Because of the pandemic, tuberculosis deaths globally have increased for the first time in over a decade. Concerning considering that before COVID, TB was the leading infectious-disease killer in the world.
In Canada we also see disruptions in services, damaging our progress toward TB elimination as part of the United Nations sustainable development goals (SDGs). Overall rates of TB are low in Canada, but the federal government has committed to ending TB by 2030 with a focus on Inuit Nunangat. This goal was reaffirmed on World TB Day 2021 by the national Inuit organization Inuit Tapiriit Kanatami (ITK) and the Canadian government. Relevant milestones in these efforts include ITK’s launch of an Inuit-specific TB elimination strategy and the establishment of a task force in 2017.
The federal government aims to achieve TB elimination by addressing social determinants of health. The subnational governments are responsible for TB clinical, laboratory and preventive services, and public health programs including contact follow-up, epidemiology and outcome monitoring. But cross-national (federal-provincial-territorial) co-ordination, data and surveillance are critical for success.
As research shows, the impact of COVID-19 has included staff diversions to deal with the pandemic and a de-prioritization of essential public-health activities such as contact-tracing and TB preventive treatment. Alarmingly, findings also indicate delays in diagnoses, which have resulted in more severe illness.
The ripple effects may prove further damaging as the disease spreads to family and community members. Recent outbreaks in Nunavut and Saskatchewan show that Canada is not immune to the devastating long-term implications of the pandemic on health care.
A survey by Stop TB Canada provides additional details of the negative effects of the pandemic on TB services. Provinces and territories are struggling with burned-out health-care workers. One TB staff member said: « 75 per cent of our workforce [was] diverted to [the] COVID-19 response team and they continue to remain there.”
Yet, the pandemic has brought health-system improvements and innovations that are opportunities. These include initiatives like telemedicine, new investments in laboratory systems, substantial medical research and development, and broad access to paid sick leave.
The pandemic has shown that investments in public health are essential to the well-being of our society. We need to build on the innovations in response to COVID-19 to “build back better” and refuel our TB response in Canada. The TB workforce and services are the backbone for any future respiratory pandemic.
Stop TB Canada has five specific calls for action to eliminate TB in Canada:
Convene a national TB elimination taskforce: It is not enough for the federal government alone to make commitments on TB. Given the recent outbreaks in Saskatchewan and Nunavut, the provincial governments must increase the response and support to communities in need. Health-care and public-health teams need to be specifically made available to provide services for TB and freed up from other duties.
Health services need to be provided with adequate funding and diagnostic and treatment supplies to deal with the outbreaks. Preventive measures need to be improved. A national parliamentary inquiry by the Health Committee would be a good method to review progress on TB elimination toward the SDGs. It could also note systemic solutions for a more equitable health system. At the same time, discussions in parliament and cabinet related to pandemic preparedness, such as Bill C-293, need to build on TB lessons and infrastructure.
Step up the TB response in First nations and Inuit communities: Canada has committed to a 50 per cent reduction in TB across Inuit Nunangat (the Inuit homeland) by 2025 and to eliminating TB by 2030. Delivering on these promises is an essential component to our nation’s commitment to reconciliation. Action is needed. A concrete example is to ensure that the diagnostic platforms (GeneXpert), for COVID testing, remain there with TB test cartridges. This avoids the diagnostic delay from transporting specimens hundreds of kilometers to southern laboratories.
“TB testing capacity needs to be a priority, especially in high incidence locations. Despite the devastating effects of our current TB outbreak, there is no capacity for utilization of Gene-Xpert for TB testing while people are being tested multiple times for COVID. Opportunities to diagnose Active TB are missed,” says Tina Campbell, a nurse in Saskatchewan and co-chair of Stop TB Canada.
Invest in TB vaccines and product development in Canada: New TB drugs and vaccines are badly needed. Massive research investments led to multiple highly effective COVID vaccines coming to market within a year. Yet, there is only one TB vaccine – the century-old and ineffective Bacille Calmette-Guérin vaccine. The pandemic has highlighted Canada’s dependence on importation of vaccines. Let’s build on our domestic expertise in medical sciences to step up vaccine capacity and TB research specifically, and meet Canada’s “fair share” expenditure on TB research.
Urgently improve TB data and surveillance systems: COVID highlighted the need for strong surveillance, integrated digital health information systems, and rapid information sharing. These are essential for analyzing trends quickly and tailoring interventions for specific areas and populations. Nearly 100 countries now report monthly to quarterly TB case notifications, and developing countries are moving to digital real-time TB surveillance. In contrast, Canada’s most recent national TB data is from four years ago with only a single infographic update for 2020.
Address health inequity: Canada’s chief public health officer Theresa Tam stated: “The COVID-19 pandemic has heightened awareness about the health and social inequities that exist in Canada, and the need to address the social determinants of health that lead to health disparities.” Crowded housing, poverty, inadequate access to health care, stigma and other social inequities are central to ending TB (and many other illnesses).
Canada must implement a comprehensive multi-sectoral TB strategy, including the needs of both Indigenous Peoples and newcomer Canadians originally from high-TB-incidence areas. TB response and systems are a pathfinder for addressing underlying issues of inequity and social determinants.
Canada is only TB free when the world is TB free. Neither COVID nor TB stop at national borders. In light of COVID-19-related disruptions in TB programs globally, Canada needs to invest $1.2 billion, its fair share, in the Global Fund to fight AIDS, TB and malaria. These resources would help to rapidly recover health and TB programs and prevent further increased disease burden and death.
We are starting to think about “living with COVID-19” – but we don’t have to “live with TB.” The pandemic is an inspiration to step up our fight to truly eliminate TB in Canada and around the world. Investing in health systems contributes directly to pandemic preparedness. The health workforce, testing and treatment infrastructure and preventive methods have all proven to be of significant use for the pandemic and also provide the foundation for the future. Canada has an opportunity now to build equitable health systems that serve the most vulnerable populations, eliminate TB and strengthen our preparedness all in one.