Public Health Agency of Canada Quarantine Stations

Guidelines regarding departure from Canada of persons with suspected respiratory tuberculosis (TB), untreated active respiratory TB or partially treated active respiratory TB

Version 2006.07.18

PDF version (40 KB)

Table of contents

• Introduction
• Criteria for Departure
• Using the Guidelines
• References
• Public Health Agency of Canada Quarantine Stations

Introduction

Persons with suspected respiratory TB, untreated active respiratory TB or partially treated active respiratory TB may infect other persons with the TB bacteria, Mycobacterium tuberculosis, if respiratory isolation precautions are not followed. Failure to maintain continuity of treatment and clinical care increases the probability that drug-resistant TB will develop, and this may be more difficult and expensive to treat. Lack of care in the receiving country reduces the chance of a lasting cure.

The purpose of these guidelines is to address the issue of persons with suspected respiratory TB, untreated active respiratory TB or partially treated active respiratory TB leaving Canada. This may occur in the following situations:

1. The person is not under any type of federal legal custody and desires to travel outside Canada.
2. The individual is the subject of a deportation order from Canada Border Services Agency.
3. The individual is being transferred from a Correctional Service Canada institution to another country's correctional system.

Policies regarding TB may differ from those related to other diseases because of the transmissibility of TB via the respiratory route and because of the risks of relapse or the development of drug-resistant TB if patients are not provided with a full course of treatment (at least 6 months) with high-quality medication following internationally recognized drug regimens. Every jurisdiction in Canada has a legal mechanism that allows provincial/territorial public health authorities to maintain patients with active, contagious TB in respiratory isolation until they are no longer deemed contagious, usually occurring after 2 to 3 weeks of appropriate drug treatment. Additional provisions of public health acts may require completion of treatment.

Patients who are leaving Canada for areas of the world where TB treatment is accessible, affordable and operating at World Health Organization (WHO) standards 1 may safely leave Canada once they are noncontagious if continuity of care is arranged. However, there are parts of the world where these conditions do not exist, and it is unlikely that patients going to those areas will receive adequate treatment for their disease. In these cases, not only will patients probably continue to be ill from their disease but as well Canada will be contributing to the global burden of TB in countries that can least afford it. Patients who do not take a full course of treatment may relapse into another episode of TB or may become chronic patients who continue to infect those around them. Importantly, the erratic use of anti-TB therapy, which occurs without appropriate supervision of patients by trained practitioners, can promote the emergence of drug-resistant infections. This "manufacturing" of drug resistance can have serious consequences for those with TB disease as well as for society at large. Drug-resistant disease often requires prolonged treatment with more toxic and more expensive medication under the care of highly specialized practitioners. Many countries do not have facilities to offer appropriate treatment for drug-resistant TB, which in turn can lead to further transmission of the drug-resistant organism and can exacerbate the situation in the country even further. It can therefore be considered irresponsible to insist that individuals with active disease leave Canada for areas of the world where accessible, adequate treatment for their disease does not exist. Facilitating the safe and appropriate transfer of TB patients from one TB care provider to another (whether across town or the border) is the most efficient and responsible strategy for ensuring treatment completion.

Criteria for Departure

For these global public health reasons, all persons departing permanently or temporarily from Canada with suspected respiratory TB, untreated active respiratory TB or partially treated active respiratory TB should meet the following criteria:

1. 1. The patient will not require respiratory isolation precautions during travel to the receiving country according to the criteria in the current Canadian Tuberculosis Standards ² AND if the patient has culture-positive respiratory TB, it is susceptible to the antibiotics being taken; or
   2. appropriate respiratory infection control measures 3 will be in place in noncommercial transport during the entire travel period. Consult the provincial/territorial TB program or, for a patient in federal custody, Tuberculosis Prevention and Control at the Public Health Agency of Canada if there is uncertainty as to whether these criteria are being met.

   If this criterion alone cannot be met and the patient wants to travel against medical advice, provincial/territorial public health acts should be used when possible to prevent travel. The Quarantine Station serving the area (Attachment) should be consulted to determine if the federal Quarantine Act may be relevant to the situation. If the patient proposes to use commercial transport, officials at the Quarantine Station or the TB program responsible for the patient's care should advise the transport company to deny boarding for communicable disease reasons, as the duty to protect the public outweighs patient confidentiality.

2. The Canadian TB program responsible for the patient's care is aware of the proposed departure and prepares a letter, for the patient to carry, which summarizes the diagnosis, smear and culture findings, antibiotic sensitivity, radiographic findings, treatment and other relevant clinical details for the patient to carry to an identified TB care provider in the country of destination. A copy may also be mailed/couriered directly or through Tuberculosis Prevention and Control, Public Health Agency, to the TB care provider and to the destination country's TB control program. The patient should be informed as to whom is receiving a copy of the letter. The Canadian TB program also needs an address in the country of destination in order to send any further pertinent information on the patient that may become available after departure from Canada. Country level TB contact information is available at <http://www.cdc.gov/nchstp/tb/pubs/international/international.htm>.

3. If the patient cannot identify an appropriate TB care provider, contact should be made with the destination country's TB control program to identify a specific TB care provider. Such contact can be made directly by the TB program responsible for the patient's care, by the respective provincial/territorial TB program or by Tuberculosis Prevention and Control, Public Health Agency of Canada. Country TB contact information is available at <http://www.cdc.gov/nchstp/tb/pubs/international/international.htm>.

4. The TB program in the receiving country is able to provide accessible continuity of care at either the Canadian or World Health Organization¹ standards, including directly observed treatment if indicated. This includes adequate antibiotic treatment according to the results of M. tuberculosis antibiotic sensitivity testing.

   If this criterion alone cannot be met, the patient should be advised to remain in Canada or to travel to another suitable country until treatment is complete.

5. The patient should be given a supply (usually 1 month) of medication by the Canadian TB care provider to last until the first visit to the TB care provider in the country of destination. The patient should not be given enough medication to complete treatment for the following reasons:

   1. Anti-TB medications can have serious and potentially life-threatening complications if taken inappropriately and/or in the absence of appropriate medical supervision.
   2. The erratic use of such medications can promote the emergence of drug-resistant TB, thereby complicating treatment options and increasing treatment costs. For these reasons, patients should remain under the supervision of a TB care provider during the duration of their treatment course. Facilitating the safe and appropriate transfer of care from one care provider to another is the most efficient and responsible strategy for ensuring that treatment has been completed.

6. For temporary departures of 1 month or less, the patient should be given a supply of medication (daily rather than intermittent dosage) for the duration of the trip, an information letter in case he or she needs to see a TB care provider in the country of destination, and instructions about how to manage the side effects of medication during the absence.

Using the Guidelines

These guidelines have been developed and approved by the Canadian Tuberculosis Committee 4 and are for consideration by Citizenship and Immigration Canada when advising Canada Border Services Agency on fitness to travel, Canada Border Services Agency (for persons under their jurisdiction, including persons to be deported), Correctional Service Canada (for persons under their jurisdiction), other relevant federal departments (for persons under their jurisdiction) and relevant provincial/territorial TB program (for all other persons).

In the event that these criteria cannot be met, please contact the Public Health Agency of Canada (PHAC), Tuberculosis Prevention and Control (613-941-0238; Off hours: 800-545-7661 and ask for the person covering for the PHAC Tuberculosis Prevention and Control Program) as soon as possible before the person leaves Canada.

PHAC will convene a teleconference to determine the best course of action given the circumstances. Participants will include the Quarantine Program of the Centre for Emergency Preparedness and Response, PHAC (613-946-6998), as the federal Quarantine Act may be relevant to the situation; the local Canadian TB program caring for the person; the person's treating physician; any relevant federal department; and any relevant provincial/territorial TB program. Based on the outcome of such teleconferences, these guidelines will be modified as necessary.

Contact:

Dr. Edward Ellis, Tuberculosis Prevention and Control, Public Health Agency of Canada,
tel. (613) 948-2153
Email: Edward.Ellis@phac-aspc.gc.ca.  

References

1. World Health Organization. Treatment of tuberculosis: guidelines for national programmes (3 rd edition), 2003. URL: <http://www.who.int/tb/publications/cds_tb_2003_313/en/index.html>.
2. Health Canada and Canadian Lung Association. Canadian Tuberculosis Standards (5 th edition), 2000. URL: <http://www.phac-aspc.gc.ca/publicat/cts-ncla00/pdf/cts00.pdf>. (NOTE: To be superseded by 6 th edition when published at http://www.phac-aspc.gc.ca/tbpc-latb/index.html).
3. Health Canada. Guidelines for preventing the transmission of tuberculosis in Canadian health care facilities and other institutional settings. CCDR 1996;22(S1):chapter 4. URL: < http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/96vol22/22s1/22s1i_e.html>. (NOTE: To be superseded by Canadian Tuberculosis Standards, 6 th edition when published at http://www.phac-aspc.gc.ca/tbpc-latb/index.html).

Public Heath Agency of Canada Duty Officer 24x7 Line: 1-800-545-7661