In 2018, the National Collaborating Center for Infectious Diseases conducted a scoping review, compiling reports and TB program performance indicators from 25 distinct programs in other low-incidence countries and regions as well as for 3 TB-affected population groups in Canada: First Nations, Inuit and foreign-born populations. Analysis of these documents led to a list of 105 program performance indicators with potential applicability to Canada. That same year, those indicators were discussed at a national meeting and ranked using a modified Delphi technique.23,24 The meeting concluded with expert consensus achieved on 8 core indicators of TB program performance relevant to the aforementioned priority populations.17,24
These eight core indicators were reviewed by all of the authors of this chapter with additions made during facilitated discussion to produce a more generalizable tool. The end result is a framework of twelve indicators (see Table 1) that can be used to evaluate TB services across Canada.
Table 1. Indicators and related targets.
|1.0||Total annual incidence (crude) rate of tuberculosis (TB), all forms||The total number of people notified with TB in the jurisdiction, expressed as a rate per 100,000 population||Pre-elimination target set at an active case rate of 1/100,000 or, as above, 10/1,000,000 population by 2035|
|Objectives for examination of immigrants and refugees|
|2.0||Of people whose immigration medical examination (IME) indicated follow-up, the proportion (%) of individuals who are evaluated by a TB clinician||The total number of appointments attended among persons whose IME led to a referral to public health for medical surveillance of TB||≥90%|
|Objectives for case management and treatment|
|3.0||Of all people with new, relapse, or retreatment TB, proportion (%) with known human immunodeficiency virus (HIV) status||The number of people with annual incident TB whose HIV status is known at the start date of treatment||>95%|
|3.1||Of all people with smear-positive, pulmonary TB, proportion (%) started treatment within 72 hours of positive nucleic acid amplification test (NAAT)||The number of people with annual incident, smear-positive pulmonary TB cases who are started on anti-TB drugs within 72 hours of a positive NAAT result||≥95%|
|3.2||Of all people with smear-positive, pulmonary TB, proportion (%) started on 4 or more anti-TB drugs to which they are likely to be susceptiblea||The number of people with annual incident smear-positive, rifampin-susceptible (by NAAT), pulmonary TB who start 4 anti-TB drugs in the absence of any risk factors for resistance, or hepatoxicity||≥95%|
|3.3||Of all people with culture positive, pulmonary TB, proportion (%) with sputum submitted for acid fast bacillus (AFB) smear/culture, and a chest radiograph (CXR) at the end of the initial phase of treatment||The number of people with annual incident culture-positive, pulmonary TB who have sputum submitted for AFB smear and culture, and have a CXR performed within 2 weeks of the end of the initial phase of treatment||≥95%|
|3.4||Of all patients who started treatment for active disease in the preceding 12 months, the proportion (%) who achieved treatment success (cure or completed)b||The proportion of patients notified in the preceding 12 months who were cured or completed treatment||≥90%|
|3.5||Does the TB program have dedicated social worker support to provide patient-centered care?||TB disease is considered a biologic expression of social inequity, thereby requiring solutions that consider social and structural factors*
*See text below for more details.
|Objectives for contact management|
|4.0||Of all close contacts of people with smear-positive, pulmonary TB, proportion (%) whose initial contact encounter is within 3 working days of having been listed as a contact||The number of close contacts of people with smear-positive, pulmonary TB, whose initial contact encounter occurred within 3 working days of having been named as a contact||≥95%|
|4.1||Of all close contacts of people with smear-positive, pulmonary TB, proportion (%) completely assessed||The number of close contacts (household and non-household) of people with smear-positive, pulmonary cases, whose assessments are completed||≥95%|
|4.2||Of all close contacts of people with smear-positive, pulmonary TB with a diagnosis of latent TB infection (LTBI), proportion (%) who began treatment||The number of close contacts of people with smear-positive, pulmonary TB with a diagnosis of LTBI who initiate preventive therapy within 12 months of source diagnosis||≥90%|
|4.3||Of all close contacts of people with smear-positive, pulmonary TB with a diagnosis of LTBI, proportion (%) completed treatment||The number of close contacts of people with smear-positive, pulmonary TB who complete treatment with TB preventive therapy after initiating||≥90%|
a Exclusions listed in definition, and supplement.
b Outcomes are available/known only for cases who were diagnosed/initiated treatment in the year prior to reporting of all other indicators.
The resulting framework comprises program performance indicators (actions) that are largely pragmatic and judged to adhere to the following criteria: relevant, well-defined, reliable, technically feasible, practical and have a history of use elsewhere.25 It is, however, not without limitation. For example, TB programs in provinces and territories that have a high proportion of foreign-born persons may ultimately perform well across most or all program performance indicators, but see limited reduction of incidence.26,27 This is because replenishment of the reservoir of TB infections may continually occur among those from high-TB-incidence nations.28–31 (see Chapter 13: Tuberculosis Surveillance and Tuberculosis Testing and Treatment in Migrants). Implementing this framework will require dedicated human resources with requisite qualifications to properly compile and report these data. This investment is justified, as program performance monitoring produces valuable information for programmatic improvement, strengthens program management activities, improves accountability and generates evidence of the value of TB services.11,18,32
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