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No. 4, 2010

U.S. Attack on Tuberculosis a Success Story

Canada Urged to Adopt Action Plan

The following article is republished in full with permission from the Winnipeg Free Press. It first appeared in print June 14, 2010.

A dramatic drop in tuberculosis rates in the U.S. has prompted a national expert to recommend Canada adopt the Americans' "aggressive" approach to track, treat, and monitor infections in First Nations.

Dr. Anne Fanning, former Alberta TB control director and medical officer with the World Health Organization, compared TB rates and control programs among aboriginals in Canada with those in New Zealand, Australia, and the United States in a 2010 report prepared for Health Canada. Health Canada was unable to release or comment on the report, but Fanning agreed to share some of her findings with the Free Press.

Fanning found the rate of TB among American Indians and Alaskan aboriginals declined 6 percent a year between 1996 and 2007. By comparison, she said the TB rate among Canadian aboriginals increased 2.6 percent a year over the same time period—and as much as 33 percent in some Inuit populations.

Fanning said the U.S. has strict measures in place to monitor all TB control programs, and takes a “vigorous and aggressive” approach to cure all infectious cases and to give any exposed contacts preventative drug therapy.

By comparison, Fanning said Canada's TB programs vary from region to region, and there are no national standards to monitor programs to determine what gaps exist. Fanning said Canada needs to strengthen its program and consider every infectious TB case an emergency in need of urgent treatment and follow-up.

Canadian aboriginals have disproportionately high rates of TB, which are 31 times higher than nonaboriginals.  Last year, a Free Press series revealed some remote Manitoba First Nations have among the highest TB rates in the world.

"There's a very determined effort (in the U.S.) to prevent TB via 1) assuring cure and 2) assuring treatment of latent infection," Fanning said.  "We need to increase the stringency of our monitoring and evaluation. That's a pretty standard requirement around the world."  News of Fanning's review comes amid growing criticism of Canada's beleaguered TB program.

Last week, a federal health committee report urged the government to improve its plan to fight the airborne illness and set clear targets to reduce high TB rates in First Nations and Inuit communities.

Experts said there are no national standards on monitoring and controlling TB, and it's tricky to do simple things such as fly in a mobile X-ray unit to help confirm a diagnosis in a remote community.

Jurisdictional gaps also complicate TB treatment, and experts suggested Health Canada clarify who is in charge of medical treatment for all aboriginals. “That’s baloney,” Fanning said of the gaps that exist in Canada. “Somebody has to assume bottom-line responsibility for doing this.”

Dr. John Jereb, medical epidemiologist with the U.S. Centers for Disease Control, credits much of the success in lowering TB rates among American Indians to strong collaboration between tribal, state, and federal health authorities.  He said the U.S. government formed the Indian Health Service in the 1950s to respond to the epidemic TB rates, and simultaneously began helping to build community-led health services in tribes.

When the Navajo Nation had problems finding transient TB patients moving between Arizona, New Mexico, Utah, and Colorado 15 years ago, Jereb said tribal officials convened a meeting with the four state health departments to hammer out a strategy that still helps track cases today.

TB cases have become extremely rare, but Jereb said cases and outbreaks still occur. Natives in remote Alaskan villages still have the highest number of annual cases, Jereb said, in part due to geography and crowded housing.

The U.S. recorded 139 TB cases [among American Indians or Alaska Natives] in 2008, and preliminary data from 2009 show that overall TB rates in the U.S. plummeted by 10 percent.  “It's about having the capacity to respond and the flexibility to change,” Jereb said.  “I would say it's a success story.”

What is TB?
An infectious disease that experts say is a byproduct of overcrowded homes, malnutrition, and poor overall health. The airborne disease is rampant in many northern Manitoba communities where cramped living quarters help it to spread.

How do TB rates among aboriginals compare between Canada, U.S.?
(approximate averages between 1996 and 2007)
Canada: 5 cases per 100,000 (national rate)
First Nations: 24 per 100,000
Inuit: 72 per 100,000
United States: 5 per 100,000 (national rate)
American Indian: 6 per 100,000
Alaskan aboriginals: 9 per 100,000

What helps explain those differences?

Dr. Anne Fanning said there is no clear way to explain those differences. However, she said American Indians generally have better education, income, and life expectancies than aboriginals in Canada, Australia, and New Zealand. She also said the United States does a good job of treating latent TB infections, so patients don't go on to develop full-blown tuberculosis.

—Reported by Jen Skerritt
Winnipeg Free Press


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