Canadian TBStandards 7thedition PPT ENG

Canadian Tuberculosis
Standards
7th edition
Highlights
and
Major
Changes
Slide 1
Copyright
2013 Canadian Thoracic Society, Canadian Lung Association,
Public Health Agency of Canada and its licensors
These slides may be reproduced for personal or internal use only without permission
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and the Public Health Agency of Canada.
A copy of the slide deck may be requested for educational purposes by sending an
e-mail request to: guidelines@lung.ca or ccdic-clmti@phac-aspc.gc.ca.
Citation:
Menzies, R. & Wong, T. (eds). 2013. Canadian Tuberculosis Standards, 7th Edition.
Canadian Thoracic Society, Canadian Lung Association, Public Health Agency of
Canada.
Slide 2
Canadian Tuberculosis Standards,

7th Edition
Updates to 6 previous editions in the past 40 years, based on the best available evidence
Jointly funded, edited and produced by:
Canadian Thoracic Society /Canadian Lung Association
Public Health Agency of Canada
In collaboration with the Association of Medical Microbiology
and Infectious Disease Canada (AMMI Canada)
Does not supersede Provincial/Territorial legislative, regulatory, policy and practice
requirements or professional guidelines in accordance with local context
Does not replace consultations between clinicians and public health professionals
Can be used in conjunction with the high level framework document, Pan-Canadian
Public Health Networks Guidance for Tuberculosis Prevention & Control Programs in
Canada
The use of trade names and commercial sources is for identification purposes only and
does not imply endorsement by the Public Health Agency of Canada, the Canadian Lung
Association or the Canadian Thoracic Society
Slide 3
CHAPTER 1
EPIDEMIOLOGY
Jessica Halverson, MPH, MSW

Edward Ellis, MD MPH, FRCPC
Victor Gallant, MA
Chris Archibald, MDCM, MHSc, FRCPC
Slide 4
Highlights
In Canada, the overall reported incidence
of active TB cases has continued to decline.
However, disparities are significant in certain
sub-populations and geographic areas.
Aboriginal peoples and foreign born
populations disproportionately affected.
In 2010, HIV status was only reported in 40%
of active TB cases.
Rate per 100,000 population
0
20
40
60
80
100
120
1924
1926
1928
1930
1932
1934
1936
1938
1940
1942
1944
1946
1948
1950
1952
1954
1956
1958
1960
1962
Year
1964
1966
Rates in Canada, 1924-2010
1968
1970
1972
1974
1976
1978
Cases
1980
Deaths
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Slide 5
2006
Reported Tuberculosis Incidence and Mortality
2008
2010
Slide 6
Reported TB Cases and Incidence Rates

in Canada, 1990-2010
2500 8
Cases 7
2000
Rate per 100, 000 population

Rate 6
5
Number of cases
1500
1000
3
2
500
1
0 0
Year
Slide 7
Reported TB Incidence Rate by Sex

and Age Group in Canada, 2010
16
14
12
Male
10 Female
0
<1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75+
Age group
Slide 8
Percentage of Reported TB Cases by

Population Group in Canada, 1970-2010
100
Canadian-born non-Aboriginal
90
Canadian-born Aboriginal
80
Percentage of cases
Foreign-born
70
60
50
40
30
20
10
Year
Slide 9
Reported TB Incidence Rate by Population

Group in Canada, 2000-2010*
35
Incidence rate per 100,000 population
30
25
20
15
Canadian-born Aboriginal
10
Canadian-born non-Aboriginal
5 Foreign-born
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Reporting year
* Population denominators obtained from Statistics Canada
Slide 10
Reported TB Incidence Rates by

Province/Territory, Canada, 2010
120
100
80
60
40
20
0
N.L P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. North
Province/territory
N.B. North includes Northwest Territories, Nunavut and Yukon
Population denominators obtained from Statistics Canada
Slide 11
Number of reported TB cases by population

group and province/territory in Canada, 2010*
700
600
500
400
Cases
300
200
100
0
N.L. P.E.I N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. North
Foreign-born 2 1 5 5 135 557 43 7 109 175 1
Canadian-born non-Aboriginal 2 0 5 5 50 52 13 5 10 39 2
Canadian-born Aboriginal 4 0 0 0 15 8 76 70 15 27 115
Province/territory
*Population denominators obtained from Statistics Canada
Slide 12
Reported TB Disease Incidence Rates in

Canada by Population Group, 2001-2010
250
First Nations - On reserve
First Nations - Off reserve
Inuit
200
Metis
Foreign-born
Canadian Born Non-Aboriginal
150
100
50
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Slide 13
Distribution of Active TB Cases and Incidence

Rates for Aboriginal Populations by
province/territory, 2010
120 350
300
100

250
Number of cases
80
200
60
150
40
100
20
50
0 0
N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alb. B.C. Y.T. N.W.T. Nvt.
Aboriginal cases 4 0 0 0 15 8 76 70 15 27 6 10 99
Aboriginal rates 16.7 0.0 0.0 0.0 13.5 3.3 39.8 41.1 7.4 13.4 68.8 39.9 333.0
Province/Territory
Slide 14
TB Cases and Incidence Rates Among

Canadian-born Aboriginal Populations by Age
Group, 2010
70 80

60 70
60
50
Number of Cases
50
40
40
30
30
20
20
10 10
0 0
<5 05-14 15-24 25-34 35-44 45-54 55-64 65-74 75+
Cases 24 23 64 57 62 35 30 21 14
Rates 18.8 9.8 27.2 31 37.3 23.3 30.5 48.3 68.9
Age Group
Slide 15
Reported Foreign-born TB Cases in Canada, 2000-2010:

Time from Arrival in Canada to Diagnosis, in Years
1200
1000
Number of Cases
800
600
400
200
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54
Years from arrival in Canada to diagnosis, 2000-2010
Slide 16
Percentage of reported cases by diagnostic

site and origin in Canada, 2010
100
90
80 Aboriginal
Percentage of all cases
70
Canadian-born non-
60 Aboriginal
50 Foreign-born
40 Canada
30
20
10
0
Primary Pulmonary Other Miliary CNS Peripheral Other
respiratory lymph node
Diagnostic site
Slide 17
Percentage of Pulmonary Cases by Sputum

Smear Microscopy Result, Canada, 2000-2010
100%
90%
80%
Percentage of cases
70%
60%
50%
40%
30%
20%
10%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Smear Positive 406 421 378 371 379 492 463 525 558 496 433
Smear Unknown 374 385 336 285 275 130 232 95 83 143 135
Smear Negative 305 339 324 318 294 350 384 403 480 469 448
Reporting year
Slide 18
Percentage of Reported TB Cases by HIV

Status, Canada, 1997-2010
100%
90%
80%
Percentage of cases
70%
60%
50%
40%
30%
20%
10%
0%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Unknown 94.4 91.7 87.1 84.2 83.5 82.1 78.9 76.4 74.0 73.4 67.8 59.4 60.8 59.5
Negative 4 6.8 11.5 13.6 14.1 13.9 18.3 20.9 22.4 22.9 28.2 34.9 35.3 38.4
Positive 1.6 1.5 1.4 2.1 2.5 4.0 2.8 2.7 3.6 3.7 4.0 5.7 3.9 2.0
Reporting year
Slide 19
Percentage of Reported Foreign-born TB Cases in

Canada by WHO TB Epidemiologic Region, 1970-2010
60
AFR
50
AMR
CEUR-
40 EEUR
EME
EMR
Percentage
30
SEAR
WPR
20
10
0
1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Year
N.B. WHO Regions: EME = Established Market Economies, WPR = Western Pacific, SEAR = South- East Asia, CEUR.EEUR = Central
Europe. Eastern Europe, AMR = American Region - Latin American Countries, EMR = Eastern Mediterranean, AFR = Africa
Slide 20
CHAPTER 2
PATHOGENESIS AND TRANSMISSION OF
TUBERCULOSIS
Richard Long, MD, FRCPC, FCCP

Kevin Schwartzman, MD, MPH
Slide 21
Highlights
The probability of transmission increases with the
following:
- Bacterial burden (smear positivity), cavitary and
upper lung zone disease, and laryngeal disease;
- Amount and severity of cough in the source case;
- Duration of exposure;
- Proximity to the source case;
- Crowding and poorer room ventilation;
- Delays in diagnosis and/or effective treatment.
Slide 22
Highlights
After infection with M. tuberculosis, early primary
TB disease develops in 5% of people unless they
first receive treatment for latent infection.
Rapid progression to primary active TB is most
frequent in infants and young children, and in
people with compromised immune systems.
Slide 23
CHAPTER 3
DIAGNOSIS OF ACTIVE TUBERCULOSIS
AND DRUG RESISTANCE
Madhukar Pai, MD, PhD

Jessica Minion, MD, MSc, FRCPC
Frances Jamieson, MD, FRCPC
Joyce Wolfe, ART
Marcel Behr, MD, MSc, FRCPC
Slide 24
New Information
New sputum collection approach
3 sputum specimens should be collected in TB
suspects
Same-day sample collection within as little as
one hour between specimens
o may reduce patient drop-out rate
o may accelerate decision-making on TB
infection control and discharge from
respiratory isolation
o provides better overall yield than with
multiple-day collection
Slide 25
New Information
A new Nucleic Acid Amplification Technique (NAAT)
Xpert MTB/RIF test (Cepheid Inc, Sunnyvale, CA)
o a cartridge-based, automated, nested, real-time
polymerase chain reaction test
o results in 2 hours
Detects M. tuberculosis for diagnosis
Detects rifampin (RMP) resistance
Recommended by WHO in 2010, and approved
by Health Canada in 2012
Slide 26
Schematic of the MTB/RMP Test. GeneXpert

(Boehme et al, NEJM, 2010; 363: 1005-13)
Slide 27
Accuracy of Xpert MTB/RIF

Cochrane review
15 studies, 7517 participants
Performance characteristics:
Sensitivity 88% (83-92)
o 98% (97-99) for smear-positive
o 68% (59-75) for smear-negative
Specificity 98% (97-99)
Rifampin (RMP) resistance detection (11 studies,
2340 participants): sensitivity 94% (87-97) and
specificity 98% (97-99)
Steingart et al. Cochrane Library 2013
Slide 28
Potential impact beyond accuracy

Reduced time to diagnosis, reduced time to treatment
Boehme Lancet 2011

Slide 29
Recommendations on Samples
Major New Recommendations

At least three sputum specimens should be
collected
and tested with microscopy as well as culture.
(Conditional recommendation, based on moderate evidence)
Where feasible, three sputum specimens (either

spontaneous or induced) can be collected on the
same day, at least 1 hour apart.
Slide 30
Recommendations on NAAT
At least one respiratory sample should be tested with a Health
Canada approved or validated in-house NAAT in all new, smear-
positive cases. In addition, NAA testing may be performed in smear-
negative patients upon request by the physician or the TB control
program. NAAT results are not recommended for monitoring TB
treatment response.
In settings where there is currently no on-site capacity for routine
smear microscopy and culture (for example, hospitals in the North
serving Aboriginal populations), an automated, cartridge-based NAA
test can be used to make rapid decisions on TB treatment and
isolation pending routine smear and culture results. All Xpert
MTB/RIF results should be confirmed by routine smears and
cultures.
Slide 31
Important caveats about use of Xpert TB/RIF

and NAAT in Canada
With the exception of the North, TB incidence is very low and MDR prevalence
is very low
Most patients have minimal, smear-negative TB
(e.g. abnormal immigration x-rays)
Many patients are asymptomatic and require sputum induction
In this setting, Xpert TB/RIF:
May not be as sensitive as suggested by the meta-analysis
(ongoing study in Montreal)
o Sensitivity 46% (95% CI 26-67)
o Specificity 100% (CI 99-100)
PPV of RMP resistance will be low
All NAAT results should be confirmed by routine smears and cultures. In
particular, all positive rifampin resistance results should be interpreted
cautiously, given the very low prevalence of MDR-TB and the likely low PPV
of rifampin resistance results
Slide 32
CHAPTER 4
DIAGNOSIS OF LATENT TUBERCULOSIS
INFECTION

Dennis Kunimoto, MD, FRCPC
Dick Menzies, MD MSc
Slide 33
New Information
Evidence base on IGRAs has expanded greatly

Predictive value of IGRAs,
Reproducibility and serial (repeat) testing
The recommendations in the 7th Edition of the

Canadian TB Standards serve as the updated
guideline on the use of both IGRAs and TST in
Canada.
Slide 34
New Recommendations
Both the TST and IGRA are acceptable alternatives

for LTBI diagnosis. Either test can be used for LTBI
screening in any of the situations in which testing is
indicated, with preferences and exceptions noted
below.
Slide 35
Recommendation 1
Situations in which neither TST nor IGRAs
should be used for testing:
Neither TST nor IGRA should be used for testing people who
have a low risk of infection and a low risk that there will be
progression to active TB disease if they are infected.
Neither TST nor IGRA should be used for active TB diagnosis
in adults (for children, Recommendation 4, second bullet).
Neither TST nor IGRA should be used for routine or mass
screening for LTBI of all immigrants (adults and children).
Neither TST nor IGRA should be used for monitoring anti-TB
treatment response.
(Strong recommendation, based on strong evidence)
Slide 36
Recommendation 2
Situations in which IGRAs are preferred for testing

but a TST is acceptable:
People who have received BCG as a vaccine after
infancy (1 year of age) and/or have received BCG
vaccination more than once.
People from groups that historically have poor rates
of return for TST reading.
Slide 37
Recommendation 3
Situations in which TST is recommended for

testing but an IGRA is NOT acceptable:
The TST is recommended whenever it is planned
to repeat the test later to assess risk of new
infection (i.e. conversions), such as repeat testing
in a contact investigation or serial testing of health
care or other populations (e.g. corrections staff or
prison inmates) with potential for ongoing
exposure.
Slide 38
Recommendation 4
Situations in which both tests can be used
(sequentially, in any order) to enhance sensitivity:
When the risks of infection, of progression to disease and of a poor
outcome are high.
In children (under age 18 years) with suspected TB disease, IGRAs may
be used as a supplementary diagnostic aid in combination with the TST
and other investigations to help support a diagnosis of TB. However,
IGRA should not be a substitute for, or obviate the need for, appropriate
specimen collection. A negative IGRA (or TST) does not rule out active TB
at any age and especially not in young children.
In addition, repeating an IGRA or performing a TST might be useful when
the initial IGRA result is indeterminate, borderline or invalid, and
a reason for testing persists.
Slide 39
LTBI test results should be interpreted along with

other clinical and risk factor data
(composite risk prediction model is available)
http://www.tstin3d.com Age
Composite risk Recent

prediction model that infection
incorporates
IGRA/TST results and HIV
risk factors
BCG, etc.
Slide 40
CHAPTER 5
TREATMENT OF TUBERCULOSIS DISEASE
Dick Menzies, MD, MSc

Kevin Elwood, MD
Slide 41
Major Changes in Recommendations

Schedule of Therapy
Initial Intensive Phase Daily
- Thrice weekly allowed after 2 weeks if low
bacillary burden (moderate evidence)
- Twice weekly NOT recommended
(there is only weak supporting evidence for this
schedule)
Continuation Phase Daily or Thrice Weekly

- Twice weekly allowed if excellent compliance
with DOT
Slide 42

Duration:
6 months standard if drug sensitive
Prolonged to 9 months if risk factors for relapse:
o Cavitation on CXR at 2 months, or at 5-6 months
o Smear and/or culture positive at 2 months
Fixed Dose Combinations Not Recommended

Based on systematic review of 15 RCTs
No difference in:
Treatment adherence or completion
Treatment failure, disease relapse or acquired drug
resistance
Patient satisfaction
Slide 43
CHAPTER 6
TREATMENT OF LATENT
TUBERCULOSIS INFECTION

Gonzalo G. Alvarez, MD, MPH
Kamran Khan, MD, MPH
Slide 44

9 months INH remains standard
3-4 months INH & RMP daily acceptable
Strong evidence (5 RCTs with a systematic review)
Equivalent to 6 months INH in most RCTs
6 months daily INH acceptable (but less efficacy)
3-4 months INH & RMP twice weekly
alternative (1 RCT)
4 months RMP alone - alternative
(3 months RMP = 6 months INH in one RCT, better
safety)
2 months RMP-PZA NOT recommended
Slide 45
3 Months Once Weekly Isoniazid (INH) &

Rifapentine (RPT) Incidence of Active TB
Sterling et al, NEJM, 2011; 365: 2155-66
9INH 3HP
Randomized 3649 3895
Completed 2536 (69%) 3190 (82%)
TB Disease - All patients 12 (0.4%) 7 (0.2%)
- Completed 5 (0.2%) 4 (0.1%)

Slide 46
3 Months Once Weekly INH & RPT

Adverse Events
Sterling et al, NEJM, 2011; 365: 2155-66
9INH 3HP
Randomized 3649 3895
Total- Grade 3-4 AE 7.4% 6.0%
Drugs stopped for AE 3.6% 5.0%
Hepatotoxicity 2.8% 0.5%
Hypersensitivity 0.8% 4.0%

Slide 47
Contacts of Drug Resistant Cases
Contacts of patients with:

INH resistance (but not Rifampin)
4 month course of daily Rifampin (4RMP)
RMP resistance (but not INH)

9 month course of daily INH (9INH)
MDR patients (INH & RMP but not fluoroquinolone)

9 month course daily of Lfx (levofloxacin) or Mfx
(moxifloxacin)
Slide 48
CHAPTER 7
NONRESPIRATORY TUBERCULOSIS
Dina Fisher, MSc, MD, FRCPC

Kevin Elwood, MD
Slide 49
New Information
Sensitivity and specificity of diagnostic tests for different forms of EP-TB
Slide 50
No major changes in treatment for most forms

6 months for uncomplicated osteoarticular
tuberculosis (shorter)
Adjunctive steroids for:

TB Meningitis strong evidence
TB Pericarditis moderate evidence
Overwhelming TB (disseminated) no evidence
Slide 51
CHAPTER 8
DRUG-RESISTANT TUBERCULOSIS
Richard Long, MD, FRCPC

Monica Avendano, MD, FRCPC
Dennis Kunimoto, MD, FRCPC
Slide 52
New Information
Globally, drug-resistant TB is increasing.
The major risk factors for drug-resistant TB in Canada
are previous treatment and foreign birth.
All initial isolates of M. tuberculosis should be tested
for susceptibility to isoniazid (INH), rifampin (RMP),
pyrazinamide (PZA) and ethambutol (EMB).
All isolates with resistance to INH and/or RMP
(with or without resistance to other first-line drugs)
should undergo drug susceptibility testing (DST)
for second-line drugs.
Intolerance to INH and/or RMP should also lead
to second-line DST.
Slide 53
New Information
In Canada, pediatric TB is largely a disease of Canadian-born
Aboriginal and foreign-born children
Children under the age of 5 are at high risk of progression
to severe forms of TB disease after infection
Every attempt should be made to collect specimens
for culture before therapy, although yield is low
Induced sputum is a promising technique for diagnosis
of TB disease in young children
TB often is diagnosed on the basis of a positive TST or IGRA,
abnormal chest x-ray, history of contact with a case of
infectious TB, and compatible clinical signs or symptoms
A negative TST or IGRA does not exclude active TB
Slide 54

The fluoroquinolones (FQNs)
Levofloxacin and moxifloxacin are considered
interchangeable with INH in the treatment of
INH-resistant TB.
(Strong recommendation, based on intermediate evidence)
Treatment of multidrug-resistant (MDR)-TB should be
individualized, based upon DST.
Treatment of MDR-TB should include a minimum of four
drugs to which the initial isolate is susceptible; if at all
possible one of these drugs should be an FQN and one an
injectable agent (for example, amikacin or capreomycin).
(Conditional recommendation, based on weak evidence)
Slide 55
Delanamid (OPC-67683) for MDR TB

(Gler,NEJM,2012:366:2151-56)
Phase 2 trial:
Standard MDR TB regimen plus
Placebo
Delamanid 100 mg BID
Delamanid 200 mg BID
2 months culture conversion
160 patients Placebo (standard MDR): 30%
161 patients Delamanid 100 mg BID: 45%
160 patents Delamanid 200 mg BID: 42%
Slide 56
TMC 207 (Bedaquiline) for MDR TB

(Diacon, NEJM, 2009: 360: 2397-2405)
Phase 2 trial:
23 patients on standard MDR + TMC for 8 weeks
24 patients on standard MDR + Placebo for 8 weeks
Time to culture conversion much faster
Hazard ratio 11.8 (2.3,61)
2 month culture conversion much higher
48% versus 9%
Slide 57
Bedaquiline (TMC207) Long Term Outcomes

(Diacon, A.A.C, 2012:56;2371-75)
47 patients - treated MDR + TMC or MDR +

Placebo
8 weeks therapy
Time to culture conversion FASTER (Hazard 2.3)
Acquired drug resistance LESS (5% vs. 22%)
Completed therapy about SAME (44% vs. 54%)
Higher mortality in Bedaquiline group
Unclear reasons, but raises concerns
Slide 58
CHAPTER 9
PEDIATRIC TUBERCULOSIS
Ian Kitai, MD, BCh, FRCPC

Anne-Marie Demers, MD, FRCPC
Slide 59
Key Messages
In Canada, pediatric TB is largely a disease of Canadian-born
Aboriginal and foreign-born children
Children under the age of 5 are at high risk of progression
to severe forms of TB disease after infection
Every attempt should be made to collect specimens
for culture before therapy, although yield is low
Induced sputum is a promising technique for diagnosis
of TB disease in young children
TB often is diagnosed on the basis of a positive TST or IGRA,
abnormal chest x-ray, history of contact with a case of
infectious TB, and compatible clinical signs or symptoms
A negative TST or IGRA does not exclude active TB
Slide 60

For treatment of TB disease, daily therapy is preferred over
intermittent regimens.
Twice weekly regimens should no longer be used because each
missed dose represents a larger fraction of the total number of
recommended treatment doses.
Ethambutol (EMB) is now routinely used as part of initial empiric
therapy of TB disease (pending sensitivities) in infants and children,
unless contraindicated or if the source case if known to be fully
susceptible.
Pyrazinamide (PZA) doses are higher than in the previous edition
of the standards.
Patients for whom therapy of latent TB infection (LTBI) is
recommended should be informed of the risk of side effects.
9INH remains the principal recommended regimen for LTBI.
Slide 61
CHAPTER 10
TUBERCULOSIS AND HUMAN
IMMUNODEFICIENCY VIRUS
Stan Houston, MD, DTM&H, FRCPC

Tom Wong, MD, MPH, FRCPC
Slide 62
Latent Tuberculosis Infection (LTBI):

Current evidence does not support use of
RPT-based regimens for treatment of LTBI
in patients with HIV (especially if receiving
antiretroviral therapy [ART])
Presence of LTBI may be a consideration in a
decision for earlier initiation of ART
Slide 63

TB Treatment and ART:
A TB diagnosis constitutes an indication for ART.
Based on the results of 3 RCTs:
if the CD4 count is <50 x 106/L, ART should be
initiated within 2 weeks of starting anti-TB treatment
if the CD4 count is >50, ART should be started within
8 weeks.
Clinical deterioration due to immune reconstitution is
not uncommon in patients with very low initial CD4
cell counts; corticosteroids are helpful in more
severe cases.
Slide 64

Anti TB and ART 2:
TB patients not receiving ART for any reason,
should extend TB treatment to 8 months.
There is currently limited experience to guide:
Use of 2nd line TB drugs with ART;
Use of newer ART agents (integrase inhibitors,
maraviroc) with anti-TB drugs.
There is increased recognition of the value of
therapeutic drug monitoring when anti-TB treatment
is given with ART
Slide 65
Re-Emphasized Previous Recommendations

Routine HIV testing of all TB patients, unless in an
individual known to be HIV-seropositive.
When caring for patients with HIV infection, one should
maintain a high index of suspicion for TB.
Routine initial screening for LTBI in HIV patients unless
there is a history of active TB or LTBI.
A TST should be repeated annually in patients at markedly
increased risk of ongoing TB exposure (e.g. homeless
shelter exposure or return travel to high TB endemic
countries).
HIV-infected patients with LTBI are a high priority for
treatment of LTBI.
Slide 66
CHAPTER 11
NONTUBERCULOUS MYCOBACTERIA
Marcel A. Behr, MD, MSc, FRCPC

Julie Jarand, MD, FRCPC
Theodore K. Marras, MD, MSc, FRCPC
Slide 67
Recommendations
Nontuberculous Mycobacteria (NTM)
Transmission of NTM between people is extremely rare.
NTM disease is not reportable, public health case
management is not required, and treatment is not mandatory.
There are many NTM species. Some are associated with
disease with a spectrum of clinical findings. Other species
are rarely associated with disease.
Isolation of NTM organisms from sputum does not necessarily
indicate disease.
Pulmonary NTM disease is diagnosed if there are:
suggestive clinical symptoms;
suggestive radiographic findings;
isolation of NTM from multiple specimens.
Slide 68
Recommendations
Nontuberculous Mycobacteria (NTM) - Continued
Ratio of benefit to harm with treatment - worse than TB.
Careful assessment of the individual risks and benefits is
recommended prior to initiating treatment.
Limited drug susceptibility testing:
MAC = macrolide testing only;
M. kansasii = rifampin testing;
Rapidly growing mycobacteria and other NTM = no data
correlating DST results with clinical outcomes.
Therapy is species specific. Multiple drugs and prolonged.
Outcomes in lung disease relatively poor, frequent relapse.
Outcomes in nonpulmonary disease - relatively good.
Slide 69
CHAPTER 12
CONTACT FOLLOW-UP AND OUTBREAK
MANAGEMENT IN TUBERCULOSIS
CONTROL
Elizabeth Rea, MD, MSc, FRCPC

Paul Rivest, MD, MSc
Slide 70
Highlights
Prioritization of contact follow-up by
Infectiousness of source
Extent of exposure and immunological
vulnerability of the exposed
(change from classic concentric circle model)
Use of social network approaches/analysis can be

helpful, especially for marginalized groups, including
site-based follow-up rather than only named contacts
Slide 71
Highlights
Contact investigation in a long term care facility
(LTC):
The search for secondary active TB cases is
most important
TST is not recommended as a primary contact
assessment tool for LTBI in residents/visitors over
65 years because of the following factors:
o Immunosuppression
o Boosting potential related to repeat TB exposure or
BCG
o For many elderly, risk of LTBI treatment outweighs
benefit
Slide 72
Highlights
Generally, no evidence supports contact tracing
related to public ground transportation unless in
circumstances involving a highly infectious case
and specific environmental exposures (e.g. long
route/ crowded school bus in winter).
Slide 73
CHAPTER 13
TUBERCULOSIS SURVEILLANCE AND
SCREENING IN SELECTED HIGH-RISK
POPULATIONS
Chris Greenaway, MD, MSc

Kamran Khan, MD, MPH
Kevin Schwartzman, MD, MPH
Slide 74
Highlights
Consideration of individuals for targeted LTBI screening
and treatment can be based on:
risk of prior TB exposure;
risk of reactivation;
risk of side effects from LTBI treatment.
In vulnerable populations (e.g. homeless individuals),
assess hepatotoxicity risk (e.g., hepatic dysfunction,
hepatitis, alcohol dependency). Directly observed
preventive therapy, incentives and enablers may be
helpful.
Challenges and barriers to the uptake of LTBI screening
and treatment in select migrant populations.
Slide 75
CHAPTER 14
TUBERCULOSIS PREVENTION
AND CARE IN FIRST NATIONS,
INUIT AND MTIS PEOPLE
Gonzalo G. Alvarez, MD, MPH, FRCPC
Pamela Orr, MD, MSc, FRCPC
Wendy Wobeser, MD, MSc, FRCPC
Victoria Cook, MD, FRCPC
Slide 76
Highlights
Social determinants of health
Health Canada 2012 TB Strategy
for First Nations on Reserve
Support treatment adherence through patient
centred care and culturally sensitive programming
Slide 77
CHAPTER 15
PREVENTION AND CONTROL OF
TUBERCULOSIS TRANSMISSION
IN HEALTH CARE AND OTHER SETTINGS
Toju Ogunremi, BSc, MSc

John Embil, MD
Slide 78
New Information
The risk of health care associated transmission
of M. tuberculosis varies with the type of setting,
health care workers (HCWs) occupational group,
patient care activity, patient/resident/client population
and the effectiveness of TB infection prevention and
control measures.
The most important contributors to health care
associated transmission of M. tuberculosis are
patients with unrecognized, respiratory TB disease.
Most important - rapid diagnosis, isolation and start
of effective therapy for these patients.
Slide 79

All health care facilities should have a TB management
or infection prevention and control program.
Airborne precautions should be initiated immediately for
any person with suspected or confirmed respiratory TB
disease.
Criteria to discontinue these precautions include an
alternative diagnosis, clinical improvement and
adherence to effective therapy, sputum smear and/or
culture conversion, and fully sensitive organisms or low
clinical suspicion of drug resistance.
Certified respirators (N95 or higher filter class) should be
used by HCWs.
Slide 80

There is insufficient evidence showing that a fit testing
program results in reduced risk of health care associated
transmission of M. tuberculosis. Nevertheless, HCWs are
referred to jurisdictional requirements regarding the
processes and frequency of fit testing. In the absence of
requirements, consult provincial/territorial public health
authorities.
Baseline tuberculin skin testing (TST) is recommended for
all HCWs with potential future exposure. Recommendations
for repeated TST vary with the setting.
Interferon-gamma release assays (IGRAs) are not
recommended for serial testing.
Slide 81
CHAPTER 16
BACILLE CALMETTE-GURIN (BCG)
VACCINATION IN CANADA
Marcel A. Behr, MD, MSc, FRCPC

Kevin Elwood, MD
Slide 82
Recommendations
With declining rates of TB in many settings, and

concern about the risk-benefit ratio associated with
a live, attenuated vaccine, fewer populations are
recommended to receive BCG in Canada.
BCG is currently recommended in Canada for
infants in high-incidence settings and also may be
administered to persons going for an extended stay
in a high TB incidence country where BCG is
routinely given.
Slide 83
Major Change in Recommendations
BCG is not recommended for adults, such as

health care workers, prior to travel to high
incidence settings.
Slide 84
Appendix A Glossary of Terms
Appendix B Surveillance Systems
Appendix C Education & Training Resources

Slide 85
APPENDIX D
TUBERCULOSIS AND MYCOBACTERIOLOGY
LABORATORY STANDARDS:
SERVICES AND POLICIES
Sara Christianson, MSc

Meenu Kaushal Sharma, PhD
Joyce Wolfe, ART
Slide 86
New Information
Recent publication of the new Canadian Biosafety

Standards and Guidelines, and the MTBC Biosafety
Directive for laboratories handling M. tuberculosis isolates
(http://canadianbiosafetystandards.collaborations.gc.ca/cbsg-nldcb/index-eng.php)
Table of ideal specimen types and submission conditions for

mycobacterial investigation
Molecular targets for first-line drug resistance detection
Key technical information for interferon-gamma release

assays (QFT-GIT, T-SPOT)
Slide 87
Highlights
Expected competency and service benchmarks for
laboratories providing mycobacteriology services
Direct detection of MTBC from specimens by
molecular methods
Susceptibility testing for antituberculous drugs
recommended drug panels for first and second-line
drugs
Interferon-gamma release assays assay
performance, quality assurance and results
interpretation
Slide 88
Contributors
Editor:
Associate Editors:
Edward Ellis, MD, MPH, FRCPC
Thomas Wong, MD MPH, FRCPC
Slide 89
Chapter Authors
Gonzalo G. Alvarez, MD, MPH, FRCPC Ian Kitai, MD, BCh, FRCPC
Chris P. Archibald, MDCM, MHSc, FRCPC Dennis Kunimoto, MD, FRCPC
Monica Avendano, MD, FRCPC Richard Long, MD, FRCPC, FCCP
Marcel A. Behr, MD, MSc, FRCPC Theodore K. Marras, MD, MSc, FRCPC
Sara Christianson, MSc Dick Menzies, MD, MSc
Victoria Cook, MD, FRCPC Jessica Minion, MD, MSc, FRCPC
Anne-Marie Demers, MD, FRCPC Toju Ogunremi, BSc, MSc
Edward Ellis, MD, MPH, FRCPC Pamela Orr, MD, MSc, FRCPC
Kevin Elwood, MD Madhukar Pai, MD, PhD
John Embil, MD, FRCPC, FCAP Elizabeth Rea, MD, MSc, FRCPC
Dina Fisher, MSc, MD, FRCPC Paul Rivest, MD, MSc
Victor Gallant, MA Kevin Schwartzman, MD, MPH
Christina Greenaway, MD, MSc Meenu Kaushal Sharma, PhD
Jessica Halverson, MPH, MSW Wendy L. Wobeser, MD, MSc, FRCPC
Stan Houston, MD, DTM&H, FRCPC Joyce Wolfe, ART
Frances Jamieson, MD, FRCPC Thomas Wong, MD, MPH, FRCPC
Julie Jarand, MD, FRCPC
Kamran Khan, MD, MPH, FRCPC
Slide 90
The Standards is a resource intended to provide information to

public health and clinical professionals and do not supersede any
provincial and territorial legislative, regulatory, policy and practice
requirements or professional guidelines that govern the practice of
health professionals in their respective jurisdictions. The Standards
do not replace consultations between clinical practitioners and
public health authorities with respect to a particular patient or
circumstance.
Slide 91
New Format
The Standards now have a new environmentally friendly format that
can be easily consulted on-line, or downloaded directly from the web,
printed and conveniently inserted into a binder.
This new format provides an opportunity for authors to be able to

regularly update each chapter as emerging issues arise, new
literature or epidemiological findings are published, and scientific
knowledge and medical practice significantly changes.
Limited print copies will be available for individuals who may have
limited access and/or difficulty downloading this document from the
web or
e-mail.
Slide 92
The final version is available on the following website:
http://www.respiratoryguidelines.ca/tb-standards-2013
Please note that many changes were made since the 2013 pre-release.
Slide 93
For More Information

Canadian Thoracic Society Centre for Communicable Diseases
c/o The Lung Association and Infection Control
National Office Public Health Agency of Canada
1750 Courtwood Crescent
Suite 300
Ottawa, ON K2C 2B5
E-mail: guidelines@lung.ca E-mail: ccdic-clmti@phac-aspc.gc.ca
www.respiratoryguidelines.ca www.phac-aspc.gc.ca
www.lung.ca/cts

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Canadian Tuberculosis Standards,

Jessica Halverson, MPH, MSW

Reported TB Cases and Incidence Rates

Rate per 100, 000 population

Reported TB Incidence Rate by Sex

Percentage of Reported TB Cases by

Reported TB Incidence Rate by Population

Reported TB Incidence Rates by

Number of reported TB cases by population

Reported TB Disease Incidence Rates in

Distribution of Active TB Cases and Incidence

Rate per 100,000 population

TB Cases and Incidence Rates Among

Rate per 100,000 population

Reported Foreign-born TB Cases in Canada, 2000-2010:

Percentage of reported cases by diagnostic

Percentage of Pulmonary Cases by Sputum

Percentage of Reported TB Cases by HIV

Percentage of Reported Foreign-born TB Cases in

Richard Long, MD, FRCPC, FCCP

Madhukar Pai, MD, PhD

Schematic of the MTB/RMP Test. GeneXpert

Accuracy of Xpert MTB/RIF

Potential impact beyond accuracy

Boehme Lancet 2011

Major New Recommendations

Where feasible, three sputum specimens (either

Important caveats about use of Xpert TB/RIF

Madhukar Pai, MD, PhD

Evidence base on IGRAs has expanded greatly

The recommendations in the 7th Edition of the

Both the TST and IGRA are acceptable alternatives

Situations in which IGRAs are preferred for testing

Situations in which TST is recommended for

LTBI test results should be interpreted along with

Composite risk Recent

Dick Menzies, MD, MSc

Major Changes in Recommendations

Continuation Phase Daily or Thrice Weekly

Major Changes in Recommendations

Fixed Dose Combinations Not Recommended

Dick Menzies, MD, MSc

Major Changes in Recommendations

3 Months Once Weekly Isoniazid (INH) &

Completed 2536 (69%) 3190 (82%)

TB Disease - All patients 12 (0.4%) 7 (0.2%)

- Completed 5 (0.2%) 4 (0.1%)

3 Months Once Weekly INH & RPT

Total- Grade 3-4 AE 7.4% 6.0%

Drugs stopped for AE 3.6% 5.0%

Hepatotoxicity 2.8% 0.5%

Hypersensitivity 0.8% 4.0%

Contacts of Drug Resistant Cases

Contacts of patients with:

RMP resistance (but not INH)

MDR patients (INH & RMP but not fluoroquinolone)

Dina Fisher, MSc, MD, FRCPC

Major Changes in Recommendations

No major changes in treatment for most forms

Adjunctive steroids for:

Richard Long, MD, FRCPC

Major Changes in Recommendations