Taima (stop) TB: the impact of a multifaceted TB awareness and door-to-door campaign in residential areas of high risk for TB in Iqaluit, Nunavut.

BACKGROUND: The incidence rate of active tuberculosis (TB) disease in the Canadian Territory of Nunavut has shown a rising trend over the past 10 years. In 2010 it was 60 times greater than the national incidence rate. The objective of the Taima (translates to "stop" in Inuktitut) TB study was to implement and evaluate a public health campaign to enhance existing TB prevention efforts in Nunavut. METHODS: A TB awareness campaign followed by a door-to-door screening campaign was carried out in Iqaluit, Nunavut. The aim of the campaign was to raise awareness about TB, and to provide in-home screening and treatment for people living in residential areas at high risk for TB. Screening was based on geographic location rather than on individual risk factors. RESULTS: During the general awareness campaign an increase in the number of people who requested TB testing at the local public health clinic was observed. However, this increase was not sustained following cessation of the awareness campaign. Targeted TB screening in high risk residential areas in Iqaluit resulted in 224 individuals having TSTs read, and detection of 42 previously unidentified cases of latent TB, (overall yield of 18.8% or number needed to screen = 5.3). These cases of latent TB infection (LTBI) were extra cases that had not been picked up by traditional screening practices (34% relative increase within the community). This resulted in a 33% relative increase in the completion of LTBI treatment within the community. The program directly and indirectly identified 5/17 new cases of active TB disease in Iqaluit during the study period (29.5% of all incident cases). CONCLUSIONS: While contact tracing investigations remain a cornerstone of TB prevention, additional awareness, screening, and treatment programs like Taima TB may contribute to the successful control of TB in Aboriginal communities.

Identification of environmental sources of lead exposure in Nunavut (Canada) using stable isotope analyses.

BACKGROUND: Blood lead levels (BLLs) were measured in the adult Inuit population of Nunavut, Northern Canada, during the Inuit Health Survey (IHS) in 2007-2008. Approximately 10% of the adult participants had BLL over the Health Canada's guidance of 100µg/L. OBJECTIVES: 1) To repeat the measurement of BLL among the IHS participants with high BLL and household members including pregnant women and children under 10years of age; 2) to measure lead (Pb) concentrations in environmental samples to identify potential sources and 3) to explore how Pb from environmental samples contributes to BLL using Pb stable isotopic analyses. METHODS: Blood samples were collected from 100 adults and 56 children in 2012. A total of 169 environmental samples (tap water, house dust, paint, country food, soil, and ammunition) were collected from 14 houses from three communities where the IHS participants had the highest BLL. Total Pb concentrations and Pb isotope mass balance were determined by inductively coupled plasma-mass spectrometry (ICP-MS). RESULTS: The geometric mean of BLL was 43.1µg/L; BLL increased with age and was higher in adults than children (71.1 vs. 17.5µg/L). Median Pb concentrations in water (1.9µg/L) and dust (27.1µg/m(2) for wiped dust, 32.6mg/kg for vacuum dust coarse fraction, and 141.9mg/kg for vacuum dust fine fraction) were generally higher than in other parts of Canada. Median Pb concentrations of food and soil coarse and fine fractions were low (36.6µg/kg, 5.4mg/kg and 11.8mg/kg respectively); paint chips exceeded the Canadian guidelines in two houses (median: 3.8mg/kg). Discriminant analyses and isotope ratio analyses showed that ammunition and house dust are major sources of Pb in this study population. CONCLUSION: Analyses of Pb stable isotopes are useful to identify the routes of exposure to Pb. This approach can contribute to develop targeted public health programmes to prevent Pb exposure.

Collaborating toward improving food security in Nunavut.

BACKGROUND: Community members, Aboriginal organizations, public servants and academics have long been describing a desperate situation of food insecurity in the Eastern Canadian Arctic. OBJECTIVE: The Nunavut Food Security Coalition, a partnership of Inuit Organizations and the Government of Nunavut, is collaborating to develop a territorial food security strategy to address pervasive food insecurity in the context of poverty reduction. DESIGN: The Nunavut Food Security Coalition has carried out this work using a community consultation model. The research was collected through community visits, stakeholder consultation and member checking at the Nunavut Food Security Symposium. RESULTS: In this paper, we describe a continuous course of action, based on community engagement and collective action, that has led to sustained political interest in and public mobilization around the issue of food insecurity in Nunavut. CONCLUSIONS: The process described in this article is a unique collaboration between multiple organizations that has led to the development of a sustainable partnership that will inform policy development while representing the voice of Nunavummiut.

Causes and risk factors for infant mortality in Nunavut, Canada 1999-2011.

BACKGROUND: The northern territory Nunavut has Canada's largest jurisdictional land mass with 33,322 inhabitants, of which 85% self-identify as Inuit. Nunavut has rates of infant mortality, postneonatal mortality and hospitalisation of infants for respiratory infections that greatly exceed those for the rest of Canada. The infant mortality rate in Nunavut is 3 times the national average, and twice that of the neighbouring territory, the Northwest Territories. Nunavut has the largest Inuit population in Canada, a population which has been identified as having high rates of Sudden Infant Death Syndrome (SIDS) and infant deaths due to infections. METHODS: To determine the causes and potential risk factors of infant mortality in Nunavut, we reviewed all infant deaths (<1 yr) documented by the Nunavut Chief Coroner's Office and the Nunavut Bureau of Statistics (n=117; 1999-2011). Rates were compared to published data for Canada. RESULTS: Sudden death in infancy (SIDS/SUDI; 48%) and infection (21%) were the leading causes of infant death, with rates significantly higher than for Canada (2003-2007). Of SIDS/SUDI cases with information on sleep position (n=42) and bed-sharing (n=47), 29 (69%) were sleeping non-supine and 33 (70%) were bed-sharing. Of those bed-sharing, 23 (70%) had two or more additional risk factors present, usually non-supine sleep position. CPT1A P479L homozygosity, which has been previously associated with infant mortality in Alaska Native and British Columbia First Nations populations, was associated with unexpected infant death (SIDS/SUDI, infection) throughout Nunavut (OR:3.43, 95% CI:1.30-11.47). CONCLUSION: Unexpected infant deaths comprise the majority of infant deaths in Nunavut. Although the CPT1A P479L variant was associated with unexpected infant death in Nunavut as a whole, the association was less apparent when population stratification was considered. Strategies to promote safe sleep practices and further understand other potential risk factors for infant mortality (P479L variant, respiratory illness) are underway with local partners.

Sources of food affect dietary adequacy of Inuit women of childbearing age in Arctic Canada.

Dietary transition in the Arctic is associated with decreased quality of diet, which is of particular concern for women of childbearing age due to the potential impact of maternal nutrition status on the next generation. The study assessed dietary intake and adequacy among Inuit women of childbearing age living in three communities in Nunavut, Canada. A culturally-appropriate quantitative food-frequency questionnaire was administered to 106 Inuit women aged 19-44 years. Sources of key foods, energy and nutrient intakes were determined; dietary adequacy was determined by comparing nutrient intakes with recommendations. The prevalence of overweight/obesity was >70%, and many consumed inadequate dietary fibre, folate, calcium, potassium, magnesium, and vitamin A, D, E, and K. Non-nutrient-dense foods were primary sources of fat, carbohydrate and sugar intakes and contributed >30% of energy. Traditional foods accounted for 21% of energy and >50% of protein and iron intakes. Strategies to improve weight status and nutrient intake are needed among Inuit women in this important life stage.

Prevalence of affirmative responses to questions of food insecurity: International Polar Year Inuit Health Survey, 2007-2008.

OBJECTIVES: Assess the prevalence of food insecurity by region among Inuit households in the Canadian Arctic. STUDY DESIGN: A community-participatory, cross-sectional Inuit health survey conducted through face-to-face interviews. METHODS: A quantitative household food security questionnaire was conducted with a random sample of 2,595 self-identified Inuit adults aged 18 years and older, from 36 communities located in 3 jurisdictions (Inuvialuit Settlement Region; Nunavut; Nunatsiavut Region) during the period from 2007 to 2008. Weighted prevalence of levels of adult and household food insecurity was calculated. RESULTS: Differences in the prevalence of household food insecurity were noted by region, with Nunavut having the highest prevalence of food insecurity (68.8%), significantly higher than that observed in Inuvialuit Settlement Region (43.3%) and Nunatsiavut Region (45.7%) (p≤0.01). Adults living in households rated as severely food insecure reported times in the past year when they or other adults in the household had skipped meals (88.6%), gone hungry (76.9%) or not eaten for a whole day (58.2%). Adults living in households rated as moderately food insecure reported times in the past year when they worried that food would run out (86.5%) and when the food did not last and there was no money to buy more (87.8%). CONCLUSIONS: A high level of food insecurity was reported among Inuit adults residing in the Canadian Arctic, particularly for Nunavut. Immediate action and meaningful interventions are needed to mitigate the negative health impacts of food insecurity and ensure a healthy Inuit population.

The development of a comprehensive maternal-child health information system for Nunavut-Nutaqqavut (Our Children).

OBJECTIVES: Nunavut is the most northerly jurisdiction in Canada of which 85% of inhabitants are Inuit. Although most infants are born healthy, Nunavut leads the country for adverse early child health outcomes such as infant mortality, rates of birth defects, prematurity and low birth weight. Public health and community efforts are needed to understand and improve outcomes. METHODS: To inform these issues, a combined University of British Columbia/Nunavut Public Health Strategy effort has initiated a comprehensive maternal-child health surveillance system (from 16 weeks gestation to age 5). A diverse group of professional and lay stakeholders were brought together initially to determine local interest. Following this, a series of small working groups were held to decide on potential prenatal, perinatal and early child health variables, to be documented. RESULTS: Over 100 Nunavut participants have now had some role in the development of the system which has been initiated. Pre-existing standard prenatal forms and well-child assessment forms have been modified to include "Nunavut specific" variables of nutrition, food and domestic security, exposures in pregnancy, birth defects, development, chronic diseases of childhood and paternal information. CONCLUSION: This comprehensive maternal-child health information system has been developed with the extensive input of health care providers and stakeholders, utilizing community and public health systems already in place. Careful assessment of local needs has contributed to database development, privacy protection, potential data utilization for health promotion and plans for dissemination of findings. It is hoped that this will be a user-friendly surveillance system, adaptable to other community and public health systems that will improve the understanding of Aboriginal maternal-child health determinants.

Severe early lower respiratory tract infection is associated with subsequent respiratory morbidity in preschool Inuit children in Nunavut, Canada.

BACKGROUND: Inuit children in Nunavut, Canada, have high rates of lower respiratory tract infection (LRTI) early in life. Whether this commonly results in chronic respiratory symptoms later in life is unknown. METHODS: A cross-sectional survey of 3- to 5-years-old Inuit children was conducted in all three regions of Nunavut, as part of the "Qanuippitali, what about us, how are we?" survey. RESULTS: Reported chronic cough and wheezing were common in preschool Inuit children, although reported asthma diagnosed by a healthcare professional was uncommon. The presence of smokers in the home tended to be associated with severe LRTI in the first 2 years of life. Reported wheezing as well as reported bronchitis or pneumonia in the previous 12 months was significantly associated with severe LRTI in the first 2 years of life. Reported wheezing was also strongly associated with reported bronchitis or pneumonia in the past 12 months. The prevalence of chronic moist cough could not be clearly assessed, due to limitations in the questionnaire. INTERPRETATION: Severe LRTI in the first 2 years of life was associated with ongoing respiratory morbidity in preschool Inuit children, although symptoms appeared to lessen in severity over time.

Maternal smoking at first prenatal visit as a marker of risk for adverse pregnancy outcomes in the Qikiqtaaluk (Baffin) Region.

INTRODUCTION: In Nunavut, 60-80% of pregnant women report smoking in pregnancy, a rate five times the Canadian average. Nunavut also has the highest rates of preterm birth and low birth weight infants in Canada. The present study assessed whether the number of cigarettes smoked per day, as recorded in the first trimester, influenced birth outcomes. METHODS: Maternal-newborn charts were reviewed for infants born between 1 January 2003 and 31 December 2005 to at least one Inuit parent in the Qikiqtaaluk (Baffin) region of Nunavut. Smoking data, as reported by the mother at an early prenatal visit, were extracted from the prenatal record. Birth outcomes including birth weights (for term births), low birth weight, small for gestational age births and rates of preterm birth, were analysed according to category of reported number of cigarettes smoked (0, 1-5, 6-10, and >10 per day). Maternal age, alcohol and street drug use were also assessed for each category of smokers. Statistical analysis among groups was carried out. RESULTS: Of 918 births meeting the study criteria, more than 80% of women reported smoking. For 80% of those, the amount smoked per day was available. Non-smokers and women smoking less than 5 cigarettes daily had perinatal outcomes equal to or better than Canadian averages for low birth weight, small for gestational age, and preterm birth. Furthermore, average birth weights at term significantly decreased from 3681 g for non smokers to 3310 g for those smoking more than 10 cigarettes per day. Compared with non-smokers, women in the highest smoking category (>10 cigarettes daily) had a six-fold increase in low birth weight infants (OR 6.7, 95% CI 2.3-19.6), almost a four-fold increase for small for gestational age births (OR 3.7, 95% CI 1.6-8.8) and twice the chance of a premature birth compared with non-smokers (OR 2.14, 95% CI 1.1-4.2). Those in the highest smoking category were also most likely to report alcohol and other substance use. CONCLUSIONS: Inuit women who reported not smoking, or smoking less than 5 cigarettes per day had birth outcomes equal or superior to average Canadian outcomes in each category evaluated. Those women reporting smoking more than 10 cigarettes daily had significantly increased risk for preterm birth, low birth weight and small for gestational age infants. Because those in the highest smoking category also reported the highest rates of alcohol and other substance use, it is likely that a combination of factors assessed in this study influenced the outcomes. Along with public health preventative measures to reduce smoking directed to this high risk group, other contributing factors for adverse birth outcomes need to be assessed more fully to understand the complex interactions that lead to increased smoking, substance use and, therefore, adverse birth outcomes. Furthermore, evidence from this study suggests that smoking more than 10 cigarettes per day, reported at first prenatal visit, may provide a marker for those women at highest risk of poor outcomes, which could provide direction for focused public health efforts.

Carnitine palmitoyltransferase 1A (CPT1A) P479L prevalence in live newborns in Yukon, Northwest Territories, and Nunavut.

Carnitine palmitoyltransferase 1A (CPT1A), encoded by the gene CPT1A, is the hepatic isoform of CPT1 and is a major regulatory point in long-chain fatty acid oxidation. CPT1A deficiency confers risk for hypoketotic hypoglycaemia, hepatic encephalopathy, seizures, and sudden unexpected death in infancy (SUDI). It remains controversial whether the CPT1A gene variant, c.1436C>T (p.P479L), identified in Inuit, First Nations, and Alaska Native infants, causes susceptibility to decompensation, in particular during times of fever and intercurrent illness. Although newborn screening for the P479L variant occurs in some jurisdictions, background knowledge about the presence of the variant in Canadian Aboriginal populations is lacking. In an effort to understand the population implications of the variant in northern Canada, overall frequencies of the variant were assessed. Further studies are underway to determine associated risk. Ethics approval was obtained from university REBs, local research institutes, and with consultation with territorial Aboriginal groups. Newborn screening blood spots from all infants born in 2006 in the three territories were genotyped for the p.P479L variant. p.P479L (c.1436C>T) allele frequencies in the three territories were 0.02, 0.08, and 0.77 in Yukon (n=325), Northwest Territories (n=564), and Nunavut (n=695), respectively. Homozygosity rates were 0%, 3%, and 64%. Aboriginal status was available only in NWT, with allele frequencies of 0.04, 0.44, 0.00, and 0.01 for First Nations, Inuvialuit/Inuit, Métis, and non-Aboriginal populations. Although individual blood spots were not identified for Aboriginal ethnicity in Nunavut infants, ~90% of infants in Nunavut are born to Inuit women. The allele frequency and rate of homozygosity for the CPT1A P479L variant were high in Inuit and Inuvialuit who reside in northern coastal regions. The variant is present at a low frequency in First Nations populations, who reside in areas less coastal than the Inuit or Inuvialuit in the two western territories. The significance of the population and geographic distribution remains unclear, but the high population frequencies of the variant suggest a historically low penetrance for adverse outcomes. Further evidence is needed to determine if there is an increased risk for infant mortality and morbidity and whether newborn screening will be indicated on a population basis.

Cultural, socioeconomic, and health indicators among Inuit preschoolers: Nunavut Inuit Child Health Survey, 2007-2008.

INTRODUCTION: Indicators of socioeconomic status, health behaviours and health histories are important for evaluating population health and indicators associated with 'indigeneity' features, prominently as determinants of health for Indigenous peoples. Health surveillance of young children, who represent society's most vulnerable, can provide meaningful data regarding achieving an optimal healthy start in life. METHODS: A cross-sectional health survey of Inuit children, aged 3-5 years, was conducted between 2007 and 2008. The latitude of the communities ranged from 56 degrees 32'N to 72 degrees 40'N. A bilingual research team conducted face-to-face interviews which included the use of questionnaires covering factors associated with indigeneity, the physical and socio-economic environment, health behaviours and health histories. Weighted prevalence estimates were calculated. RESULTS: The participation rate was 72.3%; 388 randomly selected children participated. Indicators of traditional food utilization and sharing were highly prevalent and Inuktitut was spoken by 65.2% of preschoolers in the Inuktitut speaking regions. A large percent of the preschoolers lived in a crowded dwelling (53.9%) and in public housing (69.7%), and in a home in need of major repairs (37%). There was an average of 2 smokers per household but the majority of homes restricted smoking to outside the home (83.1%). The majority of mothers smoked during pregnancy (82.5%). For children who were not adopted, there was a high prevalence of breastfeeding initiation (80.6%). A high prevalence of children were ever hospitalized, excluding deliveries (41.6%), and within the past year 40.7% of the children had to be taken to the health centre or hospital for a respiratory problem. CONCLUSION: Indicators of indigeneity suggest the Inuktitut language is thriving and that children are learning Inuit ways through extended family contact and country food utilization and sharing. The high prevalence of smoking restrictions in the home is evidence of the success of public health messaging but further work is needed to improve health behaviours. The high prevalence of household crowding, homes in need of major repairs, public housing and income support all indicate chronic economic and social disadvantages that have negative implications for children's health. Interventions are needed to improve housing and reduce poverty for families with young children.

The current state of birth outcome and birth defect surveillance in northern regions of the world.

OBJECTIVES: Little is known about the rates of congenital anomalies in the northernmost regions of the world. As in other parts of the world, it is crucial to assess the relative rates and trends of adverse birth outcomes and birth defects, as indicators of population health and to develop public health strategies for prevention. The aim of this review is to catalogue existing and developing birth outcome and birth defect surveillance within and around the geographic jurisdiction of the International Union of Circumpolar Health (IUCH). STUDY DESIGN: Descriptive study. METHODS: The representatives of the IUCH Birth Defects Working Group catalogued existing and developing birth and birth defect surveillance systems and the extent of information they contain to determine inter-regional comparability. RESULTS: Systematic population-based registration of birth outcomes including birth defects occurs to some degree in all circumpolar countries, but the quality of collection and the coverage in northernmost regions vary. There are limited circumpolar jurisdictions with surveillance systems collecting birth defect information beyond the perinatal period. Efforts are underway in Canada and Russia to improve the quality and comprehensiveness of the information collected in the northern regions. CONCLUSIONS: Although there is variability in the comprehensiveness of information collected in northern jurisdictions limiting sophisticated comparative analyses between regions, there is untapped potential for baseline analyses of specific risks and outcomes that could provide insight into geographic differences and gaps in surveillance that could be improved.

Initial management of an outbreak of the HTLV-1 virus in Nunavut, Canada.

BACKGROUND: HTLV-1 is a retrovirus known to be endemic in Japan, the Caribbean, and parts of Africa. HTLV-1 infection is rare in Canada. The last known cases prior to the present cluster in Nunavut occurred in 1993, when three Aboriginal patients with neurological symptoms in British Columbia were found to be infected with HTLV-1. The Dept. of Health and Social Services in Nunavut became aware of the presence of this virus in the Nunavut population in early June, 2005 when an individual infected with HTLV-1 died from Acute T-cell leukemia. STUDY DESIGN: A report of the interventions done by the Department in response to this outbreak. METHODS: Interviews with the key informants in the Department. A review of the record of meetings, community consultations, expert consultations and communiqués was conducted. Key information points were summarized. RESULTS: A Nunavut Dept. of Health and Social Services Task Force on HTLV-1 was established. Investigation of the population in the community in which the index case was found using blood samples to identify the virus in the carriers and for antibodies in first-degree relatives of the carriers. A literature review and summary of the epidemiology of the cluster was performed. An intense educational and counseling program regarding HTLV-1 infection was initiated for the (200) health care workers in the Territory and residents in the affected communities. A territory wide publicity and educational package was developed and implemented via meetings, press conferences, and telehealth sessions. Clinical protocols for monitoring the health status of infected individuals have been implemented. Ante-natal screening for HTLV-1 has been initiated, Territory-wide. An unlinked, anonymous HTLV-1 seroprevalence study began in early 2006. To date, approximately 300 persons have been tested for HTLV-1 in Nunavut. The number of infected individuals is less than 20. CONCLUSIONS: HTLV-1 infection is present in Nunavut. The prevalence is unknown. There has been at least one death from Acute T-cell leukemia in an individual infected. Prenatal screening and the seroprevalence study should provide important information on the breadth of the problem and allow the Department to implement appropriate measures to better manage the spread of the virus and the clinical cases of those infected with it.

Costs associated with infant bronchiolitis in the Baffin region of Nunavut.

UNLABELLED: OBJECTIVE. Although infants living in the north of Canada have been reported to have one of the highest rates of hospital admission for bronchiolitis in the world, the economic effects of this condition have not been reported. Passive immunization against the Respiratory Syncytial Virus, the most common causative agent of infant bronchiolitis, is available. METHODS: We tabulated transportation, in-hospital care and family accommodation costs for infants of less than 12 months of age residing in the Baffin Region of Nunavut aged who were admitted to Baffin Regional Hospital in Iqaluit, Nunavut, and the Children's Hospital of Eastern Ontario in Ottawa, Ontario, with a primary diagnosis of bronchiolitis or viral pneumonia, over a 36-month period, between April 1999 and March 2002. RESULTS: One hundred fifty-nine infants were admitted a total of 210 times, with 196 admissions to Baffin Regional Hospital, and 14 to the Children's Hospital of Eastern Ontario, during the study period. The overall, annual, population-based admission rate for the Baffin Region of Nunavut was 197 admissions per thousand infants per year. Total costs were $2,997,373 ($2,357,747 for Baffin Regional Hospital, $639,625 for the Children's Hospital of Eastern Ontario). Overall average costs were $14,273 per admission, $12,029 for infants admitted to Baffin Regional Hospital and $45,688 for infants admitted to the Children's Hospital of Eastern Ontario. CONCLUSIONS: Infant bronchiolitis in the Baffin Region of Nunavut represents a significant burden on the territorial health care system.