Language selection

Government of Canada / Gouvernement du Canada

Search

Preface of the Canadian Tuberculosis Standards

On this page

1. Introduction

The last 8 years have witnessed great strides in our understanding of the pathogenesis, immunology and epidemiology of tuberculosis. In the past decade, after too many decades of inaction, new diagnostics and new treatment regimens for tuberculosis (TB) infection, and drug-resistant TB disease have been developed. This 8th edition of the Canadian Tuberculosis Standards (the Standards) has been extensively revised to incorporate much of this new information, building upon the 7 previous versions of the Standards, which were published in 1972 (with a pediatric supplement in 1974), 1981, 1988, 1996, 2000, 2007 and 2013.

Specifically, in response to feedback from users of previous versions of the Standards, some sections have been expanded, while others have been reduced or eliminated. For example, the chapter on Bacille Calmette-Guérin vaccination has been dropped and updated content is now within the chapter on Pediatric TB. The chapter on disease due to non-tuberculous mycobacteria has also been dropped; some parts are now found in the chapter on diagnosis of TB disease. A new chapter on monitoring TB program performance is a fitting new edition to the Standards (promoting standards for TB programs).

The objective of this document remains to provide practical management information to public health and clinical professionals on all aspects of the pathogenesis, epidemiology, and management of TB in Canada. The guidance pertains to all individuals at risk for or confirmed to have latent or active TB. Specific target users may include: decision-makers, public health professionals, specialists managing TB (e.g., internists, respirologists, infectious diseases specialists) and primary care providers.

Of note, the document does not supersede any provincial/ territorial legislative, regulatory, policy and practice requirements, or professional guidelines that govern the practice of health professionals in their respective jurisdictions. The Standards also is not intended to replace consultations regarding management of individual patients or other circumstances, between providers and persons with relevant expertise in tuberculosis.

Reference is made to specific tests, procedures and therapies throughout the Standards. For the most part, generic terms are used rather than trade names or manufacturers' names. However, in a few instances when only a single manufacturer or product is available, a trade name may be mentioned. This is done only to enhance readers' understanding by providing a name with which they are more likely to be familiar. Use of trade names and commercial sources is for identification only and does not imply endorsement by the Canadian Thoracic Society (CTS).

2. Contributors

Editor

Dick Menzies, MD, MSc
Professor, Departments of Medicine, Epidemiology and Biostatistics
Director, McGill International TB Centre,
Montreal Chest Institute
McGill University
Montréal, QC

Associate editors

Gonzalo G. Alvarez MD, MPH, FRCPC
Associate Scientist, Ottawa Hospital Research Institute
Assistant Professor, University of Ottawa
Respirologist, Divisions of Respirology and Infectious Diseases
Department of Medicine, The Ottawa Hospital
Ottawa, ON

Christina Greenaway, MD, FRCPC, MSc
Associate Professor, Department of Medicine, McGill University
Division of Infectious Diseases, SMBD-Jewish General Hospital
McGill International TB Centre
Montréal, QC

James Johnston, MD, MPH, FRCPC
Clinical Associate Professor, Division of Respiratory Medicine, University of British Columbia
Evaluation Lead, Provincial Tuberculosis Services British Columbia Centre for Disease Control.
Vancouver, BC

Richard Long, BSc, MD, FRCPC, FCCP, FCAHS
Professor, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta and
Adjunct Professor, School of Public Health
University of Alberta
Edmonton, AB

Howard Njoo, MD, MHSc, FRCPC
Deputy Chief Public Health Officer and
Interim Vice-President
Infectious Disease Programs Branch
Public Health Agency of Canada
Ottawa, ON

Tom Wong, MD, MPH, FRCPC
Chief Medical Officer, Chief Science Officer and Director General
Office of Population and Public Health
First Nations and Inuit Health Branch
Indigenous Services Canada
Ottawa, ON

Chapter authors

Gonzalo G. Alvarez MD, MPH, FRCPC
Associate Scientist, Ottawa Hospital Research Institute
Assistant Professor, University of Ottawa
Respirologist, Divisions of Respirology and Infectious Diseases
Department of Medicine, The Ottawa Hospital
Ottawa, ON

Chris P. Archibald, MDCM, MHSc, FRCPC
Senior Medical Advisor
Vice-president's Office, Infectious Disease Programs Branch
Public Health Agency of Canada
Ottawa, ON

Leila Barss, MD, FRCPC
Clinical Assistant Professor of Medicine
Division of Respiratory Medicine
Peter Lougheed Hospital
Calgary, AB

Marcel Behr, MD, MSc, FRCPC
Associate Professor
Division of Infectious Diseases and Medical Microbiology
McGill University Health Centre
Montréal, QC

Sarah K. Brode, MD, FRCPC, MPH
Staff Physician, Department of Medicine, Division of Respirology
West Park Healthcare Centre and University Health Network
Assistant Professor of Medicine, University of Toronto
Toronto, ON

James Brooks, MD, FRCPC
Director, Antimicrobial Resistance Division,
Infectious Disease Programs Branch
Public Health Agency of Canada
Ottawa, ON

Jonathon Campbell PhD
Department of Epidemiology, Biostatistics, and Occupational Health
Faculty of Medicine, McGill University
Montréal, QC

William Connors, MPH, MD, FRCPC
St. Paul's Hospital, Providence Health Care
Vancouver General Hospital: TB Unit, Vancouver Coastal Health
BC Centre for Disease Control, Provincial Health Services Authority
Clinical Assistant Professor, Division of Infectious Diseases
Department of Medicine, University of British Columbia
Vancouver, BC

Victoria J. Cook, MD, FRCPC
Medical Lead, Provincial Tuberculosis Services
British Columbia Centre for Disease Control
Faculty of Medicine, University of British Columbia
Medical Consultant TB Services for Aboriginal Communities
Division of TB Control
British Columbia Centre for Disease Control Society
Vancouver, BC

Ryan Cooper, MD, MPH, FRCPC
Associate Teaching Professor, Division of Infectious Diseases
University of Alberta
Royal Alexandra Hospital 
Edmonton, AB

Peter Daley, MD, MSc, FRCPC, DTM + H
Associate Professor, Disciplines of Medicine and Laboratory Medicine
Faculty of Medicine, Memorial University
St. John's, NL

Katherine Defalco, RN, BSc, CIC
IPC Nurse Consultant
Centre for Communicable Diseases and Infection Control
Public Health Agency of Canada
Ottawa, ON

Maziar Divangahi, PhD
Associate Professor of Medicine
Strauss Chair in Respiratory Diseases
Assoc Director, Meakins-Christie Laboratories
Assoc Director, McGill International TB Centre
Co-Leader, Program for Translational Research in Respiratory Diseases
RI-MUHC, Centre for Translational Biology
Montréal, QC

Tanya Diefenbach-Elstob, MPH, PhD
Postdoctoral Fellow, Centre for Clinical Epidemiology, Lady Davis Institute
Jewish General Hospital
Department of Medicine, McGill University
Montréal, QC

Jonathan L. Dunn, MSc
Assembly of First Nations
Ottawa, ON

Rachel Dwilow, MD, MPH, FRCPC
Assistant Professor of Pediatrics
Section of Pediatric Infectious Diseases and Medical Microbiology
Max Rady College of Medicine, University of Manitoba
Winnipeg, MB

Giovanni Ferrara, MD PhD
Professor and Divisional Director; Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta.
Edmonton, AB

Dina Fisher, MSc, MD, FRCPC
Clinical Associate Professor of Medicine
Division of Respiratory Medicine
University of Calgary
Peter Lougheed Centre
Calgary, AB

George Giovinazzo, MD
Senior Medical Officer, Migration Health Branch
Immigration, Refugees and Citizenship Canada Government of Canada
Ottawa, ON

Simon Grandjean Lapierre, MD, MSc, FRCPC
Professeur Adjoint de Clinique, Département de Microbiologie, Immunologie et Infectiologie
Faculté de Médicine, Université de Montréal
Montréal, QC

Christina Greenaway, MD, FRCPC, MSc
Associate Professor, Department of Medicine, McGill University
Division of Infectious Diseases, SMBD-Jewish General Hospital
McGill International TB Centre
Montréal, QC

Margaret Haworth-Brockman, MSc
Senior Program Manager, National Collaborating Centre for Infectious Diseases
Assistant Professor, Community Health Sciences
Rady Faculty of Health Sciences
University of Manitoba
Winnipeg, MB

Courtney Heffernan, MA PhD
Manager, Tuberculosis Program Evaluation and Research Unit
Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta
Edmonton, AB

Stan Houston, MD, DTM and H, FRCPC
Professor of Medicine (Infectious Disease and General Internal Medicine) and Public Health
University of Alberta
Director, Northern Alberta HIV Program
Edmonton, AB

Jessika Huard, RN, MPH
Direction régionale de santé publique,
Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal
Montréal, QC
Nunavik Regional Board of Health Social Services – Public Health,
Kuujjuaq, QC

Charles Hui, MD, FRCPC
Associate Professor of Pediatrics
Faculty of Medicine, University of Ottawa
Chief of Infectious Diseases, Immunology and Allergy
Children's Hospital of Eastern Ontario
Ottawa, ON

James Johnston, MD, MPH, FRCPC
Clinical Associate Professor
Division of Respiratory Medicine, University of British Columbia
Evaluation Lead, Provincial Tuberculosis Services, British Columbia Centre for Disease Control.
Vancouver, BC

Lynn Johnston, MD, MSc, FRCPC
Professor of Medicine
Dalhousie University and Nova Scotia Health Authority
Halifax, NS

Fatima Kakkar, MD, FRCPC, MPH
Associate Professor of Pediatrics, Université de Montréal
Pediatric Infectious Diseases
Centre Hospitalier Universitaire Sainte-Justine
Montréal, QC

Faiz Ahmad Khan, MDCM, FRCPC, MPH
Respirologist, McGill University Health Centre
Ungava Tulattavik Health Centre, Inuulitsivik Health Centre
Medical Director, Tuberculosis Clinic of the Montreal Chest Institute
McGill University Health Centre
Associate Professor of Medicine, McGill University
Montréal, QC

Ian Kitai, MD, BCh, FRCPC
Professor of Pediatrics, University of Toronto
Tuberculosis Specialist
Division of Infectious Diseases, Hospital for Sick Children
Toronto, ON

Dennis Kunimoto, MD, FRCPC
Professor, Department of Medicine
Vice Dean Faculty Affairs, Faculty of Medicine and Dentistry, University of Alberta
Walter Mackenzie Health Sciences Centre
Edmonton, AB

Marlene Larocque, MPH
Senior Policy Advisor
Assembly of First Nations
Ottawa, ON

Robyn S. Lee, PhD
Epidemiologist, Nunavik Regional Board of Health and Social Services – Public Health
Quebec, QC
Epidemiology Division, Dalla Lana School of Public Health, University of Toronto
Toronto, ON

Richard Long, BSc, MD, FRCPC, FCCP, FCAHS
Professor, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta and Adjunct Professor, School of Public Health, University of Alberta
Edmonton, AB

Dick Menzies, MD, MSc, FRCPC
Professor, Departments of Medicine, Epidemiology and Biostatistics, McGill University
Director, McGill International TB Centre
Montreal Chest Institute
Montréal, QC

Aboubakar Mounchili, DVM, MSc, PhD
Manager, Antimicrobial Resistance Division
Infectious Disease Programs Branch
Public Health Agency of Canada
Ottawa, ON

Howard Njoo, MD, MHSc, FRCPC
Deputy Chief Public Health Officer and
Interim Vice-President
Infectious Disease Programs Branch
Public Health Agency of Canada
Ottawa, ON

Toju Ogunremi BSc, MSc
Senior Research Analyst
Healthcare Associated Infections and Infection Prevention and Control Section
Professional Guidelines and Public Health Practice Division
Centre for Communicable Diseases and Infection Control
Public Health Agency of Canada
Ottawa, ON

Madhukar Pai, MD, PhD
Associate Professor
Departments of Medicine, Epidemiology and Biostatistics
McGill University
Montréal, QC

Christopher Pease, MSc, MD, FRCPC
Assistant Professor, University of Ottawa
Division of Respirology
Department of Medicine, The Ottawa Hospital
Ottawa, ON

Reshel Perera, BSc, MMASc, MPH
Epidemiologist, Antimicrobial Resistance Division
Infectious Disease Prevention and Control Branch
Public Health Agency of Canada
Ottawa ON

Pierre Plourde, MD, FRCPC
Medical Officer of Health; Medical Director, Integrated Tuberculosis Services, Winnipeg Regional Health Authority
Professor, Community Health Sciences
Professor, Medical Microbiology and Infectious Diseases Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba
Winnipeg, MB

Elizabeth Rea, MD, MSc, FRCPC
Associate Medical Officer of Health
Tuberculosis Prevention and Control
Toronto Public Health
Toronto, ON

Noémie Savard, MD, MSc, FRCPC
Responsable médicale, Service Infections et immunisation
Secteur Prévention et contrôle des maladies infectieuses
Direction régionale de santé publique
CIUSSS du Centre-Sud-de-l'Île-de-Montréal
Montréal, QC

Kevin Schwartzman, MD, MPH, FRCPC, FCAHS
Professor, Department of Medicine, McGill University,
McGill International TB Centre
Montreal Chest Institute
Research Institute of the McGill University Health Centre
Montréal, QC

Inna Sekirov,
Clinical Assistant Professor
Department of Pathology & Laboratory Medicine
Faculty of Medicine, UBC
Vancouver, BC

Hafid Soualhine, PhD
Chief, National Reference Centre for Mycobacteriology
National Microbiology Laboratory
Public Health Agency of Canada
Winnipeg, MB

Stephanie W. Smith, MD, MPH, FRCPC
Professor, Division of Infectious Diseases,
Department of Medicine, University of Alberta
Director, Infection Prevention and Control, University of Alberta Hospital
Edmonton, AB

Christine Y. Turenne, MSc, PhD, D, FCCM
Assistant Professor
Department of Medical Microbiology and Infectious Diseases 
Max Rady College of Medicine, University of Manitoba,
Winnipeg, MB

Deborah Van Dyk, RN, MSc
Senior Public Health Policy Advisor,
Inuit Tapiriit Kanatami
Ottawa, ON

Eduardo Vides, MD, MPH
Senior Health Policy Advisor
Métis National Council
Ottawa, ON

Tom Wong, MD, MPH, FRCPC
Chief Medical Officer, Chief Science Officer and Director General
Office of Population and Public Health
First Nations and Inuit Health Branch
Indigenous Services Canada
Ottawa, ON

3. Acknowledgments

The editor and associate editors are grateful to the many persons and groups who contributed to the development and production of this edition of the Canadian Tuberculosis Standards. These include, but are not limited to, the following:

4. External reviewers

We are grateful to the following external reviewers for their valuable input:

William J. Burman, MD
Denver Health
University of Colorado
Denver, Colorado, USA

Nadine Caron, MA, MD, BSC
Professor
Northern Medical Program
University of Northern British Columbia
Prince George, British Columbia, Canada

Rodney Dawson MB ChB (Stell), FCP (SA), Cert. Pulm (SA)
Honorary Professor
Centre for Tuberculosis Research Innovation
University of Cape Town Lung Institute
Mowbray, Cape Town, South Africa

Claudia M. Denkinger
Head of Division of Infectious Disease and Tropical Medicine
Heidelberg University Hospital
Heidelberg, Germany

Yohhei Hamada MD, MPH
Institute for Global Health
University College London
London, United Kingdom

Awal D. Khan, PhD
Sr. Health Scientist/Health Equity Coordinator
Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
U.S. Centers for Disease Control and Prevention
Atlanta, Georgia USA

Kathleen McMullin, B. Ed, M.Ed.
Aboriginal Nursing Advisor
University of Saskatchewan
Saskatoon, Saskatchewan, Canada

Payam Nahid, MD, MPH
Professor of Medicine
Director, UCSF Center for Tuberculosis
University of California, San Francisco
San Francisco, California, USA

Jeffrey R. Starke, M.D.
Professor of Pediatrics
Department of Pediatrics
Division of Infectious Diseases
Baylor College of Medicine
Houston, Texas, USA

Timothy R. Sterling, M.D.
David E. Rogers Professor of Medicine
Division of Infectious Diseases
Vanderbilt University School of Medicine
Nashville, Tennessee, USA

Andrew Vernon, MD, MHS
Associate Director for Science, Epidemiology Task Force
CDC COVID-19 Response and Division of Viral Diseases, NCIRD
U.S. Centers for Disease Control and Prevention
Atlanta, Georgia, USA

5. Methodology

As in the past, each chapter is written by authors from across Canada with expertise in the specific topic. The editorial board, comprised of members with broad expertise in clinical and/or public health aspects of TB, reviewed multiple versions of each chapter to ensure optimal clarity and consistency of information and related recommendations. This edition was also developed in collaboration with AMMI Canada, whose expert representatives served as chapter authors and external reviewers.

The Standards were written in 2021. Between January and March 2021, priority content areas were selected by chapter authors with input from the editorial board. The Standards chapters from the 7th edition were evaluated, updates or new sections were added and obsolete sections eliminated based on a consensus of the editorial board and chapter authors and results of a survey of users of the 7th edition of the Canadian TB Standards conducted in 2018-19. Questions of interest were considered in accordance with the PICO (population, intervention, comparison, outcomes) method, addressing the Patient group(s) that should be included, the Intervention(s) that should be examined, the Comparison groups that should be part of the studies of the various interventions and the Outcome(s) of interest.

As with previous editions, the 8th edition of the Standards is based upon the best available scientific evidence. Each group of chapter authors conducted literature searches between March to July 2021, for their individual chapters. Authors then carefully reviewed all published evidence, emphasizing the most recent studies, particularly recent systematic reviews. Given the scope of the Standards, with over 120 good practice statements and over 125 different recommendations across 15 chapters, the full GRADE process was not followed. Although formal appraisal tools were not used, each author was required to appraise any included studies for quality of evidence and risk of bias, in order to determine the level of evidence (see the following section). For each recommendation, the panel of authors established a consensus on the strength of the recommendation (either strong or conditional) based on an established framework (see the following section), including their rating of the overall quality of the body of evidence. The recommendations were then vetted by the CTS CRGC Chair to optimize the language of each recommendation to ensure implementability.

Key points are presented at the top of each chapter. These were selected for emphasis based on a consensus of each chapter's authors.

5.1. Definitions for statements used in the Standards

Strong recommendation: ("We strongly recommend…")

Meaning: The action/intervention should be performed in most situations and would be the preferred choice for most individuals. The authors have little doubt that the benefits of the intervention exceed the harms (recommendation "for" the intervention) or that the harms exceed the benefits (recommendation "against" the intervention). The authors judged it unlikely that future studies of the intervention would result in a significant change in the direction or magnitude of the estimated effects (risks and benefits).

These recommendations are usually based on "good" evidence as defined in the following section. Other considerations include greater magnitude of effect and/or magnitude of difference between benefits and harms, alignment with patient values and preferences and strong feasibility based on available resources. These are summarized in the following sections.

Conditional recommendation: ("We conditionally recommend…")

Meaning: The action/intervention should be considered, based on the likelihood of benefits and harms in an individual patient. The authors concluded that there is likely a net benefit of the intervention, but there is uncertainty about the magnitude of the benefits and/or about whether benefits outweigh the risks. There is reasonable likelihood that new studies could change estimates of the magnitude of risks and benefits (and hence result in modified recommendations).

These recommendations were usually based on "poor" (or low-quality) evidence. Other considerations included smaller magnitude of differences between benefits and harms, uncertain consistency with individual patient values and preferences and/or uncertain feasibility with respect to resource requirements.

Good practice statement

Meaning: The authors would use the intervention/perform the action in most situations and for most patients. These statements are based on a clear consensus of expert opinion that this action should be beneficial (or harmful, if "against"), but there is minimal or no evidence in support of this. This type of statement is reserved for topics/actions for which there is minimal or no published evidence, and it is considered unlikely that any evidence will be available in the future.

Regulation

A recommendation identified as "regulation" is supported by federal, provincial or territorial legislation from the relevant field of authority (e.g., building codes, occupational health and safety) so no strength of evidence is assigned. Regulations are a form of law which define the application and enforcement of legislation. Regulations are made under the authority of an Act and are enacted by the body to whom the authority to make regulations has been delegated, such as a minister, etc.

5.2. Judgements regarding quality of evidence used in the Standards

Good

Therapeutic interventions
Diagnostic methods
Etiologic research

Poor

Therapeutic

Diagnostic

Etiologic

5.3. Additional considerations that affected author decisions to make strong or conditional recommendations

Additional considerations
Other considerations Effect/impact Effect on recommendation (potentially can increase to strong, or decrease to conditional)
Relative importance of the outcomes "Critical" (e.g., death, cure, failure) Strengthen
"Not critical" (e.g., intolerance, inconvenience) Weaken
Magnitude of the effect and/or difference Large effect or difference Strengthen
Small or no effect or difference Weaken
Balance of benefits and harms Benefits clearly outweigh harms (e.g., substantial benefit, but minimal harms)

Strengthen "For"

(If harms outweigh benefits would strengthen "Against")
Closely balanced benefits and harms (e.g., substantial benefit, but also substantial harms) Weaken
Patient values and preferences Judged very likely that patients would prefer intervention

Strengthen "For"

(Weaken "Against")
Judged very likely that patients would NOT prefer intervention

Strengthen "Against"

(Weaken "For")
Cost – Resource use Low cost, cost saving compared to alternative, cost-effective Strengthen
High cost, higher cost than alternative, not cost-effective Weaken
Implementability Difficult to implement Weaken

6. Review and approval process

Each chapter underwent extensive review; all chapters were reviewed by the Editor, at least one Associate Editor and one other chapter author before a 2-day meeting of all authors held on September 23 and 24, 2021. At this meeting, each chapter was presented by authors, followed by the reviewers' comments, after which all authors provided input. Specific sessions during this meeting were devoted to review of evidence and discussion of recommendations for Directly Observed Treatment (included in Chapter 5: Treatment of TB disease) and review of evidence for effect of treatment on contagiousness and TB transmission with recommendations for discontinuation of respiratory isolation (included in Appendix B: De-isolation review and recommendations). Consensus was reached on recommendations for these two topics during this meeting.

Following the all-authors' meeting, each chapter was revised by chapter authors and then reviewed by the Editor. Subsequent revised versions were sent for external reviews by experts in the topic (selected by the Editor and/or the chapter authors). Selected chapters were reviewed by representatives of AMMI Canada, and all chapters were independently reviewed by members of the CRGC. Each reviewer provided a detailed review and suggestions. Authors responded to these reviews, and all reviews, and subsequent revisions were reviewed by the Editor. Upon acceptance, the CRGC recommended approval of the guideline to the CTS Executive Committee.

7. Future updates

The Standards will be formally reviewed every three years or sooner to determine the need for and nature of any updates, in accordance with the CTS Living Guideline Model. Panel members will also use the continuously updated CTS-McMaster Plus database, whereby they will receive alerts when new articles pertaining to key PICO questions are published (starting from the last date of the literature search conducted for this guideline). This will serve to prompt members to consider timely updates with evolving evidence and will facilitate formal literature reviews.

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 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.

Page details

Date modified: