Chapter 1 of the Canadian Tuberculosis Standards: Epidemiology of tuberculosis in Canada

On this page

• Authors and affiliations
• Key points
• Background
• Data on active TB disease in Canada
• Conclusions
• Acknowledgements
• Disclosure statement
• Funding
• Notes
• References

Authors and affiliations

• Aboubakar Mounchili; Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
• Reshel Perera; Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
• Robyn S. Lee; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
• Howard Njoo; Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
• James Brooks; Infectious Disease Prevention and Control Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada

Key points

• The overall incidence rate of active tuberculosis (TB) disease in Canada is low and has remained unchanged in the last 10 years at around 4.6-5.1 individuals per 100,000 population, with males more affected than females. The rate in 2020 was 4.7 per 100,000 population.
• Pronounced disparities in certain population subgroups and geographic regions persist. Foreign-born individuals and Canadian-born Indigenous peoples in particular continue to be disproportionately affected by TB.
• The active TB disease incidence rate in Inuit communities has been the highest in Canada for the past two decades, peaking in 2012 at 251.6 individuals per 100,000 population, more than 51 times the overall Canadian incidence rate. In 2020, the incidence rate was 70.3 per 100,000 population, or 15 times the overall Canadian rate.
• The rate of active TB disease among First Nations on-reserve populations has gradually decreased since 2009, and leveled off after 2017 at just under 20.0 per 100,000 population, or three times the Canadian incidence rate. Incidence rates among First Nations off-reserve populations have been lower, at about 10.0 per 100,000 population since 2013.
• Métis have been less affected among Canadian-born Indigenous peoples, with active TB disease incidence rates that gradually decreased to levels below the overall Canadian rate since 2012, varying between 2.2 and 3.7 per 100,000 population.
• Individuals born outside Canada constitute the largest proportion of people reported with active TB disease, with an incidence rate that has remained almost unchanged since 2005, at about 15.0 individuals per 100,000 population.
• The Canadian-born, non-Indigenous population is the least affected, with an incidence rate that gradually decreased by 83.3%, from 1.2 per 100,000 population in 2001 to 0.2 per 100,000 population in 2020.
• Between 2017 and 2020, 3.5% of individuals who had active TB disease and whose human immunodeficiency virus (HIV) status was known were HIV-positive.
• In the last 20 years, on average, 12 TB-related deaths per year were reported in Canadian-born, non-Indigenous populations, compared to about 44 deaths annually for foreign-born populations.
• Over the last 12 years, drug-resistant TB was isolated in 9.5% (n = 1,598) of people diagnosed with active TB disease and whose isolates were subjected to susceptibility testing. Of these, 83.2% (n = 1,329) had mono-resistance, primarily to isoniazid (INH) (n = 1,072) and pyrazinamide (PZA) (n = 225). Multidrug resistance (i.e., resistance to INH and rifampin) accounted for 3.6% (n = 57), and extensively drug-resistance (i.e., resistance to isoniazid and rifampin), plus any fluoroquinolone and at least 1 of 3 injectable second-line drugs (i.e., amikacin, kanamycin or capreomycin), was rare and detected only 6 times.

1. Background

1.1. Global epidemiology overview

The World Health Organization (WHO) estimates that approximately 10 million (between 8.9 to 11.0 million) individuals had active TB disease worldwide in 2019. Males and females respectively accounted for around 5.6 and 3.2 million, with children accounting for a further 1.2 million.^{Reference 1} A total of 87% of these individuals were from high-TB-burden countries, including India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.

Overall improvement in general living conditions and population health, in conjunction with intensive efforts of the global Stop TB Strategy, have led to the annual number of individuals with active TB disease falling progressively since 2006. Globally, there was a cumulative reduction of 8.5% in TB incidence between 2015 and 2019: from 142 individuals with newly acquired active TB disease per 100,000 population in 2015 to 130 per 100,000 in 2019, which corresponds to an annual reduction rate of about 2.1%. The goal for the WHO End TB Strategy was for a cumulative reduction of 20% by 2020.

Worldwide, TB continues to be among the top 10 causes of death and the leading cause of death from a single infectious agent, greater than that of HIV/acquired immunodeficiency syndrome (AIDS) AIDS. In 2020, TB-related mortality was estimated at 1.4 million (1.2 million among individuals who were HIV-negative, and approximately 200,000 among individuals who were HIV-positive); while this corresponded to a 14% reduction in total deaths from 2015, it remains far short from the WHO target of reducing TB-related deaths by 35% by 2020.

1.2. Surveillance of active TB disease in Canada

In Canada, local public health authorities are required to report on all individuals diagnosed with active TB disease to their respective provincial/territorial TB program. Provincial and territorial TB programs then voluntarily submit reports that meet the surveillance definition of active incident (new and retreatment) TB disease to the Canadian TB Reporting System (CTBRS), at the Public Health Agency of Canada (PHAC). Although participation in the CTBRS is voluntary, all provinces and territories are active participants.

The CTBRS definition of active TB disease is based on either clinical or laboratory criteria. The clinical definition refers to one or a combination of:

• signs and symptoms or diagnostic imaging findings compatible with active TB disease;
• pathologic or postmortem evidence of active TB disease; and
• a favorable response to a therapeutic trial of anti-TB drugs.

A positive laboratory diagnosis requires a positive culture to Mycobacterium TB (M. tuberculosis) complex (not including Mycobacterium bovis BCG strain) or a combination of clinical findings consistent with active TB disease and a positive nucleic acid amplification test.

Individuals with active TB disease are diagnosed by health care professionals and documented for local, provincial/territorial and national reporting. Reports are collated at the CTBRS, which maintains a database of non-identifying information on each person diagnosed with active TB disease, including demographic (age, sex, indigenous identity and ethnicity), clinical, co-morbid (HIV/AIDS, diabetes), treatment and outcome details.

Incidence rates for a specific population (Indigenous, Canadian-born non-Indigenous, foreign-born) in a given location (province/territory) are calculated as the number of individuals with active TB disease in that population divided by the total population born in that location. For foreign-born incidence rates, these denominators were Statistics Canada estimates of individuals residing in Canada who were born abroad.

2. Data on active TB disease in Canada

2.1. Morbidity

In the early twentieth century, TB was a major cause of morbidity and mortality in Canada. Figure 1 displays records of active TB disease going back as far as 1924, although nationwide systematic reporting was only instituted in 1933.

Figure 1: Text description

Year	Incidence rate of active TB	Mortality rate of active TB
1924	43.6	84.1
1925	61.4	80.5
1926	59.2	84.0
1927	54.9	80.9
1928	56.4	80.0
1929	57.4	77.6
1930	64.4	79.2
1931	69.4	73.5
1932	84.2	68.3
1933	79.6	65.3
1934	76.3	60.0
1935	81.0	60.9
1936	79.0	61.9
1937	68.6	60.8
1938	77.1	55.2
1939	81.5	53.5
1940	87.5	51.3
1941	89.5	53.4
1942	87.6	51.9
1943	88.1	53.0
1944	87.3	48.8
1945	91.8	47.0
1946	103.6	48.2
1947	97.7	44.3
1948	99.8	38.0
1949	100.3	32.5
1950	101.5	26.7
1951	97.6	24.8
1952	95.5	17.5
1953	93.4	12.5
1954	88.8	10.4
1955	89.8	8.9
1956	82.2	7.8
1957	80.4	7.1
1958	70.3	6.0
1959	60.9	5.5
1960	55.1	4.6
1961	48.9	4.2
1962	45.0	4.2
1963	40.1	4.0
1964	35.3	3.5
1965	31.8	3.6
1966	26.2	3.3
1967	26.6	3.2
1968	26.9	3.0
1969	24.3	2.8
1970	21.2	2.5
1971	20.8	2.0
1972	20.2	1.8
1973	18.3	1.5
1974	16.5	1.2
1975	15.3	1.1
1976	13.4	1.1
1977	13.5	0.9
1978	12.3	0.8
1979	11.4	0.8
1980	11.3	0.8
1981	10.2	0.8
1982	9.8	0.8
1983	9.3	0.8
1984	9.2	0.7
1985	8.3	0.8
1986	8.2	0.7
1987	7.5	0.6
1988	7.3	0.6
1989	7.5	0.6
1990	7.3	0.6
1991	7.3	0.7
1992	7.5	0.6
1993	7.2	0.6
1994	7.3	0.5
1995	6.7	0.5
1996	6.3	0.5
1997	6.7	0.6
1998	6	0.5
1999	6.0	0.6
2000	5.6	0.5
2001	5.7	0.6
2002	5.3	0.4
2003	5.2	0.5
2004	5.0	0.4
2005	5.1	0.4
2006	5.1	0.4
2007	4.8	0.4
2008	4.9	0.4
2009	4.9	0.2
2010	4.7	0.2
2011	4.7	0.3
2012	4.9	0.2
2013	4.7	0.2
2014	4.5	0.3
2015	4.6	0.3
2016	4.9	0.2
2017	5.0	0.2
2018	4.8	0.3
2019	5.1	0.2
2020	4.7	-

From the available records, 1 in 13 reported deaths in Canada in 1926 were due to TB, a number slightly higher than the number of deaths reported for cancer at the time. As a result of improved living conditions and healthcare and prevention, as well as the development and implementation of public health measures and availability of antibiotics effective against M. tuberculosis, the morbidity and mortality rates have significantly decreased over time (Figure 1).

2.2. Infection sites

Respiratory TB has been the most frequently reported form of active TB disease in Canada, of which pulmonary TB is the most common (Table 1). TB of the peripheral lymph nodes accounted for the majority of reported non-respiratory TB.

Table 1. Reported incident cases of active TB disease by main diagnostic sites, CTBRS: 2001-2020

Diagnostic site	2001-2004 n (%)	2005-2008 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
Respiratory TB
Primary	382 (5.7)	320 (4.9)	234 (3.6)	213 (3.2)	181 (2.5)
Pulmonary	4,171 (62.4)	4,294 (66.0)	4,415 (67.3)	4,526 (67.8)	4,923 (67.3)
Pleurisy	223 (3.3)	287 (4.4)	288 (4.4)	271 (4.1)	252 (3.4)
Intrathoracic lymph nodes	20 (0.3)	70 (1.1)	82 (1.2)	80 (1.2)	103 (1.4)
Other respiratory	12 (0.2)	13 (0.2)	8 (0.1)	9 (0.1)	39 (0.5)
Subtotal for respiratory TB	4,808 (72.0)	4,984 (76.6)	5,027 (76.6)	5,099 (76.4)	5,498 (75.2)
Non-respiratory TB
Miliary	39 (0.6)	50 (0.8)	44 (0.7)	57 (0.9)	51 (0.7)
CNS and meninges	79 (1.2)	69 (1.1)	81 (1.2)	96 (1.4)	116 (1.6)
Peripheral lymph nodes	972 (14.5)	817 (12.5)	831 (12.7)	815 (12.2)	899 (12.3)
Intestines, peritoneum, and mesenteric glands	109 (1.6)	142 (2.2)	149 (2.3)	154 (2.3)	170 (2.3)
Bones and joints	199 (3.0)	158 (2.4)	159 (2.4)	175 (2.6)	166 (2.3)
Genito-urinary system	124 (1.9)	104 (1.6)	106 (1.6)	103 (1.5)	86 (1.2)
Other specified organsTable 1 footnote a	11 (0.2)	49 (0.8)	49 (0.7)	66 (1.0)	75 (1.0)
Other non-respiratory	244 (3.7)	137 (2.1)	115 (1.8)	105 (1.6)	161 (2.2)
Subtotal for non-respiratory TB	1,777 (26.6)	1,526 (23.4)	1,534 (23.4)	1,571 (23.5)	1,724 (23.6)
Overall
Information about diagnostic site missing	97 (1.5)	0 (0.0)	0 (0.0)	1 (0.0)	92 (1.3)
Total TB cases reported	6,682 (100)	6,510 (100)	6,561 (100)	6,671 (100)	7,314 (100)
Abbreviations: CTBRS, Canadian TB reporting system. Footnotes: Table 1 footnote a Other specified organs include: endocardium, myocardium, oesophagus, pericardium, and thyroid gland Return to table 1 footnote a

2.3. Demographics

2.3.1. Sex distribution

The overall incidence rate of active TB disease in Canada since 2002 has remained unchanged at about 5.0 individuals per 100,000 population per year (Figure 2). In 2020, 1,772 individuals with active TB disease were reported for a national rate of 4.7 per 100,000. The rate among males has remained higher than that among females, as illustrated in Table 2 and Figure 2, with active TB disease diagnosed 1.1 to 1.4 times more frequently among males compared to females. This is consistent with global TB trends.^{Reference 1}

Figure 2: Text description

Year	Female	Male	Overall
2001	5.0	6.4	5.7
2002	5.0	5.6	5.3
2003	4.6	5.7	5.2
2004	4.7	5.4	5.0
2005	4.5	5.7	5.1
2006	4.7	5.5	5.1
2007	4.3	5.3	4.8
2008	4.5	5.4	4.9
2009	4.3	5.5	4.9
2010	4.2	5.1	4.7
2011	4.3	5.2	4.7
2012	4.0	5.8	4.9
2013	4.2	5.2	4.7
2014	4.0	5.2	4.6
2015	4.3	4.9	4.6
2016	4.4	5.3	4.9
2017	4.4	5.6	5.0
2018	4.5	5.3	4.9
2019	4.5	5.7	5.1
2020	4.2	5.1	4.7

Table 2. Reported number of active TB disease by sex in Canada, CTBRS: 2009-2020

Sex	2000-2003 n (%)	2004-2007 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
Female	3,085 (46.2)	2,970 (45.6)	2,903 (44.2)	3,034 (45.5)	3,285 (44.9)
Male	3,597 (53.8)	3,540 (54.4)	3,658 (55.8)	3,637 (54.5)	4,024 (55.1)
Total	6,682 (100)	6,510 (100)	6,561 (100)	6,671 (100)	7,309Table 2 footnote a (100)
Abbreviations: CTBRS, Canadian TB reporting system. Footnotes: Table 2 footnote a Information about the sex of five individuals reported between 2017 and 2020 was unavailable. Return to table 2 footnote a

2.3.2. Age distribution

The CTBRS data demonstrate that, between 2001 and 2020, individuals 15 to 64 years of age accounted for the largest number with active TB disease in comparison to other age groups (Table 3). Until 2020, the highest age-specific incidence rate had consistently been found in the 65+ years old age group. In 2020, however, the highest incidence rate was found in the 15 to 34 years old age group, at 6.3 individuals per 100,000 population (Figure 3). For the last two decades, the lowest annual numbers (and incidence rates) have been among individuals less than 15 years of age (Figure 3).

Figure 3: Text description

Year	0-14 years old	15-34 years old	35-64 years old	65+ years old
2001	1.9	5.9	5.3	12.1
2002	1.7	6.1	4.8	10.4
2003	1.4	6.1	4.8	9.4
2004	1.5	6.0	4.8	8.9
2005	2.1	6.1	4.7	8.4
2006	1.9	5.8	4.7	9.0
2007	1.7	5.1	4.7	8.4
2008	1.6	5.6	4.8	8.2
2009	1.6	5.8	4.9	7.1
2010	1.3	5.2	4.6	7.6
2011	1.5	5.5	4.4	7.6
2012	2.0	5.7	4.5	7.6
2013	2.0	5.1	4.6	7.3
2014	1.3	5.1	4.5	7.1
2015	1.7	5.1	4.4	7.4
2016	1.5	6.1	4.3	7.7
2017	2.1	5.9	4.5	7.6
2018	1.7	5.8	4.5	7.2
2019	1.9	6.4	4.7	6.9
2020	1.1	6.3	4.5	5.8

Table 3. Reported active TB disease by age group in Canada over time, CTBRS: 2001-2020

Age group	2000-2003 n (%)	2004-2007 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
0-14 years old	379 (5.7)	410 (6.3)	363 (5.5)	375 (5.6)	404 (5.5)
15-34 years old	2,081 (31.1)	2,004 (30.8)	2,060 (31.4)	2,010 (30.1)	2,378 (32.5)
35-64 years old	2,581 (38.6)	2,609 (40.1)	2,666 (40.6)	2,621 (39.3)	2,750 (37.6)
65+ years old	1,641 (24.6)	1,487 (22.8)	1,472 (22.4)	1,665 (25.0)	1,782 (24.4)
Total	6,682 (100)	6,510 (100)	6,561 (100)	6,671 (100)	7,314 (100)
Abbreviations: CTBRS, Canadian TB Reporting System

2.3.3. Regional distribution

While the northern Canadian territories (Yukon Territory [YT], Northwest Territory [NWT] and Nunavut [NU]) collectively reported the lowest absolute numbers of individuals with active TB disease, they consistently posted the highest annual incidence rate, in part due to their small populations (Table 4 and Figure 4). The variations observed are mainly indicative of the sporadic nature of outbreaks in the territories. The incidence rates in all other regions of Canada have remained unchanged in the past two decades (Figure 4). Western (Manitoba [MB], Saskatchewan [SK], Alberta [AB] and British Columbia [BC]) Canada reported the second-highest active TB disease incidence rates (between 5.6 and 6.4 cases per 100,000 population; Figure 4). The region with the lowest incidence rates has consistently been Atlantic Canada (New Brunswick [NB], Nova Scotia [NS], Prince Edward Island [PEI] and Newfoundland [NL]), which has recorded an annual rate of 0.8 to 1.4 per 100,000 population since 2001 (Figure 4). Although there has been an increase in the overall number of individuals with active TB disease during the last 4 years, mainly in central and western Canada (Table 4), the incidence rate of active TB disease has remained approximately constant due to corresponding increases in population size.

Figure 4: Text description

Year	Northern territories	Atlantic provinces	Western Canada	Central Canada
2001	48.4	1.7	7.8	5.0
2002	30.7	1.3	6.4	5.1
2003	19.4	1.2	6.7	4.8
2004	44.0	1.1	6.5	4.6
2005	53.0	1.0	6.9	4.5
2006	53.6	1.0	6.8	4.4
2007	45.7	0.8	6.0	4.4
2008	74.8	0.8	6.9	4.1
2009	64.8	1.8	6.9	4.0
2010	105.2	1.2	5.6	4.0
2011	80.5	1.1	5.9	4.1
2012	75.9	0.8	6.6	4.1
2013	49.3	1.0	6.3	4.0
2014	78.6	0.9	6.3	3.6
2015	43.9	2.0	6.2	3.8
2016	48.3	1.8	6.7	4.0
2017	91.7	1.3	6.8	4.0
2018	50.9	1.9	6.4	4.1
2019	49.0	1.3	6.6	4.5
2020	33.2	1.4	6.4	3.9

Table 4. Reported active TB disease by geographical region in Canada over time, CTBRS: 2001-2020

Geographical region	2001-2004 n (%)	2005-2008 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
Northern territories	145 (2.2)	243 (3.9)	366 (5.8)	259 (4.0)	278 (3.9)
Atlantic Canada	124 (1.9)	84 (1.3)	114 (1.8)	137 (2.1)	142 (2.0)
Western Canada	2,581 (38.6)	2,639 (41.8)	2,639 (41.7)	2,875 (44.6)	3,120 (43.7)
Central Canada	3,832 (57.2)	3,544 (56.2)	3,442 (54.4)	3,400 (52.7)	3,774 (52.8)
Total	6,682 (100)	6,510 (100)	6,561 (100)	6,671 (100)	7,314 (100)
Abbreviations: CTBRS, Canadian TB Reporting System

2.3.4. TB in specific populations

The burden of TB in Canada is not shared equally across the entire population. Foreign-born individuals and Canadian-born Indigenous peoples are disproportionately affected by TB (Figure 5). The former has consistently accounted for the majority of reported cases: between 65% and 67% from 2001 to 2012, and between 70% and 72% from 2013 to 2020, Canadian-born Indigenous peoples, for their part, represented between 14% and 22% of individuals with active TB disease between 2001 and 2020, despite comprising only 4.3% of the Canadian population.^{Reference 2} In Canadian-born, non-Indigenous populations, the incidence rate of active TB disease has been gradually decreasing over the years, from 1.2 cases per 100,000 in 2001 to 0.4 in 2019; in 2020, however, it increased to 1.2 per 100,000 population.

Note: Indigenous status not reported by British Columbia from 2016 onward.

Figure 5: Text description

Year	First Nations on-reserve	First Nations off-reserve	Inuit	Métis	Canadian-born non-Indigenous	Foreign-born
2001	24.5	25.2	111.4	16.0	1.2	17.9
2002	21.6	18.6	67.8	11.3	1.1	17.9
2003	29.3	24.2	22.1	9.5	1.0	17.7
2004	27.2	20.1	80.4	6.6	0.9	16.4
2005	31.5	23.9	120.7	10.8	0.9	15.4
2006	31.5	26.3	114.3	8.8	0.8	15.5
2007	29.7	24.2	84.2	9.6	0.7	15.2
2008	26.8	25.7	160.0	6.1	0.9	14.6
2009	27.0	23.5	157.1	5.4	1.0	14.4
2010	23.7	18.3	200.0	5.4	0.7	14.1
2011	21.2	16.2	166.7	4.4	0.7	14.7
2012	23.8	18.5	251.6	2.2	0.7	14.6
2013	30.8	11.4	139.4	3.5	0.6	15.0
2014	21.7	14.9	177.6	3.6	0.6	14.3
2015	20.4	10.7	164.7	2.2	0.6	15.0
2016	33.9	14.5	168.7	2.1	0.5	15.5
2017	22.0	10.6	205.8	3.7	0.5	15.0
2018	19.8	11.6	194.3	2.8	0.4	14.8
2019	16.3	14.5	188.7	2.3	0.4	15.8
2020	18.5	4.6	70.3	2.8	0.3	14.3

2.3.4.1. TB in Indigenous populations

While the greatest number of individuals with active TB disease is reported among foreign-born individuals, the incidence rate of active TB disease over the past 2 decades has consistently been highest among some groups of Canadian-born Indigenous peoples (Figure 5), which include First Nations, Métis and Inuit, as per the Constitution Act of 1982 (PDF). Social conditions such as over-crowding have played an important role in the TB situation among Indigenous peoples, increasing the risk of infection^{Reference 3} as well as the risk of progression to active TB disease.^{Reference 4Reference 5} The incidence rate of TB among the Inuit has been the highest among these three groups. In 2019, the active TB disease incidence rate among the Inuit (188.7 cases per 100,000 population) was approximately 472 times that of the Canadian-born, non-Indigenous (0.4 cases per 100,000 population) population (Figure 5), but in 2020, it decreased significantly to 70.3 cases per 100,000 population. While the reasons for this decrease are not fully understood, it may be related to public health measures put in place for COVID-19 that resulted in reduced transmission, and/or the pandemic's impacts on health services access and delivery, leading to under-diagnosis of active TB disease.

Among First Nations peoples, the incidence rate of active TB disease has been consistently higher among those living on-reserve than those living off-reserve (Table 5 and Figure 5). Incidence rates for First Nations on-reserve were relatively stable from 2001 to 2010, but have been decreasing incrementally since 2015 (Figure 5). Incidence rates among First Nations off-reserve have also been decreasing, and in 2020, they reached a level below the national average of 4.6 per 100,000 population (Figure 5).

Table 5. Reported active TB disease by population subgroup in Canada over time, CTBRS: 2001-2020

Population subgroup	2001-2004 n (%)	2005-2008 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
Canadian-born
First Nations (total)	786 (11.8)	902 (13.9)	803 (12.2)	753 (11.3)	568 (7.8)
First Nations on-reserve	417 (6.2)	516 (7.9)	443 (6.8)	504 (7.6)	345 (4.7)
First Nations off-reserve	269 (4.0)	339 (5.2)	295 (4.5)	222 (3.3)	166 (2.3)
Inuit	138 (2.1)	258 (4.0)	468 (7.1)	436 (6.5)	464 (6.3)
Métis	135 (2.0)	123 (1.9)	83 (1.3)	59 (0.9)	59 (0.8)
Non-Indigenous	987 (14.8)	812 (12.5)	783 (11.9)	637 (9.5)	392 (5.4)
Unknown if Indigenous or not	0 (0.0)	0 (0.0)	0 (0.0)	34 (0.5)	160 (2.2)
Foreign-born
Foreign-born	4,476 (67.0)	4,264 (65.5)	4,337 (66.1)	4,672 (70.0)	5,353 (73.2)
Unknown if Canadian/foreign-born
Unknown if Canadian/foreign-born	161 (2.4)	151 (2.3)	87 (1.3)	80 (1.2)	318 (4.3)
Total
Total	6,682 (100)	6,510 (100)	6,561 (100)	6,671 (100)	7,314 (100)
Abbreviations: CTBRS, Canadian TB Reporting System.

Unlike Inuit and First Nations peoples, the reported TB incidence among the Métis is similar to that of the non-Indigenous, Canadian-born population. However, this may partly be influenced by challenges in collecting Métis-specific data and in separating Métis from First Nations individuals when there is shared ancestry.^{Reference 6} Reported incidence rates among Métis populations remained stable from 2000 to 2007, after which they progressively decreased and have been below the national average since 2011 (Figure 5).

2.3.4.2. TB in foreign-born populations

The total annual number of foreign-born individuals with active TB disease reported to the CTBRS increased noticeably in the last 8 years (Table 6). However, this did not significantly affect the corresponding incidence rate, which has been relatively stable since 2011 (Figure 5).

Table 6. Reported active TB disease in foreign-born individuals by WHO birth region, CTBRS: 2001-2020

Birth region	2001-2004 n (%)	2005-2008 n (%)	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)
AFR	412 (9.5)	492 (11.7)	506 (11.8)	560 (12.1)	690 (13.3)
AMR	285 (6.6)	271 (6.5)	255 (6.0)	222 (4.8)	250 (4.8)
EMR	453 (10.4)	470 (11.2)	429 (10.0)	472 (10.2)	560 (10.8)
EUR	380 (8.8)	306 (7.3)	253 (5.9)	201 (4.3)	145 (2.8)
SEAR	972 (22.4)	983 (23.5)	1,042 (24.4)	1,220 (26.3)	1,534 (29.6)
WPR	1,838 (42.4)	1,669 (39.8)	1,786 (41.8)	1,965 (42.3)	1,998 (38.6)
Overall	4,340 (100)	4,191 (100)	4,271 (100)	4,640 (100)	5,177 (100)
Abbreviations: WHO, World Health Organization; CTBRS, Canadian TB Reporting System; AFR, African Region; AMR, Region of the Americas; EMR, Eastern Mediterranean Region; EUR, European Region; SEAR, South-East Asia Region; WPR, Western Pacific Region.

Foreign-born individuals diagnosed with active TB disease are assigned to a WHO epidemiologic region on the basis of the country of birth. Table 6 depicts changes over time in the number of foreign-born individuals with active TB disease reported in Canada between 2001 and 2020 grouped by their epidemiologic region of birth as per the WHO definition. Associated incidence rates (Figure 6) are calculated using denominators produced by latest census data from Statistics Canada.^{Reference 7}

Figure 6: Text description

Year	African Region	Region of the Americas	Eastern Mediterranean Region	European Region	South-East Asia Region	Western Pacific Region
2001	39	6.8	23.9	4.3	48.5	34.1
2002	49.8	7.1	26.3	4	45.5	33.8
2003	47.5	8	23.9	3.5	49.3	33.4
2004	47.5	7.5	24.7	3	53.3	32.4
2005	51.9	7.3	26.2	3.1	47.2	27.8
2006	43.1	4.8	20.5	2.7	38.7	25.7
2007	42.6	7.5	18.8	3.2	35.6	25.5
2008	33.6	5.5	14.3	3.2	30.2	23.5
2009	29.7	5.2	14.4	3.1	29.2	22.9
2010	32.1	5.7	12.3	2.9	30.6	22.7
2011	36	5.8	14.1	2.4	32.7	23.3
2012	36.6	4.3	15.5	2.1	31.9	23.9
2013	37	4.2	15.9	1.7	35.8	24.4
2014	32.8	3.3	13.2	1.8	33.7	24.8
2015	33.8	5.1	13	2.5	34.5	24.9
2016	39.2	5	17.6	2.1	35.8	23.9
2017	28.2	4.9	13.9	1.9	31.6	23.8
2018	33.7	5.1	13.1	1.4	35.2	20.4
2019	36.2	4.1	15.1	1.3	38.8	21.8
2020	34.9	3.9	11.8	1.2	37	18

South-East Asia (SEAR) and African regions (AFR) have consistently posted the highest incidence rates of active TB disease among foreign-born individuals for the past two decades (Figure 6), followed by Western Pacific (WPR) and Eastern Mediterranean (EMR) regions. Comparatively, incidence rates have been the lowest among individuals from the European region (EUR) and the region of the Americas (AMR) (Figure 6).

For individuals born outside Canada who were diagnosed with TB disease, the dates of arrival in Canada and active TB disease diagnosis were used to estimate the time lived in Canada until active TB disease diagnosis. Among those foreign-born individuals with active TB disease reported between 2001 and 2020 with known date of arrival, 9.2% were reported within the first year of arrival, 20.2% within the first 2 years of arrival, and 42.0% within the first 5 years, with an additional 15.6% in the subsequent 5 years (Figure 7).

Figure 7: Text description

Years from arrival	Number of active TB cases	Cumulative percentages
<1	1,576	-
1	2,025	9.2%
2	1,255	-
3	1,118	-
4	903	-
5	786	42.1%
6	669	-
7	608	-
8	546	-
9	490	-
10	529	57.7%
11	458	-
12	411	-
13	406	-
14	347	-
15	341	-
16	351	-
17	329	-
18	311	-
19	315	-
20	348	-
21	268	-
22	253	-
23	255	-
24	236	-
25	217	-
26	217	-
27	199	-
28	175	-
29	151	-
30	180	-
31-35 years	614	-
36-40 years	466	-
41-45 years	318	-
46-50 years	208	-
51-55 years	145	-
56-60 years	108	-
61+ years	79	-

2.4. TB-HIV co-infection

Canada's national HIV/AIDS and TB surveillance systems have limitations regarding their ability to estimate TB-HIV co-infection. However, data collection on the HIV status of individuals reported with active TB disease has greatly improved over the years, along with the percentage of individuals who are offered HIV testing. In 2001, HIV status was unknown for 83.4% of individuals diagnosed with TB disease; by 2017, that figure had decreased to 30.9%, but in 2020, it had increased again, to 57.3% (Figure 8).

Figure 8: Text description

Year	Percent with HIV	Percent without HIV	Percent unknown
2001	2.5%	14.1%	83.5%
2002	4.0%	13.9%	82.1%
2003	2.3%	16.9%	80.8%
2004	2.4%	18.4%	79.2%
2005	3.4%	20.2%	76.5%
2006	3.5%	20.1%	76.3%
2007	3.6%	25.0%	71.4%
2008	5.2%	30.9%	63.8%
2009	3.6%	31.2%	65.2%
2010	3.1%	33.3%	63.6%
2011	3.8%	28.0%	68.2%
2012	3.3%	40.1%	56.6%
2013	4.2%	37.9%	57.9%
2014	4.0%	47.8%	48.2%
2015	4.1%	40.1%	55.8%
2016	5.2%	39.2%	55.6%
2017	1.5%	67.6%	30.9%
2018	2.3%	64.6%	33.0%
2019	1.8%	60.6%	37.6%
2020	2.8%	39.9%	57.3%

The percentage of HIV-positive individuals among those diagnosed with active TB disease whose HIV status was known decreased over time, from 15.1% in 2001-2004 (when only 1,239 of 6,682, or 18.5% of individuals with active TB disease reported their HIV-status), to 3.5% in 2017-2020 (when 4,419 of 7,314, or 60.4% of individuals with active TB disease reported their HIV-status) (Figure 9). It should be noted that underreporting of HIV status imposes serious limitations in national level interpretation of changes in the incidence of TB-HIV co-infection.

Figure 9: Text description

Year	Number of HIV-positive	Number of HIV-negative	Number of known HIV diagnosis	Total active TB cases	Percent HIV-positive among known HIV diagnoses	Percent HIV-negative among known HIV diagnoses
2001-2004	187	1,052	1,239	6,682	15.1%	84.9%
2005-2008	255	1,566	1,821	6,510	14.0%	86.0%
2009-2012	225	2,180	2,405	6,561	9.4%	90.6%
2013-2016	294	2,746	3,040	6,671	9.7%	90.3%
2017-2020	153	4,266	4,419	7,314	3.5%	96.5%

2.5. TB-Diabetes mellitus co-morbidity

Since the introduction of data collection on TB-diabetes mellitus (DM) co-morbidity into the surveillance of active TB disease in 2005, underreporting of DM status gradually decreased until 2012; since then, it has remained approximately constant (Figure 10). The overall proportion of missing information on DM has consistently been above 50%, which makes it challenging to interpret national-level data on TB-DM co-morbidity. In the last 2 years, the proportion of individuals diagnosed with active TB disease for whom DM information was missing has increased, following a period of stability: from 50.3% in 2018 to 61.9% and 56.4% in 2019 and 2020, respectively (Figure 10).

Figure 10: Text description

Year	Percent with diabetes	Percent without diabetes	Percent unknown
2005	3.5%	0.2%	96.3%
2006	5.4%	15.8%	78.7%
2007	7.4%	22.5%	70.1%
2008	6.9%	28.1%	65.0%
2009	5.6%	18.1%	76.3%
2010	8.4%	28.2%	63.4%
2011	8.4%	35.0%	56.6%
2012	10.4%	39.2%	50.5%
2013	10.4%	35.7%	53.9%
2014	10.5%	37.6%	52.0%
2015	12.1%	39.7%	48.1%
2016	11.2%	36.0%	52.8%
2017	12.0%	34.7%	53.3%
2018	11.2%	38.5%	50.3%
2019	11.4%	26.7%	61.9%
2020	12.6%	31.0%	56.4%

The percentage of individuals reported with active TB disease identified as having a DM diagnosis did not change significantly over time, remaining in the range of 21.4 to 26.5% (Figure 11).

Figure 11: Text description

Year	Number of DM-positive	Number of DM-negative	Number of known DM diagnosis	Total active TB cases	Percent with DM among known DM diagnoses	Percent without DM among known DM diagnoses
2005-2008	376	1,082	1,458	6,510	25.8%	74.2%
2009-2012	538	1,980	2,518	6,561	21.4%	78.6%
2013-2016	736	2,485	3,221	6,671	22.9%	77.1%
2017-2020	862	2,389	3,251	7,314	26.5%	73.5%

2.6. Treatment and outcomes

Data from 2000-2004 show especially high proportions (about 60%) of individuals with active TB disease lost to follow up, and so the treatment outcome data for this period are limited (Figure 12). Improved follow-up since 2004 has resulted in outcome data being obtained for 90.0% or more of individuals diagnosed with active TB disease in recent years. The proportion with successful active TB disease treatment has consistently been above 90% (Table 7).

Figure 12: Text description

Year	Treatment success	Death due to TB	Lost to follow up	Treatment changed due to initial failure
2000	33.5%	3.0%	62.4%	0.1%
2001	37.0%	3.8%	57.3%	0.0%
2002	32.2%	2.2%	64.2%	0.0%
2003	35.3%	2.1%	60.9%	0.0%
2004	37.3%	2.4%	58.4%	0.0%
2005	71.2%	3.7%	22.4%	0.0%
2006	71.1%	5.3%	17.8%	0.0%
2007	68.8%	5.8%	20.1%	0.1%
2008	85.1%	6.5%	5.0%	0.0%
2009	86.7%	5.0%	5.0%	0.2%
2010	86.5%	4.5%	3.4%	0.1%
2011	75.8%	6.4%	12.4%	0.0%
2012	83.2%	4.6%	4.8%	0.1%
2013	83.5%	5.0%	4.5%	0.1%
2014	84.3%	5.6%	5.1%	0.0%
2015	84.1%	6.5%	5.1%	0.0%
2016	79.9%	5.0%	8.3%	0.0%
2017	81.0%	4.9%	8.0%	0.0%
2018	81.5%	5.4%	8.3%	0.0%
2019	79.1%	3.6%	10.0%	0.0%

Table 7. Outcome of active TB disease treatment in Canada over the years, CTBRS: 2000-2019

Outcome	2000-2003 n (%)	2004-2007 n (%)	2008-2011 n (%)	2012-2015 n (%)	2016-2019 n (%)
Treatment success	2,345 (92.3)	4,029 (91.9)	5,432 (91.9)	5,536 (90.4)	5,876 (90.3)
Treatment changed due to initial failure	2 (0.1)	2 (0.0)	4 (0.1)	2 (0.0)	0 (0.0)
Treatment discontinued	0 (0.0)	0 (0.0)	16 (0.3)	30 (0.5)	11 (0.2)
Treatment ongoingTable 7 footnote a	1 (0.0)	76 (1.7)	98 (1.7)	198 (3.2)	270 (4.2)
Death due to TB	192 (7.6)	279 (6.4)	363 (6.1)	359 (5.9)	348 (5.3)
Subtotal of cases with outcomes	2,540 (100)	4,386 (100)	5,913 (100)	6,125 (100)	6,505 (100)
Lost to follow up	4,154	1,920	420	324	637
Abbreviations: TB, tuberculosis; CTBRS, Canadian TB Reporting System. Footnotes: Table 7 footnote a The CTBRS currently does not have follow-up of individuals under treatment beyond each surveillance year; hence these treatment outcomes are unknown. Return to table 7 footnote a

2.6.1. TB-Related mortality

Reported TB-related deaths (i.e., TB disease was either a direct cause of, or a contributing factor to, the death) increased by about 42% from 2000-2003 to 2004-2007, and by 35% from 2004-2007 to 2008-2011. Since 2011, TB-related mortality has been stable (Table 8). This increase in the two earlier periods was in part a reporting issue, since data before 2008 were significantly impacted by the relatively high proportion of individuals under treatment for active TB disease who were lost to follow-up (Figure 12).

Table 8. Summary of TB-related deaths in different population subgroups, CTBRS: 2000-2019

Population subgroup	2000-2003 n (%)	2004-2007 n (%)	2008-2011 n (%)	2012-2015 n (%)	2016-2019 n (%)
Canadian Indigenous	74 (41.8)	61 (24.3)	71 (21.0)	53 (16.0)	32 (10.1)
Canadian non-Indigenous	29 (16.4)	43 (17.1)	80 (23.7)	43 (13.0)	46 (14.6)
Foreign-born	74 (41.8)	147 (58.6)	187 (55.3)	236 (71.1)	238 (75.3)
Overall	177 (100)	251 (100)	338 (100)	332 (100)	316 (100)
Abbreviations: CTBRS, Canadian TB Reporting System.

2.6.1.1. TB-related mortality in Indigenous peoples

The majority of TB-related deaths in Indigenous peoples in Canada were among First Nations peoples and mostly among those aged 35 years and older (Figure 13A). The total numbers of deaths among the Inuit and Métis populations in each age group were significantly lower than those recorded among First Nations in general (Figure 13B and Figure 13C).

Figure 13: Text description

Figure 13a. First Nations

Age group	Number of TB related deaths (2000-2009)	Number of TB related deaths (2010-2019)
0-14 years	1	2
15-34 years	17	9
35-64 years	74	61
65+ years	49	27

Figure 13b. Inuit

Age group	Number of TB related deaths (2000-2009)	Number of TB related deaths (2010-2019)
0-14 years	2	1
15-34 years	0	5
35-64 years	3	5
65+ years	3	0

Figure 13c. Métis

Age group	Number of TB related deaths (2000-2009)	Number of TB related deaths (2010-2019)
0-14 years	0	0
15-34 years	2	1
35-64 years	11	7
65+ years	7	3

2.6.1.2. TB-related mortality in Canadian-born, non-Indigenous populations

In terms of numbers, the Canadian-born, non-Indigenous population has consistently recorded the lowest TB-related mortality compared to other population subgroups. In the last 20 years, an average of 12 TB-related deaths per year were reported for this population (Table 8). The corresponding TB case-fatality rate, however, has generally been higher compared to both the Canadian-born Indigenous and foreign-born populations since 2007 (Figure 14, upper panel). Within the Indigenous sub-populations, the TB case-fatality rate has generally been lowest among the Inuit (Figure 14, lower panel).

Note: The Canadian-born Indigenous group is broken down by sub-population in the lower panel.

Figure 14: Text description

Year	First Nations CFR	Inuit CFR	Métis CFR	Canadian Indigenous CFR	Canadian non-Indigenous CFR	Foreign-born CFR
2000	10.4%	0.0%	6.9%	7.8%	2.5%	2.1%
2001	9.4%	1.9%	12.2%	8.5%	2.5%	2.6%
2002	8.2%	0.0%	5.7%	6.7%	2.3%	1.0%
2003	4.9%	9.1%	3.3%	4.9%	3.4%	0.9%
2004	3.4%	2.4%	9.5%	3.7%	2.8%	1.7%
2005	6.9%	0.0%	0.0%	4.7%	3.2%	3.2%
2006	7.1%	1.6%	10.3%	6.4%	5.5%	4.2%
2007	7.0%	0.0%	0.0%	5.2%	11.1%	4.6%
2008	5.6%	2.3%	11.1%	5.2%	11.3%	5.4%
2009	5.7%	2.3%	4.0%	4.7%	9.2%	3.6%
2010	4.7%	0.0%	3.8%	3.0%	10.3%	3.7%
2011	14.1%	0.0%	9.5%	8.9%	7.5%	4.8%
2012	6.7%	0.0%	9.1%	3.9%	5.7%	4.0%
2013	4.4%	2.2%	0.0%	3.5%	5.7%	4.7%
2014	4.9%	3.4%	10.5%	4.7%	6.5%	5.6%
2015	5.7%	0.0%	25.0%	4.3%	7.6%	6.5%
2016	3.3%	0.0%	10.0%	2.4%	9.3%	4.7%
2017	3.2%	2.8%	5.6%	3.2%	6.4%	4.8%
2018	5.6%	0.7%	0.0%	3.1%	16.5%	5.1%
2019	3.4%	0.0%	0.0%	1.7%	8.3%	3.5%

The majority of deaths in Canadian-born, non-Indigenous populations was among those aged 65 years or older, with more than twice as many deaths in this age group compared to the 35 to 64 age group over the time period (Figure 15). The lowest mortality has been among children (aged 0 to 14 years of age), with only three deaths in total over the past 2 decades (Figure 15).

Figure 15: Text description

Age group	Number of TB related deaths (2000-2009)	Number of TB related deaths (2010-2019)
0-14 years	1	2
15-34 years	4	3
35-64 years	38	30
65+ years	76	87

2.6.1.3. TB-related mortality in foreign-born populations

The majority of TB-related deaths among foreign-born individuals in the last 2 decades in Canada occurred among older individuals, aged 65 years or older, who were born in the Western Pacific and South-East Asia regions (Figure 16E and Figure 16F), which reflects the high TB burden observed in individuals coming from these 2 regions (Table 6). The lowest annual TB mortality among foreign-born individuals has been consistently found among individuals born in the European, African, Eastern Mediterranean and Americas regions (Figure 16A, Figure 16B, Figure 16C, Figure 16D).

Figure 16: Text description

Age group	Number of TB-related deaths (2000-2009)	Number of TB-related deaths (2010-2019)
WHO region: Region of the Americas (AMR)
<15	0	0
15-34	0	0
35-64	12	14
65+	3	22
WHO region: African Region (AFR)
<15	0	0
15-34	2	9
35-64	7	14
65+	0	8
WHO region: Eastern Mediterranean Region (EMR)
<15	0	0
15-34	1	2
35-64	6	7
65+	13	34
WHO region: European Region (EUR)
<15	0	0
15-34	0	0
35-64	4	5
65+	32	42
WHO region: South-East Asia Region (SEAR)
<15	0	0
15-34	4	4
35-64	13	32
65+	48	120
WHO region: Western Pacific Region (WPR)
<15	0	0
15-34	5	2
35-64	26	42
65+	113	196

The case-fatality rate in foreign-born individuals has been variable, ranging from a low of 0.9% in 2003 to a high of 6.5% in 2015. After remaining stable at around 5.0% from 2016 to 2018, it dropped to 3.5% in 2019 (Figure 14, upper panel).

2.7. Drug resistance

Detailed information on TB-related drug resistance in Canada is collected through the Canadian Tuberculosis Laboratory Surveillance System (CTBLSS). Between 2009 and 2020, 20,546 individuals were reported with TB disease. Isolates from 81.6% (16,766) were subjected to susceptibility testing, of which 1,598 (9.5%) showed resistance to anti-TB drug(s) (Table 9). The majority of individuals reported with drug-resistant TB (83.2%; n = 1,329) had mono-resistance, primarily resistance to isoniazid (INH) (n = 1,072) or pyrazinamide (PZA) (n = 225). Multi- and polydrug resistance accounted for approximately 13% (n = 206) and 3.6% (n = 57) of all TB-resistant isolates, respectively. Extensively drug-resistance has been very sporadic and limited to a maximum of one individual per year. These trends have been stable over time (Figure 17).

In Figure 17, the abbreviations are as follows: isoniazid (INH); multidrug-resistant tuberculosis (MDR-TB); extensively drug-resistant tuberculosis (XDR-TB)

Figure 17: Text description

Type of drug resistance	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020
Mono-INH	6.3%	6.0%	7.7%	7.1%	5.4%	6.1%	6.3%	6.3%	5.8%	6.1%	7.0%	6.6%
Mono-resistance	7.4%	6.9%	9.0%	9.1%	6.8%	7.8%	8.5%	7.4%	6.6%	8.3%	8.9%	8.3%
Poly-resistance	0.8%	0.5%	0.1%	0.1%	0.3%	0.3%	0.2%	0.3%	0.4%	0.3%	0.3%	0.5%
MDR-TB	1.4%	1.4%	1.4%	0.6%	1.1%	1.4%	1.6%	1.2%	0.9%	1.5%	1.2%	0.9%
XDR-TB	0.0%	0.1%	0.1%	0.1%	0.1%	0.1%	0.0%	0.0%	0.0%	0.1%	0.0%	0.0%

Table 9. Reported drug-resistant TB over time, CTBLSS: 2009-2020

Drug resistance	2009-2012 n (%)	2013-2016 n (%)	2017-2020 n (%)	Overall n (%)
Mono-resistance TB	433 (8.13)	422 (7.63)	474 (8.02)	1,329 (7.93)
Isoniazid	363 (6.81)	333 (6.02)	376 (6.36)	1,072 (6.39)
Rifampin	6 (0.11)	10 (0.18)	12 (0.20)	28 (0.17)
Pyrazinamide	61 (1.14)	79 (1.43)	85 (1.44)	225 (1.34)
Ethambutol	3 (0.06)	0 (0.00)	1 (0.02)	4 (0.02)
Poly-resistance TB	20 (0.38)	16 (0.29)	21 (0.36)	57 (0.34)
Isoniazid + Pyrazinamide	10 (0.19)	10 (0.18)	14 (0.24)	34 (0.20)
Isoniazid + Ethambutol	7 (0.13)	5 (0.09)	7 (0.12)	19 (0.11)
Isoniazid + Ethambutol + Pyrazinamide	3 (0.06)	1 (0.02)	0 (0.00)	4 (0.02)
Multidrug-resistance TB	64 (1.20)	73 (1.32)	69 (1.17)	206 (1.23)
Extensively drug-resistance TB	3 (0.06)	2 (0.04)	1 (0.02)	6 (0.04)
Total isolates tested	5,329 (100)	5,529 (100)	5,908 (100)	16,766 (100)
Abbreviations: CTBRS, Canadian TB Reporting System.

In general, poly- and multidrug-resistance were found almost exclusively in isolates from foreign-born individuals, while mono-resistance (dominated by INH-resistance) was detected in individuals from all population groups. Additional details on TB drug resistance in Canada are available in Chapter 8: Drug-resistant tuberculosis.

3. Conclusions

As detailed in this chapter, there are pronounced disparities in Canada regarding TB. Certain populations and geographic regions continue to be disproportionately affected. In addition to foreign-born and Indigenous populations in Canada, those who are incarcerated or experience homelessness also show higher incidence rates of active TB disease, as will be outlined in subsequent chapters of these Standards. There are numerous determinants of health that relate to TB, including education, employment, physical environment, social support, access to health services, personal health practices and culture. Addressing health inequities and the underlying determinants of health is universally recognized by TB experts as being an integral component of TB prevention and response, both in Canada^{Reference 8} and globally.^{Reference 9Reference 10}

Additionally, ongoing collaboration with community partners, key stakeholders and governments, enhancement of TB surveillance data and evaluation of TB programs are needed to effectively address and reduce TB-related inequities and burden in Canada. Enhancing TB surveillance data would require a comprehensive integration of the different components of the current surveillance program (e.g., clinical, laboratory, treatment), an expansion to include subclinical TB, as well as the use of new tools such as whole genome sequencing, which could greatly support outbreak investigation and control.

A collaborative, multi-faceted approach is needed to meet these aims and, ultimately, eliminate TB in Canada, as noted in the 2018 Chief Public Health Officer (CPHO) report on eliminating TB in Canada.^{Reference 8} Specifically, continued engagement with communities by all levels of government and effective coordination of TB surveillance and programmatic areas can help ensure interventions are appropriately tailored for specific groups and are evidence-informed. This is essential to help reduce disparities and improve TB diagnosis, monitoring, treatment outcomes and, ultimately, TB prevention.

The Canadian Tuberculosis Laboratory Surveillance System contributing provincial/territorial partners

Province/territory	Name	Organization
Newfoundland and Labrador	Shawna Pierce	Dept. of Health and Community Services
Prince Edward Island	Dr. Shamara Baidoobonso	Public Health Office
Nova Scotia	Dr. David Haldane, Melissa Meagher	Dept. of Health and Wellness (Provincial Public Health Laboratory network)
New Brunswick	Dr. Duncan Webster, Janet Reid, Hope Mckenzie	Public Health New Brunswick (Saint John Regional Hospital)
Québec	Dr. Pierre-Marie Akochy	Québec National Institute of Public Health (Québec Public Health Laboratory)
Ontario	Dr. Frances Jamieson, Julianne Kus, Paul Nelson, Kevin May, Karen Lam	Public Health Ontario (Public Health Ontario Laboratory)
Manitoba	Dr. Heather Adam, Ruth Bittner	Manitoba Health, Seniors and Active Living (Diagnostic Services, Shared Health)
Saskatchewan	Rita Thomas, Sonia Atkinson	Saskatchewan Health Authority (Saskatchewan Disease Control Laboratory)
Alberta	Dr. Greg Tyrrell, Cary Shandro	Alberta Health Services
British Columbia	Dr. Inna Sekirov, Dr. Mabel Rodrigues	BC Centre for Disease Control
Yukon Territories	Lori Strudwick	Yukon Communicable Disease Control
Northwest Territories	Laura Steven	Department of Health and Social Services (Stanton Territorial Hospital)
Nunavut	Susan Marchand	Department of Health (Qikiqtani General Hospital)

The Canadian Tuberculosis Reporting System contributing provincial/territorial partners

Province/territory	Name	Organization
Newfoundland and Labrador	Beth Halfyard, Lola Gushue	Dept. of Health and Community Services
Prince Edward Island	Dr. Shamara Baidoobonso, Connie Cheverie, Stacey Burns MacKinnon	Public Health Office
Nova Scotia	Beverly Billard	Dept. of Health and Wellness
New Brunswick	Hanan Smadi, Suzanne Savoie	Public Health New Brunswick
Québec	Dr. Paul Rivest, Marc-André Dubé	Québec National Institute of Public Health
Ontario	Dr. Liane MacDonald, Michael Whelan, Karin Hohenadel, Cecilla Fung	Public Health Ontario
Manitoba	Dr. Carla Loeppky, Valerie Amable, Dr. Jillian Waruk	Manitoba Health, Seniors and Active Living
Saskatchewan	Dr. Assaad Al-Azem, Helen Bangura	Saskatchewan Health Authority
Alberta	Jeanine Robinson, David Cao, Sandy Cockburn, Liang Zheng, Christa Smolarchuk, Rosa Mahedon, Lisa Eisenbeis	Alberta Health Services
British Columbia	Dr. Jason Wong, Wrency Tang, Dr. Victoria Cook, Claire Swanston, Arina Zamanpour, Camille Herpin, Fay Hutton	BC Centre for Disease Control
Yukon Territories	Jan McFadzen, Shayla Roberts, Janelle Greer	Yukon Communicable Disease Control
Northwest Territories	Caroline NewBerry, Karen Hollet, Kitty Dang, Robert Joyce, Heather Hannah	Department of Health and Social Services
Nunavut	Keith Travers, Kethika Kulleperuma	Department of Health

Acknowledgments

The Public Health Agency of Canada (Centre for Communicable Diseases and Infection Control and National Microbiology Laboratory) would like to acknowledge the valuable contributions of the provincial and territorial tuberculosis programs and their teams to the Canadian Tuberculosis Reporting System and the Canadian Tuberculosis Laboratory Surveillance System. Without their participation, this report would not have been possible.

Disclosure statement

The Canadian Thoracic Society (CTS) TB Standards editors and authors declared potential conflicts of interest at the time of appointment and these were updated throughout the process in accordance with the CTS Conflict of Interest Disclosure Policy. Individual member conflict of interest statements are posted on the CTS website.

Funding

The 8th edition Canadian Tuberculosis Standards are jointly funded by the CTS and the Public Health Agency of Canada, edited by the CTS and published by the CTS in collaboration with the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. However, it is important to note that the clinical recommendations in the Standards are those of the CTS. The CTS TB Standards editors and authors are accountable to the CTS Respiratory Guidelines Committee (CRGC) and the CTS Board of Directors. The CTS TB Standards editors and authors are functionally and editorially independent from any funding sources and did not receive any direct funding from external sources. The CTS receives unrestricted grants which are combined into a central operating account to facilitate the knowledge translation activities of the CTS Assemblies and its guideline and standards panels. No corporate funders played any role in the collection, review, analysis or interpretation of the scientific literature or in any decisions regarding the recommendations presented in this document.

Notes

• Constitution Act, 1982 (PDF)

References