Better data to drive more effective care for people with latent tuberculosis infection in Canada
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- RE: Better data to drive more effective care for people with latent tuberculosis infection in CanadaMargaret J Haworth-Brockman and Yoav KeynanPosted on: 11 March 2019
- Posted on: (11 March 2019)Page navigation anchor for RE: Better data to drive more effective care for people with latent tuberculosis infection in CanadaRE: Better data to drive more effective care for people with latent tuberculosis infection in Canada
- Margaret J Haworth-Brockman, Senior Program Manager, National Collaborating Centre for Infectious Diseases, University of Manitoba
- Other Contributors:
- Yoav Keynan, Scientific Lead, National Collaborating Centre for Infectious Diseases; Associate Professor, Departement of Medical Microbiology
To The Editor: Strengthening TB Surveillance in Canada
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With Word TB Day approaching on March 24, Canada still has much to do to fulfil recent commitments (1) to eliminate a disease that has long required collaboration and coherence to effectively address its Indigenous and other determinants (2,3). One way to do this is to work toward a consistent approach to surveillance to fully understand the portrait of tuberculosis (TB) in Canada, inform public health actions, and monitor the progress to reach pre-elimination of TB (defined by the World Health Organization as < 10 cases per million per year (4)). That approach should include aspiring to routinely present and report dis-aggregated TB surveillance indicators, including for latent TB infections (5). We present here our arguments for consistently stratified TB data.
In anticipation of the United Nations 2015 Sustainable Development Goals (SDGs), and as the spectre of multidrug resistant TB cases increases, nation states and the World Health Organization reinforced their emphasis on reducing and eliminating TB. As in the 2008 Commission on the Social Determinants of Health (6), collecting, recording and presenting data by sex, age, geographic location, country or culture of origin, and other identifiers is recommended for all SDG indicators, including the targets for TB reduction included in SDG Goal 3. The World Health Organization Framework Towards Tuberculosis Elimination in Low Incidence Countries includ...To The Editor: Strengthening TB Surveillance in Canada
With Word TB Day approaching on March 24, Canada still has much to do to fulfil recent commitments (1) to eliminate a disease that has long required collaboration and coherence to effectively address its Indigenous and other determinants (2,3). One way to do this is to work toward a consistent approach to surveillance to fully understand the portrait of tuberculosis (TB) in Canada, inform public health actions, and monitor the progress to reach pre-elimination of TB (defined by the World Health Organization as < 10 cases per million per year (4)). That approach should include aspiring to routinely present and report dis-aggregated TB surveillance indicators, including for latent TB infections (5). We present here our arguments for consistently stratified TB data.
In anticipation of the United Nations 2015 Sustainable Development Goals (SDGs), and as the spectre of multidrug resistant TB cases increases, nation states and the World Health Organization reinforced their emphasis on reducing and eliminating TB. As in the 2008 Commission on the Social Determinants of Health (6), collecting, recording and presenting data by sex, age, geographic location, country or culture of origin, and other identifiers is recommended for all SDG indicators, including the targets for TB reduction included in SDG Goal 3. The World Health Organization Framework Towards Tuberculosis Elimination in Low Incidence Countries includes specific recommendations for surveillance and monitoring, especially for men and women with latent TB infections (LTBI):“Special attention to … disaggregation according to risk profile and monitoring of people receiving LTBI treatment can also help determine trends in transmission and incidence for assessing impact and refining interventions.
"Fewer patients may make it more feasible to collect more variables … for studying risk factors and disease determinants. Due consideration should be given to extending the range of variables beyond those usually collected in TB surveillance.” (4), page 40).
The WHO report suggests this can include demographic, clinical, geo-positioning, vital statistics and socioeconomic data (4). Some countries and regions have incorporated this approach in their most recent TB reports, Australia and England being two examples (7,8).
Health system and related indicators for diagnosis, treatment and outcomes should be presented by sex, age, province, rural, urban, and other stratifiers. Presenting dis-aggregated data encourages population health researchers and public health planners to consider the intersections of determinants that create or ameliorate inequities for good health and inequalities in health outcomes (9). In the federal Health Inequalities Report, for example, statified data uncovered new information on a range of topics such as alcohol consumption, arthritis prevalence and household food security (9). Other health status profiles in Canada have similarly contextualized dis-aggregated data, drawing on related evidence to understand the determinants that influence a given health outcome (10,11).The Opportunity
As in past years, the recent release of 2017 TB surveillance data for Canada (12) goes part way to meet these goals but falls short in consistently dis-aggregating data when reporting on treatment outcomes for TB patients. The epidemiological report and supplementary tables provide some stratified data; case counts and incidence rates are dis-aggregated by sex, province or territory, sex and age, country of origin and Indigenous group (First Nations, Métis or Inuit). These stratified data illustrate the greatest burden of disease: that 71.8 % of cases are foreign-born, and that the 17.4% of cases who are Canadian-born Indigenous are disproportionate to the size of the subpopulations. Incidence rate for First Nations, for example, was 34 times higher at 17.1/100,000 in 2017 than in the Canadian-born non-Indigenous population (0.5/100,000 population). The incidence rate for Inuit was more than 400 times higher (205.8/100,000) (12). It would be valuable to dis-aggregate these data further to know more about the sex and age compositions of patients with TB within the foreign-born and Indigenous populations.
Critically, the data presented in the 2017 TB surveillance report for treatment outcomes – that is, how Canada is doing in treating and curing TB in the populations with the high burden of disease – are not dis-aggregated by age and sex or population (12)(see supplemental tables). Essential information about public health and clinical responses (13) for these high burden populations is buried in the data across all cases in Canada. The supplemental tables indicate that for the year reported, 2017, those data are available at least at the provincial and territorial level (12).
Reporting data by sex provides information on any disproportionate health burden experienced by males or females (11,14). Holmes et al (15) as well as Yang and colleagues (16), for example found important sex differences in tuberculosis patients. Similarly, dis-aggregation by age – and ideally age and sex – can provide otherwise masked information on the TB trends faced by elderly men and women for example, young women and men who may currently not be able to participate in the labour force, or challenges in monitoring pediatric cases (13).
The Challenge
These aspirations may be challenged by the jurisdictional divide. National-level TB surveillance in Canada depends on the provinces and territories voluntarily providing data to the federal government (12,17), as health care is a provincial and territorial responsibility. Although not required to provide their data under the Public Health Act of Canada, provinces and territories can however contribute to a more comprehensive approach to TB elimination by sharing stratified data on screening, treatment and outcomes among foreign-born, First Nations, Inuit and Métis populations in Canada. Drug resistance and co-morbidity with HIV are also needed (13). Hard-to-reach populations with elevated TB risk and poor healthcare access need to be characterized by presenting concurrent evidence via proxy data on housing conditions, screening access, and other determinants to ensure that inequities in service and care are taken into account and the inequalities in TB rates are substantially reduced (18). For provinces and territories where case numbers are high, it would be possible to present these data for each of the two main sub-populations affected by sex, and by sex and age, without compromising confidentiality; where numbers are too small, aggregates by province or territory may be necessary for national reporting.
Moving Forward
Researchers, clinicians and public health personnel in Canada continue to call for a set of national-level TB indicators for the high risk populations (19), and in November 2018 experts gathered to proposal an initial list of program performance indicators for consideration (NCCID, forthcoming). Further consultation will be needed to reach agreements from all jurisdictions in the federation to determine a core set of indicators, as well as guidelines for consistent data reporting at the national level to monitor progress to TB elimination.
With coordination and consistency across the provinces and territories, national-level TB surveillance reports can illustrate the value of consistent dis-aggregation of indicator data. This would inform directed and effective interventions where they are needed most to reduce inequalities, as envisaged from the time public health systems were renewed in Canada (20,21). There are already initiatives underway to establish localized indicators. Community involvement in determining meaningful indicators is essential to these deliberations for different First Nations, Métis, Inuit – and potentially foreign-born -- communities. For example, population-specific TB determinants were recently published by Dehghani et al. (22) and the results illustrated where the greatest improvements had been made in annual reduced TB incidence.
Consistently stratified data can shed light on challenges and successes, and identify areas where the current approaches are insufficient. Coordination of these efforts will require commitment from all jurisdictions and some additional resources for data development, presentation and analysis. However, without a common aspiration for improved, meaningful data to inform public health action, monitoring and evaluation, Canada is likely to fall short of its TB elimination goal.Authorship: MHB & YK- Conceptualization and co-writing.
Conflict of Interest: None
Acknowledgements: The authors would like to thank S. Balakumar for his comments on an initial draft.References
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