Diabetes Mellitus and Tuberculosis

Tuberculosis Spike In Nunavik Has Complex Causes, Needs Complex Solutions: Experts

Tuberculosis cases are expected to reach record numbers in Nunavik, the Inuit region comprising 14 communities in the far north of Quebec, according to the Nunavik Regional Board of Health and Social Services [NRBHSS].

In June, mayors of all 14 communities wrote a joint letter requesting help from Quebec's Minister of Health and Social Services in tackling numbers that suggested 2025 would be the worst ever year for TB in Nunavik.

"We heard last year there were 94 [cases], and in April [of 2025] there were about 30, 40. It's still growing in Nunavik," Qialluk Nappaaluk, mayor of Kangiqsujuaq told APTN News.

"So the mayors [wrote] a letter asking for more funding from government, because we need tools, X-ray [machines]."

According to the NRBHSS, the 94 cases in 2024 represented the "highest TB rates in recent history."

"The incidence of TB in Nunavik is 1,000 times higher than among non-Indigenous, Canadian-born individuals and in some communities, it is 10,000 times higher," the NRBHSS reported in March.

By July 30, 2025, the region had seen 70 cases, suggesting a strong likelihood that 2025 will be Nunavik's worst year for TB.

"So many communities have been free of TB for decades," said Dr. Faiz Ahmad Khan, director of the tuberculosis clinic at McGill University Health Centre's Montreal Chest Institute.

"We talk about TB rising in Nunavik, but it's also not rising in all communities. It's about seven or eight of the 14 at this point. Really it's been over the last 10 years that in some communities that had been free of TB for decades, it's reappeared. It can spread quite rapidly and extensively."

Ahmad Khan is the only pulmonary doctor who travels to Nunavik to see patients and who is also a researcher on improving TB care in Nunavik.

"What we've seen, and this situation is worsening, is that the medical tools and the personnel needed to intervene to slow down the spread of tuberculosis have been insufficient for many years."

Why this, and why now?

Ahmad Khan stressed TB is a complicated illness to identify and equally complicated to treat. It can be both active and "sleeping."

In TB's active state, the bacteria is growing in and damaging the sick person's body, usually their lungs, while making the person contagious.

In the case of "sleeping tuberculosis," the bacteria is not causing damage to the body, growing rapidly, or spreading to other people.

"That's why it's so important, when there is TB in a community, to find people who have active disease as soon as possible," Ahmad Khan stressed, "and shortly thereafter, find people that may have contracted the infection so that you can prevent them from getting to active TB."

Yet the transmission process is long and just as complicated, noted Dr. Yassen Tcholakov, clinical lead on infectious diseases for the Nunavik Regional Board of Health and Social Services.

"Most people fall ill from TB within the first two to three years after being exposed," Tcholakov explained to APTN. "It's not something that you get an exposure and then the next week you're sick. Usually it takes a long period of time. Children usually get sick much faster.

"But for a healthy adult, usually it lasts two to three years, and it can last longer, sometimes up to ten years."

Tcholakov said the circumstances in Nunavik are ideal for the disease to spread.

Many Nunavimmiut live in crowded households near one another. Meanwhile, though TB is one of the world's oldest diseases, Tcholakov stressed that the available tools for diagnosing the disease are still imperfect, even in the 21st century, making it harder to get clear diagnostics for tuberculosis.

Read more:

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Once the disease has been diagnosed, a second challenge is the length of the treatment. On average, TB takes six months of daily treatments featuring multiple medications. Treatment can run to nine months for some patients.

"At the start of the treatment, it's four medications," Tcholakov said. "We eventually go down after a few weeks of treatment in most cases, but it still means that people have to take pills very, very often."

This treatment would be demanding in southern hospitals prepared for complex cases, but all parties said Nunavik is struggling to do its best with far less medical infrastructure.

Nunavik's communities "are very remote and sometimes have certain very small amounts of health services available," Tcholakov said. "Sometimes not all of the health services that would be needed to treat TB are available in the community.

"It creates both delays in getting treatment, but also makes treatment much more complex, meaning that people have to then travel outside of the community to get regular care."

Tcholakov stressed that the combination of these factors benefits an infectious disease that spreads from person to person by providing more time for it to spread before people are diagnosed.

That's to say nothing of the stigma of TB, whose shadow haunts Nunavimmiut. Decades ago, people were sent to tuberculosis hospitals in the south.

"Our great-grandparents or grandparents, they didn't come back," Nappaaluk said. "They died from the TB."

One of the things that makes tuberculosis so frightening, she said, is its potential for permanent damage that can be so serious it shortens lifespans.

"TB can eat our lungs when they're affected," she said. "It's not going to heal the way it was. So before destroying our lungs or [letting it] make any holes, we have to try to stop it."

Nappaaluk added she was afraid of TB before she learned it was treatable—under the right conditions.

"My mother, she was sent down when she had the TB in the 1950s and 1960s and today it's more easy," she said. "We don't have to leave from our home like the way they used to.

"It's much more easy if we just have to take the pills. I'm sure it's going to be better if they have more tools."

For the moment, Ahmad Khan said, it is not getting better.

"TB is increasing rapidly and the pace at which it's increasing, it's outpacing how quickly resources have been added and made available to address these kinds of TB rates."

How to beat TB

Along with the Nunavik communities not seeing TB resurgences, Tcholakov points to the example of Nunatsiavut, the region of Labrador home to Inuit.

"Nunatsiavut deployed TB interventions similar to the ones that we're aiming to deploy, but sometimes struggling in Nunavik," Tcholakov said. "And over time, they reduced their rates of TB to basically not having any cases over the last few years.

"They're now a few years out of their last actual case of TB disease. So it is possible to treat TB, even in settings like the small health centers in small communities in Nunavik."

The components of treatment for TB are not complex, he said. Chest X-rays and spit samples help with diagnosing the illness, while under-the-skin injections and antibiotics form the backbone of treatment.

"But some of those tools are not available or not readily available in communities," Tcholakov said. "When we're talking about X-rays, some communities that have had outbreaks have not benefited from having an X-ray on the ground.

"There are some recent changes because we've recently deployed mobile X-ray machines."

Being able to move X-ray machines into the communities reverses the tradition of flying sick people out in order to be tested in other places.

Nappaaluk, Tcholakov, and Ahmad Khan all stress the NRBHSS and local health centres are doing everything they can with the resources they have available. Unfortunately, those resources are simply not enough.

For Nappaaluk, there's no shortage of needs.

"We need doctors," she said. "We need more employees because when it's active, it could spread. We need special people who know how to take care of the TB. It's not the same with broken bones."

She underlined that it would be ideal for Inuit to become these trained professionals.

"We have to train the Inuit because they're going to be home," Nappaaluk said. "If they're wanting to learn, they can teach how to take care of the TB, but we need funding to keep for the training. If we can find Inuit to become TB nurses, I think it's getting more easier because they speak in Inuktitut.

"They can explain the TB, what it was, and they're going to be there in their own home. I hope we're all going to see that."

Tcholakov agreed, noting "in all communities in Nunavik, we need to be able to provide primary care for TB in the community itself. The patient shouldn't be moving to get basic services that take five minutes."

The challenge of Nunavik

Yet multiple factors complicate even simple needs. For one, Tcholakov noted, understaffed health centres in Nunavik need to prioritize emergencies, meaning they're often forced to push work on TB to the backburner as they tackle events like ATV crashes.

But even when the health centres have the time to focus on TB, they often don't have the physical space. The housing crisis in the north leads to overcrowding that favours the spread of TB, but it also means there's nowhere to stay for the extra medical professionals the communities need so badly.

None of these aspects is optional, said Ahmad Khan. Because anyone can be infected with TB for months before they feel sick, the primary intervention to slow it down involves screening all members of whole communities.

"It needs to happen regularly. And then attached to that is then also screening for the people with sleeping TB because if you don't find them, well, they're the ones who are going to also progress to the active TB."

Yet Ahmad Khan said both regional and provincial governments need to understand they must fund more than the basics of treatment.

"We also have to make sure that we support the people and families affected by TB. It is a long treatment. It can involve isolation. There's a lot of stigma."

TB is the only disease for which the health care system can legally force a person to take treatment.

"That should also come with some obligation to ensure people have adequate support to get them through that treatment," Ahmad Khan said.

That part, he said, is multifaceted: it may involve ensuring patients continue receiving food, financial support, and child care throughout their treatment, or may include other concerns raised by the specific circumstance of a minimum six-month treatment schedule.

"It's not an easy treatment to undertake," Ahmad Khan said, "and people who are doing it are doing it for two reasons. It's for their own health but also to protect their community, because once you start treatment for active TB, it's very soon after it's no longer contagious."

Screening is a pivotal practice for TB reduction but it is not the only factor.

"Screening can't just be implemented in the absence of the resources to provide the adequate treatment and support to the patients who are then discovered to have TB," Ahmad Khan said. "Both those things are needed urgently. We can't say screening without increasing the resources for treatment and support, and we can't just say, 'Just increase the resources for treatment and support' because, you know, it'll continue spreading without screening."

The secret is resources

As a physician treating both patients in Nunavik and those sick enough to be flown to Montreal for treatment and also a researcher on TB, Ahmad Khan is convinced a real plan for ending TB in the region needs to begin with increased funding.

"The first thing that the provincial government could do is unleash the resources, the additional budget that hospitals and clinics need to ensure rapid and effective care for people with TB, or with sleeping TB, because you have to address both," he said.

"This situation is worsening, and the medical tools and the personnel needed to intervene to slow down the spread of tuberculosis have been insufficient for many years."

That funding could help address a variety of the needs that have gone unmet for too long, whether in staffing, in equipment (like X-ray machines), or in housing.

Nappaaluk is focused on planning for what comes next. She said she's heard Quebec's Ministry of Health and Social Services has committed to help the community, but she doesn't know when that will begin.

Next week, Nunavik mayors plan to meet again to discuss what might happen next with the province.

"We will get more information," Nappaaluk said. "I really could not say how they're going to help, but we still need those tools for decreasing the TB."

APTN contacted Quebec's Ministry of Health and Social Services for comment on how they plan to address the increasing TB caseload in Nunavik, but we did not hear back prior to this article's publication.

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Breakthrough Tuberculosis Research Is Inspired By Real Patients

Dr. Stephen Carpenter has always been interested in learning about the pathogenesis of disease, or how a disease develops. While in his first year of clinical medicine residency at NYU Langone Health, he gained the opportunity to do research on tuberculosis (TB). As a member of the house-staff at NYU's Bellevue Hospital, Dr. Carpenter also had the unique opportunity to work in the TB ward, which allowed him to have firsthand experience with patients with tuberculosis and then study tuberculosis immune response in the lab. "That combination really piqued my interest in taking problems that we observe clinically and trying to figure out a way in the lab to get answers," Dr. Carpenter said.

After his residency, Dr. Carpenter began an infectious disease fellowship at Harvard Medical School and found a researcher who was also interested in the immune response to tuberculosis, Dr. Sam Behar. Together, they worked for the next six years on a variety of studies while Dr. Carpenter received his PhD. "It really set the tone for my career, and I knew I wanted to be focused on immune responses to tuberculosis," he said.

During his work with Dr. Behar, Dr. Carpenter noticed an odd phenomenon that kept occurring in the tuberculosis mouse model studies. He couldn't understand why, once infected, it took almost two weeks before they would see T cells that target TB in the infected mice. "We realized that no matter what we tried, there was a delay in transporting the bacteria to the lymph nodes, which is where T cells get primed," he said. "That led me to wonder, why is it that the memory T cells from vaccination cannot interact with the infected macrophage in the lung?"

With that in mind, Dr. Carpenter started his own lab where he sought to answer those questions but focused specifically on human cells. This meant getting samples from individuals infected with TB to study their immune response. His current study builds on that idea, with the hope of identifying CD4T cells that can recognize macrophages infected with virulent Mycobacterium tuberculosis (the bacterium that causes TB).

"Perhaps when individuals are first infected with TB, they generate a very different and diverse T cell response, as opposed to later," he said. By conducting research with a clinical cohort in Uganda, he hopes to understand the early T cell response in the lung and which T cells that persist later after infection. In this study, his team collects samples from people who live in the same household as someone with active tuberculosis. These subjects test negative for TB at the time of enrollment but are retested every three months for up to a year to determine if and why they begin to test positive. Many of them will turn positive in the first 3-6 months, so it allows the research team to study the immune system, before and during the infection.

This is done with a simple blood draw, but when some participants become newly TB positive, they also agree to undergo a bronchoscopy so that the researchers can isolate immune cells from the lungs. "We think we are going to identify antigens that these T cells target very early that are going to be important for vaccine development," Dr. Carpenter explained. "For example, if T cells target certain antigens, we have the opportunity to amplify a T cell response that targets them and perhaps prevent infection from taking hold."

Only a year into the study, Dr. Carpenter plans to continue the study as long as possible to help determine and study long-term effects of TB. "Research in general takes time and effort to make meaningful findings, it's not something that happens quickly. So, you have to find an area of research that you love enough that you are willing to work long and hard because persistence is key, and eventually you will get results."

Learn more about tuberculosis research and other researchers that the Lung Association supports through grants by visiting: Lung.Org/research.

Understanding Tuberculosis From First Signs To Cure - Rolling Out

Understanding the causes, recognizing the signs, exploring treatment options, and implementing prevention strategies

Tuberculosis (TB) remains one of humanity's oldest and most persistent health challenges. Despite significant medical advances, this infectious disease continues to affect millions globally, with particularly devastating impacts in developing regions. Understanding TB's causes, recognizing its symptoms, knowing treatment options, and implementing prevention strategies are crucial steps in controlling this ancient yet evolving threat.

What causes tuberculosis?

At its core, tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, a rod-shaped bacterium with a unique waxy cell wall that contributes to its resilience and pathogenicity. This bacterial structure explains why TB can withstand harsh environmental conditions and resist many standard antibiotics.

The primary transmission route occurs through airborne particles. When someone with active TB coughs, sneezes, speaks, or even sings, they release microscopic droplets containing the bacteria. These droplets can remain suspended in the air for hours, particularly in poorly ventilated spaces. Individuals breathing this contaminated air may then become infected if the bacteria reach their lungs.

However, not everyone exposed to TB bacteria develops the disease. The human immune system often creates a barrier around the bacteria, forming what medical professionals call a granuloma. This immune response effectively walls off the infection, preventing symptoms and disease progression. This state is known as latent TB infection.

Several factors influence whether exposure leads to infection and whether infection progresses to active disease:

Proximity and duration of contact with an infected person Concentration of bacteria in the air Immune status of the exposed individual Nutritional health of the exposed person Presence of other medical conditions, particularly HIV

The distinction between latent TB infection and active TB disease remains crucial. In latent TB, the bacteria remain dormant, causing no symptoms and remaining non-contagious. However, approximately 5-10% of those with latent infections eventually develop active TB disease when their immune system can no longer contain the bacteria.

Risk factors for progression from latent to active TB include:

Recent infection (within the past two years) HIV infection and other immunocompromising conditions Substance abuse, particularly injection drugs Certain medical treatments that suppress immunity Young age (under 5) or advanced age (over 65) Diabetes mellitus End-stage renal disease Certain cancers, particularly head and neck cancers Malnutrition and low body weight

The bacterium's remarkable adaptability has led to the emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) strains. These resistant forms develop when patients receive inadequate treatment, stop treatment prematurely, or when healthcare providers prescribe inappropriate medication regimens.

Recognizing the signs and symptoms

Tuberculosis primarily affects the lungs (pulmonary TB), but can invade other body systems (extrapulmonary TB), including the kidneys, spine, brain, and lymph nodes. The symptoms vary depending on which organs are affected.

Pulmonary TB typically produces symptoms that develop gradually over weeks or months:

Persistent cough lasting three weeks or longer, often producing blood-tinged sputum Chest pain, particularly while breathing or coughing Unintentional weight loss despite normal or increased appetite Fatigue and weakness that interferes with daily activities Fever that typically rises in the evening, often accompanied by night sweats Loss of appetite leading to nutritional deficiencies Chills and cold sweats, particularly at night

These symptoms may initially be mild, allowing individuals to dismiss them as a common cold or bronchitis. This delayed recognition contributes to ongoing transmission before diagnosis.

Extrapulmonary TB presents with symptoms specific to the affected organ system:

TB meningitis (brain and spinal cord): Headaches, confusion, neck stiffness TB lymphadenitis (lymph nodes): Swollen, often painless lymph nodes, usually in the neck Skeletal TB: Back pain, joint destruction, particularly in the spine (Pott's disease) Genitourinary TB: Painful urination, blood in urine, pelvic pain Miliary TB (disseminated throughout body): Widespread symptoms, often severe

Children with TB often present differently than adults, showing:

Poor weight gain or failure to thrive Reduced playfulness and activity Persistent fever without clear cause Enlarged lymph nodes, particularly in the neck

Elderly patients may show atypical presentations, sometimes with minimal respiratory symptoms but pronounced confusion, decreased appetite, or generalized weakness, making diagnosis particularly challenging.

Diagnosing TB involves several approaches:

Tuberculin skin test (TST) or Mantoux test, which measures immune response to TB proteins Interferon-gamma release assays (IGRAs), blood tests that detect TB infection Chest X-rays to identify characteristic lung changes Sputum microscopy and culture to detect and grow the bacteria Nucleic acid amplification tests (NAATs) for rapid identification of the bacteria Tissue biopsies for extrapulmonary TB

Early detection remains critical for effective treatment and preventing transmission. Individuals with persistent coughs lasting more than three weeks, especially when accompanied by other symptoms, should seek medical evaluation.

Modern treatment approaches

The treatment landscape for tuberculosis has evolved significantly since the discovery of streptomycin in 1943, the first antibiotic effective against TB. Today's treatment approaches balance effectiveness, duration, side effects, and the growing challenge of drug resistance.

Standard treatment for drug-susceptible TB follows a two-phase approach:

Initial intensive phase (2 months): Combination of four first-line drugs—isoniazid, rifampin, ethambutol, and pyrazinamide Continuation phase (4 months): Usually isoniazid and rifampin

This lengthy treatment duration creates adherence challenges. To address this, Directly Observed Therapy (DOT) programs have become standard practice, where healthcare workers observe patients taking their medications to ensure compliance.

For drug-resistant forms, treatment becomes more complex:

MDR-TB requires 9-20 months of treatment with second-line drugs, which often cause more severe side effects XDR-TB demands even more complex regimens, sometimes lasting two years or more Newer medications like bedaquiline, delamanid, and pretomanid offer hope for resistant cases

Common side effects of TB medications include:

Liver inflammation and potential damage Peripheral neuropathy (nerve damage) Vision changes, particularly with ethambutol Gastrointestinal disturbances Joint pain, especially with pyrazinamide

Beyond medications, supportive care plays a vital role in TB treatment:

Nutritional support to counter weight loss and support immune function Management of respiratory symptoms Psychological support for the lengthy treatment journey Addressing social factors that might impede treatment completion

Recent research has introduced shorter treatment regimens for some patients, potentially reducing the standard six-month regimen to four months for certain forms of drug-susceptible pulmonary TB. These shorter regimens may improve completion rates while maintaining effectiveness.

Surgical interventions occasionally become necessary, particularly for drug-resistant cases or when TB creates structural damage to organs. Procedures may include:

Removal of severely damaged lung tissue Drainage of TB abscesses Stabilization of spine in cases of vertebral TB

The treatment success rate for drug-susceptible TB exceeds 85% in most settings with proper adherence. However, MDR-TB and XDR-TB success rates remain significantly lower, highlighting the urgent need for new treatment approaches and improved patient support systems.

Prevention strategies: Individual to global

Preventing tuberculosis requires a multi-layered approach spanning individual measures to global public health initiatives. These strategies focus on breaking the transmission chain, identifying and treating latent infections, and creating environments resistant to TB spread.

At the individual level, several measures reduce TB risk:

Prompt diagnosis and treatment of active cases to prevent transmission Avoiding close, prolonged contact with known TB patients until they become non-infectious Maintaining good overall health through proper nutrition and management of conditions that weaken immunity Seeking medical evaluation for persistent coughs or unexplained weight loss Completing full treatment courses if diagnosed with TB

For healthcare settings, infection control measures include:

Early identification and isolation of suspected TB cases Proper ventilation systems with negative pressure rooms for TB patients Use of ultraviolet germicidal irradiation in high-risk areas Personal protective equipment for healthcare workers Regular screening of healthcare workers for TB infection

Bacillus Calmette-Guérin (BCG) vaccination plays a critical role in TB prevention in many countries. This vaccine:

Provides 80% protection against severe forms of TB in children, including TB meningitis Offers variable protection against pulmonary TB in adults Remains widely administered in countries with high TB prevalence Is not routinely given in countries with low TB rates due to its limited effectiveness against pulmonary TB and potential interference with TB testing

For contacts of TB patients and others at high risk, treating latent TB infection prevents progression to active disease. Treatment options include:

Isoniazid for 6-9 months Rifampin for 4 months Isoniazid plus rifapentine for 3 months

Public health systems focus on systematic approaches:

Active case finding in high-risk populations Contact tracing to identify exposed individuals Surveillance systems to monitor TB trends and outbreaks Integration of TB and HIV services, given their synergistic relationship

Environmental factors significantly influence TB transmission. Addressing these includes:

Improved housing conditions to reduce overcrowding Better ventilation in communal spaces Access to natural light, which contains UV radiation that kills TB bacteria Reduction of indoor air pollution from cooking fires and other sources

Socioeconomic factors play a profound role in TB prevalence. Addressing these requires:

Poverty reduction initiatives Improved access to healthcare Nutritional support programs Educational campaigns about TB symptoms and transmission

The global fight against TB requires coordinated international efforts:

Funding for TB programs in high-burden countries Research for new vaccines, diagnostics, and treatments Cross-border TB control initiatives Support for countries with limited healthcare infrastructure

Despite these multifaceted prevention strategies, TB elimination faces significant challenges:

The reservoir of latent TB infection in approximately one-quarter of the global population Increasing drug resistance The HIV epidemic, which dramatically increases TB susceptibility Socioeconomic inequalities that facilitate TB transmission Disruptions to healthcare systems during crises like the COVID-19 pandemic

Tuberculosis sits at the intersection of medical science, public health policy, and social determinants of health. Its persistence despite available prevention and treatment options highlights the complex interplay of biological, social, and economic factors that maintain its global presence.

As healthcare systems continue evolving, the approach to TB must similarly advance—incorporating new technologies, addressing persistent inequalities, and strengthening healthcare infrastructure globally. Only through comprehensive efforts addressing both the pathogen and the conditions that enable its spread can we make meaningful progress against this ancient disease.

Understanding tuberculosis—its causes, symptoms, treatment, and prevention—empowers individuals and communities to participate actively in TB control efforts. With continued attention and resources, TB elimination remains a challenging but achievable global health goal.

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