A systematic review of BCG vaccination policies among high-risk groups in low TB-burden countries: implications for vaccination strategy in Canadian indigenous communities.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccination against tuberculosis (TB) is widespread in high-TB-burden countries, however, BCG vaccination policies in low-burden countries vary. Considering the uncertainties surrounding BCG efficacy and the lower likelihood of TB exposure in low-incidence countries, most have discontinued mass vaccination, choosing instead a targeted vaccination strategy among high-risk groups. Given the increased risk of TB infection in Canadian Indigenous communities compared to the general Canadian population, these communities are a pertinent example of high-incidence groups in an otherwise low-burden country, warranting particular consideration regarding BCG vaccination strategy. This systematic review aims to synthesise and critically appraise the literature on BCG vaccination strategies in high-risk groups in low-incidence settings to provide policy considerations relevant to the Canadian Indigenous context. METHODS: A literature search of the Medline and Embase databases was conducted, returning studies pertaining to BCG vaccine efficacy, TB incidence under specific vaccination policies, BCG-associated adverse events, and vaccination policy guidelines in low-burden countries. Study screening was tracked using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and data pertaining to the above points of interest were extracted. RESULTS: The final review included 49 studies, spanning 15 countries. Although almost all of these countries had implemented a form of mass or routine vaccination previously, 11 have since moved to targeted vaccination of selected risk groups, in most cases due to the low risk of infection among the general population and thus the high number of vaccinations needed to prevent one case in the context of low-incidence settings. Regarding identifying risk groups for targeted screening, community-based (rather than individual risk-factor-based) vaccination has been found to be beneficial in high-incidence communities within low-incidence countries, suggesting this approach may be beneficial in the Canadian Indigenous setting. CONCLUSIONS: Community-based vaccination of high-incidence communities may be beneficial in the Canadian Indigenous context, however, where BCG vaccination is implemented, delivery strategies and potential barriers to achieving adequate coverage in this setting should be considered. Where an existing vaccination program is discontinued, it is crucial that an effective TB surveillance system is in place, and that case-finding, screening, and diagnostic efforts are strengthened in order to ensure adequate TB control. This is particularly relevant in Canadian Indigenous and other remote or under-served communities, where barriers to surveillance, screening, and diagnosis persist.

Community-associated methicillin-resistant Staphylococcus aureus infection: Literature review and clinical update.

OBJECTIVE: To provide information on the prevalence and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the distinction between community-associated MRSA and health care-associated MRSA. QUALITY OF EVIDENCE: The MEDLINE and EMBASE databases were searched from 2005 to 2016. Epidemiologic studies were summarized and the relevant treatment literature was based on level I evidence. MAIN MESSAGE: The incidence of community-associated MRSA infection is rising. Certain populations, including indigenous Canadians and homeless populations, are particularly affected. Community-associated MRSA can be distinguished from health care-associated MRSA based on genetic, epidemiologic, or microbiological profiles. It retains susceptibility to some oral agents including trimethoprim-sulfamethoxazole, clindamycin, and tetracyclines. Community-associated MRSA typically presents as purulent skin and soft tissue infection, but invasive infection occurs and can lead to severe, complicated disease. Treatment choices and the need for empiric MRSA coverage are influenced by the type and severity of infection. CONCLUSION: Community-associated MRSA is a common cause of skin and soft tissue infections and might be common in populations where overcrowding and limited access to clean water exist.

First Nations hepatitis C virus infections: Six-year retrospective study of on-reserve rates of newly reported infections in northwestern Ontario.

OBJECTIVE: To document rates of newly reported hepatitis C virus (HCV) cases from 2010 to 2015 in remote First Nations communities. DESIGN: Retrospective analysis of aggregate data of newly reported HCV antibody-positive (Ab+) cases. SETTING: Northwestern Ontario. PARTICIPANTS: A total of 31 First Nations communities (an on-reserve population of 20 901) supported in health care by the Sioux Lookout First Nations Health Authority. MAIN OUTCOME MEASURES: The aggregate characteristic data included year of notification, age range, and sex for a 6-year period (2010 to 2015). RESULTS: There were 267 HCV Ab+ cases in the 6-year study period. The incidence in 2015 was 324.2 per 100 000 population. This is 11 times the rate for all of Ontario. The most common associated risk factor was sharing of intravenous drug use equipment. Women made up 52% of patients with newly reported HCV Ab+ cases. More than 45% of cases were in patients between 20 and 29 years of age. CONCLUSION: This high burden of newly reported HCV Ab+ cases in geographically remote First Nations communities is concerning, and prevention and treatment resources are needed. This burden of disease might pose more urgent health and social challenges than can be generalized from the experience of the rest of Canada.

Community-wide measures of wellness in a remote First Nations community experiencing opioid dependence: evaluating outpatient buprenorphine-naloxone substitution therapy in the context of a First Nations healing program.

OBJECTIVE: To document the development of unique opioid-dependence treatment in remote communities that combines First Nations healing strategies and substitution therapy with buprenorphine-naloxone. DESIGN: Quantitative measurements of community wellness and response to community-based opioid-dependence treatment. SETTING: Remote First Nations community in northwestern Ontario. PARTICIPANTS: A total of 140 self-referred opioid-dependent community members. INTERVENTION: Community-developed program of First Nations healing, addiction treatment, and substitution therapy. MAIN OUTCOME MEASURES: Community-wide measures of wellness: number of criminal charges, addiction-related medical evacuations, child protection agency cases, school attendance, and attendance at community events. RESULTS: The age-adjusted adult rate of opioid-dependence treatment was 41%. One year after the development of the in-community healing and substitution therapy program for opioid dependence, police criminal charges had fallen by 61.1%, child protection cases had fallen by 58.3%, school attendance had increased by 33.3%, and seasonal influenza immunizations had dramatically gone up by 350.0%. Attendance at community events is now robust, and sales at the local general store have gone up almost 20%. CONCLUSION: Community-wide wellness measures have undergone dramatic public health changes since the development of a First Nations healing program involving opioid substitution therapy with buprenorphine-naloxone. Funding for such programs is ad hoc and temporary, and this threatens the survival of the described program and other such programs developing in this region, which has been strongly affected by an opioid-dependence epidemic.

Acute rheumatic fever in First Nations communities in northwestern Ontario: Social determinants of health "bite the heart".

OBJECTIVE: To document a case series of 8 young First Nations patients diagnosed with acute rheumatic fever (ARF), a preventable disease that resulted in the death of 2 patients, in northwestern Ontario in the context of late diagnosis, overcrowded housing, and inadequate public health response. DESIGN: Retrospective case series over an 18-month period. SETTING: Remote First Nations communities in northwestern Ontario. PARTICIPANTS: Eight patients with ARF. MAIN OUTCOME MEASURES: Incidence, mortality, residual rheumatic heart disease, time to diagnosis, barriers to diagnosis and treatment, housing situation of patients, patient demographic characteristics (age, sex), and investigation results. RESULTS: The incidence of ARF in this population was 21.3 per 100,000, which is 75 times greater than the overall Canadian estimated incidence. The average patient age was 9.4 years. Most cases developed joint findings, and 5 of the surviving patients had rheumatic heart disease when they received echocardiography. The average time to diagnosis was 88 days. Two 4-year-old children died from ARF. Most patients lived in inadequate and crowded housing. CONCLUSION: This rare disease still exists in remote First Nations communities. These communities demonstrate an incidence equal to that in aboriginal communities in Australia and New Zealand, which have among the highest international incidence of ARF. Primordial prevention, including improved on-reserve housing, is urgently needed. Case detection and ongoing surveillance for primary and secondary prophylaxis requires a well resourced regional strategy.

The development of a community-based public health response to an outbreak of post-streptococcal glomerulonephritis in a First Nations community.

BACKGROUND: Post-streptococcal glomerulonephritis (PSGN) is a rare immune-mediated condition that typically occurs in children as a result of group A streptococcus (GAS) infection. PSGN is not considered a disease of public health significance, or reportable, in Canada. Higher incidence of PSGN has been described among Indigenous people in Canada. No national or provincial guidance exists to define or manage PSGN outbreaks. OBJECTIVE: To describe an outbreak of seven paediatric cases of PSGN in a remote First Nations community in northwestern Ontario and the development of a community-wide public health response. METHODS: Following a literature review, an intervention was developed involving screening of all children in the community for facial or peripheral edema or skin sores, and treatment with antibiotics if noted. Case, contact and outbreak definitions were also developed. The purpose of the response was to break the chain of transmission of a possible nephritogenic strain of streptococcus circulating in the community. Relevant demographic, clinical and laboratory data were collected on all cases. OUTCOME: Seven paediatric cases of PSGN presented to the community nursing station between September 25 and November 29, 2017. Community-wide screening for skin sores was completed for 95% of the community's children, including 17 household contacts, and as a result, the last of the cases was identified. Nineteen adult household contacts were also screened. Ten paediatric contacts and two adult contacts with skin sores were treated with one dose of intramuscular penicillin, and six paediatric contacts received oral cephalexin. No further cases were identified following the screening. CONCLUSION: PSGN continues to occur in Indigenous populations worldwide at rates higher than in the overall population. In the absence of mandatory reporting in Canada, the burden of PSGN remains underappreciated and could undermine upstream and downstream public health interventions. Evidence-based public health guidance is required to manage outbreaks in the Canadian context. The community-based response protocol developed to contain the PSGN outbreak in this First Nations community can serve as a model for the management of future PSGN outbreaks.

Diabetes prevalence and demographics in 25 First Nations communities in northwest Ontario (2014-2017).

INTRODUCTION: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario. METHODS: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014-31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults. RESULTS: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%). CONCLUSION: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security.

Résumé Introduction : Les communautés des Premières nations sont reconnues pour leur taux élevé de diabète, particulièrement les communautés rurales des Premières nations du Nord-Ouest de l'Ontario. Des études régionales réalisées en 1985 et 1994 ont révélé une forte prévalence de diabète. Plus récemment, on a estimé que la prévalence dans ces communautés s'élevait à 19 %, la plus forte en Ontario et le double de la norme provinciale. Cette étude visait à examiner l'épidémiologie et la prévalence du diabète auprès de la population totale et les comorbidités cardiovasculaires auprès de la population adulte de 25 communautés des Premières nations du Nord-Ouest de l'Ontario. Méthodologie : Cette étude rétrospective visant à évaluer la prévalence du diabète a eu recours aux données sur 3 ans des dossiers médicaux électroniques des cliniques de première ligne, soit du 1er août 2014 au 31 juillet 2017. La prévalence du diabète a été calculée dans les populations totale et d'adultes (18 ans et plus) et l'hypertension et la dyslipidémie ont été dépistées en concomitance chez les adultes. Résultats: La prévalence du diabète ajustée en fonction de l'âge dans la population totale était de 15,1 % par rapport à la prévalence canadienne de 8,8 %. La prévalence ajustée en fonction de l'âge chez les adultes était de 14,1 %, soit le double de la prévalence canadienne de 7,1 %. L'âge moyen des adultes diabétiques était de 52 (±14,9) ans; et 57 % des participants étaient de sexe féminin. L'hypertension (58 %) et la dyslipidémie (73 %) étaient courantes en concomitance. La metformine était le médicament le plus fréquemment utilisé (58 %), suivie de l'insuline/analogues (23 %) et des sulfonylurées (13 %). Conclusion: La prévalence du diabète dans les populations des Premières nations du Nord-Ouest de l'Ontario est le double de celle du Canada. Pour régler la situation, il faudra se pencher sur les déterminants sociaux de la santé pertinents tels que la pauvreté et l'insécurité alimentaire. Mots-clés: Diabète, Premières nations, prévalence.

Epidemiologic features of medical emergencies in remote First Nations in northern Ontario: a cross-sectional descriptive study using air ambulance transport data.

BACKGROUND: For about 25 000 Ontarians living in remote northern First Nations communities, seeing a doctor in an emergency department requires flying in an airplane or helicopter. This study describes the demographic and epidemiologic characteristics of patients transported from these communities to access hospital-based emergency medical care. METHODS: In this cross-sectional descriptive study, we examined primary medical data on patient transportation from Ornge, the provincial medical air ambulance service provider, for 26 remote Nishnawbe Aski Nation communities in northern Ontario from 2012 to 2016. We described these transports using univariate descriptive statistics. RESULTS: Over the 5-year study period, 10 538 patients (mean 2107.6 per year) were transported by Ornge from the 26 communities. Transport incidence ranged from 9.2 to 9.5 per 100 on-reserve population per year. Women aged 65 years or more had the highest transport incidence (25.9 per 100). Girls aged 5-9 years had the lowest mean incidence (2.1 per 100). Gastrointestinal issues accounted for 13.3% of transfers. Neurologic issues, respiratory issues and trauma each accounted for about 11% of transfers, and cardiac issues for 9.6%. Patients with obstetric issues accounted for 7.6% of transfers per year, and toxicologic emergencies for 7.5%. INTERPRETATION: This study provides the epidemiologic foundation to improve emergency care and emergency transport from remote First Nation communities in Ontario.

Epidemiologic features of invasive group A Streptococcus infection in a rural hospital: 6-year retrospective report and literature review.

INTRODUCTION: High rates of invasive group A Streptococcus disease were suspected by clinicians in northwestern Ontario. Patients with sepsis were being encountered with bacteremia positive for group A Streptococcus. This study was designed to assess the incidence of invasive group A Streptococcus infection in the region and provide best-practice treatment information. METHODS: We performed a retrospective chart review at the Sioux Lookout Meno Ya Win Health Centre (SLMHC) from 2009 to 2014 to examine rates of infection due to invasive group A Streptococcus and outcomes. All blood cultures from 2015 were also examined to calculate the relative rates of distinct pathogens responsible for cases of bacteremia. A literature review on this topic was performed, with attention to rural incidence where available and clinical practice guidelines. RESULTS: Invasive group A Streptococcus disease was diagnosed in 65 patients during the study period. Most (37 [57%]) had bacteremia without a clinical focus. Type 2 diabetes mellitus was a comorbid condition in 27 (42%) and skin conditions in 30 (46%). The case fatality rate was 4.6%. In 2015, group A Streptococcus accounted for 8% of all positive blood cultures from in- and outpatients in the catchment area. The calculated annual incidence rate of invasive group A Streptococcus infection was 37.2 cases per 100 000 population. CONCLUSION: Rural physicians may encounter group A Streptococcus bacteremia in their practice. The death rate associated with these infections can be as high as 20%, and patients require urgent treatment, typically with intravenous penicillin and clindamycin therapy. The rate of invasive group A Streptococcus infection in the predominantly First Nations population served by the SLMHC exceeded the Canadian rate eightfold and is comparable to rates observed in low-income countries and among Indigenous populations in Australia. This disparity may result from inadequate housing, overcrowding or limited access to clean water.

INTRODUCTION: Des cliniciens soupçonnaient des taux élevés d'infections invasives à streptocoque du groupe A dans le Nord-Ouest de l'Ontario. Les patients infectés présentaient une bactériémie positive pour les streptocoques du groupe A. Notre étude visait à évaluer l'incidence des infections invasives à streptocoque du groupe A dans la région et à offrir des renseignements sur les meilleures pratiques de traitement. METHODS: Nous avons mené une étude rétrospective des dossiers de patients du Centre de santé Meno Ya Win de Sioux Lookout (SLMHC) entre 2009 et 2014 afin d'étudier les taux d'infections invasives à streptocoque du groupe A et les résultats. Nous avons également examiné toutes les hémocultures effectuées en 2015 afin de déterminer les taux relatifs de pathogènes distincts responsables des cas de bactériémie. Nous avons procédé à une analyse documentaire sur le sujet, en portant attention à l'incidence en milieu rural lorsque les données étaient disponibles ainsi qu'aux guides de pratique clinique. RESULTS: Soixante-cinq patients ont reçu un diagnostic d'infection invasive à streptocoque du groupe A pendant la période à l'étude. La plupart d'entre eux (37 [57 %]) présentait une bactériémie sans manifestation clinique. Vingt-sept (42 %) patients présentaient également un diabète de type 2 et 30 (46 %) patients présentaient des affections cutanées. Le taux de mortalité clinique était de 4,6 %. En 2015, les infections à streptocoque du groupe A comptaient pour 8 % de la totalité des hémocultures positives provenant des patients hospitalisés et des patients externes dans la région à l'étude. On a calculé un taux d'incidence annuel d'infections invasives à streptocoque du groupe A de 37,2 cas par 100 000 personnes. CONCLUSION: Les médecins en milieu rural peuvent rencontrer des cas de bactériémie à streptocoque du groupe A dans le cadre de leur pratique. Le taux de mortalité associé à ces infections peut atteindre 20 %. Les patients ont besoin d'un traitement urgent, reposant généralement sur l'administration de pénicilline et de clindamycine par voie intraveineuse. Le taux d'infections invasives à streptocoque du groupe A dans la population majoritairement autochtone desservie par le SLMHC était 8 fois plus élevé que le taux observé dans la population canadienne et est comparable aux taux observés dans les pays à faible revenu et chez les populations aborigènes d'Australie. Cette disparité pourrait être attribuable au logement inadéquat, au surpeuplement ou à l'accès limité à de l'eau potable.

High Incidence of Invasive Group A Streptococcal Infections in Remote Indigenous Communities in Northwestern Ontario, Canada.

BACKGROUND: Worldwide, indigenous populations appear to be at increased risk for invasive group A streptococcal (iGAS) infections. Although there is empirical evidence that the burden of iGAS disease is significant among remote First Nations communities in Northwestern Ontario, Canada, the epidemiology of iGAS infections in the area remains poorly characterized. METHODS: Individuals that met case definition for iGAS disease and whose laboratory specimens were processed by Meno Ya Win Health Centre in Sioux Lookout, Canada or who were reported to Thunder Bay District Health Unit, Canada were identified for the period 2009 to 2014. Case demographics, clinical severity, comorbidities, and risk factors were collected through chart review. Strain typing and antibiotic susceptibility were determined when possible. Basic descriptive statistics were calculated. RESULTS: Sixty-five cases of iGAS disease were identified, for an annualized incidence of 56.2 per 100 000. Primary bacteremia was present in 26.2% of cases, and cellulitis was identified in 55.4% of cases. The most common comorbidities identified were diabetes (38.5%) and skin conditions (38.5%). Prevalent risk factors included alcohol dependence (25%). Fourteen different emm types were identified among 42 isolates, with the most common being emm114 (17.4%), emm11 (15.2%), and emm118 (13.0%). Resistance to erythromycin and clindamycin was found in 24.6% of isolates. CONCLUSIONS: Rural and remote First Nations communities in Northwestern Ontario experience iGAS infections at a rate 10 times the provincial and national average. Compared with other North American series, a lower proportion of isolates causing infection were of emm types included in candidate GAS vaccines.