1.1

Each province and territory in Canada should adopt an overall goal of tuberculosis elimination (less than 1 case per 100,000) through an interim goal of a 5% reduction in the number of cases each year, with a focus on high risk groups (e.g. Aboriginal peoples, foreign-born individuals); this reduction goal should be reviewed every 5 years

1.2

The provinces and territories jointly should declare a national commitment to tuberculosis elimination with national coordination and assured funding, executed by a coordinating committee of federal and provincial/territorial representatives.

1.3

The principles guiding the national commitment must include the following features:

i) permanent: (a permanent infrastructure should be in place nationally);

ii) nation wide;

iii) adapted to the needs of the region (and in partnership with communities);

iv) integrated into the health care system.

1.4

A nationally agreed upon manual of case definitions and treatment regimens should be developed and approved.

1.5

With attention paid to issues of security and confidentiality, all cases must be reported regionally to the appropriate public health authorities with adequate demographic information to identify risk category, bacteriologic diagnosis and sensitivity pattern. All such information should subsequently be collected and analyzed at the national level.

1.6

From the point of view of program management, directly observed therapy should be the standard treatment, with the recognition that the ultimate goal of treatment in a program is either cure or completed treatment of all cases and that this goal may be secured by other means.

1.7

Adequately trained personnel must be in place to deliver tuberculosis control programs.

1.8

Quality control in laboratory, public health and clinical settings must be ensured through adequate supervision, including work evaluation and outcomes assessment.

1.9

Each province and territory must be responsible for ensuring that its tuberculosis control program achieves agreed upon national standards.

1.10

Case finding should be enhanced by ensuring that the clinical and control aspects of tuberculosis are part of the core curriculum in the training of health professionals (e.g. physicians, nurses, paramedics), as well as being included in continuing medical/ nursing education programs.

1.11

Screening of high-risk groups for case finding and prophylaxis must be carried out in every jurisdiction. (See the Aboriginal peoples, Immigration and HIV sections for further recommendations on screening of high-risk groups.)

a) In drop-in shelters for the homeless, it is recommended that TB case finding be undertaken for clients.

b) In long-term care institutions for the elderly, it is recommended that baseline tuberculin skin testing (2-step) be carried out on admission and that awareness of tuberculosis be maintained for early diagnosis, treatment and contact follow-up.

c) In correctional facilities, it is recommended that staff, volunteers and inmates be screened on arrival and annually (if longer than a 1-month stay) thereafter. Information on tuberculosis status should be transferred as an essential part of the inmate's health record.

d) In those with other immunocompromising medical conditions, it is recommended that clinical assessment for tuberculosis and prophylaxis be offered as appropriate.

e) In alcohol or drug rehabilitation programs, it is recommended that screening be carried out on clients upon admission.

f) In health care and residential settings it is recommended that screening of staff be carried out as outlined in the Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and other Institutional Settings.

g) Routine screening of children in low-risk populations should be discouraged.

1.12

Canada should establish a goal of finding all active tuberculosis cases and completing treatment in 100%.

1.13

All cases of active tuberculosis, particularly pulmonary ones, must be reported to the appropriate public health officials within 24 hours of diagnosis.

1.14

Every case of active tuberculosis must:

a) have an assigned case manager, either a physician or public health nurse, who will be responsible for monitoring compliance with treatment and checking for drug toxicity on at least a monthly basis;

b) have treatment with an appropriate anti- tuberculosis regimen started within 24 hours of diagnosis;

c) complete treatment.

1.15

All hospitalized pulmonary cases should be managed according to the Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and other Institutional Settings; those treated at home should return to work only when they are no longer infectious.

1.16

Any facility undertaking case isolation must have an effective institutional program to prevent nosocomial transmission of tuberculosis.

1.17

Consultation with a medical tuberculosis expert must be sought in any situation in which drug resistant tuberculosis is identified.

1.18

All anti-tuberculosis drugs must be provided free of charge to the patient.

1.19

All cases should be evaluated at the conclusion of treatment and be reported in terms of the following outcomes:

cure (a case who completed treatment and had a negative sputum smear at the end of treatment);

treatment completed (a case who completed treatment and did not have a sputum examination at the end of treatment);

died (a case who died during treatment, regardless of cause);

failure (a smear positive case who remained or became positive again 5 months or later after starting treatment);

defaulted (a case who, at any time after registration, had not collected drugs for 2 months or more); or

transferred out (a case who has been transferred to another reporting unit and his/her treatment results are not known).

1.20

All contact tracing should begin within 7 days of the index case report.

1.21

All contacts of smear positive cases should be assessed by tuberculin skin testing and if found to be positive (positive result: > 5 mm) should undergo chest radiography and sputum culture within 30 days of the index case report.

1.22

All contacts of active cases should be offered prophylaxis with isoniazid in accordance with the Canadian Tuberculosis Standards.

1.23

Groups of individuals at increased risk for the development of active tuberculosis following infection should be considered for chemo-prophylaxis in accordance with the Canadian Tuberculosis Standards.

1.24

Isoniazid prophylaxis should be continued for 6 to 12 months with monthly monitoring for drug toxicity in accordance with the Canadian Tuberculosis Standards.

1.25

Chemoprophylaxis program outcomes should be evaluated.

1.26

LCDC, in collaboration with the provinces and territories, should take the lead to ensure a comprehensive, national surveillance system for tuberculosis.

1.27

Canada should acknowledge the need to address the global tuberculosis epidemic in order to have an impact on the significant proportion of Canadian cases that occur in the foreign born. Accordingly, Canada should invest resources and expertise to provide assistance to tuberculosis control programs in countries where the disease has a high prevalence.