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Oct 24, 2023

Opinion: A lack of clean water for personal hygiene can have fatal consequences, especially for Indigenous communities

CSA IMAGES/ISTOCK Carl Boodman is an infectious-diseases doctor and

CSA IMAGES/ISTOCK

Carl Boodman is an infectious-diseases doctor and microbiologist for the clinical investigator program at the University of Manitoba. David McDougall is health director of the St. Theresa Point First Nation Health Authority in Manitoba.

When the media describes the Canadian government's continuing failure to provide clean running water to many Indigenous communities, as part of a long history of discrimination and neglect, they tend to focus on its suitability for drinking. But they also tend to omit two important uses: bathing and washing laundry. It's an important omission to recognize, as the inability to maintain personal hygiene can have lethal consequences.

In 2022, a rare bacterium called Bartonella quintana infected the heart valves of an 11-year-old boy in an Indigenous community in Northern Manitoba. It was the first pediatric case of Bartonella quintana's most feared complication, endocarditis, ever acquired in any high-income country.

The bacterium is transmitted through body lice, which can live on unwashed clothing for many weeks. Since a body-lice infestation causes itchiness, and lice excrete Bartonella quintana in their feces, scratching one's skin can lead to small abrasions that allow the bacterium to enter the body through tiny scrapes. It can hide within human red blood cells and cause a bloodstream infection that may last for several months – and it can even become fatal.

The 11-year-old boy required heart valve surgery, intensive care and months of antibiotics. Luckily, he survived, but Bartonella quintana endocarditis is associated with a mortality rate greater than 10 per cent, even with treatment. It is unknown exactly what percentage of infected individuals will develop the heart condition, and what percentage will have their heart valves left unscathed.

The history of the bacterium is notable, as it was notorious for causing "trench fever" among soldiers during the First World War. It was first described in 1915 by Dr. J.H.P. Graham in The Lancet as a "relapsing febrile illness of unknown origin" afflicting members of an infantry regiment. It is estimated that many hundreds of thousands, if not a million, cases of trench fever occurred during the war.

After the link with body lice was suspected, the disease was a major impetus for the introduction of mandatory showers for infantry during the later years of the war. While the original description of trench fever included a high body temperature, back pain and shin pain, today it is known that many individuals with Bartonella quintana infections may have only subtle symptoms until endocarditis develops.

Bartonella quintana infection is now associated with extreme poverty, affecting those in cramped housing with limited access to clean water. Cases have been reported among populations experiencing homelessness in many cities in the West, including Marseilles, Seattle, Denver and Winnipeg, while many outbreaks have occurred in impoverished refugee camps.

Before 2015, only one case of Bartonella quintana endocarditis had been recorded in Canada in over 20 years. But since then, an increasing number of cases of the heart condition have been discovered on several Indigenous reserves that don't have access to running water.

In 2015, a case was reported from a remote Manitoban community bordering Saskatchewan, and that same year, an individual from Nunavut died from the infection. From 2020 onward, five additional cases were found in Northern Manitoba and Alberta. It's important to note that many infections remain undiagnosed and unreported because it is not on the country's list of "nationally notifiable diseases" – diseases determined by the Public Health Agency of Canada to be of high importance.

Bartonella quintana infection is a neglected disease that is tricky to diagnose. All testing is centralized at Canada's National Microbiology Laboratory in Winnipeg. The bacterium is also missed by standard blood culture tests and requires more specialized testing.

As with most diseases disproportionately affecting people experiencing poverty, there is a dearth of high-quality studies of the bacterium. Most of the existing research consists of small, descriptive case reports. To our knowledge, there are no recent randomized controlled trials or systematic reviews of Bartonella quintana endocarditis. There are also no established Canadian laboratories dedicated to its research.

The origin of Bartonella quintana in rural Canada is unknown. Had it always been here? Was it introduced from undetected outbreaks in urban areas? Or was it introduced to communities after infected soldiers returned home after the First World War?

Regardless of its origin, it is clear that Bartonella quintana infection excessively occurs in Indigenous communities with limited access to running water. The fact that an 11-year-old was infected having never left their community indicates that transmission can occur directly on reserves.

When water is scarce, it is prioritized for drinking and cooking. For many households without clean running water, regular showers, baths and laundry are simply not possible. Body-lice infestation and Bartonella quintana infections are the results.

We have hesitated to write about this issue in the mainstream press, as we were worried about inadvertently promoting negative stereotypes about Indigenous people. To be clear, this disease may affect anyone without access to running water. The fact that Bartonella quintana disproportionately infects Indigenous people is relevant to the Canadian government's continuing failure to provide the basic necessities of life to all its citizens, and therefore warrants our collective and immediate attention.