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Doctor finds a new way to fight tuberculosis in Nunavut

About 400 people showed up to the Anglican Parish Hall for a community feast to kick off a TB research project by Gonzalo Alvarez, right, in March.

Gonzalo Alvarez was not sure what to expect the night he formally kicked off his research project in Iqaluit. How many people, he wondered, would turn up at a community feast about tuberculosis?

As it turns out, plenty. About 400 people, mostly Inuit, crammed into the Anglican Parish Hall in Nunavut's capital on a spring evening in 2011 to dine on a whole caribou and listen as Dr. Alvarez and his colleagues made a novel pitch: Let us into your homes to test you for TB and, if you have it, let us return to offer you treatment, any time, anywhere.

"It was one of the best messaging feasts that we've had," said Natan Obed, director of social and cultural development for Nunavut Tunngavik, Inc., the Inuit organization that partnered with Dr. Alvarez on the research effort, the results of which were published online Thursday in the journal Plos One. "With tuberculosis, people were really interested and I think it's because this disease specifically has had such an impact on people's lives here."

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Tuberculosis is rare among non-aboriginals born in Canada, but it remains a major public-health concern in Nunavut.

In 2010, the worst year in recent memory, the territory logged 100 cases of active TB, the equivalent of 304.7 cases per 100,000 population. The rate in the rest of Canada that year was 4.7. The number of active cases in Nunavut has dipped since then, but it remained in the high 70s as of 2012, the last year for which statistics are available.

Tackling TB has proved especially difficult in poverty-stricken Arctic communities where the Inuit remember relatives being spirited away to sanatoriums in the south in the 1940s and 1950s, when TB incidence rates in the area were some of the highest ever recorded anywhere in the world.

Dr. Alvarez, a scientist at the Ottawa Hospital Research Institute and the consultant respirologist for Nunavut, designed his study to try to overcome some of those issues.

"[Community engagement] is a buzzword people use," he said, "but for me it's much more than just the words."

The project, called TAIMA TB after the Inuktitut word for stop, is now being looked to as a possible model for tackling TB elsewhere in the North. "The great thing about TAIMA TB," Mr. Obed said, "is it showed us a new way."

Dr. Alvarez worked intimately with the Inuit to design a bilingual public awareness campaign, including a five-point primer about TB that began with the fact that "TB is treated here in Nunavut and is curable." The team produced videos that featured locals talking about their own experiences with TB.

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"It was, in my opinion, a very large part of the project," said Naomi Davies, a research nurse and clinical co-ordinator with TAIMA TB. "We all connect with people who are like us. … People would look at the videos and say, 'That's so-and-so's daughter, that's my cousin.'"

The project hired a trio of local "TB champions" to approach homes in six blocks of Iqaluit identified as at high risk for tuberculosis, based on the density of past cases. The champions made their first approaches alone, without nurses from the south, to persuade people to consent to having their medical records released and to accepting a follow-up visit that included a nurse.

Those who said yes – in the end 444 people from 162 dwellings took part – were given skin and or blood tests for latent TB, a dormant infection that produces no symptoms and is not contagious. Those who tested positive were offered a regimen of twice weekly antibiotics, delivered directly to them to be swallowed in the presence of a health worker.

The six-month, door-to-door campaign uncovered 42 previously undiagnosed cases of latent TB infection and three active cases of the disease, which led public-health officials to another five related active cases.

Of the patients with latent or "sleeping" TB infection, 30 completed a full, nine-month course of antibiotics that will dramatically reduce the likelihood of them ever developing the bloody cough, night sweats, exhaustion and weight loss that are the hallmarks of active TB disease.

The TAIMA TB project was administered on top of Nunavut's regular TB program, which includes screening at a local clinic and contact tracing when an active case is diagnosed. The $805,000 study was funded by the Public Health Agency of Canada.

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Geraldine Osborne, the acting chief medical officer of health for Nunavut, praised the project, but said she is skeptical the approach could be scaled up to serve more remote communities in the Arctic.

"It was very, very expensive and it was very much tailored for Iqaluit," she said. "To implement a similar program in a [smaller] community would be quite different. I think some people have an idea that this is the answer to eliminating TB in the North and I wouldn't agree with that."

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