Tuberculosis in First Nations communities
History
During the early decades of the 20th century, a terrible epidemic
of tuberculosis (TB) occurred in the Canadian First Nations population.
It is probable that First Nations people had less immunity to European
strains of TB, and drugs to cure TB were not yet available. Malnutrition
increased the risk of disease, and confinement on crowded reservations
allowed the disease to spread rapidly. Death rates were in excess
of 700 per 100,000, among the highest ever reported in a human
population. Death rates from TB meningitis in children aged 0-4
years ranged from 500 to 2000 per 100,000, and overall TB death
rates among children in residential schools were as high as 8000
per 100,000, during the 1930s and 1940s.
Tuberculosis infection
Elders in many First Nations communities lived through periods
when TB rates - and the risk of being infected - were extremely
high. It is generally assumed that once people are infected with
Mycobacterium tuberculosis bacteria, they remain infected for life.
Table 1 shows the results of community surveys to detect TB infection,
among First Nations people aged 30 years and more.
Table 1. The estimated prevalence of TB infection among First
Nations people aged 30+ years, in the on-reserve populations of
British Columbia and Saskatchewan (1995-1998). Note: 95% confidence
intervals in brackets.
Year |
British Columbia |
Saskatchewan |
1995 |
18.4 (14.8, 22.0) |
61.3 (52.6, 70.1) |
1996 |
21.5 (18.2, 24.8) |
55.0 (45.7, 64.2) |
1997 |
17.8 (14.1, 21.5) |
47.3 (39.3, 55.3) |
1998 |
22.0 (19.2, 24.8) |
55.2 (47.6, 62.7) |
Tuberculosis disease
National rates of TB disease from 1990 to 2000 are provided in
Table 2. First Nations TB rates remain 8-10 times higher than overall
Canadian rates, and 20-30 times higher than Canadian-born, non-Aboriginal
rates. Despite this, 2000 national TB case tally of 86 is the lowest
ever reported in the First Nations, on-reserve population. The
notification rate in 1999 was very high due to the occurrence of
several large outbreaks. Of the areas where Health Canada's First
Nations and Inuit Health Branch (FNIHB) provides TB programs, TB
rates are highest in the four western provinces (B.C., Alberta,
Saskatchewan, and Manitoba), and northwestern Ontario (the communities
of Sioux Lookout Zone).
Table 2. National, age-standardized notification rates of TB disease
in the First Nations, on-reserve and overall Canadian populations,
and standardized morbidity ratios (SMR) (1990-2000). The data includes
reported TB cases in the First Nations, on-reserve populations
of British Columbia, Alberta, Saskatchewan, Manitoba, Ontario,
New Brunswick, and Nova Scotia.
The SMR figure represents the First Nations rate
divided by the overall Canadian rate, expressed as a percentage.
Year |
First Nations |
Canada |
SMR (%) |
1990 |
69.4 |
7.2 |
960 |
1991 |
59.5 |
7.2 |
830 |
1992 |
74.8 |
7.4 |
1010 |
1993 |
54.3 |
7.0 |
780 |
1994 |
56.3 |
7.1 |
790 |
1995 |
53.4 |
6.5 |
820 |
1996 |
49.0 |
6.3 |
780 |
1997 |
53.3 |
6.6 |
810 |
1998 |
41.6 |
5.9 |
710 |
1999 |
61.5 |
5.9 |
1040 |
2000 |
34.0 |
n/a |
n/a |
Figure 1 shows the rates of TB in four different age categories,
in the on-reserve populations of the four western provinces. Rates
of pediatric TB (age 0-14 years) decreased from 187.1 per 100,000
to 25 per 100,000 from 1990 to 2000. The majority of pediatric
cases (79.2 %) during this time period were reported in Saskatchewan.
The decrease from 1990 to 2000 is encouraging, although the 1999
rate of 72 per 100,000 was 29 times higher than the overall Canadian
rate that year. In 2000, people aged 55 years and older had the
highest rate of the four age groups, at 123 per 100,000.
Risk factors
HIV, diabetes, substance abuse, and other factors that weaken
the immune system can increase the risk of TB disease after infection.
These factors may be present in many TB endemic communities, increasing
the risk of disease and spread:
- The proportion of HIV and AIDS cases attributed to Aboriginal
persons in Canada increased throughout the 1990s.
- Diabetes prevalence is 3-5 times higher in the First Nations
population.
- In 2000, substance abuse was a reported risk factor in 47.6%
of TB cases living on reserve in B.C. and Alberta.
Case fatality
TB caused or contributed to a death in 4.1% of First Nations TB
cases in Canada between 1990 and 2000. The risk of death is highly
age-dependent, and increases with age (Figure 2). Only one of 803
childhood TB cases (aged 0-14 years) died from TB, while 19.8%
of cases among people aged 75 years or over were fatal.
Infectious TB
If a person has pulmonary or laryngeal TB disease, and TB bacteria
have been found in a sputum sample using microscopy or culture,
that person is considered infectious and can spread tuberculosis
to others. Figure 3 shows the proportion of total TB cases which
were infectious, by age group, in the First Nations population
between 1990 and 2000. The distribution of total infectious TB
cases by age group is then shown in Figure 4. These data indicate
that a high proportion of infectious cases occur among young adults,
aged 15-34 years.
Housing and Tuberculosis
Overcrowded living conditions increase the contact rate between
individuals, and the risk of person-to-person transmission from
infectious TB cases to others. The overall Canadian population
has a housing density of 0.4 persons per room (0.4 ppr). The corresponding
statistic for First Nations people living on reserve is 0.7 ppr.
First Nations communities with higher average housing densities
have higher TB rates (Figure 5). The ten communities with the highest
number of reported TB cases between 1997 and 2000 all had housing
densities of 0.8 or more, and eight of them had 1.0 ppr or more.
Eight of these communities were also located in remote areas, with
no road access.
Linking the data to the Tuberculosis Elimination
Strategy
These data show that the burden of TB is much higher among First
Nations people than among non-First Nations people in Canada. Programs
to control and prevent TB in this population must therefore be
maintained and strengthened. Several elements of the
National
Tuberculosis Elimination Strategy are being implemented effectively.
Compliance rates for treatment of disease are very high, and pediatric
rates are decreasing from year to year. Directly observed treatment
of TB patients and rapid investigation of high-risk contacts are
difficult and challenging tasks, especially in remote communities
where TB outbreaks often occur.
Large outbreaks, high pediatric TB rates, and the high risk of
infectious TB in young adults all confirm that a cycle of transmission
still exists in many First Nations communities. Many people in
this population are infected with TB bacteria, and problems such
as substance abuse, diabetes, and HIV can increase the risk of
disease following infection. Young adults at high risk for infectious
TB are often highly mobile, moving from community to community,
on and off reserve. Overcrowded housing then increases the likelihood
that infectious cases will spread TB to others. This cycle of transmission
must be stopped, so that younger generations can grow up free of
infection and TB is eliminated.
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