Government of Canada’s Tuberculosis Response (2025): Working towards Tuberculosis Elimination

Table of contents

• Land acknowledgement
• Executive summary
• Setting the stage
  • Introduction
  • Global and domestic commitments
• Tuberculosis landscape
  • Overview of TB trends globally and in Canada
  • Health inequities and their impact on TB
  • Key populations impacted by TB
  • Addressing TB: Public health challenges and advances
• Government of Canada's vision, mission, strategic goals, and areas of action
• Conclusion
• Appendix 1: Federal departments and agencies role in the TB response
• References

Land acknowledgement

We respectfully acknowledge that the lands on which this document was developed are the homelands of First Nations, Inuit, and Métis. Specifically, it was developed on the following lands:

In Ottawa, also known as Adawe, on the traditional unceded and unsurrendered territory of the Algonquin People, members of the Anishinabek Nation Governance Agreement.

In Toronto, also known as Tkaronto, the traditional territory of many nations, including the Mississaugas of the Credit, the Anishinaabeg, the Chippewa, the Haudenosaunee, and the Wendat peoples and is now home to many diverse urban First Nations, Inuit, and Métis. Toronto is within the lands protected by the Dish with One Spoon Wampum Belt Covenant, an agreement between the Haudenosaunee and Anishinaabeg and allied nations to peaceably share and care for the resources around the Great Lakes.

Lastly, in Calgary, which is also known by several Indigenous names, including Moh'kinstsis, ʔaknuqtapȼik', otôskwanihk,Guts'ists'I, Wicispa Oyade, Klincho-tinay-indihay and Otos-kwunee. These names reflect the rich cultural heritage of the area, which is named after the shape of the Elbow and Bow Rivers that meet in the heart of the city—just as many Indigenous Peoples have traditionally gathered and continue to come together where the rivers converge. Calgary is located on Treaty 7 territory, and is the ancestral lands of the Blackfoot confederacy (Siksika, Kainai, Piikani the Tsuut'ina, the îethka Nakoda Nations (Chiniki, Bearspaw, Goodstoney), the Otipemisiwak Métis Government (Districts 5 and 6).

We acknowledge that there remains a great deal of work to be done, when it comes to TB and more generally in the health sector, to address the damaging impacts of colonialism and racism that continue to reproduce inequities between First Nations, Inuit, and Métis and non-Indigenous communities. Using drivers such as the Truth and Reconciliation Commission's (TRC) Calls to Action, particularly #19, and the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), particularly Article 24, and the Missing and Murdered Indigenous Women and Girls and 2SLGBTQI+ People (MMIWG2S+), we remain committed to working collaboratively to address health inequities across the country, to advance towards TB elimination, to build an equitable public health system, and support the self-determination of First Nations, Inuit, and Métis.

Executive summary

Tuberculosis (TB) is preventable and curable yet globally remains one of the most common infectious diseases and was the top global cause of infectious disease mortality in 2023. While Canada is classified as a low-incidence country for TB, Inuit, First Nations, and Métis communities, as well as people born outside of Canada, continue to be disproportionately impacted.

In September 2023, at the second United Nations General Assembly High-Level Meeting on TB, Canada, alongside many global leaders, reaffirmed its commitments to eliminating TB around the world. This historic moment also signaled the need to refocus efforts to achieve ambitious TB elimination targets. The Government of Canada's Tuberculosis Response (2025): Working Towards Tuberculosis Elimination lays the foundation for ongoing collaborative work with communities, provincial and territorial partners and Indigenous rights-holders towards shared goals for TB elimination.

The Government of Canada is committed to eliminating TB through four strategic goals:

1. Improve early detection of TB
2. Enhance linkages to care, treatment, and support for people with TB infection and active TB disease to prevent onward transmission
3. Build capacity and increase knowledge and awareness for TB prevention
4. Champion collaborative action to achieve health equity

To support these goals, the Government of Canada will take action in each of the following areas:

• Surveillance, monitoring, and outbreak support
• Research and innovation
• Capacity building and professional guidance
• Knowledge mobilization and convening
• Regulatory processes
• Policy development
• Global engagement
• Healthcare services

In April 2024, a Federal, Provincial, Territorial, and Indigenous TB Task Group was established to support collaborative action and develop a TB Elimination Strategy for Canada. The Government of Canada is grateful to learn from and build on the regional and community-based expertise of the Task Group, including the Inuit-led development and implementation of tailored, regional TB Elimination Action Plans in Inuit Nunangat. Community-led initiatives are core to TB elimination and help build healthier communities, through stigma reduction, reconciliation and Indigenous self-determination.

Achieving TB elimination requires meaningful and sustained action. This document serves as a foundation to build upon progress and drive continued action toward eliminating TB in Canada.

Setting the stage

Introduction

Tuberculosis (TB) is a major global public health concern that disproportionately impacts people experiencing social inequities. While TB is treatable and curable, in 2023 over 10 million people fell ill with this disease globally and 1.25 million died from it making it the world's leading cause of death from an infectious disease^{Reference 1}. It was also the leading killer of people with HIV and a major cause of deaths related to antimicrobial resistance. Despite advances in public health and medicine, Canada's progress towards TB elimination has plateaued, with Indigenous Peoples and people born outside of Canada experiencing the highest rates.

Caused by the bacterium Mycobacterium tuberculosis, TB is spread from person to person via the air, often after prolonged, close contact with someone with contagious TB disease^{Reference 2}. After breathing in the TB bacteria, most people's immune systems are able to fight off TB infection. In instances where the immune system is not able to eliminate the bacteria, it forms an enclosure around the bacteria to "contain" them, which prevents or delays the onset of TB disease. This is called TB infection (previously known as latent TB). A person with TB infection has no symptoms and is not contagious. However, of those persons with TB infection, about 1 in 10 people will develop active TB disease over time. Reactivation of TB often occurs in the first two years after infection but can occur up to decades later.

Given the potentially long latency period between infection and development of active TB disease, people can have inactive TB for an extended period of time. The chance of developing TB disease increases if someone has a medical condition that weakens the immune system (such as: human immunodeficiency virus (HIV), diabetes, severe kidney disease, organ transplant recipient), takes medications that weaken the immune system, or is of a young or advanced age^{Reference 3}.

Symptoms of active pulmonary TB can vary but typically include a cough that lasts two weeks or longer; coughing up blood or phlegm, chest pain, weakness or tiredness, weight loss, loss of appetite, fever and chills, and night sweats. TB primarily infects the lungs but can also affect other parts of the body, including the kidneys, spine and brain.

The Government of Canada is committed to working with provincial and territorial partners and Indigenous rights-holders to develop a TB Elimination Strategy for Canada. Addressing TB is a shared responsibility that requires collaboration among local communities, governments and non-governmental organizations. Multiple jurisdictions, Indigenous health authorities and sectors have specific roles and mandates in addressing TB. However, there is a pressing need for a coordinated and cohesive, Canada-wide approach, involving all levels of government and partners, to reach our shared TB elimination targets.

As part of the Government of Canada's commitment to TB elimination we are renewing, reaffirming, and updating our responsibilities for TB elimination that were first advanced in 2014, with the release of Tuberculosis Prevention and Control in Canada: A Federal Framework for Action.

As we move forward with many collaborative initiatives for TB elimination together with our partners, herein we identify the objectives, roles and key areas of action across federal departments and agencies to establish a foundation for the Government of Canada's commitment to TB elimination. This foundation integrates advancements in science and research, prioritizes health equity and equity-denied populations, and outlines current federal activities that aim to advance the prevention and care of TB, with the goal of TB elimination. The role of each federal department in the TB response is outlined in Appendix 1.

Global and domestic commitments

In September 2023, at the United Nations General Assembly (UNGA), Canada re-affirmed its commitment to address TB in Canada and abroad^{Reference 4}. Canada's commitments include global TB targets set by the World Health Organization (WHO) as part of the End TB Strategy (PDF) and United Nations Sustainable Development Goals. In addition to endorsing the WHO strategies in 2014, Canada has also pledged to meet domestic targets which include: reducing the incidence of active TB by 50% (compared to 2016 rates) among Inuit in Inuit Nunangat by 2025, eliminating TB among Inuit in Inuit Nunangat by 2030, and eliminating TB across the country by 2035^{Reference 5}.

TB pre-elimination and elimination

TB pre-elimination is defined as less than 10 notified TB cases (all forms) per million population and year^{Reference 6}.

TB elimination is defined as less than 1 notified TB case (all forms) per million population and year^{Reference 6}.

Despite these commitments, the incidence of active TB in Canada has remained unchanged over the last decade. To meet Canada's domestic and global targets, the overall incidence will need to decline by approximately 17% per year. However, some populations will need to experience a higher rate of decline compared to others depending on their respective TB burden. This highlights the critical need for partners and all levels of government to strengthen collaborative efforts to eliminate this disease.

Tuberculosis landscape

Overview of TB trends globally and in Canada

Between 2012 and 2023, the number of new active TB cases in Canada ranged from 1,615 to 2,217 per year^{Reference 7}. While the incidence of TB has remained relatively stable over the past decade, it increased to 5.5 per 100,000 in 2023^{Reference 7}. In 2023, higher rates of TB were found in several other countries, highlighting the need to refocus efforts domestically and globally to eliminate TB^{Reference 7}.

Health inequities and their impact on TB

As highlighted in the Chief Public Health Officer's 2018 Report on TB, TB is considered a social disease and does not affect all people equally. It is strongly influenced by both the social and structural determinants of health such as poverty, global socioeconomic inequalities, racism, discrimination, rapid urbanization and population growth, high levels of population mobility, inadequate housing leading to overcrowding, food insecurity, stigma, historical and ongoing trauma, and barriers to accessing healthcare. These underlying risk factors for TB contribute to health inequity and can impact mental health and increase social isolation for affected individuals and communities.

Many of these inequities are experienced by Inuit, First Nations, and Métis populations with Indigenous-specific determinants of TB infection and disease directly resulting from colonial policies and practices such as forced relocation, loss of lands, creation of the reserve system, banning of Indigenous languages and cultural practices, Indian hospitals and TB sanitoria, and the creation of the residential school system. Historical and ongoing trauma from colonialism, TB sanitoriums, forced displacements, and removal from communities have contributed to factors such as crowded living conditions, food insecurity, barriers in seeking medical care, mistrust of the health system and government, medical co-morbidities, lack of robust support for patients to achieve completion of TB treatment regimens, and stigma that allow TB to continue to disproportionately impact Indigenous Peoples. Ongoing inequities and barriers to safe and quality health care are maintained by systemic racism and discrimination across health systems coupled with inadequate resources and data.

Key populations impacted by TB

Populations disproportionately impacted by TB in Canada include Inuit, First Nations, Métis and people born outside of Canada, each facing unique challenges related to TB elimination. Achieving the shared goal of TB elimination among impacted populations requires collaborative and tailored solutions that reflect their diverse contexts and priorities. Another important factor to consider is the spatial and geographic spread distribution of the disease, particularly in provinces such as Nunavut, Manitoba and Saskatchewan where some of the highest TB rates in Canada are reported.

First Nations, Inuit and Métis

Indigenous Peoples continue to be disproportionately affected by TB, especially Inuit living in Inuit Nunangat experiencing the highest incidence rates in the country regardless of the observed fluctuations, followed by First Nations with rates comparable or slightly superior to those of individuals born outside Canada (Figure 1). Though comparatively lower and stable, the incidence rates of TB among Métis have been consistently higher than those of non-Indigenous Canadian-born individuals (Figure 1). For persons born outside of Canada, the incidence of active TB remained relatively stable throughout the reporting period. TB incidence trends during the COVID-19 pandemic, especially from 2020 to 2022, should be interpreted with caution due to potential disruptions in TB programming and redirection in dedicated public health resources during that time period.

Figure 1: Text description

The left side shows TB incidence among different population subgroups in Canada from 2014 to 2023, with Inuit consistently posting values to the magnitude of 80.5 - 204.2 cases per 100,000 people, and making it difficult to fully appreciate the differences in lower incidence values (less than 25.0 per 100,000) recorded by other population subgroups (such as First Nations, Metis, People Born Outside of Canada, and non-Indigenous Canadian-born) without the magnification of the scale as presented in the right side.

Population group	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Inuit	142.8	181.9	168.6	171.9	211.2	197.4	190.2	80.5	140.3	133.2	204.2
First Nations	20.6	17.9	15.0	23.5	17.0	16.1	15.4	13.8	14.7	19.1	18.5
Métis	3.4	3.4	2.0	1.9	3.4	2.6	2.2	2.7	1.8	1.8	2.7
Individuals born outside of Canada	15.0	14.3	15.0	14.3	15.1	14.9	15.9	14.5	12.7	14.3	15.5
Non-Indigenous Canadian born	0.6	0.6	0.6	0.6	0.5	0.4	0.4	0.3	0.3	0.4	0.4

Note: Place of birth and Indigenous identity was not available for certain jurisdictions. Incidence rates have been adjusted accordingly. Information for Quebec is also excluded.

Many Inuit, First Nations and Métis Peoples experience barriers to timely health care that result in delays from diagnosis to treatment. These delays can be caused by many factors including (but not limited to) geographic remoteness and related lack of infrastructure, lack of culturally safe services and outreach in the languages of populations most impacted, and economic factors such as inability to take time off work or lack of childcare. Structural determinants of health such as inadequate housing and food security, and health systems issues such as a lack of health human resources including the lack of dedicated TB programs also contribute to barriers to timely care. Access to diagnostic tools and medications and awareness of TB among health care staff is also needed. Treatment for TB is long and difficult for patients to complete and fulsome, supportive services to facilitate the completion of TB treatment patients are required. For example, access to the Interferon Gamma Release Assay, a screening test for TB infection, is limited in many remote Indigenous communities due to the nature of the test. Additionally, access to many standard-of-care TB medications is limited as not all manufacturers choose to seek regulatory approval in Canada due to market conditions. Delays in diagnosis and treatment increase the risk of consequences to the person, including death, and increase likelihood that the TB bacteria will be transmitted to others.

Holistic approaches led by Indigenous organizations and communities have done much to address stigma and provide person-centered care, however large gaps remain and require a concerted effort to address them. Supported by the Government of Canada, the Inuit Tuberculosis Elimination Framework developed by Inuit Tapiriit Kanatami, with the associated Regional Action Plans, is an example of an initiative that has brought partners together to build on regional strengths and unique contexts in order to address public health priorities^{Reference 8}. The Government of Canada has much to learn from Indigenous-led initiatives.

Some examples of culturally sensitive community-led initiatives highlighting the resilience of Indigenous communities are as follows:

• Community-based TB program workers are advocating for and delivering holistic, person-centered, culturally safe TB care.
• Strong collaborations, prior to and during community wide screening in Nunavut shows that stigma and mistrust can be overcome.
• The provision of food hampers and bagged lunch programs increase access to nutritious and culturally appropriate foods, strengthening the immune systems of persons affected by TB, and promoting recovery from active TB.

There are TB outbreaks in parts of Canada that have deep health inequities, such as the territories. In 2023, Nunavut had the highest incidence of active TB in Canada (169.5 per 100,000 population).

In the same year, the incidence of active TB in Northwest Territories was 2.2 per 100,000 and 6.6 per 100,000 in the Yukon.

The Public Health Agency of Canada's (PHAC) work on TB elimination has included providing epidemiological, laboratory, operational and logistical support for TB outbreaks and community-wide screening initiatives. In the last two years, PHAC has led multi-program and department work to facilitate several territorial requests for federal assistance (RFA), including multiple Operational Framework for Mutual Aid Requests (OFMAR) requests, with respect to health human resource support to TB outbreaks in Nunavut.

PHAC also provides training to the Canadian Field Epidemiology Program (CFEP) fellows, which includes a primer on the investigation of TB outbreaks within remote Northern communities. The CFEP provides medium-term epidemiological support through the deployment of field epidemiologists on a rotational basis, both on site and virtually.

PHAC's TB Program provides technical support and expert consultation for requests for assistance, as required. The National Microbiology Laboratory (NML) can deploy laboratory staff and equipment to support outbreaks or testing initiatives, as well as conduct genome sequencing and surveillance on TB. The Canadian Public Health Service (CPHS) placed 3 Public Health Officers (PHO) (e.g., Epidemiologists) in northern jurisdictions supporting public health priorities related to TB. The National Emergency Strategic Stockpile (NESS) provides medical supplies/equipment, pharmaceuticals, social service supplies, and emergency triage units/mini-clinics, when requested. For the Pangnirtung and Naujaat community-wide screening initiatives, PHAC mobilized a total of 18 epidemiologists, lab techs and biologists (7 epidemiologists, 11 lab staff).

Indigenous Services Canada supported the two communities, in collaboration with Nunavut Tunngavik Incorporated, the Government of Nunavut and PHAC to offer community-wide tuberculosis screening (CWS): 8 ISC Public Health Surge Team and regional nurses were mobilized.

Over 1,100 people attended screening, representing 94% of the target in Pangnirtung. Nearly 900 people attended screening, representing 89% of the target in Naujaat.

People born outside of Canada

An estimated 25% of the world's population has been infected with TB and about 5-10% of people infected with TB eventually develop TB disease. Although the incidence of TB is highest among Inuit and First Nations, most of Canada's active TB cases occur among people born outside of Canada (Table 1). While about 80% of all TB cases in Canada in 2023 occurred among people born outside of Canada, this population represents 26% of the Canadian population (Table 1). People born outside Canada are disproportionately impacted by TB; particularly those born in the Western Pacific and south-East Asian regions, followed by those from the African and Eastern Mediterranean regions. Active TB among people born outside of Canada is largely thought to result from reactivation of TB infection that was acquired abroad, underscoring the importance of addressing TB globally.

Table 1. Counts, proportion, and incidence of active TB (per 100,000) by population group, Canadian Tuberculosis Reporting System, 2023

Population group	Case counts	Proportion(%)	Incidence (per 100,000)
Inuit	148	7.2%	202.8
First Nations	150	7.3%	18.5
On reserve	79	3.9%	22.2
Off reserve	51	2.5%	13.4
Born outside Canada	1,638	80.1%	15.5
Métis	12	0.6%	2.7
Non-Indigenous Canadian-born	96	4.7%	0.4
Note: First Nations, Inuit, Métis, and non-Indigenous Canadian born exclude Manitoba, Nova Scotia, and British Columbia.

People born outside of Canada may face challenges such as stigma, racism, difficulty navigating the healthcare system, linguistic and cultural barriers to accessing medical care, and unique stresses associated with migration (e.g., financial insecurity and isolation, mental health challenges, housing instability, experiences of racism, and lack of trust in the medical system). Additionally, medical co-morbidities may increase risk of progression to active TB disease. Appropriate early screening for TB infection and timely access to health care remain critical factors for TB elimination in this population.

Persons born outside of Canada are routinely screened for active pulmonary TB as part of the immigration process and clients identified with previously treated active TB have a condition placed on their visa that requires them to follow up with provinces/territories upon arrival (called post-landing medical surveillance). Federal, provincial and territorial partners continue to work together on areas identified for improvement, including ways to offer more precision on the volume of medical surveillance referrals and also improving data collection and data sharing that could help assess effectiveness of immigration screening procedures.

Increased collaboration and data-sharing between federal, provincial and territorial partners is required to understand the impacts of screening criteria on TB outcomes and tailor approaches to immigration screening in an evidence-based manner. Supporting newcomers to access follow-up requires creating accessible pathways to receive health services (e.g., addressing language barriers, eliminating waiting periods for health insurance, facilitating appointments with incentives or enablers). With increasing immigration rates in Canada, there is a need to address any gaps in screening and facilitate timely connections to healthcare after arrival.

To support TB elimination across affected populations, additional work will need to be completed to support capacity building and training for affected communities, laboratories, health professionals, surveillance and public health systems, and health care services. This capacity building and training should involve outreach, screening, diagnostic services, access to medications, treatment and other care.

Addressing TB: Public health challenges and advances

Although notable gains have been made in reducing the incidence of TB in Canada since the 1940s due to the development of antibiotics and public health interventions, progress towards elimination has stalled, with minimal change in rates over the past 40 years.

Health system capacity

Overall, health system capacity is a challenge with respect to screening, diagnosis and providing culturally safe, trauma- and violence-informed care and treatment for TB. This includes both healthcare and public health capacity to address TB as there are many competing priorities. Additionally, similar to the situation in many other countries, the COVID-19 pandemic had an impact on Canada's efforts to eliminate TB as public health services were diverted to support critical functions related to the pandemic. It is suspected that the COVID-19 pandemic led to an increased number of people with undiagnosed and untreated TB, which led to TB transmission and contributed to the ongoing rates of active TB disease currently seen in Canada.

Canada is currently facing a health human resources crisis. Furthermore, since TB is not commonly seen in Canada, few health care providers have expertise in this topic or significant knowledge on the ways TB disproportionately impacts Indigenous populations and people born outside of Canada. These factors contribute to delays in TB screening, diagnosis, and treatment.

Drug resistance, access, and availability

In the global context, there remain several challenges in addressing drug resistant TB and supporting people through treatment. Innovative and rapid molecular tests are needed for early detection and treatment of drug-resistant TB. Given the small number of individuals impacted and market size, manufacturers of drugs used to treat multi-drug-resistant TB have chosen not to submit an application for market authorization in Canada. Instead, most drugs may be accessed through the Special Access Program on a patient-by-patient basis when requested by a health care provider. This can result in delays in access to treatment. Challenges with Canada being a small market also affects the availability of other medications such as drug formulations appropriate for children and rifapentine, a first-line treatment for TB infection. Rifapentine is currently available via Health Canada's Urgent Public Health Need program, which allows public health officials to purchase bulk drug supplies for immediate use from certain foreign jurisdictions. In addition, there have been global shortages of essential TB drugs, compounded by some domestic shortages of medications produced by a single supplier in Canada.

Advances have been made in some areas of treatment of TB including the approval of shorter duration TB therapies, and all oral regimens with lower drug toxicity for the treatment of resistant active TB disease.

Sustained efforts are required for technological advancements, surveillance, research and medical solutions (e.g., virtual care, vaccinations, near-patient testing) to improve diagnosis and treatment of TB infection to break the cycles of TB reactivation that lead to active disease and outbreaks. While there have been advances in diagnostic tools, and treatment regimes deployment challenges remain in TB care among northern, remote and isolated communities across Canada.

Government of Canada's vision, mission, strategic goals, and areas of action

Despite the challenges that are faced in addressing TB in Canada and globally, there is a way forward. The Government of Canada is committed to working collaboratively to meet our global and domestic commitments for TB elimination, which are guided by our vision, mission, strategic goals and areas of action. These areas of action reflect the responsibilities of specific federal departments involved in the TB response (Appendix 1).

Vision

A Canada free from the impacts of TB.

Mission

Aim to eliminate TB through collaboration and evidence-informed decision-making with communities and partners using a social equity lens.

Strategic goals

The federal government focuses its efforts to eliminate TB through the following 4 strategic goals:

1) Improve early detection of TB

Early detection of active TB, including case finding and systematic screening for members of groups at high risk of TB is essential to support TB elimination, especially for populations with ongoing outbreaks and transmission. Activities such as community-wide screenings, increasing awareness about the signs and symptoms of active TB, ensuring the availability of trained health care professionals, capacity building, implementation of rapid detection methods as well as access to diagnostic testing and treatment remain important considerations for TB elimination. Health care system supports to improve access to testing and treatment for TB infection remain the cornerstone of prevention, for persons involved as part of contact tracing initiatives for those who may have acquired TB infection outside Canada, and in routine screening in other risk environments (e.g., congregate living and correctional facilities).

2) Enhance linkages to care, treatment, and support for people with TB infection and active TB disease to prevent onward transmission

A people-centered and culturally relevant approach is critical to improve the outcomes and quality of life of people receiving TB treatment. TB care must be holistic, accessible and provided in a supportive environment to ensure adherence to treatment and to prevent transmission. With the support of innovative tools and community-led approaches, we can enhance linkages to TB care and treatment.

3) Build capacity and increase knowledge and awareness for TB prevention

Building capacity among key populations, communities, public health systems and health care providers most impacted by TB to prevent and respond to TB in their communities provides the foundation for successful interventions. Efforts to improve awareness and knowledge of the impact of TB can help reduce the stigma and discrimination associated with TB.

4) Champion collaborative action to achieve health equity

TB typifies inequity in public health and is often referred to as a social disease with a medical aspect. The key to reaching our targets and achieving TB elimination is reducing the disproportionate impact of the disease on key populations, in particular Inuit, First Nations, Métis and individuals born outside of Canada. Doing so requires sustained collaborative action that prioritizes community-led solutions and efforts that address social and structural inequities coupled with improved diagnosis and treatment of active TB disease and TB infection.

Figure 2: Text description

This figure illustrates the 3 key components of the TB response: prevention, detection and treatment. In the centre of the figure is health equity, which is central to the TB response. The figure illustrates that the 3 components are interconnected, and that health equity is central to the prevention, detection and treatment of TB.

Our approach to TB elimination is guided by the principles outlined in Table 2. These principles will inform our collective action to address TB in Canada and reach our strategic goals.

Areas of action

Actions in each of the eight areas below seek to address one or more of our strategic goals. These actions also aim to contribute to progress on reaching global and domestic commitments for TB elimination targets (see Appendix 1 for a list of federal departments and agencies with shared responsibilities in TB activities for Canada).

1) Surveillance, monitoring, and outbreak support

TB surveillance systems, comprised of the collection, management, analysis and interpretation of public health related TB data, are critical to monitor progress towards the elimination of TB. They provide indispensable information that allows for improvements in prevention and care efforts. Robust surveillance programs help identify gaps within health systems, which allow for refinements to improve TB interventions. These systems require collaborative and coordinated efforts between federal, provincial and territorial and Indigenous (FPTI) partners as well as settlement service provider organizations, health care providers including panel physicians and refugee and migrant focused primary care providers. Coordinated and collaborative management of outbreaks is also crucial for the successful care and elimination of TB. Management of outbreaks implicate various jurisdictional and Indigenous health authorities and Indigenous governments as well as partner organizations. Successful outbreak management facilitates requests for assistance for outbreaks, supports community wide screening and epidemiological analysis, provides additional access to human resources, and access to specialized laboratory services (e.g., rapid diagnostic tests and whole genome sequencing). The Government of Canada contributes to surveillance, monitoring, and outbreak support efforts through the following actions:

Surveillance, monitoring, and outbreak support

• Perform and support surveillance to monitor epidemiological trends of active TB and drug-resistant TB.
• Support the development of data system(s) for integrated case management, contact tracing and surveillance of TB in impacted communities with aim of improving timeliness and effectiveness of TB testing, linkage to care, and outbreak response.
• Collaborate with communities affected by TB to support responsible and culturally appropriate practices in relation to data collection, including the collection and use of disaggregated data and conducting intersectional analysis, sharing, stewardship, and reporting standards.
• Support projects and initiatives that seek to improve data sharing pathways and public health data exchange between providers and FPTI partners.
• Ensure active TB screening in the Immigration Medical Exam and support screening for TB infection and surveillance notifications to P/Ts.
• Extend implementation of digital and molecular diagnostic tests (Digital Xray, nucleic acid amplification tests, Blood tests).
• Perform event-based surveillance worldwide for early warning of outbreaks.
• In collaboration with Five Eyes intelligence (FVEY) partners (Australia, Canada, New Zealand, United Kingdom, United States), monitor classified intelligence for indicators and warnings of potential TB outbreaks to inform decision-makers' preparation and consequence management processes.
• Combine and, where possible, integrate innovative molecular methods including whole genome sequencing, with geomatics and wastewater testing for detection, analysis and surveillance for TB outbreaks.
• Facilitate administrative process for communities submitting request(s) for assistance (RFA) for outbreak management in affected communities.
• Invest in existing Health Emergency Management programs to address TB outbreaks in affected communities.
• Working with Nunavut, the Nunatsiavut and Newfoundland and Labrador governments to support partners' efforts to address earlier TB outbreaks.
• Provide additional public health human resources support (public health officers and field epidemiologists) to impacted regions during TB outbreaks, including culturally sensitive community-wide screening where needed.

2) Research and innovation

Research is an essential component of TB prevention, care and treatment efforts. Support for tailored TB research programs that evaluate existing interventions and investigate new strategies (such as new vaccine developments, innovative solutions, and risk factors and related social determinants) are key to developing tailored evidence-based interventions to improve methods in identifying infection, reducing risks, and mitigation. Successes in other areas of health research focused on structural determinants of health (e.g., HIV/AIDS) could guide similar efforts such as with community-based TB research. The Government of Canada contributes to research and innovation towards TB elimination through the following actions:

Research and innovation

• Current research investments on TB through CIHR are primarily through open grants, which could invest in TB research to improve biological understanding, including projects to improve TB diagnostic, treatment and prevention interventions of TB across Canada, and research to improve rapid diagnosis in rural and remote communities (e.g., TB wastewater study, First Nations, Inuit and Métis-specific research; respiratory health research).
• CIHR and Inuit Tapiriit Kanatami have developed a joint work plan (2021-2025) on research supporting the implementation of the National Inuit Strategy on Research (NISR), including a key activity on TB elimination and aiming to enhance Inuit capacity, knowledge, and self-determination in research.
• Support research and development for the next generation of TB vaccines, innovative laboratory testing approaches, identification, drug resistance, genotyping and nontuberculosis mycobacteria.
• Support the deployment and allocation of screening and treatment technologies that allow TB diagnosis to take place closer to home.
• Develop outbreak response mechanisms by leveraging technological advances in TB testing (e.g., reference and diagnostic services, laboratory standards proficiency panels, genotyping, whole genomic sequencing, drug susceptibility, including advancement of anti-microbial resistance monitoring through whole genome sequencing).
• Support research initiatives that focus on making structural changes to TB programming in Indigenous communities (e.g., Pathways to Health Equity for Indigenous Peoples Initiative) and that enhance Indigenous capacity, knowledge, and self-determination in research.
• Modeling TB epidemics and economics with special focus on Inuit Nunangat.

3) Capacity building and professional guidance

Successful TB programming involves sustained efforts to build capacity among health care providers and communities most impacted by TB. Developing and strengthening the knowledge and skills of community organizations and members to prevent and respond to TB in their communities provides the foundation for successful interventions to reach those who need it. This also includes supporting the development and improvement of research capacity across Canada, and in particular for TB within Indigenous organizations, communities, and researchers. Successful TB prevention and care is informed by the regular development and publication of professional guidance standards for TB. These standards are intended to provide practical management information to public health and clinical professionals on all aspects of the pathology, epidemiology, and management of TB in Canada. The Government of Canada contributes to capacity building and professional guidance efforts through the following actions:

Capacity building and professional guidance

• Recruit and place field staff (public health officers with relevant experience, including nursing and epidemiology) in Inuit Nunangat to build screening and surveillance infrastructure in the jurisdictions to support local, regional, and national TB surveillance and elimination efforts.
• Work closely with its Tri-Agency research partners (Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council, and Canada Foundation for Innovation) via CIHR to strengthen Indigenous research through the shared strategic plan – with an area of focus on reducing barriers for Indigenous-led research.
• Promote and support the provision of training and development for Indigenous community health workers and other health human resources in high-incidence communities.
• Work with Inuit, First Nations, and Métis, provincial and territorial governments, and other parties to address the social and structural determinants of health, including housing, food security, income, and access to culturally appropriate healthcare that contribute to the disproportionate rates of TB among Indigenous Peoples in Canada.
• Strengthen community-level TB resources for newcomers and support organizations working with migrants to facilitate access to culturally relevant health and social services after arrival.
• In collaboration with professional bodies, explore and offer capacity building opportunities (i.e., webinars, educational talks, resource sharing, network meetings) for frontline health care providers, policy leaders and community outreach workers in communities with high TB incidence to improve culturally relevant, violence and trauma informed TB care for people born outside of Canada, Indigenous Peoples and sharing of best practices for elimination efforts.
• Invest and support the elimination of TB in Inuit Nunangat through supporting Inuit partners in the implementation of their Regional Action Plans.
• Mobilize regional and contextual specific resources to respond to community needs through the First Nations Inuit Health Branch.
• Provide financial and content support to produce guidance for TB prevention and treatment through contributions to: the Canadian TB Standards with the Canadian Thoracic Society (various editions), Bacille Calmette-Guérin vaccine guidance via the National Advisory Committee on Immunization (NACI) and the Committee to Advise on Tropical Medicine and Travel (CATMAT) statement.
• Implement laboratory testing and biosafety/biosecurity based on national and international standards (e.g., Clinical and Laboratory Standards Institute, Canadian Biosafety Standard).
• Provide guidance for clinicians carrying out Immigration Medical Exams in Canada and overseas.

4) Knowledge mobilization and convening

Awareness and knowledge of TB is often limited, and some people with TB face stigma and discrimination. Knowledge mobilization efforts aimed at delivering accurate, evidence-informed, culturally appropriate, accessible, and trauma and violence-informed information to target audiences (i.e., public, key populations, health care professionals, and communities) contribute to ongoing TB elimination efforts. Activities that support convening partners and stakeholders in various settings also facilitate knowledge transfer and sharing of best practices for improved interventions. The Government of Canada contributes to knowledge mobilization and convening efforts through the following actions:

Knowledge mobilization and convening

• Increase awareness of TB through public education and knowledge mobilization activities such as webinars and the development of guidance and policy documents.
• Invest in TB knowledge mobilization through strategic and open funding opportunities.
• Convene provinces, territories, partners (e.g., National Collaborating Centres for Public Health, National Indigenous Organizations, TB experts) and other stakeholders to understand priorities, offer supports (e.g., surge capacity and on the ground placements of field staff such as federal field epidemiologists and public health officers), and share best practices for elimination efforts.
• Provide leadership by organizing working groups in current matters.
• Improve collaboration and continuity of care across jurisdictions and government organizations that have mandate to work on TB.

5) Regulatory processes

Regulating and evaluating the safety, efficacy and quality of health products and tools required for detection, diagnosis and treatment contributes to effective TB elimination efforts. To respond effectively to potential outbreaks, federal activities need to improve access to approved drugs and maintain adequate supplies, mitigating shortages. The Government of Canada contributes to regulatory TB work through the following actions:

Regulatory processes

• Evaluate and monitor the safety, efficacy and quality of health products and tools to detect, diagnose and treat TB.
• Engage with regulatory bodies to explore opportunities for task shifting, by providing training and supervised operational guidance for community health workers to operate medical imaging equipment.
• Ensure access to rifapentine, a short course TB infection treatment, by continuing to allow access via the List of Drugs for Urgent Public Health Need.
• Facilitate access to TB and NTMI (non-tuberculous mycobacteria infections) treatments not currently approved for use in Canada through HC's Special Access Program (SAP).
• Engage with industry stakeholders and non-governmental organizations (e.g., World Health Organization, Unitaid, Global Drug Facility) to explore pathways to facilitate improved access to TB medication.
• Maintain HC's Pathogens of Interest List, prioritizing and encouraging submissions for products that target pathogens on this list where the most urgent need for innovative therapeutic drugs and diagnostic devices in Canada have been identified.

6) Policy development

Strong TB programming is built on policy development and implementation that addresses regional and contextual challenges in TB prevention and elimination. The Government of Canada contributes to TB policy development through the following actions:

Policy development

• Convene a time-limited FPTI TB Task Group under the Communicable and Infectious Disease Steering Committee to support engagement and collaboration on TB elimination activities including the development of a TB Elimination Strategy for Canada.
• Facilitate collaboration, accountability and reporting on federal policy and programing to address the social and structural determinants of health that most impact TB rates among key populations (e.g., correctional environments, inadequate housing, food insecurity, access to healthcare).
• Facilitate collaborative efforts between FPTI partners and non-governmental partners for TB elimination plans through investments.
• Explore continuous improvement of TB screening methods in the Immigration Medical Exam.
• Support development of a set of TB indicators, spearheaded by community partners and regional TB leads, reported by partners to track the progress of TB elimination activities.

7) Global engagement

Prevention and elimination of TB must be grounded in understanding and addressing the global burden of the disease. Efforts to eliminate TB in Canada are being complemented by Canada's support to international initiatives to address TB in other contexts, particularly low and middle-income countries (LMICs). The Government of Canada contributes to global engagement on TB through the following actions:

Global engagement

• Continue to invest in the Stop TB Partnership, established by the WHO as a global coordinating mechanism to galvanize and facilitate global efforts in TB prevention and elimination.
• Continue to invest in the Global Fund to Fight AIDS, TB and Malaria ("Global Fund") which operates as a financing mechanism, mobilizing and channeling resources from governments, foundations, and the private sector to support countries to combat the three diseases.
• Collaborate with international partners to address TB issues (e.g., the United States Centers for Disease Control and Prevention, Circumpolar Health, the UK Foreign and Commonwealth Development Office, the Migration 5 Health Working Group, etc.) and engage in international TB forums to work towards elimination (e.g., United Nations High Level Meetings, WHO, International Union Against Tuberculosis and Lung Disease).
• Provide credible and timely information in its Travel Advice Advisories.

8) Health-care services

Prevention and elimination of TB requires the provision of timely health-care services for those who need it. This includes access to TB screening, diagnostic and treatment services for federal populations. The Government of Canada contributes to TB health-care services through the following actions:

Health-care services

• Provide provinces and territories, with long term, predictable funding for health care service delivery through the Canada Health Transfer.
• Commit close to $200B in funding over ten years through the Working Together to Improve Health Care for Canadians Plan, which includes a 5% growth guarantee for the Canada Health Transfer for five years, and 25$ billion in targeted bilateral funding to provinces and territories to improve health care for Canadians. The Plan also includes increased funding for the territories through the Territorial Health Investment Fund (THIF) and $2 billion to address the unique challenges Indigenous Peoples face when it comes to fair and equitable access to quality and culturally safe health services.
• Collaborate with provinces and territories, Indigenous communities, and other stakeholders to modernize health systems through standardized health data and digital tools, enhancing the flow of data across jurisdictions. This work is supported by the Working Together Plan and Joint FPT Action Plan on Health Data and Digital Health.
• Work with provinces and territories on health workforce initiatives to improve recruitment and retention. Provide funding for Health Workforce Canada to help address current challenges and support long-term planning.
• Provide $16.2 million over three years in 2023 to address TB elimination in Inuit Nunangat.
• Provide temporary coverage of healthcare costs for eligible migrant populations (e.g., refugees, refugee claimants, immigration detainees, and victims of human trafficking) including coverage of TB treatment costs for eligible beneficiaries in Canada and for refugees prior to arrival through the Interim Federal Health Program (IFHP).
• Participate in different fora and national networks (e.g., the Canadian TB Elimination Network - CTBEN, and the Communicable and Infectious Disease Steering Committee TB Task Group), providing information on the supply of TB drugs and to collaborate with TB partners on potential solutions to improve access to treatments.

Conclusion

The Government of Canada is committed to addressing TB by integrating advances in science and research, prioritizing health equity and equity-denied populations, and outlining actions to advance the prevention and care of TB, with the goal of TB elimination. We recognize the importance of engaging closely with our partners and stakeholders to collectively address TB elimination in Canada. This document reaffirms our commitment to working together and paves a path forward for future work across jurisdictions and organizations in Canada using a community centered approach to collectively develop a TB Elimination Strategy for Canada.

Multi-sectoral collaboration is key in our efforts to build a Canada that is free from the impacts of TB. It is essential that people affected by TB are central to the planning and implementation of TB elimination efforts. The Government of Canada plays an important convening role to bring FPTI partners and stakeholders together. Moving forward, we will continue taking an integrated approach across federal departments and agencies and prioritize supporting community-led activities and initiatives for affected populations through capacity building, ensuring self-determination and addressing key social determinants of health. The work of Inuit, First Nations, and Métis rights-holders, and provincial/territorial partners among others demonstrates that TB elimination is within our reach when guided by a holistic strategy anchored in core principles, including respect and listening to people with lived and living experience.

Appendix 1: Federal departments and agencies role in the TB response

Canadian Institutes of Health Research (CIHR):

• CIHR funds research and knowledge mobilization activities related to TB and supports several aspects of TB research, including biomedical, clinical, health system and population health issues.

Correctional Service Canada (CSC):

• CSC is responsible for administering court-imposed sentences of 2 years or more and provides essential health services to federally incarcerated individuals in accordance with professionally accepted standards.

Crown–Indigenous Relations and Northern Affairs Canada (CIRNAC):

• CIRNAC supports First Nations, Inuit and Métis and Northerners in their efforts to improve social well-being and economic prosperity; develop healthier, more sustainable communities; which includes championing initiatives that prioritize TB elimination.

Department of National Defence (DND):

• DND provides all Regular Force members and certain Reserve Force members with the complete range of screening, diagnostic and treatment services for TB.

Employment and Social Development Canada (ESDC):

• ESDC leads on a broad portfolio of policies, programs and services that positively impact the social determinants of health for Canadians. These programs and initiatives increase access to social, educational and socioeconomic resources for Canadians. Increased access to these resources creates a cascading effect which enhances the well-being of individuals and communities, reducing health disparities and promoting the health of Canadians. Key examples include targeted cash transfers to families, seniors, persons with disabilities and low-income workers to improve income security and reduce poverty; programs that provide support to working families when facing unemployment or requiring leave from work; student financial assistance and education savings benefits for students pursuing post-secondary education, including Canada Student Loans forgiveness for doctors and nurses working in rural and remote communities; targeted interventions in the afterschool space for youth at risk of disengagement in their learning; and various types of agreements with provinces and territories to fund skills development, essential family services such as affordable early learning and child care and school food programming. ESDC also promotes social development by supporting community organizations active on a range of issues, and actively works to advance reconciliation with Indigenous peoples, including through the co-development of distinctions-based initiatives, respecting the self-determination of Indigenous partners. For example, the co-development and implementation of the Indigenous Early Learning and Child Care Framework provides culturally appropriate programs in partnership with First Nations, Métis and Inuit communities. Furthermore, the Federal Anti-Racism Secretariat, now housed at ESDC, and mandated to implement Canada's Anti-Racism Strategy, recently collaborated with PHAC to address anti-Black racism in healthcare and achieve an increase in COVID-19 vaccine intake among Black communities.

Global Affairs Canada (GAC):

• GAC works in tandem with other government departments in Canada to engage in several international multilateral policy fora and funding mechanisms to advance collective efforts to end TB.

Health Canada (HC):

• HC is responsible for evaluating and monitoring the safety, efficacy and quality of health products to detect, diagnoses and treat TB.

Immigration, Refugees and Citizenship Canada (IRCC):

• Screening for TB is an integral part of the immigration medical examination for applicants from countries around the world. IRCC ensures that clients identified as having active TB are referred and complete treatment prior to entry into Canada, and requires those with previously treated active TB and LTBI (Latent TB Infection) follow up with PTs upon arrival in Canada. Clients applying from within Canada are also referred for treatment if active TB disease is detected. The Interim Federal Health Program (IFHP) covers treatment costs for active TB for eligible beneficiaries.

Indigenous Services Canada (ISC):

• ISC supports Indigenous partners in their development and implementation of distinctions-based TB elimination efforts, works collaboratively with partners to ensure First Nations, Inuit and Métis populations have access to high quality services, equipment and medicines. ISC supports Indigenous Peoples to independently deliver services and address the socio-economic conditions in their communities that result in the disproportionate rates of TB seen in this population.

Public Health Agency of Canada (PHAC):

• PHAC provides national leadership related to the public health aspects of TB and works collaboratively with domestic and international partners to address TB prevention and care. This includes surveillance, guidance, diagnosis and treatment, outbreak management, applied research, enforcing measures under the Quarantine Act to prevent the introduction and spread of TB and providing laboratory reference services.