Tuberculosis—the Global and Canadian Situation

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Global and Canadian Tuberculosis Picture--Role
of the Public HealthAgency of Canada

• Dr. Edward Ellis
• Manager, TB Prevention and Control
• Edward.Ellis_at_phac-aspc.gc.ca
• [phone]
• www.publichealth.gc.ca/tuberculosiswww.santepubli
  que.gc.ca/tuberculose

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Tuberculosisthe Peoples Plague
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The TB situation in Canada

• Forgotten by most
• But not gone A new TB case in Canada every 6
  hours
• A death every 2 weeks

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Tuberculosisthe Peoples Plague
Ce qu'il faut pour vivre
The Necessities of Life
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Outline

• Global TB situation
• The Canadian TB incidence target
• TB in Canada in general
• Drug resistance
• TB and HIV
• TB among the foreign born in Canada
• TB among Aboriginal Peoples in Canada
• Role of interferon-gamma release assays for
  latent TB infection
• Canadian Tuberculosis Standards
• Canadian Tuberculosis Strategy
• Role of Pubic Health Agency of Canada
• Top short-term priorities for TB prevention and
  control in Canada

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Global TB Situation

• In high-incidence areas, each contagious case can
  infect 10-15 people per year
• 1/3 of the world population is infected (if all
  positive TSTs are accurate)
• New case every 3 seconds (9.4 million per year)
• Death every 18 seconds (1.8 million per year)
• Global incidence rate decreased from peak of
  143/100,000 in 2004 to 139 in 2008

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Global TB Situation (2)

• Population growth is faster than TB growth so the
  rate goes down while the number of cases goes up.
• 61 of smear positive pulmonary TB cases were
  detected vs. 70 target
• 87 were successfully treated vs. 85 target
• 8,000,000 deaths have been averted through DOTS,
  1995-2008 !

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Global TB Targetsfor 2015

• UN Millennium Development Goals
• To have halted and begun to reverse incidence
• On target in all regions!
• Stop TB Partnership targets
• Halve prevalence and deaths by 2015 compared to
  1990
• WHO Africa not on target

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The Canadian Target

• Reduce the 1990 incidence rate of 7.2 per 100,000
  population to 3.6 by 2015 in keeping with the
  spirit of the Global Plan to Stop TB, 2006-2015

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Reaching the 2015 Canadian Target (Eh!)

• To reach the new Canadian target, we need to
  reduce the incidence rate from 4.8 (1,600) cases
  in 2008 to 3.6 (1,252) cases by 2015
• Average 3.6 annual rate decrease is needed

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Conquering TB is not as simpleas this picture
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Tuberculosis incidence rate and counts Canada
1980-2008
Cases
Rate per 100,000 population
Number of Cases
Rate
Rough estimate of slope
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Canadian Tuberculosis Incidence Rates by
Province/Territory, 2008
lt 4.8 (national rate) 4.9--9 10--29 gt 30
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Tuberculosis incidence rate by origin Canada
1993 - 2015
Rate per 100,000 population
Year
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Proportion of TB cases by age group and origin
Canada 2008
Proportion
Age group
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Respiratory sputum smear positive TB cases -
Canada 1998-2008
Number of Cases
Year
Respiratory includes Pulmonary and primary and
other respiratory diagnoses
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Global TB Drug Resistance, 2008

• 4 of all cases were multidrug resistant (MDR)
• Of these about 500,000 cases, 1 were known to
  receive adequate treatment
• About 1 in 4 died
• Highest burden countries for MDR China, India,
  Russia (including former Soviet Union), Pakistan,
  Philippines, South Africa
• 5 of MDR cases were XDR-TB

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Overall pattern of reported TB drug resistance in
Canada 2009
Drug resistance ()
Multidrug resistance TB (MDR-TB) is resistance
to at least isoniazid and rifampin. Extensively
drug resistant TB (XDR-TB) is MDR-TB plus
resistance to any fluoroquinolone and at least 1
of 3 injectable second-line drugs amikacin,
capreomycin and kanamycin. Source Tuberculosis
drug resistance in Canada 2009
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Pattern of reported TB drug resistance by origin
status Canada 2007
Proportion
Type of resistance
Multidrug-resistant TB (MDR-TB) is resistance
to at least isoniazid and rifampin.
Source Canadian Tuberculosis Reporting System
February 2010.
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Extensively drug-resistant TB (XDR-TB), Canada

• 16,714 TB isolates tested 1998-2009
• 199 MDR-TB (1.2 of all isolates compared to 2006
  WHO global estimate of 4 MDR)
• 4 XDR-TB (2.0 of MDR isolates compared to 2006
  WHO global estimate of 5 XDR)
• 5 XDR-TB cases reported to date in Canada
• 1997 diagnosed in retrospect
• 2002, 2003, 2006, 2008
• 3 of 5 likely developed outside Canada

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Predictors of Drug-Resistant TB

• Previous treatment for TB or latent TB infection,
  even if for only 1 month
• Being in a country with high rates of drug
  resistance
• Contact of a case of drug-resistant TB
• Contact of a TB case who failed treatment or
  relapsed and drug sensitivity is not known

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Global TB-HIV Disease

• New TB case every 3 seconds
• New TB-HIV case every 21 seconds
• TB death every 18 seconds
• TB-HIV death every minute
• 3 things are needed
• Intensified case finding
• INH treatment for LTBI
• Infection control

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Percentage of tuberculosis cases by HIV status
Canada, 1997-2008
Percentage of cases
Year
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HIV among immigration applicantsCanada, 2002-2008
Number of HIV infected applicants Identified in Canada () Identified outside Canada ()
2008 603 61 39
Jan. 2002 to Dec. 2008 3,706 61 39
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Diagnosis within 2 years of arrival in Canada by
country of birth 1998 - 2008
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TB control among the foreign-born

• About 500,000 immigration medical exams annually
• 250 pulmonary TB cases (54/100,000 applicants)
  found, treated and declared admissable during the
  Immigration Medical Exam overseas, 2008
• If they entered Canada and were then diagnosed
  and treated, our TB rate would go up 16
• 7,800 diagnosed with inactive pulmonary TB and
  are referred for medical surveillance guidelines
  in Canadian TB Standards, 6th edition

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Screening foreign-born after arrivalfor latent
TB infection

• Usual co-morbidity risk factors for progression
  of LTBI to disease, or
• Lived in a high TB incidence country (smear
  positive TB rate of gt 15/100,000 see
  http//www.phac-aspc.gc.ca/tbpc-latb/itir-eng.php)
  and immigrated within past 2 years
• Under age 15 all
• Age 15 and older have lived with or in known
  contact with a TB case in the past or at high
  risk for development of active TB per Canadian TB
  Standards, page 65

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TB incidence rate by Aboriginal origin Canada
1994-2008
Rate per 100 000 population
Year
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First Nations   2004 2005 2006 2007 2008 5 YEAR AVERAGE
On Reserve Case 113 133 135 130 118  
  Rate 26.5 30.4 30.1 28.2 25 28
Off Reserve Case 64 78 88 83 93  
  Rate 20.5 23.5 26 24.3 26.7 24.2
Unknown Case 25 2 0 13 7  
Inuit   2004 2005 2006 2007 2008 5 YEAR AVERAGE
Cases Cases 41 63 61 46 88  
Population Population 51003 52187 53389 54615 55860  
Rate Rate 80.4 120.7 114.3 84.2 157.5 111.4
Canadian Born non-Aboriginal   2004 2005 2006 2007 2008 5 YEAR AVERAGE
Cases Cases 214 218 201 172 211  
Population Population 24115074 24240326 24473438 24615830 24717444  
Rate Rate 0.9 0.9 0.8 0.7 0.85 0.8
Ratios Ratios 2004 2005 2006 2007 2008 5 YEAR AVERAGE
First Nations On Reserve/Canadian Born non-Aboriginal First Nations On Reserve/Canadian Born non-Aboriginal 29.4 33.8 37.6 40.3 29.3 34.1
First Nations Off Reserve/Canadian Born non-Aboriginal First Nations Off Reserve/Canadian Born non-Aboriginal 22.8 26.1 32.5 34.7 31.3 29.5
Inuit/Canadian Born non-Aboriginal Inuit/Canadian Born non-Aboriginal 89.3 134.1 142.8 120.3 184.5 134.2
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Proportion of Inuit TB cases by age and sex
Canada, 1997-2008
Proportion
Age group
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TB among Aboriginal Peoples in Canada Some
reasons the rate is high

• Historically high exposure to the bacteria
  leading to 20-30 of adults being TB skin test
  positive vs. 11 for all Canadians in general
• Some may have less natural resistance to TB
  disease due to genetic factors (e.g., Larcombe,
  Journal of Infectious Diseases, 2008)
• Co-morbidities such as HIV infection and diabetes
  mellitus type 2 increase the risk of latent TB
  infection progressing to disease

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TB among Aboriginal Peoples in Canada Some
reasons the rate is high (2)

• Decreased nutritional status
• Substance abuse and/or cigarette smoking in some
  cases
• Crowded, inadequately ventilated housing
  increases household transmission
• Delayed suspicion of disease by health care
  providers
• Delayed diagnosis, due to the time required to
  obtain sputum and x-ray data, results in
  prolonged exposure time for contacts
• Lack of continuity of health care providers in
  some remote communities

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Housing conditions that serve as risk factors
for TB infection and diseaseCanadian
Tuberculosis Committee, 2007www.publichealth.gc.c
a/tuberculosis

• 50 of First Nations housing on reserve are below
  Canada Mortgage and Housing Corporation suitable
  housing standards
• 10 of on-reserve households have too few
  bedrooms compared to 1.4 for Canadian-born
  non-Aboriginal households, (2001)
• Inadequate ventilation, mould and no plumbing in
  some cases
• Housing needs to meet national standards

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Role of Interferon-Gamma Release Assays (IGRA)

• Two products registered in Canada
• QuantiFERON-TB Gold In-Tube (Cellestis Limited,
  Australia)
• T-SPOT.TB (Oxford Immunotec, U.K.)
• T-cells previously sensitized to TB antigens
  produce high levels of interferon-gamma when
  re-exposed to the same mycobacterial antigens
• Negative result with BCG and non-tuberculous
  Mycobacteria
• The Canadian Tuberculosis Committee (CTC)
  recommends that all provincial and territorial
  governments fund the use of IGRAs for use
  according to the current CTC recommendations.

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Canadian Tuberculosis Standards6th edition,
2007ltwww.publichealth.gc.ca/tuberculosisgt
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Canadian TB Prevention and Control Strategy
(Canadian TB Committee)

• GOAL Reduce the incidence rate of TB in Canada
  to 3.6/100,000 by 2015 in the spirit of the
  Global Plan to Stop TB
• PURPOSE Provide a framework for coordination and
  program linkages
• CONTENT Elaborate essential activities and gaps
  for TB prevention and control programs and in at
  risk populations

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Canadian TB Prevention and Control Strategy
Contents

• Epidemiology of TB in Canada
• Optimizing current TB prevention and control
  efforts
• Education, awareness and practice
• International collaboration
• Research
• Responsibilities, partnerships and linkages
• Resources and moving forward
• Appendices including First Nations and Inuit
  Health plans

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Role of Tuberculosis Prevention and
ControlPublic Health Agency of Canada

• Surveillance of TB Disease in Canada TB in
  Canada reports
• Surveillance of TB Drug Resistance in Canada TB
  Drug Resistance in Canada
• Correctional Service Canada Tuberculosis Tracking
  System
• Canadian Tuberculosis Standards
• Canadian Tuberculosis Committee and 4
  subcommittees

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Role of Tuberculosis Prevention and
ControlPublic Health Agency of Canada (2)

• Travel -Related Risk Assessment and Response
• Technical Assistance and Training
• Field epidemiologist available to do EPI-AID
• Advice to Citizenship and Immigration Canada,
  CIDA, Health Canada
• Funding up to 10,000 for various projects of
  national value
• International collaboration with other countries,
  PAHO, WHO and STOP-TB Canada

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Top short-term priorities for TB prevention and
control in Canada(Ellis view)

• Training and funding to implement the Canadian
  Tuberculosis Standards
• Increase our efforts to control TB among First
  Nations and Inuit populationsespecially in
  remote communities
• Completion of medical surveillance for all
  immigrants with inactive pulmonary TB
• More LTBI screening and treatment among
  immigrants in Canada for less than 2 years
  delivered in primary care settings
• HIV testing of all TB cases in order to monitor
  co-infection trends more precisely
• Fund TB control in high incidence countries

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Dont Forget Some of the Basics

• Sir William Osler (1849-1919) Canadian born and
  trained physician
• "Tuberculosis is a social disease with a medical
  aspect.
• Unfortunately, this remains largely true today

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Never, never give up!

• Eleanor Wilson, wife of President Roosevelt, died
  in New York City, 1962 with TB resistant to INH
  and streptomycin
• You must do the thing you think you cannot do."
• So, what are we doing to stop TB?

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Acknowledgements

• Victor Gallant, Melissa Phypers, Andrea Saunders,
  Derek Scholten--Public Health Agency of Canada
• Canadian Tuberculosis Committee and Subcommittees
• Authors of the Canadian Tuberculosis Standards
• Dr. Sylvie Martin--Citizenship and Immigration
  Canada
• Irwin Sherman, Twelve Diseases That Changed Our
  World, ASM Press, Washington D.C., 2007
• Photography U.S. National Institute of Allergy
  and Infectious Diseases, STOP-TB, Merriam-Webster
  Online, Rimrock Opera