Tuberculosis rising after COVID-19 pandemic redirected services, say Canadian health officials

Canada's longstanding efforts to reduce and eliminate tuberculosis suffered a setback as a result of the COVID-19 pandemic, according to Canadian health officials.

The ability to offer crucial services such as contact tracing, prevention, early diagnosis, treatment and care for tuberculosis were reduced as resources were redirected to fight the COVID-19 pandemic, said Dr. Tom Wong, chief medical officer of public health for Indigenous Services Canada.

"All of those have contributed to, in some areas, stalling of the progress made or in some cases reversing the downward trend of TB," Wong said.

Tuberculosis is a treatable and curable disease caused by bacteria that frequently affects the lungs, but can also live in other parts of the body. In Canada, it kills about five per cent of those infected. In 2020, 10 percent of active TB cases were resistant to TB drugs.

Across the country, several areas have seen recent increases in cases, especially in Inuit and First Nations communities, losing ground after years of progress.

TB on decline before COVID-19

Saskatchewan, for instance, has seen its annual number of TB cases rise from 67 in 2019, to 144 in 2022.Of those cases, 44 per cent were among children in northern First Nations communities.

"In our region we have the highest rates in our province," said Tina Campbell, a registered nurse and tuberculosis advisor with the Northern Inter-Tribal Health Authority in Prince Albert, Sask.

The health authority is responsible for 33 First Nations communities where there are currently three declared tuberculosis outbreaks.

In 2020, Campbell said, there were 16 TB cases across all of the communities. In 2022, that number rose to 72.

"Before COVID, TB programs in Canada and globally were starting to see a decline because of the efforts of health care practitioners responding to outbreaks and to cases everywhere," said Campbell.

But limitations from the pandemic including lockdowns and staffing issues hampered those efforts. In northern Saskatchewan it meant most cases were diagnosed only when people presented to health centres or hospitals, resulting in lower case counts, Campbell said.

Now that more intensive contact investigations have picked up again, case counts are rising.

"The numbers did increase. We did identify more active TB because we were physically in the community doing the investigation," Campbell said.

Campbell said those investigations are a major undertaking that take a lot of coordination between the health authority and the communities.

The health authority deploys nurses and an X-ray technician from Prince Albert. After screening, those diagnosed have to self-isolate, begin treatment and are monitored by health workers five times a week, to start.

Manitoba, Nunavut have highest rates in Canada

In Manitoba, after years of declines, there was a 10 to 12 per cent increase in the number of TB deaths in 2022, according to Dr. Pierre Plourde, medical director for integrated tuberculosis services with the Winnipeg Regional Health Authority.

While that trend is reversing in 2023, Plourde said the gains the province had made, with 10 to 15 per cent annual decreases in deaths before the pandemic, were lost.

"We had a huge rebound," he said.

Earlier in the pandemic, Plourde said most TB services shut down as staff were re-deployed to deal with COVID-19.

"People stayed home with their TB and presented only when they were desperately ill," he said.

Nunavut, with the highest TB rates in Canada, has also seen an increase in cases, with current outbreaks in Pond Inlet and Pangnirtung.

"We are recording more cases than we did over the pandemic," said Dr. Sean Wachtel, Nunavut's chief public health officer. There are several possible reasons for that, he said, but no sure answers.

"It may be that people did not seek healthcare because of the pandemic lockdowns, so we didn't diagnose them. It may be that people are mixing more," he said.

The deputy mayor of Pond Inlet, Joshua Idlout, said territorial health officials have visited thatcommunity to inform people about the outbreak.

"I think more should be done, but what they are doing now is coming to communities now when they have these outbreaks, which we have hardly seen in the past," said Idlout.

"I hope that we can keep fighting to eradicate this TB in our community."

Disproportionate impact on Indigenous people

Tuberculosis has long had a disproportionate impact on Indigenous people and immigrants and refugees to Canada.

Cases remain particularly elevated in Inuit populations, which have rates 300 times higher than those of Canadian-born non-Indigenous people.

"This is unacceptably high," said Wong. "Even though there has been an improvement over the past ten years, there are social determinants of health issues."

Those include a lack of adequate housing and access to healthy, affordable food elements that make TB "a social disease with a medical manifestation," said Dr. Wong.

In Manitoba, Plourde sees those same social issues affecting First Nations communities.

"I have heard so many times that so many northern communities are 300 housing units short of where they need to be to eliminate the crowded housing conditions," Plourde said.

"With the crowded housing you spread TB like wildfires."

Dark history of tuberculosis impacts treatment today

Campbell, in northern Saskatchewan, also points to a lack of adequate housing as a factor contributing to rising rates of TB in the communities she works with.

"If you have one person with active TB in a two-bedroom house with 20 people and all the windows are boarded up, it would become very likely that a lot of those people would become infected with TB," she said.

On top of that, the painful history of tuberculosis for Indigenous people continues to affect trust in healthcare today.

In the past, many Indigenous people diagnosed with tuberculosis were forced from their communities and families and taken to tuberculosis hospitals where they remained for months or years at a time. Some survivors allege physical and psychological abuse.

Campbell, who is Cree, said her grandmother and aunt were sent to the TB sanatorium in Fort Qu'Appelle, Sask.

"Understanding the history and why people still have these negative views of healthcare systems and tuberculosis care has an impact on how people will receive care," she said.

Efforts to get back on track

In 2018, the Canadian government, along with thenational advocacy group Inuit Tapiriit Kanatami, committed to cut tuberculosis rates among Inuit in half by 2025, and eliminate it by 2030.

Wong is confident with a redoubling of efforts, those goals are still within reach. Compared to 2017, Wong points out, there has been a 30 per cent decrease in Inuit TB.

Campbell, along with the group Stop TB Canada, which she co-chairs, is asking federal health minister Jean-Yves Duclos to develop a Canada-wide TB elimination plan.

"To enforce that tuberculosis is something we all need to be focused on and aware of," she said.

In a statement, a spokesperson for Health Canada said the government"recognizes the importance of developing a set of common indicators and a framework for TB elimination," but said it would take a commitment acrossjurisdictions, with provinces and territories as well.