The Canadian Tuberculosis Prevention and Control Strategy: Targeting our Efforts

The Canadian Tuberculosis Prevention and Control Strategy: Targeting our Efforts Andrea Saunders Tuberculosis Prevention and Control Public Health Agency of Canada

The Global Burden of Tuberculosis 1 in 3 people worldwide believed to have latent TB infection (LTBI) Globally in 2007: 9.3 million new TB cases 1.8 million deaths due to TB Spread is fuelled by HIV/AIDS epidemic and emergence of drug resistant strains

TB Incidence in Canada: 1924-2007 140 120 Rate per 100,000 Population 100 80 60 40 20 0 1924 1932 1940 1948 1956 1964 1972 1980 1988 1996 2004 Year

TB Incidence in Canada: 1980-2007 12 Rate per 100,000 Population 10 8 6 4 2 Estimate of slope 0 1980 1984 1988 1992 1996 2000 2004 2007 Year

TB Incidence in Canada by Origin: 1996-2006 (3-Year Moving Averages) 30.0 25.0 Rate per 100,000 Population 20.0 15.0 10.0 5.0 Canadian-born Aboriginal Canadian-born Non-Aboriginal Foreign-born Overall 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

TB in Canadian-born Aboriginals Historically high exposure to TB bacteria 20-30% of adults TST positive, compared to ~10% for Canadian-born non-aboriginals Co-morbidities, decreased nutritional status Substance abuse (in some cases) Delayed diagnosis of infectious cases Crowded, inadequately ventilated housing

Housing Conditions as Risk Factors for TB Infection and Disease 50% of First Nations housing on-reserve below suitable housing standards 10% of on-reserve households have too few bedrooms vs. 1.4% for non-aboriginal households Other issues include: lack of plumbing, inadequate ventilation, mould Canadian TB Committee Advisory Committee Statement, CCDR October 2007

TB in Foreign-born Canadians Most foreign-born TB cases associated with reactivation of LTBI acquired prior to arrival Risk of developing active TB disease is highest within the first two years following immigration Factors influencing development of active TB: Cumulative lifetime risk of infection Length of time in host country Return travel to country of origin Status at time of immigration

TB in Foreign-Born Canadians: Top Source Countries, 2007 1. China 2. India 3. Philippines 4. United States 5. Pakistan 6. United Kingdom 7. Iran 8. Korea, Republic of 9. France 10. Colombia

TB in Foreign-Born Canadians: Top Source Countries, 2007 1. China 2. India High burden TB countries: 3. Philippines 34.5% of immigrants 4. United States 5. Pakistan 6. United Kingdom 7. Iran 8. Korea, Republic of 9. France 10. Colombia

The Stop TB Partnership A global movement to accelerate social and political action to stop spread of TB Consists of a network of over 400 committed international organizations, countries, donors (public and private), governmental and nongovernmental organizations, and individuals Goal is to eliminate TB as a public health problem and, ultimately, to secure a world free of TB

Global Plan to Stop TB 2006-2015 Three key goals to achieve by 2015: Halt and begin to reverse incidence of TB Reduce TB prevalence and TB mortality rates by 50% relative to 1990 levels Detect at least 70% of infectious TB cases and of these, successfully treat 85% to cure/completion Ultimate goal is to eliminate TB by 2050 Elimination defined as <1 case per 1 million population per year

Canada s Commitment The Canadian Tuberculosis Committee has set the following goal for 2015: To reduce the incidence rate of TB in Canada by 50% from 1990 levels (7.2 per 100,000) To achieve this goal, TB incidence will need to be reduced to 3.6 per 100,000 (~1250 cases) This will require an annual decrease of 3.2%

Target TB Incidence for Canada, 2015 (3.6 per 100,000) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year Rate per 100,000 Population

Target TB Incidence for Canada, 2015 (3.6 per 100,000) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Overall Rate 2015 Target Rate -3.2% Year Rate per 100,000 Population

Target TB Incidence for Canada, 2015 (3.6 per 100,000) 30.0 25.0 20.0 15.0 Overall Rate 10.0 2015 Target Rate 5.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Canadian-born Non-Aboriginal -3.2% Year Rate per 100,000 Population

Target TB Incidence for Canada, 2015 (3.6 per 100,000) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015-21.8% Canadian-born Aboriginal Canadian-born Non-Aboriginal Overall Rate 2015 Target Rate -3.2% Year Rate per 100,000 Population

Target TB Incidence for Canada, 2015 (3.6 per 100,000) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015-21.8% Canadian-born Aboriginal Canadian-born Non-Aboriginal Foreign-born Overall Rate 2015 Target Rate -15.7% -3.2% Year Rate per 100,000 Population

Meeting Targets: What s Needed? Targeted actions in origin-based groups: Canadian-born Aboriginals Foreign born Global concerted effort to reduce TB: HIV screening of all newly diagnosed cases Comprehensive drug-resistance testing A commitment by all to THINK TB!

www.publichealth.gc.ca/tuberculosis www.santepublique.gc.ca/tuberculose

Questions?

22 High Burden Countries India China Indonesia Nigeria South Africa Bangladesh Ethiopia Pakistan Philippines DR Congo Russian Federation Viet Nam Kenya Brazil Tanzania Uganda Zimbabwe Thailand Mozambique Myanmar Cambodia Afghanistan

TB Incidence in Canada by Origin: 1996-2006 (3-Year Moving Averages) Rate per 100,000 Population 120.0 100.0 80.0 60.0 40.0 20.0 Inuit Status (Registered) Indian 0.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year

Drug-Resistant TB Primary vs. acquired Multidrug-resistant TB (MDR-TB): Resistance to at least isoniazid (INH) and rifampin (RMP) Extensively drug-resistant TB (XDR-TB): Resistance to INH and RMP, plus resistance to any fluoroquinolone and at least one of the second-line anti-tb injectable drugs

Drug-Resistant TB Globally WHO estimates 490,000 MDR-TB cases emerge every year with more than 110,000 deaths 55 countries have reported cases of XDR-TB (including Canada): WHO estimates ~ 40,000 XDR-TB cases emerge every year Highest rates of drug resistance are in China and countries of former Soviet Union Limited data available from Africa

Drug-Resistant TB Canada, 2008 Percent (%) 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 8.8 Resistant to one or more drugs 7.1 Mono Resistant 1.1 MDR-TB 0.4 Other Patterns 0.1 XDR-TB Source: Tuberculosis drug-resistance in Canada, 2008

HIV and TB Co-infection HIV infection is most significant risk factor for developing active TB disease in those with LTBI HIV-negative and LTBI: Lifetime cumulative risk ~10% HIV-positive and LTBI: Annual risk > 10% TB is the most common cause of death in HIV-infected individuals

HIV and TB Co-infection - Globally In 2006, 7.6% of all new TB cases and 11.6% of deaths due to TB were in HIV-positive people In countries with a high prevalence of HIV/TB, up to 80% of TB patients are HIV-positive Estimated that one-third of the 40 million people living with HIV/AIDS worldwide are co-infected with TB

TB Cases with Known HIV Status: Canada, 1997-2006 Percent (%) 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 22.1 23.4 25.1 27.8 13.1 15.7 17.1 18.0 5.8 8.4 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006*