INTRODUCTION:Chlamydia trachomatis is the most commonly encountered sexually transmitted infection. Our objective was to describe the evolution of chlamydia incidence rates in Alberta, Saskatchewan, and Manitoba as compared to Canada overall, from 1991 to 2022. METHODS:We conducted an ecological study, collecting data on chlamydia infection from publicly available reports throughout Canada, laying special emphasis on Alberta, Saskatchewan, and Manitoba. As variables, we used: Chlamydia incidence rate per 100,000 inhabitants, stratified by sex, age group, ethnicity, province, and year. RESULTS:In 1991, chlamydia incidence in Alberta (265.0/100,000), Saskatchewan (328.2/100,000), and Manitoba (410.2/100,000) largely exceeded the nationwide rate (164.0/100,000). Incidence subsequently increased dramatically, peaking between 2013 and 2019 (Canada overall: 335.1/100,000; Alberta: 399.9/100,000; Saskatchewan: 534.6/100,000; Manitoba: 604.5/100,000). Females aged 20-29 years accounted for 61.6% of the cases, while incidence in individuals aged 30-39 pronouncedly increased. Coinfection rates with Neisseria gonorrhoeae increased in Alberta (1998-2006) from 2.1% to 5.2% and decreased in Manitoba (2004-2012) from 14.8% to 9.8%. One case of lymphogranuloma venereum was reported in Canada in 2004, 36 in 2005, and 96 between 2004 and 2011. Data on other equity indicators are limited or nonexistent. CONCLUSIONS:Between 1991 and 2022, the incidence of chlamydia infection increased across Canada and, more particularly, in three provinces (Alberta, Saskatchewan, and Manitoba), which consistently reported chlamydia infection incidence rates 1.5 to 2 times the national average. Young people and females were the most severely affected groups. More complete and consistent epidemiological data, which would include incidence disaggregated by equity indicators, are crucial to addressing the increasing burden of chlamydia in Canada and, more particularly, the Prairie provinces.

BACKGROUND:Canada aims to eliminate hepatitis C (HCV) by 2030. While national rates have dropped, regional disparities persist. In 2021, Manitoba had the highest new HCV rates, and Saskatchewan's rates were double the national average. This study aimed to describe the incidence and risk factors associated with HCV infections in Alberta, Saskatchewan, and Manitoba, compared to Canada,1980-2023. METHODS:This ecological study used publicly available government reports from Alberta, Saskatchewan, Manitoba, and Canada (1980-2023) on HCV cases and rates by year and disaggregated by sex (female/male), age, ethnicity, province, sexual orientation (gay/bisexual men who have sex with men, heterosexual), and risk factors (injection drug use, blood products, and history of incarceration). RESULTS:Since becoming nationally notifiable in 1991, HCV incidence in Canada has declined, but Saskatchewan has reported consistently rates above the national average since 2005. Manitoba's incidence rose, peaking in 2018, with the highest national rate in 2021 (42.8/100,000), while Alberta had the lowest rate (14.5/100,00 people). Males represented 61 % of HCV cases in Canada in 2022, but the sex gap is narrowing, particularly in the Prairies. Most cases in Canada occur among individuals aged 40-59, but younger groups (20-39) are increasingly affected in the Prairies, particularly females of childbearing age and males aged 30-39. Injection drug use was the leading risk factor in Saskatchewan and Manitoba. CONCLUSION:Canada is on a downward trend in rates of HCV; however, Manitoba and Saskatchewan have higher rates, possibly due to syndemics of substance use, which are leading to increased rates of HIV and STBBIs. A collaborative effort in surveillance, testing, treatment, and prevention of HCV across the three provinces is necessary.

We aimed to describe the evolution of gonorrhea infection and its antimicrobial resistance patterns in the Prairie provinces compared to Canada between 1980 and 2022. Data was collected from publicly available sexually transmitted infection reports in Canada, Alberta, Saskatchewan, and Manitoba. We extracted the number and rates of gonorrhea cases; percentage of cases by sex, age, ethnicity, sexual orientation; and data on cases diagnosed by culture and antimicrobial resistance. Descriptive statistics and age-period-cohort effect analysis were used. Gonorrhea cases in Canada rose from 32.4 per 100 000 in 1992 to 92.3 in 2022. In 2020, 36.9% of gonorrhea cases in Canada were females, compared to 42.8% in Alberta, 55.3% in Saskatchewan and 56% in Manitoba. People aged ≥30 years represented 22.5% of cases in 1980, and 54.1% in 2022. By 2022, the proportion of Canadian cases detected by culture declined to less than 10%, and azithromycin resistance of N. gonorrhoeae isolates was 8.1%. Alberta, Manitoba, and Saskatchewan reported higher rates of gonorrhea compared to Canada, with a higher proportion of female cases in Manitoba and Saskatchewan. Rising antimicrobial resistance rates and decreased culture testing present significant concerns for gonorrhea control and surveillance.

Background:Canada aims to end the HIV epidemic as a public health threat by 2030. However, the provinces Alberta, Saskatchewan, and Manitoba reported 564 new HIV diagnoses in 2021 and over 600 in 2022. This study describes changes in HIV epidemiology in these three provinces compared to the rest of Canada between 1985 and 2022. Methods:This was an ecological study that used data from publicly available HIV reports published by the Governments of Manitoba, Saskatchewan, Alberta, and Canada from the first reported HIV diagnoses to the latest available information. Variables of interest included number of HIV diagnoses per year (new, introduced), advanced HIV disease, proportion of diagnoses by sex (female/male), ethnicity, age, self-reported HIV mode of transmission, and mortality. We report the HIV incidence, advanced HIV disease, and mortality over time by province, and by sex, ethnicity, age, and mode of HIV transmission when data are available. Results:Canadian HIV incidence decreased over time, while new HIV diagnoses in Manitoba and Saskatchewan increased to the highest ever recorded. In Saskatchewan and Manitoba, the male-to-female ratio is 1:1, while in Alberta and Canada, it is 2:1. Indigenous people have been overrepresented in Saskatchewan and Manitoba diagnoses since 2006 and 2016, respectively. The most common modes of HIV transmission are injection drug use and heterosexual sex in Saskatchewan and Manitoba for several years, while "out-of-country" is the most common category in Alberta. The advanced HIV disease and mortality statistics have decreased over time in Canada and the three provinces. Conclusion:HIV incidence in Canada has slowly decreased; however, Manitoba and Saskatchewan have shown unprecedented increases in HIV incidence. The current epidemiology requires immediate public health action from local, provincial, and federal governments, considering that Alberta, Saskatchewan, and Manitoba contribute to about 40% of all new HIV diagnoses in Canada.

Background: We aimed to describe trends in M. genitalium prevalence and associated resistance in Canada between 1980 and 2022. Methods: Ecological study and a scoping review. We collected publicly available data published by the governments of all Canadian provinces and territories. We also systematically searched PubMed, Medline, Embase, and grey literature using the keywords ‘M. genitalium’, ‘Canada’, and all provinces and territories. We reported M. genitalium prevalence, age, sex, gender, symptoms, coinfections, sample types used for diagnosis, and macrolide and fluoroquinolone resistance rates. Results: National or provincial surveillance systems for M. genitalium are absent. Eight studies reported the epidemiology of M. genitalium. The prevalence ranged between 3% in Quebec and 30.3% in Ontario. Half of the patients reported symptoms. The most collected sample for M. genitalium diagnosis was urine, followed by cervical and urethral swabs. Co-infection with Chlamydia trachomatis was reported in 3.3% to 16.4% of cases and with Neisseria gonorrhoeae in 0.0% to 24.0%. Macrolide resistance ranged between 25% and 82.1%, and fluoroquinolone resistance between 0.0% and 29.1%. Conclusions: M. genitalium prevalence and resistance rates varied by sex, gender, province, and specimen type. In the absence of routine surveillance, incomplete data hinders understanding the bacterium’s natural history, its impact on some key groups, and the tracking of antibiotic resistance.

Background: Canada aims to end the HIV epidemic as a public health threat by 2030. However, the provinces Alberta, Saskatchewan, and Manitoba reported 564 new HIV diagnoses in 2021 and over 600 in 2022. This study describes changes in HIV epidemiology in these three provinces compared to the rest of Canada between 1985 and 2022. Methods: Ecological study. Data: publicly available HIV reports published by the Governments of Manitoba, Saskatchewan, Alberta, and Canada from the first reported HIV diagnoses to the latest available information. Variables: Number of HIV diagnoses per year (new, introduced), advanced HIV disease, proportion of diagnoses by sex (female/male), ethnicity, age, self-reported HIV mode of transmission, and mortality. We report the HIV incidence, advanced HIV disease, and mortality over time by province, and by sex, ethnicity, age, and mode of HIV transmission when data are available. Results: Canadian HIV incidence decreased over time, while new HIV diagnoses in Manitoba and Saskatchewan increased to the highest ever recorded. In Saskatchewan and Manitoba, the male-to-female ratio is 1:1, while in Alberta and Canada, it is 2:1. Indigenous people have been overrepresented in Saskatchewan and Manitoba diagnoses since 2006 and 2016, respectively. The most common modes of HIV transmission are injection drug use and heterosexual sex in Saskatchewan and Manitoba for several years, while “out-of-country” is the most common category in Alberta. The advanced HIV disease and mortality have decreased over time in Canada and the three provinces. Conclusion: HIV incidence in Canada has slowly decreased; however, Manitoba and Saskatchewan have shown unprecedented increase in HIV incidence. The current epidemiology requires immediate public health action from local, provincial, and federal governments, considering that Alberta, Saskatchewan, and Manitoba contribute to ∼40% of all new HIV diagnoses in Canada.

Importance In the US and Canada, women comprise approximately one-third of people who inject drugs (PWID); however, clinical characteristics and outcomes of injection drug use complications in women are poorly described. Objective To identify clinical characteristics and outcomes of infective endocarditis (IE) among women who inject drugs (WWID). Design, Setting, and Participants This is a retrospective cohort study of PWID with definite IE (per 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria) admitted from April 5, 2007, to March 15, 2018, at 5 tertiary-care hospitals in London, Ontario, and Regina, Saskatchewan, Canada. Data were analyzed from June 1, 2023, to August 2, 2024. Descriptive analyses were conducted for baseline characteristics at index hospitalization and stratified by sex. Main Outcomes and Measures The primary outcome was the difference in 5-year survival between female and male PWID with IE. The secondary outcome was 1-year survival. Multivariable time-dependent Cox proportional hazards regression analyses were conducted for variables of clinical importance to evaluate 5-year mortality. Results Of 430 PWID with IE, 220 (51.2%) were women; of 332 non-PWID with IE, 101 (30.4%) were women. WWID with IE were younger than men (median [IQR] age, 31.5 [27.0-38.5] vs 38.5 [31.0-49.0] years), and 11 of 220 (5.0%) were pregnant at index hospitalization, although only 12 of 220 (5.5%) had contraceptive use documented. Women had a larger proportion of right-sided IE than men (158 of 220 women [71.8%] vs 113 of 210 men [53.8%]). WWID living in urban areas had higher mortality than WWID in rural areas (adjusted hazard ratio [aHR], 2.70; 95% CI, 1.15-6.34; P = .02). Overall mortality was lower among PWID referred for substance use disorder counseling in centers with inpatient services compared with centers with only outpatient referrals (aHR, 0.29; 95% CI, 0.17-0.51; P < .001). Overall mortality was lower with right-sided heart disease for both women (aHR, 0.44; 95% CI, 0.27-0.71; P < .001) and men (aHR, 0.22; 95% CI, 0.10-0.50; P < .001) and was higher with congestive heart failure for both women (aHR, 2.32; 95% CI, 1.29-4.18; P = .005) and men (aHR, 1.73; 95% CI, 1.07-2.79; P = .02). Conclusions and Relevance In this cohort of PWID with IE, women were overrepresented. Reasons for women's disproportionately high IE incidence need further study. Inpatient substance use disorder services, contraception counseling, and enhanced social support for WWID living in urban areas need to be prioritized.

HIV/HCV prevention among people who inject drugs (PWID) is of key public health importance. We aimed to assess the impact of COVID-19 and associated response measures on HIV/HCV prevention services and socio-economic status of PWID in high-HIV-risk sites. Sites with recent (2011–2019) HIV outbreaks among PWID in Europe North America and Israel, that had been previously identified, were contacted early May 2020. Out of 17 sites invited to participate, 13 accepted. Semi-structured qualitative site reports were prepared covering data from March to May 2020, analyzed/coded and confirmed with a structured questionnaire, in which all sites explicitly responded to all 103 issues reported in the qualitative reports. Opioid maintenance treatment, needle/syringe programs and antiretroviral treatment /hepatitis C treatment continued, but with important reductions and operational changes. Increases in overdoses, widespread difficulties with food and hygiene needs, disruptions in drug supply, and increased homelessness were reported. Service programs rapidly reformed long established, and politically entrenched, restrictive service delivery policies. Future epidemic control measures should include mitigation of negative side-effects on service provision and socio-economic determinants in PWID.

First Nation people residing in rural and remote communities have limited primary healthcare access, which often affects chronic disease management leading to poor health outcomes. Individuals with lived experiences of chronic disease and substance use, along with health directors, advocated for improved services. Subsequently, an urban healthcare team in partnership with four First Nation communities developed an Outreach clinic to address healthcare access barriers. Established in 2016, this community-led clinic improves primary care access and chronic disease management in First Nation communities. Employing a qualitative research design, interviews were conducted with 15 clinic providers and 9 community members to explore the clinic's 1-year post-implementation impacts. Thematic data analysis indicated that engagement and approval by community leadership, support from Elders and community members and collaboration with existing community healthcare staff were crucial for establishing the Outreach clinic. Initial logistical challenges with space allocation, equipment, medical supplies, funding, staffing, medical records and appointment scheduling were resolved through community consultation and creative solutions. A nurse coordinator ensured continuity of care and was integral to ensuring clients receive seamless care. The commitment of the outreach team and the collective goal of providing client-centered care were instrumental in the clinic's success. In partnership with communities, access to healthcare in First Nation communities can be enhanced by coordinating Outreach clinics through existing community healthcare facilities.

Despite high prevalence of hepatitis C virus (HCV), linkage to care and treatment for Indigenous people is low. In an Indigenous community in Saskatchewan, Canada a retrospective review identified 200 individuals (∼12% prevalence) had HCV antibodies though majority lacked ribonucleic acid (RNA) testing, and few received treatment despite availability of an effective cure. Following Indigenous oral traditions, focus group discussions were held with key community members and leadership. Participants emphasized the need for a community-based screening and treatment programme. A team of community members, peers and healthcare professionals developed a streamlined screening pathway termed 'liver health event' (LHE) to reduce stigma, reach undiagnosed, re-engage previously diagnosed, and ensure rapid linkage to care/treatment. LHEs began December 2016. Statistics were tracked for each event. As of July 2019, there were 10 LHEs with 540 participants, 227 hepatitis C tests and 346 FibroScans completed. This represented 294 unique individuals, of which 64.3% were tested, and of those, 40.8% were Ab positive. Among those positive for antibodies, 41.7% had active hepatitis C infections, and among these, 90% were linked to care, and 14 new positive individuals were identified. Following the success of LHEs, these were adapted and implemented in 10 other communities in this region, resulting in 17 additional LHEs. This intervention is reaching the undiagnosed and linking clients to care through a low-barrier and de-stigmatizing approach. It has facilitated collaboration, knowledge exchange and mentorship between Indigenous communities, significantly impacting health outcomes of Indigenous people in this region.

Watch a video presentation of this article Ahtahkakoop Cree Nation (ACN) is an indigenous community located in rural Central Saskatchewan with a high prevalence of hepatitis C virus (HCV) infection. Based on data from clinical records, approximately 12.5% of the community population (200 cases of N = 1600) had a history of HCV infection (i.e., HCV antibody positive). An existing program serving HIV clients identified almost 97% of clients to be HCV antibody positive, with few receiving HCV treatment. To address the need for HCV care in the community, health care staff supported by ACN leadership integrated HCV care with the HIV program, operating toward HCV elimination. This review describes the indigenous community-led HCV program and elimination campaign from inception to its current state and outcomes. Using the Learning Healthcare System framework,1 this comprehensive HCV care model was built on the foundation of an existing community-based HIV model of care, termed “Know Your Status” (KYS).2 Between 2016 and 2019, the program expanded to holistically meet the needs of clients and reach a sustainable community-driven program (Fig. 1). The HCV care model functions through: (1) HCV education and advocacy, (2) screening, (3) treatment, and (4) knowledge translation. All aspects of care in the community were and continue to be delivered by the community nurse-led health care team, who in response to an HIV outbreak in the community expanded their scope of practice to test (phlebotomy) and care for clients with HIV, with support from a visiting infectious disease physician and their urban health care/research team (Table 1). Community leadership and members supported this program development. Prior to 2016, direct-acting antivirals (DAAs) for HCV treatment were not covered through the federal program for Status First Nations individuals,3 treatment was unavailable in the community, and care outside of the community was poorly accessed. The inclusion of DAA treatment into the formulary in 2016 enabled the community to expand KYS and begin an HCV program. The community health care team provided HCV education to all sectors of the community, reducing stigma and creating awareness about HCV infection, risk factors, treatment options, and prevention strategies. Health care staff advocated for HCV care as a priority to Chief and Council. Community engagement (radio spots, educational booths) helped gain approval for KYS expansion from Chief and Council and the community at large. Meaningful engagement with the community during program development and delivery ensured ownership, greater commitment, program fidelity, and high-quality care. Chief and Council were given annual reports of HCV treatment outcomes (testing, incidence, number of clients in care, on treatment, etc.) that identified areas of improvement and priorities for funding. Liver Health Event Planning Photo. Liver Health Event Registration Photo. ACN’s HCV Care Model aims to achieve the targets set out by the World Health Organization’s strategy for viral hepatitis4 through key targeted steps with ambitious goals: (1) encourage screening uptake to identify all people living with HCV, (2) engage those not in care by offering preventative services/supports, (3) retain clients in treatment and support them during and posttreatment, (4) case-manage through nurse and outreach worker follow-up, and (5) monitor HCV treatment outcomes (Fig. 2). To minimize the risk for reinfection, cohorted treatment initiations among injecting partners and household members were implemented where possible. Knowledge translation events with academic, clinical, and administrative audiences advocated for improved access to screening and treatment for indigenous people. HCV education, screening, treatment, and knowledge translation are delivered simultaneously. Lessons learned inform better practices enhancing client retention and the program’s sustainability in reaching HCV elimination goals. The HCV elimination campaign commenced with four radio spots to create awareness and share HCV program goals, with community booths at Treaty Days for ongoing education/awareness. Peers promoted LHE attendance while distributing harm reduction supplies and education. ACN ran 10 LHEs between December 2016 and July 2019, with 18% of the community’s overall population and 34% of the adult population participating in LHEs, following the testing algorithm shown in Fig. 3. Of these, 64% were screened for HCV (n = 189). Of those identified to have chronic HCV infection, 90% were linked to care. Peers provided education and harm reduction supplies and answered questions for those not yet ready or interested in HCV care, bridging connections with the nursing team. Four to six peers were employed in the program. Prior to HCV program implementation, three known individuals started treatment for HCV infection. From 2016 to 2019, the program linked 83 to care, treated 55 (66%), and cured 42 (77%), as shown in Table 2. With recent advances in HCV treatment, HCV elimination is achievable. Limited availability of health care services in geographically isolated indigenous communities creates access barriers for HCV screening and treatment. This HCV care model was developed to address gaps, aiming for hepatitis C elimination. Risk for reinfections is high due to mobility between urban centers and other communities and active injection drug use during and posttreatment. Additional mental health and addiction support for individuals injecting drugs before, during, and after treatment to prevent infections and reinfections is required. Program delivery and outcomes are dependent on the presence of dedicated, trained, and motivated health care providers engaged with clients and fully committed toward program goals. This client-centered care model improved knowledge about liver health and access to liver disease assessments. FibroScan score initially used for determining treatment eligibility served as a visual aid for clients to make lifestyle changes and promote liver health. It was an invaluable engagement tool with clients. The health care team developed expertise in HCV care and management. The program was acknowledged by provincial, national, and international audiences, drawing positive regard toward ACN. The model can be used as a template and adapted to address other chronic illnesses in other communities to address their health priorities. Testing events have been paused temporarily to redirect efforts to control the spread of coronavirus disease 2019 (COVID-19). Active clients continue to be supported through treatment in the community by the community program staff with support from urban clinicians through in-person visits and virtual care.

Abstract Background The province of Saskatchewan has had the highest rates of HIV and Hepatitis C in Canada for over 10 years, the majority of which is related to People who inject drugs (PWID) and with higher proportion of young women. However, the most severe complications of injection drug use (IDU) are infective endocarditis (IE) and its associated sequelae. While high rates of IE have been noted, no data exists to show the burden of infective endocarditis and its clinical outcomes. Thus, we looked to determine the mortality and impact of IE amongst PWID and also establish the epidemiology while comparing to non-PWID IE. Methods This is a retrospective chart review of consecutive adult patients (age > 18) admitted for IE, as defined by Duke’s IE Criteria, at tertiary care hospitals in Regina, the capital city of Saskatchewan, between January 1, 2013 and December 31, 2018. PWID were identified through chart documentation of self-reported IV drug use. Outcomes included 1-year mortality, surgical intervention and referral to addiction services. Results Of the total 227 patients in our cohort, 130 (57.3%) were female, and the 1-year mortality was 39.2%. PWID related IE comprised 132 (58.1%) of the cohort. In comparison to non-PWID related IE, PWID were younger (median age 38.0, compared to 68.0 for non-PWID), more likely to be female (RR 2.06; 95% CI [1.44-3.04]; p< 0.001), to suffer right-sided disease (RR 9.14; 95% CI [4.74-15.14]; p< 0.001) and less likely to receive surgical management (RR 0.30; 95% CI [0.27-0.77]; p< 0.001). Surgical management was associated with lower mortality (RR 0.40; 95% CI [0.11-0.65]; p< 0.001). Addiction support and treatment also was protective (RR 0.89; 95% CI [0.34-1.21]; p=0.051). Conclusion This cohort study of IE episodes shows for the first time the devastating impact of IDU in Saskatchewan and identifies PWID as having a 39% mortality at 1 year, which coupled with their younger age translates into an enormous years of life lost. Additionally, the over-representation of young women amongst PWID IE is consistent with the higher percentage of young women with HIV and HCV infections, and identifies them as a group that is particularly vulnerable to complications of IDU. Targeted programs for PWID, particularly towards young women at risk are urgently needed. Disclosures All Authors: No reported disclosures

Background Infectious complications of injection drug use (IDU) often require lengthy inpatient treatment. Our objective was to identify the number of admissions related to IDU in Regina, Canada, as well as describe patient demographics and comorbidities, yearly mortality, readmission rate, and cumulative cost of these hospitalizations between January 1 and December 31, 2018. Additionally, we sought to identify factors that increased risk of death or readmission. Methods This study is a retrospective chart review conducted at the two hospitals in Regina. Eligible study cases were identified by querying the discharge database for predetermined International Classification of Diseases code combinations. Electronic medical records were reviewed to assess whether each admission met inclusion criteria, and hospitalization and patient data were subsequently extracted for all included admissions. Mortality data were gleaned from hospital and Ministry of Health databases. Data were analyzed using Excel and IBM SPSS Statistics to identify common comorbidities, admission diagnoses, and costs, as well as to compare patients with a single admission during the study period to those with multiple admissions. Logistic regression analysis was used to identify the relationship between individual variables and in- and out-of-hospital annual mortality. Results One hundred and forty-nine admissions were included, with 102 unique patients identified. Common comorbidities included hepatitis C (47%), human immunodeficiency virus (HIV) (25%), and comorbid psychiatric disorders (19%). In 23% of all admissions, patients left hospital prior to treatment completion, and 27% of patients experienced multiple admissions. Female patients and those with chronic pain were more likely to be readmitted ( p = 0.024 and p = 0.029, respectively). Patients admitted with infective endocarditis were more likely to die during hospitalization ( p = 0.0001). The overall mortality was 15% in our cohort. The estimated cumulative cost of inpatient treatment of complications of IDU in Regina was $3.7 million CAD in 2018. Conclusion Patients with history of IDU and hospital admission experience high mortality rates in Regina, a city with paucity of inpatient supports for persons who use injection drugs. Needle syringe programs, opioid agonist therapy, and safe consumption sites have been shown to improve outcomes as well as reduce healthcare costs for this patient population. We will use our findings to advocate for increased access to these harm reduction strategies in Regina, particularly for inpatients.

Alveolar echinococcosis (AE) is a life-threatening parasitic disease caused by the zoonotic cestode Echinococcus multilocularis. Our goals were to confirm infection, identify species, and analyze biogeographical origin of metacestode tissues from a suspected human AE case in Saskatchewan, Canada. We conducted polymerase chain reaction (PCR) targeting the nad1 mitochondrial gene for E. multilocularis and the rrnS ribosomal RNA gene for E. granulosus and conducted haplotype analysis at the nad2 locus. Our analysis confirmed AE and indicated that sequences matched infected Saskatchewan coyotes and European E3/E4 haplotypes. The patient had no travel history outside North America. This suggests autochthonous transmission of a European-type strain.

Chronic diseases disproportionately affect indigenous people in Saskatchewan, with high rates of HIV, hepatitis C, and diabetes. Concentration of health care services in urban centers and minimal in-community health care service delays access to diagnostic testing and treatment for those residing in

During 2011-16, HIV outbreaks occurred among people who inject drugs (PWID) in Canada (southeastern Saskatchewan), Greece (Athens), Ireland (Dublin), Israel (Tel Aviv), Luxembourg, Romania (Bucharest), Scotland (Glasgow), and USA (Scott County, Indiana). Factors common to many of these outbreaks included community economic problems, homelessness, and changes in drug injection patterns. The outbreaks differed in size (from under 100 to over 1000 newly reported HIV cases among PWID) and in the extent to which combined prevention had been implemented before, during, and after the outbreaks. Countries need to ensure high coverage of HIV prevention services and coverage higher than the current UNAIDS recommendation might be needed in areas in which short acting drugs are injected. In addition, monitoring of PWID with special attention for changing drug use patterns, risk behaviours, and susceptible subgroups (eg, PWID experiencing homelessness) needs to be in place to prevent or rapidly detect and contain new HIV outbreaks.