Abstract
BackgroundTuberculosis (TB) is an important public health problem in Inuit communities across Canada, with an annual incidence rate in 2017 that was nearly 300 times higher than in Canadian-born non-Indigenous individuals. Social and behavioral factors that are prevalent in the North, such as commercial tobacco use, excessive alcohol use, food insecurity and overcrowded housing put individuals at higher risk for TB morbidity and mortality. We examined the potential impact of mitigation strategies for these risk factors, in reducing TB burden in this setting.MethodsWe created a transmission model to simulate the epidemiology of TB in Nunavut, Canada. We then used a decision analysis model to assess the potential impact of several evidence-based strategies targeting tobacco use, excessive alcohol use, food insecurity and overcrowded housing. We predicted TB incidence, TB-related deaths, quality adjusted life years (QALYs), and associated costs and cost-effectiveness over 20 years. All costs were expressed in 2018 Canadian dollars.ResultsCompared to a status quo scenario with no new interventions for these risk factors, the reduction strategy for tobacco use was most effective and cost-effective, reducing TB incidence by 5.5% (95% uncertainty range: 2.7–11%) over 20 years, with an estimated cost of $95,835 per TB case prevented and $49,671 per QALY gained. The addition of the food insecurity reduction strategy reduced incidence by a further 2% (0.5–3%) compared to the tobacco cessation strategy alone, but at significant cost.ConclusionsStrategies that aim to reduce commercial tobacco use and improve food security will likely lead to modest reductions in TB morbidity and mortality. Although important for the communities, strategies that address excess alcohol use and overcrowding will likely have a more limited impact on TB-related outcomes at current scale, and are associated with much higher cost. Their benefits will be more substantial with scale up, which will also likely have important downstream impacts such as improved mental health, educational attainment and food security.
Highlights
Tuberculosis (TB) is an important public health problem in Inuit communities across Canada, with an annual incidence rate in 2017 that was nearly 300 times higher than in Canadian-born non-Indigenous individuals
Strategies that aim to reduce commercial tobacco use and improve food security will likely lead to modest reductions in TB morbidity and mortality
By simulating the spread of TB in this region, we were able to estimate the distribution of the population with respect to the four risk factors as well TB-related health states in 2018, which included the proportion of the population uninfected by Mycobacterium tuberculosis, the proportion of the population with latent infection, and proportion of the population who had recovered from active disease
Summary
Tuberculosis (TB) is an important public health problem in Inuit communities across Canada, with an annual incidence rate in 2017 that was nearly 300 times higher than in Canadian-born non-Indigenous individuals. Tuberculosis (TB) remains the deadliest infectious disease worldwide, with 1.4 million deaths in 2019 [1] It is often the most vulnerable people who bear a disproportionate burden of TB morbidity and mortality; this is the case with Indigenous peoples [2]. This reflects colonization and disenfranchisement, as well as a high prevalence of risk factors for TB in many Indigenous communities, such as Aboriginal peoples and Torres Strait Islanders in Australia, Maori communities in New Zealand, and Inuit, First Nations and Métis communities in Canada. All components of this combined strategy occur within the first year of the simulation, and do not repeat after that. Returns to background decrease of 0.013% per year for the remaining 10 years
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