infection
CRBSI : catheter-related bloodstream infection
MBI : mucosal barrier injury
Non-CRBSI : non-catheter-related primary bloodstream infection
HD: hemodialysis

A total of 5 deaths within 30 days were observed, yielding an all cause case-fatality of 35.7% (Table 5).

Table 5 – Number of Deaths and 30-days all cause case-fatality in Patients Infected by a CPGNB, Québec, 2014-2015

 

2014-2015

CPGNB infections (all sources)

14

Number of deaths

5

All cause case-fatality

35.7 %

Table 6 – Risk Factors Associated With CPGNB colonization, Québec, 2014-2015

Risk Factors

New carrier

Known carrier
N = 3

Undefined carrier
N = 13

 

No contact with
a known carrier
N = 42

Contact with
a known carrier
N = 9

Contact with known carrier

-

9

-

7

Healthcare abroad

3

-

-

2

Travel abroad in the last 12 months

8

-

-

-

 

 

 

 

 

Other risks

 

 

 

 

Carba-3GC*-Fluo

3

1

-

4

No Carba-3GC-Fluo

7

1

-

-

Diabetes

4

-

-

2

Acute renal failure

2

-

1

-

Chronic renal failure

-

-

1

2

Non hematologic active neoplasia

13

2

1

-

Solid organ transplant

3

-

-

-

* 3GC: 3rd generation cephalosporin.
Carba-3GC-Fluo: Taking a carbapenem / 3rd generation cephalosporin / fluoroquinolone in the last two weeks prior to diagnosis.
Carba-3GC-Fluo: Taking a carbapenem / 3rd generation cephalosporin / fluoroquinolone in the last two weeks prior to diagnosis.

In 2014-2015, the acquisition rate of healthcare-associated CPGNB colonization (cat. 1a + 1b) was 0.16 / 10,000 patient days (table 7).

Table 7 – Change in the Number of Cases and Acquisition Rate of Healthcare-associated CPGNB  Colonization (Cat. 1a + 1b) by Type of Healthcare Facility, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000  patient-days)

 

2014-2015

Type of Facility

Number of Colonization

Acquisition Rate of HA-CPGNB  Colonization

Non-teaching (N = 45)

33

0.22 [0.15-0.31]

Teaching (N = 22)

19

0.11 [0.07-0.16]

Total (N = 67)

52

0.16 [0.12-0.21]

Table 8 shows the number of non-teaching facilities that identified the type of screening used at admission (29 out of 45) and during hospitalization (26 out of 45). About two-thirds of teaching facilities identified the type of screening used at admission (16 out of 22) and during hospitalization (16 out of 22).

Table 8 – Number of Healthcare Facilities that Identified the type of Screening Procedure Used at Admission and During Hospitalization by Type of Facility, Québec, 2014-2015

 

Number of Facilities That Identified the Type of Screening Procedure Used*

Type of Facility

At admission

During Hospitalization

Total

Non-teaching (N = 45)

29

26

33

Teaching (N = 22)

16

16

17

Total (N = 67)

45

42

50

* The "at admission" and "during hospitalization" categories are not mutually exclusives.

Tables 9 and 10 feature the total number of screening tests performed at admission and during hospitalization, as well as the mean number of CPGNB screening tests per admission.

Table 9 – Total Number of Screening Tests Performed at Admission and During Hospitalization by Type of Healthcare Facility, Québec, 2014-2015

 

Total Number of Screening Tests

Type of Facility

At admission

During Hospitalization

Unspecified

Total

Non-teaching 

2,619

8,102

795

11,516

Teaching 

10,686

17,417

29

28,132

Total

13,305

25,519

824

39,648

Table 10 – Mean Number of CPGNB Screening Tests by Type of Healthcare Facility, Québec, 2014-2015 (Mean CPGNB Screening Tests per Admission)

 

Mean Number of CPGNB Screening Tests

Type of Facility

At admission

During Hospitalization

Total
(N)

Non-teaching 

0.013

0.040

0.057

Teaching 

0.046

0.075

0.121

Total

0.031

0.059

0.092

Figure 1 features the distribution of microorganisms isolated from all cases. A total of 35 colonizations were due to Citrobacter freundii (52 %), 11 colonizations were due to Klebsiella pneumonia (16 %) and 7 were due to Enterobacter cloacae (10 %). Most deaths occurred in patients with KPC-producing Klebsiella pneumonia (n = 5; 62.5%). All 8 deaths occurred in patients with KPC-producing microorganisms.

Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Isolated Microorganisms - All Cases
Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Isolated Microorganisms – Deaths at 30 Days (N = 8)
Figure 1 – Categories of Isolated Microorganisms for all Cases (n = 67) and for Deaths at 30 days (N = 8), Québec, 2014-2015

Table 11 presents the resistance profile as reported by the healthcare facilities towards carbapenems of all reported microorganisms (colonization and infection). All the E. coli, K. oxytoca, S. marcescens and Serratia spp. were ertapenem resistant (100%). All the A. baumanii, E. cloacae, E. coli, K. oxytoca, Klebsiella spp, and Serratia spp. were meropenem resistant (100%).

Table 11 – Resistance Profile Towards Carbapenem of CPGNB Microorganisms isolated, Québec, 2014-2015

Microorganism

N

Antibiotics

Resistants

N

%

Acinetobacter baumannii

3

Doripenem

2

66.7

 

 

Imipenem

3

100.0

 

 

Meropenem

3

100.0

Citrobacter freundii

35

Ertapenem

32

91.4

 

 

Imipenem

12

34.3

 

 

Meropenem

28

80.0

Enterobacter cloacae

7

Ertapenem

4

57.1

 

 

Imipenem

6

85.7

 

 

Meropenem

7

100.0

Escherichia coli

5

Ertapenem

5

100.0

 

 

Imipenem

4

80.0

 

 

Meropenem

5

100.0

Klebsiella oxytoca

4

Ertapenem

4

100.0

 

 

Imipenem

2

50.0

 

 

Meropenem

4

100.0

Klebsiella pneumoniae

12

Ertapenem

11

91.7

 

 

Imipenem

9

75.0

 

 

Meropenem

11

91.7

Klebsiella spp.

1

Ertapenem

1

100.0

 

 

Meropenem

1

100.0

Serratia marcescens

1

Ertapenem

1

100.0

 

 

Imipenem

1

100.0

Serratia spp.

1

Ertapenem

1

100.0

 

 

Imipenem

1

100.0

 

 

Meropenem

1

100.0

Table 12 shows the carbapenemase gene detected for every microorganisms reported during the surveillance period (colonization and infection). Among the 67 cases, one infection was associated with two different CPGNB (1 NDM-producing Escherichia coli and 1 OXA-48 producing Klebsiella pneumonia). Also, one patient was colonizationed by two different CPGNB (1 KPC-producing Escherichia coli and 1 KPC-producing Klebsiella oxytoca). Finally, one Klebsiella pneumonia strain produced both OXA-48 and NDM.

Table 12 – Distribution of Carbapenemase-encoding Genes from Reported Microorganisms, Québec, 2014-2015

Microorganism

No Isolated

Gene

N

% gene among
microorganism

Acinetobacter baumannii

3

OXA-23

3

100.0

Citrobacter freundii

35

KPC

35

100.0

Enterobacter cloacae

7

KPC

6

85.7

 

 

NMC

1

14.3

Escherichia coli

5

KPC

1

20.0

 

 

NDM

3

60.0

 

 

OXA-48

1

20.0

Klebsiella oxytoca

4

KPC

4

100.0

Klebsiella pneumoniae

12

KPC

9

69.2

 

 

OXA-48

1

7.7

 

 

OXA-48/NDM

1

7.7

 

 

VIM

1

7.7

Other Klebsiella spp.

1

OXA-48

1

100.0

Serratia marcescens

1

SME

1

100.0

Serratia spp.

1

SME

1

100.0

Total

69

 

 

 

KPC: Klebsiella pneumonia carbapenemase (Class A).
NDM: New-Dehli metallo--lactamase (Class B).
NMC: Not metalloenzyme carbapenemase.
OXA-23: Oxacillinase-23 (Class D).
OXA-48: Oxacillinase-48 (Class D).
SME: Serratia marcescens enzyme.
VIM: Verona integron-encoded metallo--lactamase (Class B).

The incidence rate of HA-CPGNB infection and the percentile rankings by type of facility are shown in figure 2 and 3. Figure 4 and 5 present the rate of acquisition of healthcare-associated colonization by type of facility.

Figure 2 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB infection (Cat. 1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

Figure 2 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB infection (Cat. 1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

NB: Facilities 9, 11, 16, 23, 26, 32, 34, 35, 36, 37, 40, 42, 45, 46, 47, 49, 52, 53, 56, 58, 61, 63, 64, 65, 67, 71, 74, 75, 77, 81, 82, 83, 84, 85, 88, 89, 91, 97, 100, 103, 107, 109, 113 and 130 did not report any cases of infection in 2014-2015.

Figure 3 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

Figure 3 – Incidence Rate and Percentile Ranking of Healthcare-Associated CPGNB Infection (Cat. 1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days)

 NB: Facilities 2, 6, 8, 12, 13, 15, 18, 20, 21, 24, 27, 28, 30, 31, 116 and 118 did not report any cases of infection in 2014-2015.

Figure 4 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Non-Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

Figure 4 – Taux d’acquisition des colonisations nosocomiales à BGNPC (cat. 1a + 1b) dans les installations non universitaires, Québec, 2014-2015 (taux d’acquisition des colonisations nosocomiales à BGNPC par 10 000 jours-présence)

NB: Facilities 9, 11, 16, 23, 26, 32, 34, 35, 36, 37, 40, 42, 45, 46, 47, 49, 52, 53, 56, 61, 63, 64, 65, 67, 71, 74, 75, 77, 81, 82, 83, 84, 85, 88, 89, 91, 97, 100, 103, 107, 109, 113 and 130 did not report any cases of colonization in 2014-2015.

Figure 5 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

Figure 5 – Acquisition Rate of Healthcare-Associated CPGNB Colonization (Cat.1a + 1b) for Teaching Healthcare Facilities, Québec, 2014-2015 (Acquisition Rate of Healthcare-Associated CPGNB Colonization per 10,000 Patient-Days)

NB: Facilities 2, 6, 8, 12, 13, 15, 18, 20, 21, 24, 27, 28, 30, 31, 116 et 118 did not report any cases of colonization in 2014-2015.

At the local level, in 2014-2015, the incidence rate of HA-CPGNB infections ranged from 0 to 0.56 / 10,000 patient-days, whereas the acquisition rate of HA-CPGNB colonization ranged from 0 to 4.81 / 10,000 patient-days. A total of 60 facilities (89.6%) did not report any HA-CPGNB infection or colonization in 2014-2015. A detailed summary of the surveillance data for HA-CPGNB infection by healthcare facility can be found in table 13.

Table 13 – Incidence Rate of Healthcare-Associated CPGNB Infection (cat. 1a + 1b), Acquisition Rate of Healthcare-Associated CPGNB Colonization and Mean CPGNB Screening Tests by Admission and by Facility, Québec, 2014-2015 (Incidence Rate per 10,000 Patient-Days [95% CI]; Acquisition Rate of Colonization per 10,000 Patient-Days)

Health
Region

Facility

Incidence Rate of HA-CPGNB Infection (cat. 1a + 1b)
[95% CI]

Acquisition Rate of HA-CPGNB Colonization
(cat. 1a + 1b)

Mean CPGNB Screening Tests per Admission*

Number

Name

01

16

HÔPITAL RÉGIONAL DE RIMOUSKI

0

0

0.149

32

CENTRE HOSPITALIER RÉGIONAL DU GRAND-PORTAGE

0

0

0.016

61

HÔPITAL NOTRE-DAME-DE-FATIMA

0

0

0.011

71

HÔPITAL DE MATANE

0

0

0.002

77

HÔPITAL D'AMQUI

0

0

-

84

HÔPITAL DE NOTRE-DAME-DU-LAC

0

0

-

 

BAS-SAINT-LAURENT

0

0

0.070

02

20

HÔPITAL DE CHICOUTIMI

0

0

0

67

HÔPITAL ET CENTRE DE RÉADAPTATION DE JONQUIÈRE

0

0

0.137

74

HÔPITAL DE DOLBEAU-MISTASSINI

0

0

0.002

88

HÔPITAL, CLSC ET CENTRE D'HÉBERGEMENT DE ROBERVAL

0

0

-

100

HÔPITAL DE LA BAIE

0

0

-

 

SAGUENAY–LAC-SAINT-JEAN

0

0

0.021

03

2

HÔPITAL DE L'ENFANT-JÉSUS

0

0

0.066

7

PAVILLON L'HÔTEL-DIEU DE QUÉBEC

0.12 [0-0.47]

0.12

0.015

24

HÔPITAL DU SAINT-SACREMENT

0

0

0.021

27

PAVILLON CENTRE HOSPITALIER DE L'UNIVERSITÉ LAVAL

0

0

0.014

28

PAVILLON SAINT-FRANÇOIS D'ASSISE

0

0

0.006

33

INSTITUT UNIVERSITAIRE DE CARDIOLOGIE ET DE PNEUMOLOGIE DE QUÉBEC

0.13 [0-0.49]

0.50

0.184

 

CAPITALE-NATIONALE

0.04 [0-0.10]

0.09

0.051

04

23

HÔTEL-DIEU D'ARTHABASKA

0

0

0.007

31

PAVILLON SAINT-JOSEPH

0

0

0.004

85

CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DU HAUT-SAINT-MAURICE

0

0

-

 

MAURICIE ET CENTRE-DU-QUÉBEC

0

0

0.005

05

15

HÔPITAL FLEURIMONT

0

0

-

30

HOTEL-DIEU DE SHERBROOKE

0

0

-

49

CENTRE DE SANTÉ ET DE SERVICES SOCIAUX MEMPHRÉMAGOG

0

0

-

75

CENTRE DE SANTÉ ET DE SERVICES SOCIAUX DU GRANIT

0

0

-

 

ESTRIE

0

0

0

06

3

HÔPITAL ROYAL VICTORIA

0.09 [0-0.36]

0.09

0.015

4

HÔPITAL NOTRE-DAME DU CHUM

0.56 [0.05-1.60]

0.84

-

5

HÔPITAL GÉNÉRAL JUIF

0.07 [0-0.27]

0.56

1.280

6

L'HÔPITAL DE MONTRÉAL POUR ENFANTS

0

0

0.002

8

PAVILLON MAISONNEUVE/PAVILLON MARCEL-LAMOUREUX

0

0

0.066

12

CENTRE HOSPITALIER UNIVERSITAIRE SAINTE-JUSTINE

0

0

-

13

INSTITUT DE CARDIOLOGIE DE MONTRÉAL

0

0

0.090

21

HÔPITAL SAINT-LUC DU CHUM

0

0

-

26

HÔPITAL DE VERDUN

0

0

0.011

29

HÔPITAL GÉNÉRAL DE MONTRÉAL

0.24 [0.02-0.68]

0.24

0.061

34

HÔPITAL SANTA CABRINI

0

0

-

36

HÔPITAL GÉNÉRAL DU LAKESHORE

0

0

0.964

83

HÔPITAL DE LASALLE

0

0

0.014

116

INSTITUT THORACIQUE DE MONTRÉAL

0

0

0.024

118

HÔPITAL NEUROLOGIQUE DE MONTRÉAL

0

0

0.034

 

MONTRÉAL

0.07 [0.03-0.14]

0.16

0.257

07

40

HÔPITAL DE HULL

0

0

0.001

 

OUTAOUAIS

0

0

0.001

08

47

HÔPITAL DE ROUYN-NORANDA

0

0

0.028

52

HÔPITAL D'AMOS

0

0

0.001

65

HÔPITAL ET CLSC DE VAL-D'OR

0

0

-

82

PAVILLON SAINTE-FAMILLE

0

0

0.102

 

ABITIBI-TÉMISCAMINGUE

0

0

0.019

09

64

HÔPITAL LE ROYER

0

0

0.009

 

CÔTE-NORD

0

0

0.009

11

53

HÔPITAL DE CHANDLER

0

0

-

91

HÔPITAL HÔTEL-DIEU DE GASPÉ

0

0

-

97

HÔPITAL DE MARIA

0

0

0.024

107

HÔPITAL DE L'ARCHIPEL

0

0

0.031

109

HÔPITAL DE SAINTE-ANNE-DES-MONTS

0

0

0.013

 

GASPÉSIE–ÎLES-DE-LA-MADELEINE

0

0

0.012

12

18

HÔTEL-DIEU DE LÉVIS

0

0

0.009

63

HÔPITAL DE SAINT-GEORGES

0

0

0.003

89

HÔPITAL DE MONTMAGNY

0

0

0.088

113

HÔPITAL DE THETFORD MINES

0

0

0.013

 

CHAUDIÈRE-APPALACHES

0

0

0.017

13

19

HÔPITAL CITÉ DE LA SANTÉ

0.06 [0-0.22]

0.34

0.115

 

LAVAL

0.06 [0-0.22]

0.34

0.115

14

11

HÔPITAL PIERRE-LE GARDEUR

0

0

0.020

 

LANAUDIÈRE

0

0

0.020

15

45

HÔPITAL DE SAINT-EUSTACHE

0

0

0.007

56

CENTRE DE SANTÉ ET DE SERVICES SOCIAUX D'ARGENTEUIL

0

0

0.043

81

HÔPITAL DE MONT-LAURIER

0

0

0.004

103

HÔPITAL LAURENTIEN

0

0

0.002

 

LAURENTIDES

0

0

0.008

16

9

HÔPITAL DU HAUT-RICHELIEU

0

0

0

35

HÔPITAL HONORÉ-MERCIER

0

0

0.027

37

HÔTEL-DIEU DE SOREL

0

0

0.001

42

CENTRE HOSPITALIER ANNA-LABERGE

0

0

0.060

46

HÔPITAL DE GRANBY

0

0

-

58

HÔPITAL DU SUROÎT

0

4.81

0.373

130

HÔPITAL BARRIE MEMORIAL

0

0

0.487

 

MONTÉRÉGIE

0

0.70

0.75

 

 

Total

0.03 [0.01-0.05]

0.16

0.092

* Number of screening test divided by number of admisions.

Comité de surveillance provinciale des infections nosocomiales (SPIN)

Editorial Committee 

Christophe Garenc, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Muleka Ngenda-Muadi, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Mélissa Trudeau, Direction des risques biologiques et de la santé au travail, Institut national de santé publique du Québec

Christian Lavallée, Hôpital Maisonneuve-Rosemont

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