Tuberculosis (TB) remains a serious — and possibly underreported — health problem for indigenous people in Canada, data suggest. Ongoing efforts have helped reduce disease incidence, however.
The World Health Organization (WHO) estimates that about 10 million people had active TB worldwide in 2019. But global initiatives to prevent and treat TB have been impressive.
Recently released data from the Public Health Agency of Canada show that the overall incidence rate of active TB was 4.7 per 100,000 population in 2020. Government officials consider this rate low, and it has remained unchanged for the past 10 years. During that time, the rate has hovered between 4.6 and 5.1 people per 100,000 persons.
Three Indigenous Populations
The situation is markedly different among indigenous and foreign-born populations, however. These groups are disproportionately affected by TB, sometimes at dramatically higher rates than the general population.
According to the Canadian government, “indigenous peoples” is a collective name that describes the original people of North America and their descendants. The term “aboriginal peoples” is commonly used as well. The Constitution of Canada recognizes the following 3 groups:
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Indians (more commonly referred to as First Nations)
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Inuit (people who inhabit the country’s Arctic and subarctic regions)
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Métis (people of mixed Indigenous and European ancestry)
The three populations have their own unique “histories, languages, cultural practices, and spiritual beliefs.”
Citing the latest data published by the Public Health Agency of Canada in March, Maddy Warlow, a spokesperson for Indigenous Services Canada (ISC), said, “The reported rate of active TB in Inuit residing in Inuit Nunangat (Inuit Homelands – northernmost regions of Canada) was 90.8, in First Nations on-reserve was 18.2, in First Nations off-reserve was 4.1, in Métis was 2.8, and in the Canadian-born non-Indigenous population was 0.3, all per 100,000 population.”
In comparison with the rate of TB in 2019, the new rate in Inuit persons is lower, while the rate has essentially not changed in First Nations and Métis populations, said Warlow. These rates have been gradually decreasing during the past several years.
Still, the rates are appreciably higher than in the general population, even if they have leveled off or declined. In 2020, the rate of active TB in Inuit communities, for instance, was 70.3 per 100,000, or 15 times the overall Canadian rate. That rate has decreased, however, from its 2012 peak of 251.6 per 100,000, or more than 51 times the overall Canadian incidence rate.
The COVID-19 pandemic may have caused reporting delays, Warlow added, which should be taken into consideration when concluding that the reported rate of active TB in Inuit peoples has decreased. Officials are not sure whether the observed drop among the Inuit is part of a longer-term trend or an aggregate of reporting that isn’t complete, she said.
Explaining the Disparities
The First Nations and other populations face many social challenges, said Tina Campbell, RN, co-chair of Stop TB Canada, an advocacy network. These challenges include crowded households, which have been linked to increased exposure to TB. “It’s not 5 people in 2 bedrooms, but [sometimes] 20 in 2 bedrooms,” said Campbell of the indigenous population.
Poor diet is also a factor, Campbell said. Research shows an association between poor diet, malnutrition, and increased susceptibility to infection, including TB. Delays in diagnosis as a result of lack of resources also increase the rates, she added.
Knowledge and attitudes also affect the rates of TB in these populations. For example, stigma surrounding the diagnosis can inhibit detection and treatment. There is also misunderstanding and a lack of awareness among the population about how the disease is spread and how poor nutrition and overcrowding can play a role. In addition, the indigenous peoples tend to mistrust the medical community, said Campbell.
The diversion of healthcare professionals to confront the coronavirus pandemic may have affected the rates of TB, she added. In 2019, “from my understanding, the numbers were going down, then everyone started working on COVID.”
Ongoing Efforts
Warlow described the following active Canadian government programs that are focused on reducing the rate of TB in the indigenous populations:
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The 2018 budget included $27.5 million in funding over 5 years to support Inuit-specific approaches to eliminate TB. The efforts are aimed at enhancing community-wide prevention, screening, detection, treatment, awareness, and communication.
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Another $640 million over 10 years, announced in the 2017 and 2018 budgets, will address Inuit Nunangat housing needs.
The goals set forth by the Canadian government and its partners, said Warlow, include eliminating TB across Inuit Nunangat by 2030 and reducing active TB by at least 50% by 2025. Among the several programs meant to help achieve that goal are the TB outbreak screening clinics conducted in 2018 and 2019, which the ISC supported. All three clinics had more than 80% community participation, Warlow said. Ongoing efforts are targeting housing, food security, and low income (which also is linked with higher TB rates) to prevent disease, she added.
As an example of a program that has made a tangible difference in public health, Warlow described an enhanced TB surveillance effort in Manitoba First Nations communities in 2016 and 2017 that brought the number of reported, active cases of TB down from 28 in 2016 to just 5 in 2018.
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