Saskatchewan health authorities are warning medical practitioners to watch for tuberculosis in children as a handful of First Nations reserves experience an unusual uptick in cases, a worrisome phenomenon that is playing out in other parts of Canada and around the world as COVID-19 recedes.
At least three deaths, two of them in patients younger than 18, have been linked to TB outbreaks in Black Lake, Fond du Lac and Pelican Narrows. A fourth community, Wollaston Lake, is being closely monitored for the spread of TB, but an outbreak has not been declared there, according to Nnamdi Ndubuka, Medical Health Officer for the Northern Inter-Tribal Health Authority, which serves about 55,000 people across 33 reserves.
Forty-four per cent of active TB cases diagnosed in Saskatchewan’s northern First Nations communities in 2022 were in children under 16, which spurred the Saskatchewan Health Authority and two regional authorities to send an alert last month cautioning doctors and nurses of an increase in pediatric tuberculosis.
“This is quite concerning,” Dr. Ndubuka said. “We do regard TB in children as an emergency because the outcome is often very devastating, particularly in the context of northern communities.”
Tuberculosis case counts are rising globally because early detection efforts fell by the wayside during the worst of the pandemic, allowing TB to spread. In some places, tuberculosis death rates have increased because patients weren’t diagnosed until it was too late for antibiotics to save them.
The most recent data from the World Health Organization show that in 2021 the number of people falling ill with TB and dying of the disease increased for the first time in nearly 20 years, reversing slow but steady progress against an affliction once known as consumption or the “white plague,” a reference to the pallor of its victims.
Tuberculosis is caused by airborne bacteria that can infect different organs but most often lodge in the lungs, where they cause aches, fever, sweating, deep exhaustion and a relentless, sometimes, bloody cough. TB can be prevented and cured with long courses of antibiotics, but can be fatal if left untreated.
“TB is insidious and chronic,” said Pierre Plourde, the medical director for integrated tuberculosis services with the Winnipeg Regional Health Authority. The disease progresses slowly and can sometimes be mistaken for smokers’ cough or, in children, run-of-the-mill viral illness, he added.
Manitoba is one province that saw TB death rates more than double in the wake of the pandemic, from between 3 per cent and 4 per cent before COVID-19 to 8.6 per cent in 2021 and 7.2 per cent in 2022.
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The death rates increased, Dr. Plourde said, because TB contact-tracing programs all but ceased as public-health workers were redeployed to chase COVID-19. As well, patients with TB-like symptoms either avoided health care facilities or couldn’t access in-person medical care until it was too late.
“We had a ticking time bomb,” Dr. Plourde said. “That reservoir just grew and grew for two and a half years until everything exploded in 2022.”
Manitoba recorded 195 cases of active TB disease in 2022, up from 174 cases in 2021 and 160 in 2020, a year when cases were almost certainly undercounted because of the pandemic. Early indications suggest the situation is improving this year, Dr. Plourde added.
Saskatchewan, meanwhile, logged 144 cases of TB in 2022, up from 121 in 2021, 103 in 2020 and just 67 in 2019. The three continuing outbreaks in northern Saskatchewan, two of which were declared in October of 2021, led to a total of 97 active cases of TB and the discovery of 212 latent infections – the kind that aren’t contagious and don’t make people sick, but that can eventually turn into active TB disease.
Manitoba and Saskatchewan share many of the same challenges in controlling TB. In both provinces, the living conditions in remote First Nations communities – overcrowded housing, poverty, high smoking rates and scant access to medical care – make residents more vulnerable to tuberculosis than most other people born in Canada. (Foreign-born Canadians tend to have higher TB rates, especially if they emigrate from countries where TB is endemic.)
“We know that housing on First Nations communities is not comparable to many other communities in Canada,” said Michael Isaac, the Manitoba regional medical officer for Ottawa’s First Nations and Inuit Health Branch. “Those social determinants of health are structural risks that are greater in First Nations communities. That’s a big factor.”
Historically, Inuit have struggled even more to combat TB than First Nations. In 2021, the most recent year for which the federal government has released national data, Inuit had a TB case rate of 135.1 per 100,000, compared with 16.1 for First Nations, 2.1 for Métis and 13.4 for people born outside of Canada. The rate among non-Indigenous people born in Canada was 0.2 cases per 100,000.
Prime Minister Justin Trudeau’s government vowed in 2018 to eliminate tuberculosis in Inuit lands by 2030, but the statistics available for some Inuit regions suggest that, much like in Saskatchewan and Manitoba, the trends are moving in the wrong direction.
Nunavut, which is grappling with TB outbreaks in two Baffin Island communities, recorded 77 cases in 2021, the most recent year for which data are available, up from 34 in 2020, an unusually low number for the territory that likely reflects missed cases in the first year of the pandemic.
In the Nunavik region of northern Quebec, 38 cases were logged in 2022, up from 17 the year before. Thirty cases have already been identified in Nunavik in the first three months of this year.
The federal Liberals earmarked $16.2-million over three years in their recent budget to reduce TB rates in Inuit communities, a figure that Inuit Tapiriit Kanatami, the organization that joined Ottawa in making the elimination pledge, called a “modest” sum that doesn’t fulfill their joint pledge to tackle tuberculosis.
Kelly Grant