Northwestern Ontario in Canada provides a unique clinical challenge for providing optimal medical care. It is a large geographic area (385,000 km) and is home to 32 remote First Nations communities, most without road access. These communities suffer a heavy burden of infectious disease and specialist consultations are difficult to obtain. The Division of Infectious Diseases at the Ottawa Hospital and the Sioux Lookout Meno Ya Win Health Centre established a telemedicine-based infectious disease consultation service in July 2014. We describe the implementation of this service, types of cases seen and patient satisfaction, as well as some of the challenges encountered. Information on visits was prospectively collected through an administrative database, and patient satisfaction surveys were administered after each initial consultation. During our first year of operation, 191 teleconsultations occurred: 76 initial consultations, 82 follow-up appointments and 33 case conferences. The scope of cases has been broad, mostly involving musculoskeletal infections (26%), followed by skin and soft tissue infections (23%). HCV, acute rheumatic fever, and respiratory infections (including pulmonary tuberculosis) were other diagnoses. Patient satisfaction has been very high and 28 telemedicine patient visits have occurred in their remote home communities, minimizing travel. The infectious disease consulting service and local clinicians have succeeded in addressing needs for care in infectious diseases in northwestern Ontario, where important gaps in service to First Nations' communities continue to exist. Regular scheduled available access to an infectious disease specialist is a well-received advancement of care in this remote region of Canada.
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.
Background: Previous publications indicated an emerging issue with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), particularly skin and soft tissue infections (SSTIs), in Indigenous communities in Canada. The objectives of this analysis were to explore the prevalence of SSTIs due to CA-MRSA and patterns of antimicrobial use in the community setting. Methods: A retrospective chart review was conducted as part of an environmental scan to assess antibiotic prescriptions in 12 First Nations communities across five provinces in Canada including Alberta, Saskatchewan, Manitoba, Ontario, and Québec. Charts were randomly selected from nursing stations and patients who had accessed care in the previous 12 months and were ≥ 18 years were included in the review. Data was collected from September to December, 2013 on antibiotic prescriptions, including SSTIs, clinical symptoms, diagnostic information including presence of CA-MRSA infection, and treatment. Results: A total of 372 charts were reviewed, 60 from Alberta, 70 from Saskatchewan, 120 from Manitoba, 100 from Ontario, and 22 from Québec. Among 372 patients, 224 (60.2%) patients had at least one antibiotic prescription in the previous 12 months and 569 prescriptions were written in total. The prevalence of SSTIs was estimated at 36.8% (137 cases of SSTIs in 372 charts reviewed). In 137 cases of SSTIs, 34 (24.8%) were purulent infections, and 55 (40.2%) were due to CA-MRSA. Conclusions: This study has identified a high prevalence of antibiotic use and SSTIs due to CA-MRSA in remote and isolated Indigenous communities across Canada. This population is currently hard to reach and underrepresented in standard surveillance system and randomized retrospective chart reviews can offer complimentary methodology for monitoring disease burden, treatment and prevention.
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