SSTI research in Indigenous populations
A small but growing body of research on skin conditions in Canada’s remote communities identifies health challenges and needed research directions (1,300 words, 6 minutes).
Skin diseases in North American Indigenous populations are under-documented in medical literature, Dr. Rachel Netahe Asiniwasis told the delegates at the 2nd annual Indigenous Skin Spectrum Summit on June 11, 2022. She said she and a team of researchers conducted a systematic scoping review of existing literature to assess the quality of the studies.
Dr. Asiniwasis is a dermatologist in Regina, and she and her team serve remote northern First Nations communities through fly-in visits and teledermatology clinics.
“My goal with our team is to systematically and formally document North American Indigenous skin disease and use findings and gaps as launch points for future research designs, discussion and awareness,” she said.
Dr. Asiniwasis said the review, expected to be published later in 2022, discovered little Indigenous content in regular databases. This finding led her team to search some smaller databases with Indigenous content. She said she recognizes the significant differences among Indigenous peoples in North America but wanted to cast a wide net.
“These are things such as the Native Health Database, the Circumpolar Health Bibliographic Database and the Bibliography of Native North Americans,” she said. “We are also looking at the representation of Indigenous peoples in North America in phase three and four clinical trials of small molecule and biological therapy.”
Some of the review findings Dr. Asiniwasis discussed were:
While limited, the amount of literature on dermatologic health in North American Indigenous communities has been increasing
In this literature, there has been a growing focus on rural and remote communities
Most of the literature consists of case reports, case series, observational studies and other population-based data
The major categories of diseases covered in the literature include:
o Inflammatory dermatoses
o Skin and soft tissue infections
o Diabetic and other wounds
o Autoimmune connective tissue disorders
Barriers and social determinants of health are major contributors to skin disease.
Bottom Line: A scoping review on skin diseases in North American Indigenous peoples found a lack of literature. An assessment of the data available suggested that inflammatory diseases and skin infections are significant problems in remote and rural Indigenous communities. Barriers and social determinants of health such as poverty, isolation, lack of clean water and crowded housing can contribute to skin disease, making patients and communities vulnerable to MRSA and staph infections. Urgent action and more information are needed to address the prevalence of these infections in Indigenous communities.
From the literature on skin infections in minority communities
Dimensions of poverty as risk factors for antimicrobial resistant organisms in Canada: A structured narrative review
The authors of this study searched the MEDLINE, EMBASE and Web of Science databases for articles on poverty and infection with antibiotic-resistant organisms (AROs) in Canada between 1990 and 2020. They included 43 studies in their final review.
Some of their findings included:
One study found a 73% risk reduction in community-acquired (CA) MRSA infection for each $100,000 increase in income
Results regarding homelessness and MRSA suggested transmission was related to patterns of frequent drug use, skin-to-skin contact and sexual contact more than contact in shelters
Indigenous persons have high rates of CA-MRSA, though having more rooms in the home offers significant protection
One study found that two factors—household income higher than $60,000 and higher maternal education—protected against otitis media due to ARO among children
None of the 20 papers that discussed tuberculosis used income in their analysis.
Antibiotic use among 12 Canadian First Nations communities: A retrospective chart review of skin and soft tissue infections
This retrospective chart review assessed antibiotic prescriptions in 12 First Nations communities across five provinces in Canada. The data was collected from Sept. to Dec. 2013 on antibiotic prescriptions. The data covered skin and soft tissue infections (SSTIs), clinical symptoms, diagnostic information such as the presence of community-acquired (CA) MRSA infection, and treatment.
Among 372 patients, 224 (60.2%) had at least one antibiotic prescription in the previous 12 months. There were 569 total prescriptions. The estimated prevalence of SSTIs was 36.8%—137 cases of SSTIs in 372 charts reviewed. Of the SSTI cases, 34 (24.8%) were purulent infections, and 55 (40.2%) were due to CA-MRSA.
Prospective surveillance for invasive Staphylococcus aureus and group A Streptococcus infections in a setting with a high community burden of scabies and impetigo
Researchers studied patients admitted to a referral hospital in northern Fiji with invasive Staphylococcus aureus (iSA) or group A Streptococcus (iGAS) infection between July 2018 and June 2019. In that period, there were 55 admissions for iSA and 15 for iGAS—incidence rates of 45.2 and 12.3 per 100,000 person-years, respectively. The highest incidence was in patients aged 65 years or older. Indigenous Fijians (iTaukei) had higher rates of iSA compared to other ethnicities. Most cases of iSA (75%) and iGAS (53.3%) had SSTIs. There was a high rate of fatalities for both iSA (10.9%) and iGAS (33.3%) infection.
The researchers conclude there is a need for improved SSTI control strategies in Fiji.
The prevalence, risk, and management of methicillin-resistant Staphylococcus aureus infection in diverse populations across Canada: A systematic review
This study reviewed the existing literature on MRSA prevalence in Canada over time and in diverse populations across the country. The authors reported that MRSA prevalence increased steadily in the 1990s and 2000s and is a public health concern in Canada. The concern around MRSA prevalence is also more significant in Indigenous and other vulnerable populations. Infection control measures, low socioeconomic status and personal demographic status all had an impact on MRSA infection rates.
Antibiotic resistance patterns and risk factors for MRSA infection included high susceptibility (>85%) to trimethoprim-sulfamethoxazole. No significant resistance for vancomycin, linezolid, or rifampin was reported.
The authors conclude that while MRSA continues to be susceptible to several antibiotics, the high and sometimes variable rates of resistance to other medications emphasize the importance of antimicrobial stewardship.
VIDEO: Soft tissue infections in rural Indigenous communities
At the intersection of skin and society
The 2022 National Black Canadians Summit will take place in Halifax from July 29 to 31. According to the event website, the Summit will bring together “Black Canadians from all ages, sectors and walks of life to share their experiences, raise awareness and spark an inclusive national dialogue.”
This Summit is an initiative of the Michaëlle Jean Foundation, a charitable organization established in 2010 that works to support young Canadians who are experiencing exclusion. The Foundation was created by the 27th Governor-General of Canada, the Right Honourable Michaëlle Jean, and her husband, Jean-Daniel Lafond.
A statement from the Foundation notes: “This large-scale mobilization event allows for a truly national and inclusive dialogue because creating a just, equitable and inclusive society must be a shared responsibility and everyone’s business. Everyone has a role to play in deconstructing the overwhelming racial discrimination around the world, including in Canada.
“Throughout the Summit, honest conversations will be had about rights to be reclaimed, barriers to be broken down, and the devastating impacts of racism on mental health and living conditions.”
In addition to in-person attendance, the Michaëlle Jean Foundation has announced the Summit will be accessible through an online live stream. According to a press release from the Foundation, the stream “will showcase the Opening ceremony, youth-focused workshops, keynote addresses, roundtable discussions and the Halifax Declaration.” The Declaration is a call to action to end systematic racial discrimination.
Registration for the in-person Summit and the live stream, and an event program are available online at https://www.blackcanadiansummit.ca/
July 18 is Nelson Mandela International Day
July 24 is International Self-Care Day
Something to think about in the week ahead…
Lou Holtz (January 6, 1937—): Former American professional football player, coach and analyst.
During the 2022 Indigenous Skin Spectrum Summit, Nurse Practitioner Rachel Johnson discusses the realities of primary care dermatology in remote clinics in Canada.
Upcoming events and learning opportunities
Registration is open for the 2022 Summer of Dialogue: Focus on Black Skin, which will be held virtually on Wed. August 17, 7:00 PM to 8:30 PM EDT.
In recognition of persistent gaps in dermatologic training regarding skin of colour, the Summer of Dialogue colloquium, Focus on Black Skin, will discuss recent progress on advancing the inclusion of diverse skin tones in research and medical education.
This 90-minute live discussion will address treatment challenges specific to Black skin (Fitzpatrick Types V & VI), including phenotypic variations from standard training models and the necessity of cultural competence.
This non-accredited program will be available to attend at no charge, thanks to the support of our sponsors.
Highlights of the event include:
The Dr. Mercy Alexis Keynote Lecture: Gaps in Aesthetic Treatment for Richly Pigmented Skin by Dr. Pearl Grimes of Los Angeles
Moderator: Dr. Andrew F. Alexis
Educating new and existing HCPs on optimal skincare for Black patients
Register for the 2022 Summer of Dialogue: Focus on Black Skin here:
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