Background.Worldwide, indigenous populations appear to be at increased risk for invasive group A streptococcal (iGAS) infections. Although there is empirical evidence that the burden of iGAS disease is significant among remote First Nations communities in Northwestern Ontario, Canada, the epidemiology of iGAS infections in the area remains poorly characterized.Methods.Individuals that met case definition for iGAS disease and whose laboratory specimens were processed by Meno Ya Win Health Centre in Sioux Lookout, Canada or who were reported to Thunder Bay District Health Unit, Canada were identified for the period 2009 to 2014. Case demographics, clinical severity, comorbidities, and risk factors were collected through chart review. Strain typing and antibiotic susceptibility were determined when possible. Basic descriptive statistics were calculated.Results.Sixty-five cases of iGAS disease were identified, for an annualized incidence of 56.2 per 100 000. Primary bacteremia was present in 26.2% of cases, and cellulitis was identified in 55.4% of cases. The most common comorbidities identified were diabetes (38.5%) and skin conditions (38.5%). Prevalent risk factors included alcohol dependence (25%). Fourteen different emm types were identified among 42 isolates, with the most common being emm114 (17.4%), emm11 (15.2%), and emm118 (13.0%). Resistance to erythromycin and clindamycin was found in 24.6% of isolates.Conclusions.Rural and remote First Nations communities in Northwestern Ontario experience iGAS infections at a rate 10 times the provincial and national average. Compared with other North American series, a lower proportion of isolates causing infection were of emm types included in candidate GAS vaccines.
BackgroundBacille Calmette-Guérin (BCG) vaccination against tuberculosis (TB) is widespread in high-TB-burden countries, however, BCG vaccination policies in low-burden countries vary. Considering the uncertainties surrounding BCG efficacy and the lower likelihood of TB exposure in low-incidence countries, most have discontinued mass vaccination, choosing instead a targeted vaccination strategy among high-risk groups. Given the increased risk of TB infection in Canadian Indigenous communities compared to the general Canadian population, these communities are a pertinent example of high-incidence groups in an otherwise low-burden country, warranting particular consideration regarding BCG vaccination strategy. This systematic review aims to synthesise and critically appraise the literature on BCG vaccination strategies in high-risk groups in low-incidence settings to provide policy considerations relevant to the Canadian Indigenous context.Methods: A literature search of the Medline and Embase databases was conducted, returning studies pertaining to BCG vaccine efficacy, TB incidence under specific vaccination policies, BCG-associated adverse events, and vaccination policy guidelines in low-burden countries. Study screening was tracked using the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia), and data pertaining to the above points of interest were extracted.ResultsThe final review included 49 studies, spanning 15 countries. Although almost all of these countries had implemented a form of mass or routine vaccination previously, 11 have since moved to targeted vaccination of selected risk groups, in most cases due to the low risk of infection among the general population and thus the high number of vaccinations needed to prevent one case in the context of low-incidence settings. Regarding identifying risk groups for targeted screening, community-based (rather than individual risk-factor-based) vaccination has been found to be beneficial in high-incidence communities within low-incidence countries, suggesting this approach may be beneficial in the Canadian Indigenous setting.ConclusionsCommunity-based vaccination of high-incidence communities may be beneficial in the Canadian Indigenous context, however, where BCG vaccination is implemented, delivery strategies and potential barriers to achieving adequate coverage in this setting should be considered. Where an existing vaccination program is discontinued, it is crucial that an effective TB surveillance system is in place, and that case-finding, screening, and diagnostic efforts are strengthened in order to ensure adequate TB control. This is particularly relevant in Canadian Indigenous and other remote or under-served communities, where barriers to surveillance, screening, and diagnosis persist.
OBJECTIVE: To document the incidence and clinical characteristics of (tropical) pyomyositis in a predominantly First Nations population in northwestern Ontario. METHODS: The present study was a retrospective case series conducted over a 38-month period in a population of 29,105 in northwestern Ontario. RESULTS: The authors identified seven cases of pyomyositis and describe demographics, comorbidity, clinical course, and the results of imaging and microbiology investigations. The incidence of pyomyositis in northwestern Ontario is 7.6 cases per 100,000 person-years, a rate that is approximately 15 times higher than the only published incidence rate for a developed country (Australia). CONCLUSION: The rate of pyomyositis is high. It may be mediated by overcrowded housing, inadequate access to clean water, and high background rates of methicillin-resistant Staphylococcus aureus infection, injection drug use, and type 2 diabetes mellitus.
A lmost all residents of Ontario, Canada live within 30 minutes of an emergency department. 1 However, for about 25 000 Ontarians living in remote commun ities, accessing a doctor in an emergency department requires flying in a plane or helicopter. 1 Patients in these northern com munities access medical care through a local nursing station, with intermittent incommunity physician coverage. Patients with highacuity conditions are transported from remote com munities to hospital by Ornge, the provincial medical air ambulance service provider. 2,3 Even under ideal conditions, these transfers take several hours. Air transports from these communities can face delays due to weather, visibility, mechan ical issues and personnel issues. More than half of the associ ated remote airports do not have key visual aids that pilots use to land aircraft during periods of reduced visibility, which makes medical transports dependent on weather conditions. 4 First Nations populations living in remote communities are known to face challenging social determinants of health: isolated geography, insufficient housing, unemployment, and the cultural impact of colonialism and residential schools. 5 Access to potable water is an issue in many communities, with 188 boil water advisories in First Nations in the Sioux Look out area between 2007 and 2016. 6 These populations face trauma at rates 2.5-8 times greater than the Canadian aver age. 7-10 People living in these communities face elevated rates of chronic disease, which manifest as critical health emergen cies including mental health, infectious disease, diabetic and cardiovascular emergencies. 11-14 The characteristics of patients requiring air medical trans port in this region have not been well described, with only a handful of published papers describing medical emergencies in these remote communities over the last 35 years. 2,6,7,15,16 We aimed to describe who is transported from 26 remote Nish nawbe Aski Nation communities in northern Ontario to access hospitalbased emergency medical care and to describe the primary clinical reason for their transport as stated in the
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