Appendix 1: Monitoring tuberculosis program performance

The framework for monitoring tuberculosis program performance outlined in Chapter 15 consists of 12 program performance indicators; a rationale for each is provided below along with international and national history of use or recommendation precedents. As in the text, in 2018, the National Collaborating Center for Infectious Diseases performed a scoping review of TB program performance indicators in epidemiologically similar settings (high-income, low-TB incidence) coupled with general global recommendations. Indicators were selected from this review. As shown in the following data, more recent recommendations and strategies have been reviewed in preparation of this chapter for a history of use. This list of prior use/recommendation is representative, and not exhaustive.

Goal of Elimination
Indicator, Target and Rationale	Notes
1.0 Crude incidence rate of TB: all forms Target: Report incidence, and rate of decline. Rationale: This is the hard target of pre-elimination and elimination. This measurement establishes the ultimate standard by which the program is performing. Incidence should be monitored and reported annually to inform effective mid-course changes on the path to elimination.⁵⁶^, ⁵⁷Canada is responsible for reporting national and subnational data to the global community; therefore, these data should be accessible and reportable.⁵⁸	Program leads should establish a rate of decline that is adequate to achieve elimination targets.
Precedence
Recommended internationally by: WHO- Compendium of Indicators for Monitoring and Evaluation of National Tuberculosis Control Programs;⁵⁶CDC – National Tuberculosis Program Objectives and Performance Targets for 2025;⁵⁹Australia – The Strategic Plan for Control of Tuberculosis in Australia 2011-2015, and National Tuberculosis Performance Indicators, Australia 2013-2014;^5,⁶⁰Public Health England – Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020 (three-year average)⁷Alaska – Alaska Department of Health and Social Services TB Manual¹; Minnesota – Tuberculosis (TB) Prevention and Control Program; ⁶²and California – CID TB Performance Trends for US, California Objectives. ⁶³	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada;¹⁵FNIHB – Health Canada Strategy against Tuberculosis for First Nations on-Reserve and Monitoring and Performance Framework;^13,¹⁴Inuit Tuberculosis Elimination Framework;¹⁶Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada?; ⁶⁴and NCCID – Toward TB Elimination: Shared Priorities for TB Program Performance Measurement in Canada, a Proposal for Discussion. ¹⁷

Objectives for examination of immigrants and refugees
Indicator, Target and Rationale	Notes
2.0 Proportion of individuals referred for immigration medical surveillance who are evaluated by physician Target: ≥90% Rationale: Foreign-born persons contribute the absolute highest number of total cases identified in Canada (now >70% nationally), creating pressure on the pace of decline that can be achieved domestically. ²⁶ ^, ³³ A systematic and meta-review of TB incidence among migrants deemed ‘high-risk’ in pre-migration screening reported an elevated incidence of active disease in this group. The pooled cumulative incidence of TB post-migration in the study population from 22 cohorts was 2,794 per 100,000 persons (95% CI 2179-3409; I² = 99%). The pooled cumulative incidence of TB at the first follow-up visit from ten cohorts was 3,284 per 100,000 persons (95% CI 2173-4395; I² = 99%). The pooled TB incidence from 15 cohorts was 1,249 per 100,000 person-years of follow-up (95% CI 924-1574; I² = 98%). ⁶⁵ There is recent debate about whether the phenotypic expression of disease in newcomers poses a significant public health risk, suggesting that the risk of in-country transmission is limited compared to the risk of transmission by people who develop reactivation pulmonary disease from undetected LTBI on arrival. ²⁸ ^, ⁶⁶ As a result, this indicator alone is insufficient for long-term reduction of TB in foreign-born persons. Although referral of foreign-born persons to public health for medical surveillance is understood to be minimal ⁶⁷ in contributing to elimination, targeted screening for LTBI among immigrants and refugees arriving in Canada has not yet reached its potential.	Despite the limitations, this performance indicator is a measurable aspect of TB prevention and care services and helps generate evidence in support of value (ROI).
Precedence
Recommended internationally by: CDC – National Tuberculosis Program Objectives and Performance Targets for 2025; ⁵⁹ California – CID TB Performance Trends for US, California Objectives ⁶³ ; and Public Health England – Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020. ⁶¹	Recommended for Canada by: Pan-Canadian Public Health Network –Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada?. ⁶⁴ Chapter 15 of the sixth Edition of the Canadian Tuberculosis Standards, Immigration and Tuberculosis Control in Canada records an evaluation of compliance on this indicator done at the national level (average performance reported to be about 50% at the time). ⁶⁸

Objectives for case management and treatment
Indicator, Target and Rationale	Notes
3.0 Proportion of all new, relapse, or re-treatment TB cases whose HIV status is known Target: ≥95% Rationale: A diagnosis of HIV, independent of TB, has individual and public health implications ⁶⁹ and, in the event of co-infection, has implications for treatment. In Alberta, where >90% of TB patients are HIV tested (attributable to an opt-out strategy), nearly 50% of HIV infections are discovered at the time of a TB diagnosis. ⁷⁰ A recent systematic review and meta-analysis of the adoption of indicator condition-guided HIV testing in Western nations showed that there has been scarce reporting of HIV testing of TB patients in Canada (4/28 articles), with variability in achievement ranging from 53.6 to 90.6% known HIV status during TB treatment. This indicates both a greater need for reporting as well as implementation of strategies to improve adherence to recommendations at the program level. ⁷¹	The target is to offer an HIV test to all incident TB cases if HIV status is unknown at the time of diagnosis, 100% of the time; it is understood that the rate of acceptance will be lower.
Precedence
Recommended internationally by: WHO – Compendium of Indicators for Monitoring and Evaluating National Tuberculosis Programs; ⁵⁶ Horsburgh et al. – Practice Guidelines for the Treatment of Tuberculosis; ³⁴ WHO – End TB Strategy ⁴ ; WHO/UNAIDS – Guide to Monitoring and Evaluation for Collaborative TB/HIV activities; ⁷² Australia – The Strategic Plan for Control of Tuberculosis in Australia 2011-2015, and National Tuberculosis Performance Indicators, Australia 2013-2014; ⁵ ^, ⁶⁰ Public Health England – Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020 (three-year average); ⁷ Alaska – Alaska Department of Health and Social Services TB Manual; ⁶¹ and, California – CID TB Performance Trends for US, California Objectives. ⁶³	Recommended for Canada by: Canadian Tuberculosis Directors of Canada and the Department of National Health and Welfare in consultation with P/T epidemiologists – Guidelines for the identification, investigation and treatment of individuals with concomitant tuberculosis and HIV infection; ⁷³ Canadian Tuberculosis Committee, Health Canada – Recommendations for screening and prevention of tuberculosis in patients with HIV and for screening for HIV in patients with tuberculosis and their contacts; ⁷⁴ Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ and Haworth-Brockman & Keynan – Strengthening tuberculosis surveillance in Canada. ⁷⁵
Indicator, Target and Rationale	Notes
3.1 Proportion of all smear-positive, pulmonary cases who start treatment within 72 hours of positive NAAT Target: ≥95% Rationale: Timely treatment initiation provides an individual benefit by limiting increased risk of complications associated with delay as well as a public health benefit, by rapidly reducing infectivity. ⁷⁶ A prospective cohort study in the United States found an increased risk of transmission to close contacts (outcome = TST positivity) of US-born patients who experienced a delay in treatment initiation ≥90 days (40%) vs those who had a shorter delay in treatment initiation (24%) (aOR 2.34; p = 0.03), and increasing to (aOR 3.29; p = 0.01) among close contacts of US-born patients sputum smear-positive for AFB and whose treatment initiation was delayed. ⁷⁷ Accordingly, rapid initiation of anti-TB drugs for pulmonary cases is a priority, and program performance should be leading in these patients.	The indicator and related target here is to initiate treatment rapidly (within 3 days), ≥95% of the time. This choice was based on the proficiency turnaround time expectation for labs to perform, and report results of the test within 24 hours of submission. Two additional days are proposed to allow for the possibility that notification of a positive NAAT may occur at the beginning of a long weekend.

Precedence
Recommended internationally by: CDC – National Tuberculosis Program Objectives and Performance Targets for 2025; ⁵⁹ Alaska – Alaska Department of Health and Social Services TB Manual⁶¹; and California – CID TB Performance Trends for US, California Objectives. ⁶³	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada. ¹⁵
Indicator, Target and Rationale
3.2 Proportion of smear-positive pulmonary cases who start four or more anti-TB drugs Target: ≥95% Rationale: Rapid initiation of anti-TB drugs, especially for smear-positive pulmonary cases, is critical to reduce infectivity and interrupt transmission. ⁷⁶ ^, ⁷⁸ Given this reality, and in light of the delays associated with obtaining drug susceptibility test results, the greater individual and public health benefits derive from initiating empiric treatment among those infectious cases without risk factors for resistance, suspicion of hepatoxicity or gout. Of note, in Canada, drug resistance is a relatively infrequent phenomenon, but there is variability in the regional epidemiology of drug-resistant forms of TB that could contribute to more frequent exceptions to the numerator that some programs can anticipate. ⁷⁹
Precedence
Recommended internationally by: CDC –National Tuberculosis Program Objectives and Performance Targets for 2025;⁵⁹ and Public Health England – Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020. ⁷	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ FNIHB/Health Canada – Strategy against Tuberculosis for First Nations on-Reserve, and related Monitoring and Performance Framework; ^13, ¹⁴ NCCID – Toward TB Elimination: Shared Priorities for TB Program Performance Measurement in Canada, a Proposal for Discussion; ¹⁷ and Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada? ⁶⁴
Indicator, Target and Rationale
3.3 Proportion of all culture-positive pulmonary cases who have sputum submitted for AFB smear/culture, and a CXR at the end of the initial phase of treatment Target: ≥95% Rationale: Sputum culture-conversion at the end of the initial phase is understood to be a good predictor of eventual cure; more significantly, there are implications for treatment. ⁵⁶ Sustained culture positivity, or having unclosed cavitation on CXR at the end of the initial phase of treatment, may be suggestive of treatment failure/relapse and induced drug resistance. ⁸⁰ A recent systematic review and meta-analysis of sputum conversion during effective treatment found 12, and 41% of persons with smear-positive disease, remained solid and liquid culture-positive, respectively, at the end of the initial phase of treatment but sub-group analyses by important covariates known to be independently associated with sputum conversion, such as HIV status, and cavitation, were limited. ⁸¹ Monitoring adherence to best clinical practice provides useful information to the program relating to efforts that ostensibly improve treatment outcomes by reducing risk of relapse.

Precedence
Recommended internationally by: WHO – Compendium of Indicators for Monitoring and Evaluation of National Tuberculosis Control Programs; ⁵⁶ California – CID TB Performance Trends for US, California Objectives; ⁶³ and CDC – National Tuberculosis Program Objectives and Performance Targets for 2025. ⁵⁹	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ and FNIHB/Health Canada – Strategy against Tuberculosis for First Nations on-Reserve, and related Monitoring and Performance Framework. ¹³ ^, ¹⁴
Indicator, Target and Rationale
3.4 Treatment success (cure or completed) within 12 months of starting treatment Target: ≥90% of cases Rationale: Treatment success (cure or completed) is essential to eliminating TB by preventing transmission, disease severity and death. Incomplete treatment or loss to follow-up can lead to drug resistance and transmission to others. A 1991 World Health Assembly resolution established a global target for treatment success to be 85%, but in low-HIV-prevalence settings with universal health coverage, a higher rate of achievement should be possible. ⁸²
Precedence
Recommended internationally by: WHO- Compendium of Indicators for Monitoring and Evaluation of National Tuberculosis Control Programs; ⁵⁶ CDC – National Tuberculosis Program Objectives and Performance Targets for 2025; ⁵⁹ Australia – The Strategic Plan for Control of Tuberculosis in Australia 2011-2015, and National Tuberculosis Performance Indicators, Australia 2013-2014; ^5, ⁶⁰ WHO – End TB Strategy ⁴ ; Alaska – Alaska Department of Health and Social Services TB Manual; ⁶¹ Minnesota – Tuberculosis (TB) Prevention and Control Program ⁶² ; and California – CID TB Performance Trends for US, California Objectives. ⁶³	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ FNIHB/Health Canada – Health Canada Strategy against Tuberculosis for First Nations on-Reserve and Monitoring and Performance Framework; ^13, ¹⁴ ITK – Inuit Tuberculosis Elimination Framework¹⁶ ; and Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada? ⁶⁴
Indicator, Target and Rationale
3.5 Does the TB program have dedicated social worker support? Target: Yes Rationale: This chapter recommends that TB programs have dedicated support of a social worker, and that their associated workflow be evaluated. Some examples of possible measurements of the social worker’s performance include: the proportion of patients who are connected to a primary care provider by the end of TB care; the proportion of patients experiencing homelessness, or are underhoused, who are adequately housed through their efforts; monitoring of patients who report crowded housing. The objective psycho-social needs of clients and patients may vary by jurisdiction, and should be clearly defined by the program manager/lead.
Precedence
Recommended by: A specific program performance indicator about whether TB programs have dedicated social worker support could not be located. Recommendations, however, to meet the psycho-social needs of patients and clients who suffer the effects of TB infection and disease are common, but practical guidance about how to achieve this remains limited. ⁸³ As a result, this indicator is included as a means to generate information about the practical steps programs take to address the impacts of structural, and social determinants of health in the lives of clients/patients served.

Objectives for contact management
Indicator, Target and Rationale	Notes
4 Proportion of close contacts of persons with smear-positive pulmonary disease whose initial contact encounter occurs within 3 working days. Target: ≥95% Rationale: TB programs in Canada generally rely on a stone-in-pond method for unmasking evidence of transmission among contacts of persons with pulmonary TB. ⁸⁴ This method is considered favorable when the relative risk of transmission to contacts is higher than the risk of infection in the general public. ⁸⁴ ^, ⁸⁵ A public health benefit of timely contact investigations is limiting transmission into broader circles of contact. ⁸⁶ The rapid identification and initial encounter of close contacts of infectious source cases provides a mechanism for prioritization. A modification to stone-in-pond is the rapid assessment (prioritization) of vulnerable contacts (young children, and persons with immunocompromising conditions, notably HIV) who have been shown to be at risk of very rapid progression to disease. ⁸⁷ ^, ⁸⁸	Three days is considered timely and reasonable, but also somewhat arbitrary. ⁸⁶ The purpose is to monitor with the ambition to meet and exceed the target, redirecting efforts if underperforming.
Precedence
Recommended internationally by: CDC – Guidelines for the investigation of contacts of patients with infectious tuberculosis: Recommendations from the National Tuberculosis Controllers Association and the CDC. ⁸⁶	Recommended for Canada by: Chapter 12 of the seventh Edition of the Canadian Tuberculosis Standards, Contact follow-up and outbreak management in tuberculosis control. ⁸⁹
Indicator, Target and Rationale
4.1 Proportion of close contacts of persons with smear-positive pulmonary disease who are completely assessed Target: ≥95% Rationale: Prevention of reactivation TB is equally important to appropriate case management, especially of infectious cases, in its contribution to pre-elimination and elimination goals.
Precedence
Recommended internationally by: WHO – End TB Strategy ⁴ ; CDC – National Tuberculosis Program Objectives and Performance Targets for 2025; ⁵⁹ and Public Health England – Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020 (in development). ⁷	Recommended for Canada by: FNIHB/Health Canada – Strategy against Tuberculosis for First Nations on-Reserve, and related Monitoring and Performance Framework; ^12, ¹³ and Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada? ⁶⁴
Indicator, Target and Rationale	Notes
4.2 Proportion of close contacts of persons with smear-positive pulmonary disease eligible for TPT, who initiate treatment Target: ≥90% Rationale: LTBI is the seedbed of future cases but treatment of LTBI, in the absence of a risk of reinfection, is considered to be fully protective against reactivation TB. ^90–95 As a result, pairing the prevention of reactivation with excellent infectious source case management work as hand-in-glove strategies to reduce future incidence of TB. ⁴⁹ ^, ⁹⁰	Targets are ambitious, but performance here and with respect to completion are likely to benefit from the current wealth of research aimed at reducing treatment duration and pill burden while maintaining efficacy and safety, as the expanded use of 4 R compared to the long-standing 9INH has shown. ⁹⁶ ^, ⁹⁷

Precedence
Recommended internationally by: WHO- End TB Strategy; ⁴ CDC – National Tuberculosis Program Objectives and Performance Targets for 2025; ⁵⁹ and Public Health England –Public Health England Tuberculosis Strategy Monitoring Indicators 2015-2020 (in development). ⁷	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ FNIHB/Health Canada – Health Canada Strategy against Tuberculosis for First Nations on-Reserve and related Monitoring and Performance Framework; ¹³ ^, ¹⁴ and Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada? ⁶⁴
Indicator, Target and Rationale	Notes
4.3 Proportion of close contacts of persons with smear-positive pulmonary disease who began, and completed, TPT for a diagnosis of LTBI Target: ≥90% Rationale: As above, successful treatment is protective against reactivation of TB (for the infection it is treating); success is a function of completion and strategies to facilitate completion are encouraged, especially for shorter regimens where each dose is a greater contributor to the effectiveness of the therapy. ^96–99	As in 4.2
Precedence
Recommended internationally by: CDC – National Tuberculosis Program Objectives and Performance Targets for 2025. ⁵⁹	Recommended for Canada by: Pan-Canadian Public Health Network – Guidance for Tuberculosis Prevention and Control Programs in Canada; ¹⁵ FNIHB – Health Canada Strategy against Tuberculosis for First Nations on-Reserve and Monitoring and Performance Framework;¹³ ^, ¹⁴ NCCID – Toward TB Elimination: Shared Priorities for TB Program Performance Measurement in Canada, a Proposal for Discussion; ¹⁷ and Heffernan & Long – Would program performance indicators and a nationally coordinated response accelerate tuberculosis elimination in Canada? ⁶⁴

^{Abbreviations: TB, tuberculosis; NCCID, National Collaborating Center for Infectious Diseases; WHO, World Health Organization; CDC, Centers for Disease Control and Prevention; FNIHB, First Nations and Inuit Health Branch; ROI, return on investment; HIV, human immunodeficiency virus; P/T, provincial and territorial; NAAT, nucleic acid amplification test; CI, confidence interval; aOR, adjusted odds ratio; TST, tuberculin skin test; AFB, acid fast bacillus; CXR, chest radiograph; ITK, Inuit Tapiriit Kanatami; 4R, daily rifampin for 4 months; 9INH, 9-month daily isoniazid regimen; TPT, tuberculosis preventive treatment; LTBI, latent tuberculosis infection}

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TB Manual

Appendix 1: Monitoring tuberculosis program performance