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Background: Inuit children from Nunavut have been observed to have high rates of macrocephaly, which sometimes leads to burdensome travel for medical evaluation, often with no pathology identified upon assessment. Given reports that World Health Organization (WHO) growth charts may not reflect all populations, we sought to compare head circumference measurements in a cohort of Inuit children with the WHO charts., Methods: We extracted head circumference data from a previous retrospective cohort study where, with Inuit partnership, we reviewed medical records of Inuit children (from birth to age 5 yr) born between Jan. 1, 2010, and Dec. 31, 2013, and residing in Nunavut. To create a cohort of Inuit children similar to the cohorts used in the development of the WHO growth charts, we excluded children with preterm birth, documented neurologic or genetic disease, and most congenital anomalies. We compared head circumference values with the 2007 WHO charts using centiles estimated with a generalized additive model., Results: We analyzed records of 1960 Inuit children (8866 data points), of whom 993 (50.8%) were female. Most data were from ages 0 to 36 months. At all age points, we found that the study cohort had statistically significantly larger head circumferences than WHO medians, with most z scores for head circumference measurements among Inuit children falling 0.5-1 standard deviations above the WHO reference ( p < 0.001). At age 12 months, median head circumferences were 1.3 cm and 1.5 cm larger for male and female Inuit children, respectively. Using WHO growth curves, macrocephaly was significantly overdiagnosed and microcephaly was underdiagnosed ( p < 0.001)., Interpretation: Our results support the observation that Inuit children from Nunavut have larger head circumferences than other populations, and use of the WHO charts may thus lead to overdiagnosis of macrocephaly and underdiagnosis of microcephaly. Population-specific growth curves for Inuit children should be considered to provide timely and appropriate diagnoses of microcephaly and avoid overinvestigation of macrocephaly., Competing Interests: Competing interests:: Amber Miners sits on the executive committee of the Canadian Paediatric Society and is the representative for Nunavut, the Northwest Territories, and the Yukon. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Concentrations of plasma per and poly-fluoroalkyl substances (PFAS) are elevated in the Inuit population of Nunavik and may be causing adverse health effects. Respiratory health outcomes have been associated with PFAS, but have not been explored in Inuit communities. The aim of the study was to examine the association between PFAS and respiratory health outcomes, and the moderating role of nutritional biomarkers., Methods: We included up to 1298 participants of the Qanuilirpitaa? 2017 survey aged 16-80 years. Generalized regression models were used to estimate the associations between six individual PFAS congeners and four self-reported symptoms, four spirometry measures, and physician-diagnosed asthma. Outcomes associated with PFAS from single chemical models were further explored using Bayesian Kernel Machine Regression (BKMR). The modifying effect of n-3 PUFA in red blood cell quartiles and vitamin D deficiency were examined on the associations between PFAS and respiratory outcomes., Results: PFNA and PFOS were associated with asthma (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.12, 2.32; OR 1.45 95% CI 1.04, 2.03). PFOA, PFNA, PFDA and PFHxS were associated with a decrease in the ratio between the forced expiratory volume in the first second and forced vital capacity (FEV1/FVC). No associations were observed with self-reported respiratory symptoms. No associations were observed between a PFAS mixture and asthma. Some associations were modified by nutritional factors, namely, stronger associations between PFOA and PFHxS and asthma with lower n-3 PUFA levels and stronger associations between PFDA, PFUnDA and PFOS and FEV1/FVC with vitamin D deficiency., Conclusion: These findings add to the growing literature on the impacts of PFAS on respiratory health, and the importance of their global regulation. Associations were modified by nutritional factors pointing to the nutritional value of traditional Inuit foods., (© 2024. The Author(s).)

Haemophilus influenzae serotype a (Hia) has recently emerged as an important cause of invasive disease in the North American Arctic and Sub-Arctic regions, mainly affecting young Indigenous children. In this study, we addressed the question of whether the prevalence of Hia and all H. influenzae in the nasopharynx differed between paediatric populations from regions with high versus low incidence of invasive Hia disease. Nasopharyngeal specimens from children with acute respiratory tract infections (ARTI) collected for routine diagnostic detection of respiratory viruses were analysed with molecular-genetic methods to identify and serotype H. influenzae . In Nunavut, a region with a high incidence of invasive Hia disease, all H. influenzae and particularly Hia were found in the nasopharynx of 60.6% and 3.0% children. In Southern Ontario (Hamilton region), where Hia invasive disease is rare, the frequencies of all H. influenzae and Hia detection were 38.5% and 0.6%, respectively. In both cohorts, non-typeable H. influenzae was prevalent (57.0% and 37.9%, respectively). Considering that Hia is an important cause of severe invasive disease in Nunavut children, 3% prevalence of Hia among children with ARTI can reflect continuing circulation of the pathogen in the Northern communities that may result in invasive disease outbreaks.

Objective: The Cannabis Policy Study in the Territories (CPST) is an annual repeat cross-sectional study aiming to evaluate the impacts of cannabis legalization in the Canadian territories (Yukon, Northwest Territories, and Nunavut), where there is a paucity of data on cannabis use. This current study's objective was to describe the 2022 CPST, including methods, population prevalence estimates of cannabis use, and legal cannabis sources and perceptions in the territories., Methods: The 2022 CPST includes 2462 respondents (aged 16 +) residing in the territories who either use or do not use cannabis. Respondents were recruited through mail-push-to-web invitations sent via licensed mailing lists, sampling from a near census of households in the territories. Population-weighted indicators of cannabis use are described., Results: Past 12-month cannabis use was self-reported by 46.1%, and 21.8% self-reported daily/almost daily use. The most commonly used product types among past 12-month consumers were dried flower (73.4%), edibles (59.0%), and vape oils (35.7%). On average, 74.8% of cannabis products used in the past 12 months were from legal sources, though legal sourcing varied by product type (54.4‒92.2%). Cannabis consumers reported favourable perceptions of legal compared to illegal cannabis products regarding quality, convenience, and safety, but a lesser extent for price., Conclusion: Cannabis use is highly prevalent in the territories, particularly daily/almost daily use, and legal market penetration is high despite region remoteness. Following cannabis legalization, monitoring cannabis use prevalence and patterns in remote regions is important for informing the development of harm reduction and prevention initiatives that consider the unique needs of these regions., (© 2024. Crown as represented by King's Printer for Ontario.)

Circumpolar regions face unique challenges in establishing and maintaining mental health care systems, including forensic psychiatry services. The scarcity of data and lack of evidence concerning the forensic psychiatry patient (FPP) populations of Nunavut and Greenland exacerbates the challenges of informing best practices and healthcare planning. By comparing the prevalence of forensic psychiatry patients, the mental health care services, and the legislation in these two relatively similar but unique regions, insight may be gained that can help inform healthcare planning. This cross-sectional study includes all forensic psychiatry in- and outpatients in one year from Nunavut (2018) and on February 29, 2020, in Greenland. The Greenland sample (n = 93) was nearly four times larger than the Nunavut sample (n = 15) at the population level. Despite considerable differences in forensic legislation and service supply, the forensic psychiatry patients in the two areas share several similarities. A total of 87% (n = 13) in the Nunavut sample were diagnosed with a DSM-5 schizophrenia spectrum disorder or other psychotic disorder. In Greenland, 82% (n = 76) were diagnosed with an ICD-10 F2 diagnosis (schizophrenia, schizotypal and delusional disorders). Approximately 2/3 of the patients in both populations were diagnosed with substance use disorder, and 60% of the Nunavut FPP received long-acting antipsychotic injections versus 62% in Greenland. Nearly half of the FPPs in both populations had never been convicted prior to entering the forensic psychiatry system; Nunavut 45% versus Greenland 47%. A substantial proportion of Greenlandic FPPs were outpatients compared to Nunavut (83% versus 47%). This study is an essential first step toward describing a Model of Care for forensic psychiatry patients in circumpolar regions; furthermore, the clinical similarities between the two populations provide support for future joint Arctic research and the inclusion of artic forensic patients in international studies., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In Canada, there are vast differences between the state of accommodation/housing, health, social inequalities, education and economic conditions for people in the northern and southern regions of the country. Overcrowding in Inuit Nunangat is a direct result of the promises made by past government policy that led to Inuit people settling in sedentary communities in the North on the understanding that they would be provided with social welfare. However, these welfare programmes proved to be either insufficient or non-existent for Inuit people. Therefore, Inuit are living in overcrowded homes in Canada, resulting in a severe housing shortage, poor-quality housing and homelessness. This has led to the spread of contagious diseases, mould, mental-health issues, gaps in education for children, sexual and physical violence, food insecurity and adverse challenges for the youth of Inuit Nunangat. This paper proposes several actions to ease the crisis. First, funding should be stable and predictable. Next, there should be ample construction of transitional homes which could be used to accommodate people before moving them into proper public housing. Policies regarding staff housing should be amended, and if possible, these vacant staff houses could provide shelter to eligible Inuit people, which could help lessen the housing crisis. The advent of COVID-19 has made the issue of affordable and safe housing more serious because without safe housing, the health, education and well-being of the Inuit people in Inuit Nunangat are in peril. This study focuses on how the governments of Canada and Nunavut are dealing with this issue., Competing Interests: Declaration of conflicting interestsThe author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: The Qanuinngitsiarutiksait study aimed to develop detailed profiles of Inuit health service utilization in Manitoba, by Inuit living in Manitoba (approximately 1,500) and by Inuit from the Kivalliq region of Nunavut who travel to Manitoba to access care not available in Nunavut (approximately 16,000 per year)., Methods: We used health administrative data routinely collected in Manitoba for all services provided and developed an algorithm to identify Inuit in the dataset. This paper focused on health services used by Inuit from the Kivalliq for prenatal care and birthing., Results: Our study found that approximately 80 percent of births to women from the Kivalliq region occur in Manitoba, primarily in Winnipeg. When perinatal care and birthing are combined, they constitute one third of all consults happening by Kivalliq residents in Manitoba. For scale, hospitalizations for childbirths to Kivalliq women about to only 5 percent of all childbirth-related hospitalizations in Manitoba., Conclusions: The practice of evacuating women from the Kivalliq for perinatal care and birthing is rooted in colonialism, rationalized as ensuring that women whose pregnancy is at high risk have access to specialized care not available in Nunavut. While defendable, this practice is costly, and does not provide Inuit women a choice as to where to birth. Attempts at relocating birthing to the north have proven complex to operationalize. Given this, there is an urgent need to develop Inuit-centric and culturally appropriate perinatal and birthing care in Manitoba., (© 2022. The Author(s).)

Background: Nunavut, the northernmost Arctic territory of Canada, experienced three community outbreaks of the coronavirus disease 2019 (COVID-19) from early November 2020 to mid-June 2021. We sought to investigate how non-pharmaceutical interventions (NPIs) and vaccination affected the course of these outbreaks., Methods: We used an agent-based model of disease transmission to simulate COVID-19 outbreaks in Nunavut. The model encapsulated demographics and household structure of the population, the effect of NPIs, and daily number of vaccine doses administered. We fitted the model to inferred, back-calculated infections from incidence data reported from October 2020 to June 2021. We then compared the fit of the scenario based on case count data with several counterfactual scenarios without the effect of NPIs, without vaccination, and with a hypothetical accelerated vaccination program whereby 98% of the vaccine supply was administered to eligible individuals., Results: We found that, without a territory-wide lockdown during the first COVID-19 outbreak in November 2020, the peak of infections would have been 4.7 times higher with a total of 5,404 (95% CrI: 5,015-5,798) infections before the start of vaccination on January 6, 2021. Without effective NPIs, we estimated a total of 4,290 (95% CrI: 3,880-4,708) infections during the second outbreak under the pace of vaccination administered in Nunavut. In a hypothetical accelerated vaccine rollout, the total infections during the second Nunavut outbreak would have been 58% lower, to 1,812 (95% CrI: 1,593-2,039) infections. Vaccination was estimated to have the largest impact during the outbreak in April 2021, averting 15,196 (95% CrI: 14,798-15,591) infections if the disease had spread through Nunavut communities. Accelerated vaccination would have further reduced the total infections to 243 (95% CrI: 222-265) even in the absence of NPIs., Conclusions: NPIs have been essential in mitigating pandemic outbreaks in this large, geographically distanced and remote territory. While vaccination has the greatest impact to prevent infection and severe outcomes, public health implementation of NPIs play an essential role in the short term before attaining high levels of immunity in the population., (© 2022. The Author(s).)

This study explores the ways in which a rehousing intervention shapes the mental well-being of Inuit adults living in Nunavut, Canada, where the prevalence of core housing need is four times the national average. More specifically, it compares the housing experiences of participants who were rehoused in a newly built public housing unit, to the experiences of participants on the public housing waitlist. The study was developed in collaboration with organizations based in Nunavut and Nunavik. Semi-structured interviews were transcribed, and a deductive-inductive thematic analysis was performed based on Gidden's concept of ontological security, and Inuit-specific mental health conceptualization. Twenty-five Inuit adults participated (11 rehoused, 14 waitlist). Three themes were identified to describe how the subjective housing experiences of participants improved their mental well-being after rehousing: (1) refuge creation; (2) self-determination and increased control; (3) improved family dynamics and identity repair. Implicit to these themes are the contrasting housing experiences of participants on the waitlist. Construction initiatives that increase public housing stock and address gaps in the housing continuum across Inuit regions could promote well-being at a population level. However, larger socio-economic problems facing Inuit may hamper beneficial processes stemming from such interventions.

Background: Structural aspects of health care systems, such as limited access to specialized surgical and perioperative care, can negatively affect the outcomes and resource use of patients undergoing elective and emergency surgical procedures. The aim of this study was to compare postoperative outcomes of Nunavut Inuit and non-Inuit patients at a Canadian quaternary care centre., Methods: We conducted a retrospective cohort study involving adult (age ≥ 18 yr) patients undergoing inpatient surgery from 2011 to 2018 at The Ottawa Hospital, the quaternary referral hospital for the Qikiqtaaluk Region of Nunavut. The study was designed and conducted in collaboration with Nunavut Tunngavik Incorporated. The primary outcome was a composite of in-hospital death or complications.Secondary outcomes included postoperative length of stay in hospital, adverse discharge disposition, readmissions within 30 days and total hospitalization costs., Results: A total of 98 701 episodes of inpatient surgical care occurred among patients aged 18 to 104 years; 928 (0.9%) of these involved Nunavut Inuit, and 97 773 involved non-Inuit patients. Death or postoperative complication occurred more often among Nunavut Inuit than non-Inuit patients (159 [17.2%] v. 15 691 [16.1%]), which was significantly different after adjustment for age, sex, surgical specialty, risk and urgency (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.51). This association was most pronounced in cases of cancer (OR 1.63, 95% CI 1.03-2.58) and elective surgery (OR 1.58, 95% CI 1.20-2.10). Adjusted rates of readmission, adverse discharge disposition, length of stay and total costs were significantly higher for Nunavut Inuit., Interpretation: Nunavut Inuit had a 25% relative increase in their odds of morbidity and death after surgery at a major quaternary care hospital in Canada compared with non-Inuit patients, while also having higher rates of other adverse outcomes and resource use. An examination of perioperative systems involving patients, Inuit leadership, health care providers and governments is required to address these differences in health outcomes., Competing Interests: Competing interests: Caitlin Champion reports a research grant from the Northern Ontario Academic Medicine Association for the Canadian Frostbite Collaborative project. Nadine Caron reports being a board member for the Heart and Stroke Foundation of Canada, a board member for CyberPatient, co-director for the Centre for Excellence in Indigenous Health, a First Nations Health Authority Chair in Cancer and Wellness, a UBC Indigenous Health Special Advisor, and a board member for the Canadian Cancer Society. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

The arctic fox variant of the rabies virus (RABV) is enzootic in the circumpolar north. Reports of abortive RABV exposures motivated a retrospective analysis of sera from 41 arctic foxes (Vulpes lagopus) captured at Karrak Lake in Nunavut, Canada, during 2011-15. Estimated RABV antibody prevalence among foxes was 15% (95% confidence interval, 7-28%)., (© Wildlife Disease Association 2022.)

Background: In the last decade, tuberculosis (TB) incidence among Inuit in the Canadian Arctic has been rising. Our aim was to better understand the transmission dynamics of TB in this remote region of Canada using whole-genome sequencing., Methods: Isolates from patients who had culture-positive pulmonary TB in Iqaluit, Nunavut, between 2009 and 2015 underwent whole-genome sequencing (WGS). The number of transmission events between cases within clusters was calculated using a threshold of a ≤3 single nucleotide polymorphism (SNP) difference between isolates and then combined with detailed epidemiological data using a reproducible novel algorithm. Social network analysis of epidemiological data was used to support the WGS data analysis., Results: During the study period, 140 Mycobacterium tuberculosis isolates from 135 cases were sequenced. Four clusters were identified, all from Euro-American lineage. One cluster represented 62% of all cases that were sequenced over the entire study period. In this cluster, 2 large chains of transmission were associated with 3 superspreading events in a homeless shelter. One of the superspreading events was linked to a nonsanctioned gambling house that resulted in further transmission. Shelter to nonshelter transmission was also confirmed. An algorithm developed for the determination of transmission events demonstrated very good reproducibility (κ score .98, 95% confidence interval, .97-1.0)., Conclusions: Our study suggests that socioeconomic factors, namely residing in a homeless shelter and spending time in a gambling house, combined with the superspreading event effect may have been significant factors explaining the rise in cases in this predominantly Inuit Arctic community., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

The prevalence of Toxoplasma gondii exposure in Inuit living in Nunavut (20%) is twice that of the US (11%); however, routes of exposure for Inuit communities in North America are unclear. Exposure to T. gondii in humans has been linked with consumption of raw or undercooked shellfish that can accumulate environmentally resistant oocysts. Bivalve shellfish, such as clams, are an important, nutritious, affordable and accessible source of food in many Northern Communities. To date, presence of T. gondii in clams in Northern Canada has not been reported. In this study, we tested for T. gondii presence in clams (Mya truncata) that were harvested in Iqaluit, Nunavut over a 1-week period in September 2016. Of 390 clams, eight (2.1%) were confirmed to contain T. gondii DNA (≥99.7% identity), as determined using polymerase chain reaction (PCR) and sequence confirmation. Additionally, three clams (0.8%) were confirmed to contain Neospora caninum-like DNA (≥99.2% identity). While N. caninum is not known to be a zoonotic pathogen, its presence in shellfish indicates contamination of the nearshore with canid faeces, and the potential for marine mammal exposure through marine food webs. Notably, the PCR assay employed in this study does not discriminate between viable and non-viable parasites. These findings suggest a possible route for parasite exposure through shellfish in Iqaluit, Nunavut. Future research employing viability testing will further inform public health messaging on the infectious potential of T. gondii in shellfish., (© 2021 Wiley-VCH GmbH.)

Background: 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. 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., Methods: We 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., Results: Compared 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., Conclusions: Strategies 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.

Background : The incidence of TB among Inuit is the highest in Canada. A significantly shorter latent TB infection (LTBI) treatment with rifapentine and isoniazid once weekly for 12 weeks (3HP) is now available in limited settings in Canada. Methods : A prospective open-label 2-year observational postmarketing study was conducted introducing 3HP for the first time in Canada in Iqaluit followed by a program rollout in Qikiqtarjuaq, Nunavut. Results : A total of 247 people were offered 3HP, 102 in the Iqaluit postmarketing study and 145 in the Qikiqtarjuaq program roll out. Although statistical significance was not reached, more people who started treatment completed treatment in the 3HP group (Iqaluit, 60/73 (82.2%) and Qikiqtarjuaq, 89/115 (77.4%)) than in the historical control 9INHgroup (306/420 = 72.9%) (p = 0.2). Most of the adverse events in 3HP treated patients were associated with mild discomfort but no disruption of normal daily activity. Not drinking alcohol was associated with increased 3HP completion (OR 13.33, 95% CI, 2.27-78.20) as was not taking concomitant medications (OR 7.19, 95% CI, 1.47-35.30). Conclusions : The present study supports the feasibility and safety profile of 3HP for the treatment of LTBI in Nunavut.

Free-ranging cervids in Canada face diverse threats such as climate change, human population expansion, and the northward spread of vector-borne pathogens. However, we currently have a limited understanding of the impacts of these health challenges in Ontario cervids. Our objective was to identify and characterize causes of morbidity and mortality in free-ranging cervids submitted to the Ontario and Nunavut node of the Canadian Wildlife Health Cooperative (CWHC) over a 27-yr period (1991 to 2017). Submissions included carcasses submitted for full postmortem examination (gross and histopathology; n=196) and field-collected tissues (n=384). Ancillary tests were performed on a case-by-case basis. Univariable logistic regression was used to test for associations between select causes of morbidity and mortality, and factors such as sex, age, and season. Four cervid species were examined: white-tailed deer (Odocoileus virginianus; n=211), moose (Alces alces; n=140), elk (Cervus canadensis; n=136), and caribou (Rangifer tarandus caribou; n=93). Noninfectious disease was the most common general cause of morbidity and mortality (38.1%; 221/580) and was most commonly attributed to trauma (49.7%; 110/221). Deaths attributed to infectious diseases (34.3%; 199/580) were most often bacterial in etiology (45.7%; 91/199). The most common primary infectious disease diagnosed in caribou was digital limb infection, and moose were most commonly diagnosed with parasitic causes, including meningeal worm (Parelaphostrongylus tenuis) and winter tick (Dermacentor albipictus). Chronic wasting disease was not diagnosed among cervids tested during the study period, consistent with the previous lack of detection of the disease in Ontario. These results reveal that anthropogenic, infectious, and environmentally associated causes of morbidity and mortality are commonly diagnosed in cervids submitted to the CWHC Ontario and Nunavut regions, and represent potential population threats that should continue to be monitored., (© Wildlife Disease Association 2020.)

The purpose of this review is to summarise past Inuit health and wellness studies in Manitoba and the Kivalliq region of Nunavut to provide a snapshot of the types of studies available and identify the gaps in knowledge. Research to date has largely been disease-based and often provides comparisons between Indigenous and non-Indigenous people. Distinct Inuit experiences are rarely written about from an Inuit perspective. However, Inuit Tapiriit Kanatami, the national organisation of Inuit in Canada, and Pauktuutit Inuit Women of Canada have been leaders in strengths-based community research and publications that address priorities determined by the Inuit, including the 2018 Inuit Tapiriit Kanatami document National Inuit Strategy on Research (132).

Aims: The cancer burden among Circumpolar Inuit is high. Palliative radiotherapy is a mainstay treatment for controlling symptoms of advanced cancers, but Inuit are required to travel far distances to access this service. Access to palliative radiotherapy and time away from home communities have not been explored among this population. We sought to describe the time intervals from symptom onset to the start of palliative radiotherapy among Canadian Inuit patients treated at The Ottawa Hospital (TOH)., Materials and Methods: A retrospective review of Inuit patients from Nunavut treated with radiotherapy between 2005 and 2014 at TOH., Results: Of a total of 152 radiotherapy patients, 88 (58%) were treated palliatively. Of these, 61 (70%) had stage IV disease at diagnosis and 63 (72%) had lung cancer. The median time from referral for specialist care to the patient's first flight to Ottawa was 4 days (range 0-97). The median length of treatment was 7 days (range 0-27), but patients spent a median of 64.5 days (range 14-633) in Ottawa. The median survival from the date of pathological diagnosis was 5.2 months., Conclusions: Most Inuit radiotherapy patients at TOH were treated palliatively. Patients were brought from Nunavut relatively quickly for specialist care, which is encouraging. However, patients spent over 2 months away from home, in the context of a median survival of less than 6 months. Opportunities for improvement include both provider and system-level changes, which may be applicable to other Circumpolar Inuit regions across Europe and North America., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Background: A remote arctic region of Canada predominantly populated by Inuit with the country's highest incidence of tuberculosis., Methods: The study was undertaken to describe the latent tuberculosis infection (LTBI) cascade of care and identify factors associated with non-initiation and non-completion of LTBI treatment. Data were extracted retrospectively from medical records for all patients with a tuberculin skin test (TST) implanted in Iqaluit, Nunavut between January 2012 and March 2016. Associations between demographic and clinical factors and both treatment non-initiation among and treatment non-completion were identified using log binomial regression models where convergence could be obtained and Poisson models with robust error variance where convergence was not obtained., Results: Of 2303 patients tested, 439 (19.1%) were diagnosed with LTBI. Treatment was offered to 328 patients, was initiated by 246 (75.0% of those offered) and was completed by 186 (75.6% of initiators). In multivariable analysis, older age (adjust risk ratio [aRR] 1.17 per 5-year increase, 95%CI:1.09-1.26) and undergoing TST due to employment screening (aRR 1.63, 95%CI:1.00-2.65, compared to following tuberculosis exposure) were associated with increased non-initiation of treatment. Older age (aRR 1.13, 95%CI: 1.03-1.17, per 5-year increase) was associated with increased non-completion of treatment., Conclusions: A similar rate of treatment initiation and higher rate of treatment completion were found compared to previous North American studies. Interventions targeting older individuals and those identified via employment screening may be considered to help to address the largest losses in the cascade of care.

Transmission dynamics of Toxoplasma gondii , a parasite of importance for wildlife and human health, are enigmatic in the Arctic tundra, where free-ranging wild and domestic felid definitive hosts are absent and rarely observed, respectively. Through a multiyear mark-recapture study (2011-17), serosurveillance was conducted to investigate transmission of T. gondii in Arctic foxes ( Vulpes lagopus ) in the Karrak Lake region, Nunavut, Canada. Sera from adult foxes and fox pups were tested for antibodies to T. gondii by using serologic methods, including the indirect fluorescent antibody test, direct agglutination test, and modified agglutination test. The overall seroprevalence was 39% in adults and 17% in pups. Mature foxes were more likely to be exposed (seroconvert) than young foxes (less than 1 yr old), with the highest level of seroprevalence in midaged foxes (2-4 yr old). Pups in two different litters were seropositive on emergence from the den, around 5 wk old, which could have been due to passive transfer of maternal antibody or vertical transmission of T. gondii from mother to offspring. The seropositive pups were born of seropositive mothers that were also seropositive the year before they gave birth, suggesting that vertical transmission might not be limited to litters from mothers exposed to T. gondii for the first time in pregnancy. All recaptured seropositive foxes remained seropositive on subsequent captures, suggesting that antibodies persist or foxes are constantly reexposed or a combination of both. The results of this study provided insights into how foxes were likely exposed to T. gondii , the dynamics of antibody persistence and immune response, and how the parasite was maintained in a terrestrial Arctic ecosystem in the absence of felid definitive hosts.

Clostridium (Clostridioides) difficile has been identified in humans and a wide range of animal species, but there has been little study of remote animal populations with limited human contact. The objective of this study was to determine the prevalence and types of C. difficile in wild and captive polar bears (Ursus maritimus). Fecal samples were collected from two populations of wild polar bears in Nunavut Canada; M'Clintock Channel and Hudson Strait (Davis Strait or Foxe Basin), as well as from a facility (PBJ) in Churchill, Manitoba that temporarily houses nuisance polar bears and from captive bears in a zoological park. Enrichment culture was performed and isolates were characterized by ribotyping and toxinotyping. Clostridium difficile was isolated from 24/143 (16.8%) of samples; 18/120 (15%) wild bear samples, 4/7 (57%) from the PBJ and 2/16 (13%) samples from three zoo bears. The prevalence of C. difficile was significantly higher in bears that were housed at the PBJ vs wild bears (P = 0.0042), but there was no difference between wild bears from M'Clintock Channel (14/100, 14%) and those from Hudson Strait (4/20, 20%) (P = 0.50). Fourteen of the 24 (58%) isolates were toxigenic; 13/18 (72%) wild bear isolates, 0/4 PBJ isolate and 1/2 zoo isolates. Four toxigenic ribotypes were identified, with one that possessed tcdB and cdtA predominating. None of the toxigenic isolates were ribotypes that have been identified previously by the authors. There was no overlap in toxigenic ribotypes between the different populations. Clostridium difficile was not uncommonly identified in polar bears, with differences in type distribution amongst the different regions. The presence of strains that have not been identified in humans or domestic animals suggests that polar bears may be a natural reservoir of unique strains of this important bacterium., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Rapid changes in the food and built environments in the Canadian Arctic have contributed to a dramatic increase in the prevalence rates of obesity. The objective of this study was to explore the determinants of Nunavut public health system's commitment to implement obesity prevention policies and programs in the territory to reduce the burden of obesity-related diseases., Methods: In total, 93 program managers, program officers, and policy analysts who are responsible for program and policy development and implementation within the Nunavut Department of Health (NDH) were asked to complete the validated Organizational Readiness for Implementing Change (ORIC) questionnaire. Organization-level readiness (commitment) was determined based on aggregated individual-level data using bivariate correlations and multivariate linear regression analyses., Results: Of the 93 questionnaires that were distributed only 67 (72%) were returned fully completed. Organization-level commitment to implement obesity prevention policies and programs was low. Only 2.9% of respondents strongly agreed that NDH was committed to implementing obesity prevention policies and programs. The study showed a strong positive correlation between NDH's commitment and perceived value (r = .73), perceived efficacy (r = .50), and resource availability (r = .25). There was no correlation between commitment and knowledge. In the multivariate linear regression model, perceived value was the only significant predictor of NDH's commitment to implement obesity prevention policies and programs ( β = 0.66)., Conclusions: Successful adoption and implementation of obesity prevention policies and programs in the Canadian Arctic largely depend on the perception of value and benefits of and belief in the change efforts among employees of the Nunavut Department of Health. Convincing policy makers of the value of preventive policies and programs is an important and necessary first step towards decreasing the prevalence of obesity in the Inuit population.

Background: Tuberculosis (TB) remains a significant health burden among Inuit in Canada. Social determinants of health (SDH) play a key role in TB infection, disease and ongoing transmission in this population. The objective of this research was to estimate the prevalence of social determinants of Inuit health as they relate to latent TB infection (LTBI) among people living in residential areas at high risk for TB in Iqaluit, Nunavut., Methods: Inperson home surveys were conducted among those who lived in predetermined residential areas at high risk for TB identified in a door-to-door TB prevention campaign in Iqaluit, Nunavut in 2011. Risk ratios for SDH and LTBI were estimated, and multiple imputation was used to address missing data., Results: 261 participants completed the questionnaire. Most participants identified as Inuit (82%). Unadjusted risk ratios demonstrated that age, education, smoking tobacco, crowded housing conditions and Inuit ethnicity were associated with LTBI. After adjusting for other SDH, multivariable analysis showed an association between LTBI with increasing age (relative risk, RR 1.07, 95% CI 1.04 to 1.11), crowded housing (RR 1.48, 95% CI 1.10 to 2.00) and ethnicity (RR 2.76, 95% CI 1.33 to 5.73) after imputing missing data., Conclusion: Among high-risk residential areas for TB in a remote Arctic region of Canada, crowded housing and Inuit ethnicity were associated with LTBI after adjusting for other SDH. In addition to strong screening and treatment programmes, alleviating the chronic housing shortage will be a key element in the elimination of TB in the Canadian Inuit Nunangat., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Inuit have experienced a rapid transition in diet and lifestyle over the past several decades, paralleled by the emergence of chronic diseases such as obesity, diabetes, and hypertension., Objective: To identify contemporary dietary patterns among Inuit and investigate their association with cardiovascular disease outcomes., Design: This was an association study in a cross-sectional population health and nutrition survey., Participants: The participants included 1,570 adults (aged ≥18 years) from Nunavut in the International Polar Year Inuit Health Survey 2007-2008 who completed diet/health questionnaires and provided blood samples., Main Outcome Measures: Outcomes measured included the prevalence of coronary heart disease, myocardial infarction, stroke, hyperlipidemia, and hypertension., Statistical Analyses Performed: Principal component analysis was used to derive dietary patterns based on the consumption of nine market food groups and four country food groups reported in 24-hour dietary recalls. The associations between cardiovascular outcomes and identified dietary patterns were examined with logistic regression., Results: Three dietary patterns were identified: market food, country food-fat, and country food-fish. The market food diet, characterized by high consumption of market-bought meat, cereals, vegetables, and added oil, was associated with elevated prevalence of coronary heart disease, myocardial infarction, and hypertension (odds ratio [OR] 1.44, 95% CI 0.82 to 2.51; OR 2.27, 95% CI 0.88 to 5.83; and OR 1.36, 95% CI 0.88 to 2.09). The country food-fish diet, characterized by high fish consumption and low sugar and sweets intake, was inversely associated with the prevalence of coronary heart disease, myocardial infarction, stroke, and hyperlipidemia (OR 0.78, 95% CI 0.43 to 1.37; OR 0.46, 95% CI 0.18 to 1.20; OR 0.34, 95% CI 0.07 to 2.13; and OR 0.69, 95% CI 0.39 to 1.22). The country food-fat diet, characterized by high marine mammal and added fat intake, was positively associated with the prevalence of coronary heart disease., Conclusions: A diet featuring high food variety, high fish intake, and low sugar intake was negatively associated with the prevalence of cardiovascular outcomes among Inuit., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize the major components of the contemporary Inuit diet and identify the primary sources of energy and essential nutrients., Design: Dietary data were derived from the 24 h recall collected by the Inuit Health Survey (IHS) from 2007 to 2008. The population proportion method was used to determine the percentage contribution of each group. Unique food items/preparations (ninety-three country foods and 1591 market foods) were classified into eight country food groups and forty-one market food groups. Nutrient composition of each food item was obtained from the Canadian Nutrient File., Setting: Thirty-six communities across three Inuit regions of northern Canada., Subjects: A representative sample (n 2095) of non-pregnant Inuit adults (≥18 years), selected through stratified random sampling., Results: Despite their modest contribution to total energy intake (6·4-19·6 %, by region) country foods represented a major source of protein (23-52 %), Fe (28-54 %), niacin (24-52 %) and vitamins D (up to 73 %), B6 (18-55 %) and B12 (50-82 %). By contrast, the three most popular energy-yielding market foods (i.e. sweetened beverages, added sugar and bread) collectively contributed approximately 20 % of total energy, while contributing minimally to most micronutrients. A notable exception was the contribution of these foods to Ca (13-21 %) and vitamins E (17-35 %) and C (as much as 50 %). Solid fruits were consumed by less than 25 % of participants while vegetables were reported by 38-59 % of respondents., Conclusions: Country foods remain a critical dimension of the contemporary Inuit diet.

Introduction: First Nations/Métis populations develop diabetes earlier and at higher rates than other Canadians. The Canadian diabetes risk questionnaire (CANRISK) was developed as a diabetes screening tool for Canadians aged 40 years or over. The primary aim of this paper is to assess the effectiveness of the existing CANRISK tool and risk scores in detecting dysglycemia in First Nations/Métis participants, including among those under the age of 40. A secondary aim was to determine whether alternative waist circumference (WC) and body mass index (BMI) cut-off points improved the predictive ability of logistic regression models using CANRISK variables to predict dysglycemia., Methods: Information from a self-administered CANRISK questionnaire, anthropometric measurements, and results of a standard oral glucose tolerance test (OGTT) were collected from First Nations and Métis participants (n = 1479). Sensitivity and specificity of CANRISK scores using published risk score cut-off points were calculated. Logistic regression was conducted with alternative ethnicity-specific BMI and WC cut-off points to predict dysglycemia using CANRISK variables., Results: Compared with OGTT results, using a CANRISK score cut-off point of 33, the sensitivity and specificity of CANRISK was 68% and 63% among individuals aged 40 or over; it was 27% and 87%, respectively among those under 40. Using a lower cut-off point of 21, the sensitivity for individuals under 40 improved to 77% with a specificity of 44%. Though specificity at this threshold was low, the higher level of sensitivity reflects the importance of the identification of high risk individuals in this population. Despite altered cut-off points of BMI and WC, logistic regression models demonstrated similar predictive ability., Conclusion: CANRISK functioned well as a preliminary step for diabetes screening in a broad age range of First Nations and Métis in Canada, with an adjusted CANRISK cutoff point for individuals under 40, and with no incremental improvement from using alternative BMI/WC cut-off points., Competing Interests: Dr. Gina Agarwal was contracted to lead this project by the Science Integration Division of the Public Health Agency of Canada. Research ethics board approval was obtained from each of the regions in which data were collected and from the Health Canada/Public Health Agency of Canada Research Ethics Board. The authors declare no conflict of interest.

Epidemiological data shows an alarming prevalence of suicide in Aboriginal populations around the world. In Canada, the highest rates are found in Inuit communities. In this article, we present the findings of a secondary analysis conducted with data previously collected as part of a larger study of psychological autopsies conducted in Nunavut, Canada. The objective of this secondary analysis was to identify protective factors in the Inuit population of Nunavut by comparing people who died by suicide, people from the general population who attempted suicide, and people from the general population who never attempted suicide. This case-control study included 90 participants, with 30 participants in each group who were paired by birth date, sex, and community. Content analysis was first conducted on the clinical vignettes from the initial study in order to codify the presence of protective variables. Then, inferential analyses were conducted to highlight differences between each group in regards to protection. Findings demonstrated that (a) people with no suicide attempt have more protective variables throughout their lifespan than people who died by suicide and those with suicide attempts within the environmental, social, and individual dimensions; (b) people with suicide attempts significantly differ from the two other groups in regards to the use of services; and (c) protective factors that stem from the environmental dimension show the greatest difference between the three groups, being significantly more present in the group with no suicide attempt. Considering these findings, interventions could focus on enhancing environmental stability in Inuit communities as a suicide prevention strategy., Competing Interests: The authors declare no conflict of interest. The founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

Canada has one of the lowest rates of tuberculosis (TB) in the world, however, among certain sub-populations, disease incidence rates approach those observed in sub-Saharan Africa, and other high incidence regions. In this study, we applied mycobacterial interspersed repetitive unit (MIRU) variable number of tandem repeat (VNTR) and whole genome sequencing (WGS) to the analysis of Mycobacterium tuberculosis isolates obtained from Northern communities in the territory of Nunavut. WGS was carried out using the Illumina MiSeq, with identified variants used to infer phylogenetic relationships and annotated to infer functional implications. Additionally, the sequencing data from these isolates were augmented with publically available WGS to evaluate data from the Nunavut outbreak in the broader Canadian context. In this study, isolates could be classified into four major clusters by MIRU-VNTR analysis. These could be further resolved into sub-clusters using WGS. No evidence for antimicrobial resistance, either genetic or phenotypic, was observed in this cohort. Among most subjects with multiple samples, reactivation/incomplete treatment likely contributed to recurrence. However, isolates from two subjects appeared more likely to have occurred via reinfection, based on the large number of genomic single nucleotide variants detected. Finally, although quite distinct from previously reported Canadian MTB strains, isolates obtained from Nunavut clustered most closely with a cohort of samples originating in the Nunavik region of Northern Quebec. This study demonstrates the benefit of using WGS for discriminatory analysis of MTB in Canada, especially in high incidence regions. It further emphasizes the importance of focusing epidemiological intervention efforts on interrupting transmission chains of endemic TB throughout Northern communities, rather than relying on strategies applied in regions where the majority of TB cases result from importation of foreign strains.

The Arctic Ram Exercise was conducted in February 2016, near Resolute Bay on Cornwallis Island in Nunavut, Canada, to demonstrate the ability of the Canadian Armed Forces (CAF) to rapidly deploy to the arctic as an immediate response team. This report describes medical problems experienced by the 187 CAF and 28 U.S. forces involved in the exercise. Sixty-six airborne soldiers performed tactical static line jumps and linked up with soldiers on the ground for the exercise. Medical events were recorded by medics on the drop zone and by medical personnel at the Unit Medical Station in Resolute Bay. Average temperature during the exercise was -21°C and wind chill was -44°C. Two U.S. soldiers were injured in association with the jump and an additional 62 patients presented at the clinic during the exercise for an overall medical event incidence of 30%. The incidence of frostbite was 17%. At the end of the exercise, a physician actively examined CAF soldiers in one unit (n = 126) and found that 21% had experienced frostbite. The incidence of frostbite was high in this exercise compared to past cold-weather military operations, likely related to the very low temperatures and wind chills., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Chronic hepatitis B virus (HBV) infection within the Canadian Arctic is considered endemic (>2% prevalence). Within the Arctic region of Nunavut, a vaccination program targeted at newborn infants was initiated approximately 20years ago, along with interim grade school catch-up programs, with the result that individuals born after 1980 are presumed vaccinated. This study investigates the effectiveness of these programs and is the first seroepidemiological survey to determine HBV prevalence in Nunavut in the post-vaccination era. Anonymized serum specimens scheduled for destruction following medical testing were collected between April 2013 and April 2014 from individuals granting consent. Specimens were tested for HBV antibodies, surface antigen (HBsAg), and HBV DNA to perform molecular characterization. Four thousand eight hundred and two specimens (13% of the population) were collected, with a resulting median age of 29years (range 1week to 93years). The prevalence of antibody to the HBV core protein was 9.4%; however, a 10-fold decrease in the rate of HBV exposure was noted among those born after 1980 compared to those born before (1.8% vs. 19.8%, p<0.01). HBsAg positivity was primarily documented in individuals born before 1980 (2.5%), although cases still occurred among the vaccine age cohort (0.3%). HBV subgenotype B5 (previously B6) was the most prevalent genotype observed (81.8%) indicating persistence of locally acquired infection. Vaccine-based antibody as the sole serological marker was evident in the vaccine age cohort, although the rate of decay with increasing age was much greater than predicted (less than 10% in those aged 5-19years). Nearly two decades after the advent of HBV vaccination in Nunavut, HBV prevalence has decreased to 1.2%, indicating non-endemic prevalence. However, the persistence of infection and a lower than expected prevalence of vaccine-based immunity in the vaccine age cohort will require further investigation to understand the causes and consequences., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: High rates of food insecurity are documented among Inuit households in Canada; however, data on food insecurity prevalence and seasonality for Inuit households with children are lacking, especially in city centres. This project: (1) compared food consumption patterns for households with and without children, (2) compared the prevalence of food insecurity for households with and without children, (3) compared food consumption patterns and food insecurity prevalence between seasons, and (4) identified factors associated with food insecurity in households with children in Iqaluit, Nunavut, Canada., Methods: Randomly selected households were surveyed in Iqaluit in September 2012 and May 2013. Household food security status was determined using an adapted United States Department of Agriculture Household Food Security Survey Module. Univariable logistic regressions were used to examine unconditional associations between food security status and demographics, socioeconomics, frequency of food consumption, and method of food preparation in households with children by season., Results: Households with children (n = 431) and without children (n = 468) participated in the survey. Food insecurity was identified in 32.9% (95% CI: 28.5-37.4%) of households with children; this was significantly higher than in households without children (23.2%, 95% CI: 19.4-27.1%). The prevalence of household food insecurity did not significantly differ by season. Demographic and socioeconomic characteristics of the person responsible for food preparation, including low formal education attainment (OR Sept  = 4.3, 95% CI: 2.3-8.0; OR May  = 3.2, 95% CI: 1.8-5.8), unemployment (OR Sept  = 1.1, 95% CI: 1.1-1.3; OR May  = 1.3, 95% CI: 1.1-1.5), and Inuit identity (OR Sept  = 8.9, 95% CI: 3.4-23.5; OR May  = 21.8, 95% CI: 6.6-72.4), were associated with increased odds of food insecurity in households with children. Fruit and vegetable consumption (OR Sept  = 0.4, 95% CI: 0.2-0.8; OR May  = 0.5, 95% CI: 0.2-0.9), as well as eating cooked (OR Sept  = 0.5, 95% CI: 0.3-1.0; OR May  = 0.5, 95% CI: 0.3-0.9) and raw (OR Sept  = 1.7, 95% CI: 0.9-3.0; OR May  = 1.8, 95% CI: 1.0-3.1) fish were associated with decreased odds of food insecurity among households with children, while eating frozen meat and/or fish (OR Sept  = 2.6, 95% CI: 1.4-5.0; OR May  = 2.0, 95% CI: 1.1-3.7) was associated with increased odds of food insecurity., Conclusions: Food insecurity is high among households with children in Iqaluit. Despite the partial subsistence livelihoods of many Inuit in the city, we found no seasonal differences in food security and food consumption for households with children. Interventions aiming to decrease food insecurity in these households should consider food consumption habits, and the reported demographic and socioeconomic determinants of food insecurity.

Background: Selenium (Se) has been reported to protect against the neurotoxicity of mercury (Hg). However, the effect of Se against Hg on cardiovascular diseases remains unclear. Inuit living in the Arctic have high exposure to both Se and Hg through their marine mammal and fish rich traditional diet., Objective: To characterize the co-exposure of Hg and Se among Inuit in Canada and to assess the associations between Hg, Se and cardiovascular health outcomes, including stroke, hypertension, and myocardial infarction (MI)., Methods: Data was collected from the International Polar Year Inuit Health Survey (IHS) conducted in 2007 and 2008. Blood Se and Hg were measured, and self-report cardiovascular health outcomes were collected through a questionnaire interview from 2169 adults aged 18 and above., Results: The mean age was 42.4years, and 38.7% of the participants were male. The geometric means (GM) of blood Se and total Hg were 319.5μg/L and 7.0μg/L, respectively. The crude prevalence of heart attack, stroke and hypertension were 3.55%, 2.36%, and 24.47% respectively. Participants were categorized into 4 exposure groups according to blood Hg (high: ≥7.8μg/L; low: <7.8μg/L), and Se (high: ≥280μg/L; low: <280μg/L). The odds ratio (OR) of cardiovascular outcomes were estimated using general linearized models. Results showed the low Se and high Hg group had a higher prevalence of cardiovascular disease (OR=1.76 for hypertension, 1.57 for stroke, and 1.26 for MI. However, the prevalence was decreased in both the high Se and low Hg group (OR=0.57 for hypertension, 0.44 for stroke, and 0.27 for MI) and the high Se and high Hg group (OR=1.14 for hypertension, 0.31 for stroke, and 0.80 for MI)., Conclusions: The high Se and low Hg group had the lowest prevalence of cardiovascular outcomes, except for stroke. These results provide evidence that Se may exhibit a protective effect against Hg on cardiovascular disease., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: The Public Health Agency of Canada adapted a Finnish diabetes screening tool (FINDRISC) to create a tool (CANRISK) tailored to Canada's multi-ethnic population. CANRISK was developed using data collected in seven Canadian provinces. In an effort to extend the applicability of CANRISK to northern territorial populations, we completed a study with the mainly Inuit population in the Kitikmeot region of Nunavut., Methods: We obtained CANRISK questionnaires, physical measures and blood samples from participants in five Nunavut communities in Kitikmeot. We used logistic regression to test model fit using the original CANRISK risk factors for dysglycemia (prediabetes and diabetes). Dysglycemia was assessed using fasting plasma glucose (FPG) alone and/or oral glucose tolerance test. We generated participants' CANRISK scores to test the functioning of this tool in the Inuit population., Results: A total of 303 individuals participated in the study. Half were aged less than 45 years, two-thirds were female and 84% were Inuit. A total of 18% had prediabetes, and an additional 4% had undiagnosed diabetes. The odds of having dysglycemia rose exponentially with age, while the relationship with BMI was U-shaped. Compared with lab test results, using a cut-off point of 32 the CANRISK tool achieved a sensitivity of 61%, a specificity of 66%, a positive predictive value of 34% and an accuracy rate of 65%., Conclusion: The CANRISK tool achieved a similar accuracy in detecting dysglycemia in this mainly Inuit population as it did in a multi-ethnic sample of Canadians. We found the CANRISK tool to be adaptable to the Kitikmeot region, and more generally to Nunavut.

Background: In Canada, active tuberculosis (TB) disease rates remain disproportionately higher among the Indigenous population, especially among the Inuit in the north. We used mathematical modeling to evaluate how interventions might enhance existing TB control efforts in a region of Nunavut., Methods: We developed a stochastic, agent-based model of TB transmission that captured the unique household and community structure. Evaluated interventions included: (i) rapid treatment of active cases; (ii) rapid contact tracing; (iii) expanded screening programs for latent TB infection (LTBI); and (iv) reduced household density. The outcomes of interest were incident TB infections and total diagnosed active TB disease over a 10- year time period., Results: Model-projected incidence in the absence of additional interventions was highly variable (range: 33-369 cases) over 10 years. Compared to the 'no additional intervention' scenario, reducing the time between onset of active TB disease and initiation of treatment reduced both the number of new TB infections (47% reduction, relative risk of TB = 0.53) and diagnoses of active TB disease (19% reduction, relative risk of TB = 0.81). Expanding general population screening was also projected to reduce the burden of TB, although these findings were sensitive to assumptions around the relative amount of transmission occurring outside of households. Other potential interventions examined in the model (school-based screening, rapid contact tracing, and reduced household density) were found to have limited effectiveness., Conclusions: In a region of northern Canada experiencing a significant TB burden, more rapid treatment initiation in active TB cases was the most impactful intervention evaluated. Mathematical modeling can provide guidance for allocation of limited resources in a way that minimizes disease transmission and protects population health.

Objective: High rates of sexually transmitted infections in the Arctic have been a focus of recent research, and youth are believed to be at greatest risk of infection. Little research has focused on understanding youth perspectives on sexual health. The goal of this study was to collect the perspectives of youth in Nunavut on sexual health and relationships with the intent of informing public health practice., Method: This qualitative research study was conducted within an Indigenous knowledge framework with a focus on Inuit ways of knowing. Data were collected through face-to-face interviews in three Nunavut communities with 17 youth between the ages of 14 and 19 years. Participants were asked open-ended questions about their experiences talking about sexual health and relationships with their family, peers, teachers or others in the community., Results: There are four key findings, which are important for public health: (a) Parents/caregivers are the preferred source of knowledge about sexual health and relationships among youth respondents; (b) youth did not report using the Internet for sexual health information; (c) youth related sexual decision-making to the broader community context and determinants of health, such as poverty; and (d) youth discussed sexual health in terms of desire and love, which is an aspect of sexual health often omitted from the discourse., Implications and Contribution: The youth in this study articulated perspectives on sexual health, which are largely neglected in current public health practice in the North. The findings from this study underscore the important role of community-led participatory research in contributing to our understanding of the public health challenges in our communities today, and provide direction for future interventions and research., Competing Interests: and funding The author received a small grant from the Northern Students Training Program, Indigenous and Northern Affairs, for the partial cost of travel to participating communities.

Infectious diseases have the potential to spread rapidly and cause high mortality within populations of immunologically naïve hosts. The recent appearance of avian cholera, a highly virulent disease of birds caused by the bacterium Pasteurella multocida, at remote Arctic seabird colonies is an emerging conservation concern. Determining disease risk to population viability requires a quantitative understanding of transmission potential and the factors that regulate epidemic persistence. Estimates of the basic (R 0 ) and real-time (R t ) reproductive number are critical in this regard - enumerating the number of secondary infections caused by each primary infection in a newly invaded host population and the decline in transmission rate as susceptible individuals are removed via mortality or immunized recovery. Here, we use data collected at a closely monitored common eider (Somateria mollissima) breeding colony located in the Canadian Arctic to examine transmission and host population dynamics. Specifically, we infer epidemic curves from daily mortality observations and use a likelihood-based procedure to estimate changes in the reproductive number over a series of annual outbreaks. These data are interpreted in relation to concurrent changes in host numbers to assess local extinction risk. Consistent with expectations for a novel pathogen invasion, case incidence increased exponentially during the initial wave of exposure (R 0  = 2·5; generation time = 6·5 days ± 1·1 SD). Disease conditions gradually abated, but only after several years of smouldering infection (R t  ≈ 1). In total, 6194 eider deaths were recorded during outbreaks spanning eight consecutive breeding seasons. Breeding pair abundance declined by 56% from the pre-outbreak peak; however, a robust population of >4000 pairs remained intact upon epidemic fade-out. Overall, outbreak patterns were consistent with herd immunity acting as a mitigating factor governing in the extent and duration of mortality. Disease mortality is frequently modelled as a form of stochastic catastrophe in wildlife population assessments, whereas our approach gives shape to the functional response between transmission and host population dynamics. We conclude that increased emphasis on integrating epidemiological and population processes is essential to predicting the conservation impact of emerging infectious diseases in wildlife., (© 2016 The Authors. Journal of Animal Ecology © 2016 British Ecological Society.)

Background: Access to hearing health care is limited in many parts of the world, creating a lack of prompt diagnosis, which further complicates treatment. The use of portable audiometry for hearing loss testing can improve access to diagnostics in marginalized populations. Our study objectives were twofold: (1) to determine the prevalence of hearing loss in children aged 4 to 11 years in Iqaluit, Nunavut, and (2) to test and demonstrate the use of our tablet audiometer as a portable hearing-testing device in a remote location., Study Design: Prospective cross-sectional observational., Setting: Remote elementary schools in 3 Canadian Northern communities., Subjects and Methods: Tablet audiometers were used to test hearing in 218 children. Air conduction pure tones thresholds were obtained at 500, 1000, 2000, and 4000 Hz. Children with hearing loss ≥30 dB in either ear were referred for audiology services., Results: Tablet audiometry screening testing revealed abnormal results in 14.8% of the study participants. No significant difference in the rate of hearing loss was seen by sex; however, the rate of hearing loss decreased significantly with increasing age. The median duration of the hearing test was 5 minutes 30 seconds., Conclusions: Of the study population, 14.8% tested positive for hearing loss based on our interactive tablet audiometer. In this setting, the tablet audiometer was both time efficient and largely language independent. This type of testing is valuable for providing much-needed hearing health care for high-risk populations in rural and remote areas where audiology services are often unavailable., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Rationale: Rehabilitation-oriented criminal court mental health initiatives to reduce the number of people with mental illness caught in the criminal justice system exist in many North American cities and elsewhere but not in the mainly Inuit Canadian Arctic territory of Nunavut., Objective: This study explores whether the therapeutic aims of these resource-intensive, mainly urban initiatives can be achieved in criminal courts in Nunavut's resource constrained, culturally distinct and geographically remote communities., Method: A qualitative multiple-case study in the communities of Iqaluit, Arviat and Qikiqtarjuaq involved 55 semi-structured interviews and three focus groups with participants representing four sectors essential to these initiatives: justice, health, community organizations and community members. These interviews explored whether the therapeutic jurisprudence (TJ) principles that guide criminal court mental health initiatives and the component objectives of these principles could be used to improve the criminal court response to people with mental illness in Nunavut., Results: Interviews revealed 13 themes reflecting perceptions of Inuit culture's influence on the identification of people with mental illness, treatment, and collaboration between the court and others. These themes include cultural differences in defining mental illness, differences in traditional and contemporary treatment models, and the importance of mutual cultural respect., Conclusion: The findings suggest Inuit culture, including its recent history of cultural disruption and change, affects the vulnerability of Nunavut communities to the potential moral and legal pitfalls associated with TJ and criminal court mental health initiatives. These pitfalls include the dominance of biomedical approaches when identifying a target population, the medicalization of behaviour and culture, the risk of "paternalism" in therapeutic interventions, and shortcomings in interdisciplinary collaboration that limit considerations of Inuit culture. The pitfalls are not fatal to efforts to bring the rehabilitative benefits of these initiatives to Nunavut, but they require careful vigilance when employing TJ principles in an Indigenous circumpolar context., (Copyright © 2016. Published by Elsevier Ltd.)

Objectives: Unintentional injury is a leading cause of morbidity and mortality in Nunavut, where the importance of land-based activities and reliance on semi-permanent trails create unique risk profiles. Climate change is believed to be exacerbating these risks, although no studies have quantitatively examined links between environmental conditions and injury and distress in the Canadian Arctic. We examine the correlation between environmental conditions and land-based search and rescue (SAR) incidents across Nunavut., Study Design: Case study., Methods: Case data were acquired from the Canadian National Search and Rescue Secretariat. Gasoline sales from across the territory are then used to model land-use and exposure. We compare weather and ice conditions during 202 SAR incidents to conditions during 755 non-SAR days (controls) between 2013 and 2014., Results: We show daily ambient temperature, ice concentration, ice thickness, and variation in types of ice to be correlated with SAR rates across the territory during the study period., Conclusions: These conditions are projected to be affected by future climate change, which could increase demand for SAR and increase injury rates in the absence of targeted efforts aimed at prevention and treatment. This study provides health practitioners and public health communities with clearer understanding to prepare, respond to, and prevent injuries across the Arctic., (Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Residents in the Canadian Arctic regularly travel in remote, backcountry areas. This can pose risks for injuries and death, and create challenges for emergency responders and health systems. We aimed to describe the extent and characteristics of media-reported backcountry travel emergencies in two Northern Canadian territories (Nunavut and Northwest Territories). A case-series of all known incidents between 2004 and 2013 was established by identifying events in an online search of two media outlets, Nunatsiaq News and Northern News Services. We identified 121 incidents; these most commonly involved young men, and death occurred in just over 25% of cases. The territories differed in the seasonal patterns. News media provides a partial source of data to estimate the extent and characteristics of backcountry emergencies. This information is needed to improve emergency preparedness and health system responsiveness in the Arctic.

Background: Food insecurity, vitamin D deficiency and lower respiratory tract infections are highly prevalent conditions among Inuit children. However, the relationship between these conditions has not been examined in this population., Objective: The objective of this study was to examine the relationship between food insecurity and severe respiratory infections before age 2 years and health centre visits for a respiratory problem in the past year. We also explored the relationship between serum vitamin D status and respiratory outcomes in this population., Design: We included children aged 3-5 years who participated in a cross-sectional survey of the health of preschool Inuit children in Nunavut, Canada, from 2007 to 2008 (n=388). Parental reports of severe respiratory infections in the first 2 years of life and health care visits in the past 12 months were assessed through a questionnaire. Child and adult food security were assessed separately and serum 25-hydroxyvitamin D3 levels were measured in a subgroup of participants (n=279). Multivariate logistic regression was performed to assess the association between food security, vitamin D and each of the 2 respiratory outcomes., Results: Child and adult food insecurity measures were not significantly associated with adverse respiratory outcomes. Household crowding [odds ratio (OR)=1.51, 95% confidence interval (CI) 1.09-2.09, p=0.01 for the child food security model] and higher birth weight (OR=1.21, 95% CI: 1.02-1.43, p=0.03) were associated with reported severe chest infections before age 2 years while increasing age was associated with decreased odds of reported health care visits for a respiratory problem (OR=0.66, 95% CI: 0.48-0.91, p=0.02). Neither vitamin D insufficiency nor deficiency was associated with these respiratory outcomes., Conclusions: Using a large cross-sectional survey of Inuit children, we found that household crowding, but not food security or vitamin D levels, was associated with adverse respiratory outcomes. Further studies are warranted to examine the impact of decreasing household crowding on the respiratory health of these children.

Background: With invasive Haemophilus influenzae serotype b (Hib) disease controlled by vaccination with conjugate Hib vaccines, there is concern that invasive disease due to non-serotype b strains may emerge., Objective: This study characterized invasive H. influenzae (Hi) isolates from Nunavut, Canada, in the post-Hib vaccine era., Methods: Invasive H. influenzae isolates were identified by conventional methods at local hospitals; and further characterized at the provincial and federal public health laboratories, including detection of serotype antigens and genes, multi-locus sequence typing and antibiotic susceptibility., Results: Of the 89 invasive H. influenzae cases identified from 2000 to 2012, 71 case isolates were available for study. There were 43 serotype a (Hia), 12 Hib, 2 Hic, 1 Hid, 1 Hie, 2 Hif and 10 were non-typeable (NT). All 43 Hia were biotype II, sequence type (ST)-23. Three related STs were found among the Hib isolates: ST-95 (n=9), ST-635 (n=2) and ST-44 (n=1). Both Hif belonged to ST-124 and the 2 Hic were typed as ST-9. The remaining Hid (ST-1288) and Hie (ST-18) belonged to 2 separate clones. Of the 10 NT strains, 3 were typed as ST-23 and the remaining 7 isolates each belonged to a unique ST. Eight Hib and 1 NT-Hi were found to be resistant to ampicillin due to β-lactamase production. No resistance to other antibiotics was detected., Conclusion: During the period of 2000-2012, Hia was the predominant serotype causing invasive disease in Nunavut. This presents a public health concern due to an emerging clone of Hia as a cause of invasive H. influenzae disease and the lack of published guidelines for the prophylaxis of contacts. The clonal nature of Hia could be the result of spread within an isolated population, and/or unique characteristics of this strain to cause invasive disease. Further study of Hia in other populations may provide important information on this emerging pathogen. No antibiotic resistance was detected among Hia isolates; a small proportion of Hib and NT-Hi isolates demonstrated resistance to ampicillin due to β-lactamase production.

Aim: HIV infections occur across the Arctic but their incidence among aboriginal populations varies vastly. At the time this research was initiated there were no data on their occurrence, risk of HIV/AIDS or preventive strategies among Inuit living in the Nunavut territory of Canada. This review is the first to assess the risk of HIV infection among Inuit and evaluate current prevention strategies among Canadian-Inuit populations., Materials and Methods: The contents of this article are based on the author's own research, undertaken during 3 visits to the Canadian Arctic and the published literature., Results: Disproportionately high rates of Chlamydia and Gonorrhoea within Inuit communities confirm the potential threat of silent HIV transmission. Inuit awareness of HIV/AIDS issues remains inadequate. It is easy to blame distorted perceptions fuelled by the media, religious influence and socio-cultural factors. Aboriginal and Inuit groups, including youth, women and injection drug abusers are at increased risk of infection. The adaptability of proven prevention methods including condom use and male circumcision are discussed. Access to treatment, adherence and resistance issues in the North Canada, require attention., Conclusion: HIV/AIDS poses a considerable threat to Canadian Inuit public health. The most important problem to be addressed is Inuit lack of awareness and understanding of HIV. Education is the single most effective means of prevention. Inuit-specific and culture-sensitive interventions are recommended. Further research opportunities exist to investigate Inuit understanding over HIV/AIDS issues and to assess local prevention efforts., (Copyright © 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Although the protozoan parasite Toxoplasma gondii is ubiquitous in birds and mammals worldwide, the full suite of hosts and transmission routes is not completely understood, especially in the Arctic. Toxoplasma gondii occurrence in humans and wildlife can be high in Arctic regions, despite apparently limited opportunities for transmission of oocysts shed by felid definitive hosts. Arctic foxes (Vulpes lagopus) are under increasing anthropogenic and ecologic pressure, leading to population declines in parts of their range. Our understanding of T. gondii occurrence in arctic foxes is limited to only a few regions, but mortality events caused by this parasite have been reported. We investigated the exposure of arctic foxes to T. gondii in the Karrak Lake goose colony, Queen Maud Gulf Migratory Bird Sanctuary, Nunavut, Canada. Following an occupancy-modeling framework, we performed replicated antibody testing on serum samples by direct agglutination test (DAT), indirect fluorescent antibody test (IFAT), and an indirect enzyme-linked immunosorbent assay (ELISA) that can be used in multiple mammalian host species. As a metric of test performance, we then estimated the probability of detecting T. gondii antibodies for each of the tests. Occupancy estimates for T. gondii antibodies in arctic foxes under this framework were between 0.430 and 0.758. Detection probability was highest for IFAT (0.716) and lower for DAT (0.611) and ELISA (0.464), indicating that the test of choice for antibody detection in arctic foxes might be the IFAT. We document a new geographic record of T. gondii exposure in arctic foxes and demonstrate an emerging application of ecologic modeling techniques to account for imperfect performance of diagnostic tests in wildlife species.

Background: Xpert MTB/RIF testing for Mycobacterium tuberculosis and rifampin resistance is being used extensively in countries with a high burden of TB. However, recent evidence suggests that it may not have the same accuracy or impact in high-income, low-burden TB countries., Methods: A prospective, pragmatic study was done between March 2012 and March 2014 to determine the feasibility, accuracy, and impact on TB disease management provided by the Xpert test in a remote, medically underserved, predominantly Inuit population in Iqaluit, Nunavut, Canada., Results: A total of 453 Xpert tests were run on sputum samples from 344 patients with suspected TB. Twenty-seven patients were identified as having active TB disease by culture. There were no cases of drug-resistant TB. Using culture as the gold standard, one Xpert test compared with one, two, or three sputum samples cultured per patient had a sensitivity of 85% (95% CI, 66%-95%) and a specificity of 99% (95% CI, 97%-100%) for detection of M tuberculosis. The indeterminate rate was 4.4% of all samples run. Treatment initiation was significantly shortened using Xpert vs the national standard of three smears (1.8 days vs 7.7 days, P < .007) and particularly shorter in smear-negative, culture-positive cases (1.8 days vs 37.1 days, P < .008)., Conclusions: In a predominantly Inuit population in a remote region of Canada where the burden of TB is high and no TB testing facilities are available, onsite Xpert testing was feasible and accurate and shortened the time to TB treatment initiation.

Background: Food insecurity is an ongoing problem in the Canadian Arctic. Although most studies have focused on smaller communities, little is known about food insecurity in larger centres., Objectives: This study aimed to estimate the prevalence of food insecurity during 2 different seasons in Iqaluit, the territorial capital of Nunavut, as well as identify associated risk factors., Designs: A modified United States Department of Agriculture Food Security Survey was applied to 532 randomly selected households in September 2012 and 523 in May 2013. Chi-square tests and multivariable logistic regression were used to examine potential associations between food security and 9 risk factors identified in the literature., Results: In September 2012, 28.7% of surveyed households in Iqaluit were food insecure, a rate 3 times higher than the national average, but lower than smaller Inuit communities in Nunavut. Prevalence of food insecurity in September 2012 was not significantly different in May 2013 (27.2%). When aggregating results from Inuit households from both seasons (May and September), food insecurity was associated with poor quality housing and reliance on income support (p<0.01). Unemployment and younger age of the person in charge of food preparation were also significantly associated with food insecurity. In contrast to previous research among Arctic communities, gender and consumption of country food were not positively associated with food security. These results are consistent with research describing high food insecurity across the Canadian Arctic., Conclusion: The factors associated with food insecurity in Iqaluit differed from those identified in smaller communities, suggesting that experiences with, and processes of, food insecurity may differ between small communities and larger commercial centres. These results suggest that country food consumption, traditional knowledge and sharing networks may play a less important role in larger Inuit communities.

Background: Although the prevalences of infection with the protozoan parasites Cryptosporidium spp. and Giardia duodenalis in humans appear to be relatively high in the Canadian North, their transmission patterns are poorly understood., Objective: To determine the detection rate and the molecular characteristics of Cryptosporidium spp. and Giardia duodenalis in diarrhoeic patients in the Qikiqtani (Baffin Island) Region of Nunavut, Canada, in order to better understand the burden of illness and the potential mechanisms of transmission., Study Design/methods: Diarrhoeal stool specimens (n=108) submitted to the Qikiqtani General Hospital for clinical testing were also tested for the presence of Cryptosporidium spp. and Giardia duodenalis using epifluorescence microscopy and polymerase chain reaction (PCR). DNA sequencing and restriction fragment length polymorphism (RFLP) analyses were performed on PCR-positive specimens to determine the species, genotypes and sub-genotypes of the parasites., Results: Cryptosporidium was detected in 15.7% of the diarrhoeic patients, while Giardia was detected in 4.6%. DNA sequencing of a fragment of the small subunit rRNA gene indicated that all of the Cryptosporidium amplicons had a 100% homology to C. parvum, and a gp60 assay showed that all aligned with C. parvum sub-genotype IIa. Microsatellite analysis revealed 3 cases of sub-genotype IIaA15G2R1, 2 of IIaA15G1R and 1 case each of sub-genotypes IIaA16G1R1 and IIaA15R1. For Giardia, results based on the amplification of both the 16S rRNA gene and the gdh gene were generally in agreement, and both DNA sequencing and RFLP demonstrated the presence of the G. duodenalis Assemblage B genotype., Conclusions: Both C. parvum and G. duodenalis Assemblage B were present in human diarrhoeal stool specimens from Nunavut, which was suggestive of zoonotic transmission, although human-to-human transmission cannot be ruled out. To fully understand the public health significance of the different Cryptosporidium and Giardia species and genotypes in diarrhoeic patients, it will be imperative to establish the extent of genetic diversity within these parasites through comprehensive studies of the molecular epidemiology of cryptosporidiosis and giardiasis in the Nunavut region.