Canadian Tuberculosis Tracker
Introduction
This tracker was compiled by Stop TB Canada, to provide transparent tracking of progress towards domestic and global TB elimination targets to which Canada has committed, and hold policy-makers accountable for progress towards these goals. The tracker will be updated as new data become available. A glossary of terms and an overview of data sources are provided in the last two sections.
For questions about the tracker, or suggestions for improvements/additions to the tracker, don’t hesitate to contact us at hello@stoptbcanada.com.
Summary scorecard
The scorecard below summarizes progress on various indicators regarding TB in Canada. For details on each indicator, see the relevant sections below. The progress scores (Good/Needs improvement/Insufficient) are a Stop TB Canada assessment, defined as follows: good=target met, needs improvement=target not yet met, some improvement needed, insufficient=target not met and not on track to be met, major improvements needed. Changes from the previous year’s scorecard (2022) are represented as follows: ↓ score set back compared to previous year, ↑ score advanced compared to previous year, = no change from previous year.
Latest national TB surveillance report snapshot
The Canadian Notifiable Disease Surveillance System (CNDSS) provides TB case numbers up to 2020, and the latest TB surveillance summary report, published in 2022, provides data dating back to 2020 (with TB outcomes dating back to 2019). The latest full report was published in 2020, presenting case data from 2018 and outcome data from 2017. This is entirely inadequate for planning current efforts to end TB and monitoring progress towards TB elimination targets. In addition, Canada lacks a national strategic plan for ending TB.
- Latest TB in Canada Report published in: 2022
- Presents case data from: 2020 (and outcome data from 2019).
- Reports 1,772 TB cases in 2020 and 120 deaths before or during TB treatment in 2019. a
- Note: Across all figures in this report, the large drops in reported TB cases in 2020 are likely due to missed diagnoses due to the COVID-19 pandemic rather than actual declines in the incidence of TB in Canada.
TB cases and incidence
TB in children
TB incidence by Province/Territory
TB incidence in key populations
Drug-Resistant TB
Drug-resistant TB is a form of TB resistant to first-line drugs, making it more difficult to treat, and increasing the likelihood for poorer treatment outcomes. The figure below shows reported drug-resistant TB isolates as a percentage of all TB isolates tested for drug resistance in Canada between 2008 and 2018.
TB drug resistance as defined in the 2018 TB Drug Resistance in Canada Report - Monoresistance: Resistance to one first-line TB drug. MDR-TB: (Multidrug-resistant TB) Resistance to the TB drugs isoniazid and rifampin, with or without resistance to other TB drugs. Polyresistance: Resistance to more than one first-line TB drug, not including isoniazid and rifampin. XDR-TB: (Extensively drug-resistant TB) Resistance to isoniazid, rifampin and any fluoroquinolone in addition to at least one injectable second-line drug.
TB treatment success
The World Health Organization (WHO) recommends TB programs to have a treatment success rate (TSR, defined as the proportion of registered TB cases completing treatment without bacteriological evidence of failure) of at least 90%. Unfortunately, Canada did not meet this target in the most recent year with data available (2019), with the WHO reporting TSRs of 79% for new and relapse TB cases, and 76% for those affected by both HIV and TB in 2019.* 2020 TSRs for Canada are not yet available in the WHO database.
* Source: 2020 WHO TB country profile for Canada, now replaced with the 2021 country profile
World Health Organization (WHO) estimates of the TB burden in Canada
The following data are TB burden estimates for Canada (i.e. represent expected burden rather than actual notified cases), extracted from the World Health Organization’s TB burden estimates database. The most recent estimates available are for 2021. The methods used by the WHO to produce these estimates vary by country and are detailed here.
Canada’s progress towards global and domestic TB elimination goals
Eliminating TB across Inuit Nunangat by 2030
In 2017, the Government of Canada established an Inuit TB Elimination Task Force and committed to eliminating TB across Inuit Nunangat (the Inuit homeland) by 2030 (with an interim goal of a 50% reduction in incidence by 2025, compared to 2017). According to the WHO’s definition of TB elimination, this means reaching a TB incidence of less than 1 TB case per million population by 2030. The latest data available stratifying Inuit / non-Inuit TB cases are from 2020 (TB Surveillance in Canada 2010-2020 Summary Report), and report an incidence of 72.2 TB cases / 100,000 population in 2020, i.e. 722 cases / million. However, this drop in incidence compared to the previous year - 188.7 cases / 100,000 in 2019 - is likely due to a high number of missed diagnoses due to the COVID-19 pandemic. The pre-COVID-19 incidence of 188.7 cases / 100,000 in the Inuit population is over 400 times higher than in non-Indigenous Canadians (0.4 cases / 100,000) and suggests we are far from reaching the 2030 elimination target. In addition, it is impossible to accurately assess current progress towards this target given that the COVID-19 pandemic likely resulted in missed diagnoses of TB and set back TB elimination efforts in Canada. If we have any hope of achieving this goal, we must at the very least measure how far we are currently falling short of it.
The graph below shows TB incidence (cases / million) among Inuit, compared to the Government of Canada’s Inuit TB elimination targets. Note that 2020 incidence is not shown, due to likely significant under-reporting during the COVID-19 pandemic.
TB R&D funding
At the first-ever United Nations High-Level Meeting on TB (UNHLM) in 2018, member states set a global TB R&D funding target (for 2018 to 2022) of 2 billion USD annually, to allow development of the tools and knowledge needed to end TB. In 2021, the world unfortunately still lagged far behind this goal, having committed only half of the 2 billion target (just over 1 billion USD) in 2021 (according to the 2022 Treatment Action Group TB Funding Report. Individual member states committed to contributing their “fair share” to this global target, defined as countries allocating at least 0.1% of their overall research spending to TB research. Unfortunately, Canada has consistently failed to meet its fair share target (which is set at 25.3 million USD), as shown in the following figure. Canada fell short of this target by 33% in 2021, which unfortunately represents a set-back from the prior year (2020), in which we missed our fair-share by 20%.
* The fair share target is defined as at least 0.1 per cent of a country’s overall R&D spending (gross domestic expenditure on research and development, GERD) going to TB research. For Canada, this annual fair share target is 25.3 million USD. Spending on TB research by Canada in 2021 was therefore 8.4 million USD (33%) below this target.
End TB Strategy targets
The WHO’s End TB Strategy, launched in 2015, outlines milestones for reaching TB elimination, including the following:
Milestones - by 2025:
- 75% reduction in TB deaths (compared to 2015)
- 50% reduction in TB incidence rate (compared to 2015)
- No affected families facing catastrophic costs due to tuberculosis
Targets - by 2035:
- 95% reduction in TB deaths (compared to 2015)
- 90% reduction in TB incidence rate (compared to 2015)
- No affected families facing catastrophic costs due to tuberculosis
TB incidence reduction target:
The chart below shows Canada’s progress towards the End TB milestone of reducing TB incidence by 50% by 2025, and the target of reducing it by 90% by 2035 (compared to 2015 levels). Having reported a TB incidence of 46 cases / million in 2015, this corresponds to a 2025 milestone of 23 cases / million, and a 2035 target of 5 cases / million. As evident from the graph, we are not on track to meeting this target, and incidence has in fact increased from 46 cases / million in 2015 to 51 cases / million in 2019, while slightly decreasing to 47 cases / million in 2020.
TB death reduction target:
Regarding Canada’s progress towards the End TB target of reducing TB deaths by 75% (2025 milestone) and 95% (2035 target) compared to 2015, this is difficult to assess due to Canada’s outdated TB outcome data, with the latest outcomes being available for 2019. However, 142 deaths were reported before or during treatment among TB patients in Canada in 2015, at the time of the launch of the End TB Strategy, and 120 deaths were reported in 2019. Canada-wide TB deaths must drop to 36 by 2025 and to 7 by 2035 to meet the End TB milestone and target.
Protection from catastrophic TB-related costs target:
There are no data available on the number of households facing catastrophic costs due to TB.
Low-incidence country-specific End TB goals:
As the overall goal of the strategy is to end the global TB epidemic by 2035, which is defined as having a global incidence of fewer than 100 TB cases per million population, the strategy needs adaptation to countries who already have a TB incidence lower than 100 cases / million. In its Action Framework for Low-Incidence Countries, the WHO therefore sets goals for low-incidence countries, such as Canada, to reach the following pre-elimination and elimination targets by the specified dates:
Canada’s progress towards pre-elimination and elimination targets:
- Pre-elimination Target: <10 TB cases / million population - by 2035
- Elimination Target: <1 TB case / million population - by 2050
- Canada’s current incidence (2020): 47 TB cases / million
The graph below shows Canada’s progress towards these pre-elimination and elimination targets.
Canada’s progress in WHO’s priority areas for TB elimination in low-incidence countries:
The framework also outlined 8 priority areas for low-incidence countries. We provide brief comments on how Canada is doing in each area, along with a progress score (Good/Needs improvement/Insufficient). Note that this progress score is a Stop TB Canada assessment, defined as follows: good=target met, needs improvement=target not yet met, some improvement needed, insufficient=target not met and not on track to be met, major improvements needed.
Score card for Canada’s progress in 8 priority areas identified in the WHO’s End TB Framework for low-incidence countries:
| Priority area | Progress score | Situation | Score change from previous year |
|---|---|---|---|
| Ensure political commitment, funding and stewardship for planning and essential services of high quality. | Insufficient | The government of Canada has voiced political commitment to TB elimination through signing on to global and domestic targets, however, more needs to be done to back these commitments with action and financial support. It is particularly concerning to see that Canadian funding for TB R&D has dropped since the previous year. | ↓ |
| Address the most vulnerable and hard-to-reach groups. | Insufficient | The persistence of TB in Canada is suggestive of a continuing failure to address health inequities in the country, particularly with respect to Inuit, First Nations and newcomer communities. For example, although the government has committed to eliminating TB across Inuit Nunangat by 2030, the failure to conduct timely and detailed national TB surveillance makes it impossible to plan ongoing TB prevention efforts or track progress towards this elimination target. In addition, addressing the needs of another key group, children with TB, is hindered by the ongoing lack of availability of child-friendly TB drug formulations in Canada, increasing the risk of poor TB outcomes in children. | = |
| Address special needs of migrants and cross-border issues. | Insufficient | Ongoing barriers to access to healthcare for newcomers, which represent the majority of the TB burden in Canada. | = |
| Undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment. | Insufficient | Active case-finding and LTBI management have been significantly scaled back in Canadian TB programs during the ongoing COVID-19 pandemic.* In addition, Rifapentine a drug part of a newer, shorter regimen for the management of LTBI still lacks approval for use in Canada. | = |
| Optimize the prevention and care of drug-resistant TB. | Needs improvement | Although Canada met its country-specific UNHLM targets for DR-TB detection (see UNHLM section below) in 2018 and 2019, it fell short of the 2020 target, likely due to missed diagnoses during the COVID-19 pandemic. In addition, it is difficult to assess the status of this priority area, given that recent TB outcome data stratified by drug resistance status are not available. Regulatory barriers and the high prices of DR-TB drugs also continue to hinder DR-TB care. | = |
| Ensure continued surveillance, programme monitoring and evaluation and case-based data management. | Insufficient | The quality of TB surveillance in Canada in recent years has been poor, with national TB reports becoming increasingly less detailed as well as being released with significant delays - this hinders planning of the current TB response and conducting program monitoring and evaluation. | = |
| Invest in research and new tools. | Insufficient | Canada has consistently failed to meet its fair share funding target for TB R&D. (See funding section above). It failed to meet this target again in 2021, falling even further short of it than in 2020. | = |
| Support global TB prevention, care and control. | Needs improvement | As a founding partner of the Global Financing Facility, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and TB REACH (which funds programs to improve TB case detection among the world’s most–affected communities), Canada has a strong track record of supporting global TB elimination efforts. However, especially in light of COVID-19-related disruptions to TB programs globally, Canada should urgently step up its contributions, including by reaching its agreed-upon fair-share funding target for TB research. | = |
* See Stop TB Canada’s report on the impact of COVID-19 on TB programs in Canada
Source: World Health Organization. Towards TB Elimination: An Action Framework for Low-Incidence Countries, 2014
UNHLM commitments:
The 2018 United Nations High-Level Meeting on TB, for the first time ever, brought together world leaders to discuss progress toward TB elimination. This resulted in commitments by member states, including Canada, to contribute to achieving specific global TB elimination targets. Apart from the TB funding goal mentioned in the funding section above, these targets included to successfully diagnose and treat 40 million people with TB globally by 2022 (including 3.5 million children) and 1.5 million people with drug-resistant TB (including 115 000 children with drug-resistant TB).
To make these global goals relevant to countries with varying epidemiological contexts, the global Stop TB Partnership has provided country-level breakdowns of these targets based on WHO TB burden estimates in each country. Again, our ability to track progress towards these targets for Canada is severely limited by the unavailability of up-to-date Canadian TB data, but the following tables provide a summary of the Canada-specific targets for TB, DR-TB and TB in children, vs. case notifications. It should be noted, however, that notification does not guarantee successful treatment initiation.
Score card for Canada’s progress towards the country-specific UNHLM TB diagnosis and treatment targets
| Year | WHO active TB burden estimate for Canada (95%CI) | Canada-specific UNHLM target, number of people diagnosed and treated for TB | Reported active TB cases | Percent (%) of target notified |
|---|---|---|---|---|
| 2018 | 2100 (1800-2400) | 1800 | 1797 | 99.8 |
| 2019 | 2200 (1900-2500) | 1900 | 1912 | 100 |
| 2020 | 2000 (1700-2300) | 1800 | 1772 | 98.4 |
| 2021 | 2000 (1700-2400) | 1700 | Data unavailable * | Unknown |
| 2022 | Data unavailable | 1500 | Data unavailable * | Unknown |
* TB case data not available beyond 2020.
Sources: TB case data: Canadian Notifiable Disease Surveillance System., TB burden estimates: World Health Organization, Canada-specific UNHLM targets: Stop TB Partnership. UNHLM on TB - Key Targets and Commitments
Score card for Canada’s progress towards the country-specific UNHLM DR-TB diagnosis and treatment targets
| Year | Canada-specific UNHLM target, number of people diagnosed and treated for DR-TB | Reported MDR-TB cases | Percent (%) of target notified |
|---|---|---|---|
| 2018 | 16 | 22 | 100 |
| 2019 | 16 | 20 | 100 |
| 2020 | 19 | 14 | 73.7 |
| 2021 | 24 | Data unavailable * | Unknown |
| 2022 | 22 | Data unavailable * | Unknown |
* Data by drug-resistance status not available.
Sources: MDR-TB case data: Canadian TB surveillance summary report, (2010-2020), Canada-specific UNHLM targets: Stop TB Partnership. UNHLM on TB - Key Targets and Commitments
Score card for Canada’s progress towards the country-specific UNHLM childhood TB diagnosis and treatment targets
| Year | Canada-specific UNHLM target, number of children* diagnosed and treated for TB | Reported active TB in children* | Percent (%) of target notified |
|---|---|---|---|
| 2018 | 100 | 100 | 100 |
| 2019 | 100 | 114 | 100 |
| 2020 | 100 | 67 | 67 |
| 2021 | 100 | Data unavailable ** | Unknown |
| 2022 | 100 | Data unavailable ** | Unknown |
* Defined as TB in those under 15 years of age.
** TB case data not available beyond 2020.
Sources: TB case data: Canadian TB surveillance summary report, (2010-2020), Canada-specific UNHLM targets: Stop TB Partnership. UNHLM on TB - Key Targets and Commitments
TB vaccine development
Vaccine development snapshot, 2021
- Number of TB vaccine candidates (vaccines in clinical trials): 16
- Number of TB vaccines in Phase 1 trials: 4
- Number of TB vaccines in Phase 2 trials: 8
- Number of TB vaccines in Phase 3 trials: 4
- Number of approved TB vaccines: 1
- Global investment in TB vaccine development (2021): 120.5 million USD
- Canadian investment in TB vaccine development (2021): 224,912 USD
Sources: TB vaccine development: Global Tuberculosis Report, 2022, TB vaccine funding: 2022 Treatment Action Group TB R&D Funding Report
There is currently only one TB vaccine approved for use. It was developed in 1921, and it is ineffective at preventing the most common form of TB (pulmonary TB) in adults. This highlights the urgent need for a new TB vaccine, but adequate investment in TB vaccine development is lacking. In contrast, COVID-19 vaccine funding and development has been extensive and rapid, with multiple highly effective vaccines rolled out within just the first year of the pandemic. The need for increased commitment to TB vaccine development has been further outlined by Stop TB Canada here, including a comparison to investments in COVID-19 vaccines.
Glossary of terms
- Active TB: Active TB disease is when an individual has symptoms of TB and can transmit TB to others. Symptoms of TB can include fever, night sweats, chills, persistent coughing, weight loss, loss of appetite, and fatigue.
- Latent TB Infection (LTBI): Latent TB infection is when an individual is infected with TB bacteria but has no symptoms of the disease and cannot spread TB to others. LTBI can progress to active TB disease, but only about 5-10 % of people with LTBI will develop active TB in their lifetime, with the highest likelihood of progression being within the first 2 years of exposure.
- TB incidence: The number of new TB cases per number of people in the population.
- Treatment success rate (TSR): The proportion of registered TB cases successfully completing treatment without bacteriological evidence of treatment failure.
- Monoresistant TB: Resistance to one first-line TB drug.
- Multidrug resistant TB (MDR-TB): Resistance to the TB drugs isoniazid and rifampin, with or without resistance to other TB drugs.
- Polyresistant TB: Resistance to more than one first-line TB drug, not including isoniazid and rifampin.
- Extensively drug-resistant TB (XDR-TB): Resistance to isoniazid, rifampin and any fluoroquinolone in addition to at least one injectable second-line drug.
Contributors
- Lena Faust, Stop TB Canada & McGill International TB Centre
- Miranda Zary, Stop TB Canada & McGill International TB Centre
Data sources
- Canadian Notifiable Disease Surveillance System (CNDSS): Provinces and territories report annual data on notifiable diseases (diseases which have been identified as priorities for monitoring), including TB, to the federal government via the CNDSS. CNDSS data are accessible via the Notifiable Diseases Online platform, which reports data from 1924 onwards.
- TB in Canada Reports: The Public Health Agency of Canada compiles national TB reports, using data reported from provinces and territories. Although these reports were initially annual, their frequency and detail has decreased in recent years, with the latest summary report published in 2022, presenting 2020 data. The most recent full report (presenting more detailed data) was published in 2020 and presents 2018 data.
- World Health Organization (WHO) TB database: This database comprises TB data from all countries and territories asked to report TB data to the WHO.
- WHO Global TB Reports: These annual reports, published every year since 1997, compile global and country-level data from the WHO TB database (see above).
- Treatment Action Group (TAG) TB R&D Funding Reports: TAG releases annual reports tracking global TB R&D funding contributions from governments, organizations and other donors.
- Data for country-level UNHLM target estimates: Country-level breakdowns for the UNHLM targets are provided by the Stop TB Partnership, and are based on TB burden estimates in each country, sourced from the WHO TB database.