HESA Committee Report
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RESPONSE OF THE GOVERNMENT OF CANADA TO THE THE WAY FORWARD: ADDRESSING THE ELEVATED RATES OF TUBERCULOSIS INFECTION IN INTRODUCTION 1. The Standing Committee on Health (hereafter referred to as “the Committee”) Report, The Way Forward: Addressing the Elevated Rates of Tuberculosis Infection in On-Reserve First Nations and Inuit Communities, presents a valuable examination of the impact of tuberculosis (TB) on First Nations and Inuit (FN/I) populations in Canada. The report brings attention to recent surveillance data which demonstrate an ongoing gap in TB rates between First Nations and Inuit and non-Aboriginal Canadians, while recognizing the complexities involved in addressing these elevated rates. 2. The Government of Canada (GoC) shares the Committee’s interest in increasing efforts to reduce TB rates among on-reserve First Nations and Inuit. The Government would like to take this opportunity to elaborate on its current actions to address TB among First Nations and Inuit communities, and respond to the considerations raised in the Report. 3. As recognized in the Report, while provincial and territorial governments have primary responsibility for TB treatment, reducing rates of tuberculosis among Aboriginal people is an area of shared responsibility. 4. Under Health Canada’s National TB Elimination Strategy, the GoC provides access to equitable, culturally appropriate and timely diagnostics, treatment and follow up care to on-reserve First Nations. For Inuit living in Nunatsiavut in Labrador, Health Canada enhances TB programming delivered by the province. All Health Canada programming is managed in close collaboration with provincial TB control regimes, scientific experts and a range of other TB partners. The provision of TB treatment to Inuit living in Nunavik, Quebec and to off-reserve Aboriginal people (including FN/I living in the territories) is managed by the respective provincial and territorial governments. 5. However, all partners are engaged in coordinated efforts to reduce TB rates nationally and internationally. In 2006, the Minister of Health announced Canada’s adoption of a TB reduction target of 3.6 cases per 100,000 by 2015, in line with the Global Plan to Stop TB 2006 – 2015[1] . Led by the Public Health Agency of Canada (PHAC), the federal agency responsible for overall management of TB prevention and control in Canada, the GoC is currently in the process of completing the Canadian Tuberculosis Prevention and Control Strategy to support realization of this target. Collaboration with the provinces and territories will be key to the development and implementation of the strategy. 6. Given the impact of TB on First Nations and Inuit, the GoC recognizes that reducing the current national TB rate of 4.8 cases per 100,000 to the Stop TB target of 3.6 per 100,000 will require new approaches targeting these population groups. The GoC is currently engaged in a broad renewal of the 1992 National TB Elimination Strategy in order to further reduce TB rates among on-reserve First Nations and Inuit of Nunatsiavut in Labrador. The renewal will be one component of the broader Canadian strategy. 7. As a significant number of the Committee’s recommendations focus on the National TB Elimination Strategy, the response will begin with an overview of current and planned federal actions under the strategy. It will then turn to the remaining three themes addressed by the Committee: Collaboration Across Jurisdictions, Involvement of First Nations and Inuit Communities in TB Prevention and Control, and Social Determinants of Health. HEALTH CANADA’S NATIONAL TB CONTROL PROGRAM AND ELIMINATION STRATEGY Current Programming – Health Canada First Nations and Inuit Health Branch 9. Funding has increased steadily since 1992, with investments from 2004/2005 to 2009/2010 totaling $42.4 million. Last fiscal year alone (2009/2010), the GoC invested $9.6 million to support and deliver TB prevention and control programs on reserve and in Nunatsiavut. This included emergency outbreak funding of $2.3 million. The GoC consistently ensures resources are available to cover any surge capacity required to address TB outbreaks. 10. Under the strategy, national responsibilities include policy-making and surveillance. Activities such as case management, drug supply, outbreak management, and community health education are managed at the Regional level. TB program activities vary across Regional offices according to the unique needs and circumstances of the populations served, and in collaboration with the respective provincial TB regimes. Regional activities include: surveillance, mobile clinics to support TB control in some areas; TB education sessions and workshops for community members, leaders, nurses and Directly Observed Therapy (DOT) workers; coordination of case finding, contact tracing, screening, initiation and ongoing follow-up of treatment; medication administration through DOT for active TB cases and Directly Observed Prophylactic Therapy (DOPT) for clients on treatment for Latent TB Infection (LTBI); and improved community and professional awareness of the impact of social determinants of health on overall health and the development of certain diseases including TB. Finally, Health Canada’s Regional offices track indicators to measure program performance in key areas such as: workforce competencies, public education, surveillance, and coordination with provinces and health authorities to ensure effective delivery of TB services. 11. The reporting of TB cases is mandatory at the P/T level. Health care staff at the community level report TB cases to the appropriate provincial or territorial authority. Provinces and territories then voluntarily report all TB cases to PHAC, which manages the Canadian Tuberculosis Reporting System (CTBRS). The Public Health Agency of Canada provides data to Health Canada’s FNIH officials under an interdepartmental data sharing agreement. PHAC also shares data with the provinces and territories and various other partners, including FN/I communities. This valuable epidemiological information is used to enhance TB prevention and control efforts across the country. The Role of the Public Health Agency of Canada (PHAC) in TB 13. The Canadian Tuberculosis Committee (CTC) is an advisory body with representation from Federal/Provincial/Territorial (F/P/T), non-governmental organizations (NGO) and professional societies. It is mandated to provide scientific advice to PHAC on strategies and priorities with respect to tuberculosis prevention and control. Decisions of the CTC are reported to member organizations and to the Communicable Disease Control Expert Group of the Pan-Canadian Public Health Network. PHAC supports and funds the CTC as well as its sub-committees. The Aboriginal TB Scientific Subcommittee provides scientific, evidence-based and expert advice to the CTC regarding TB prevention and control in Aboriginal populations in Canada. 14. PHAC also monitors TB antibiotic drug resistance through the Canadian Tuberculosis Laboratory Technical Network and produces the annual Tuberculosis Drug Resistance in Canada report. This report is used by clinical and public health authorities across the country to aid in the understanding of antimicrobial resistance in Canada; and as a tool to assist the development of strategies for the prevention and control of antimicrobial resistant TB. Renewal of Health Canada’s 1992 National TB Elimination Strategy 16. TB rates dropped among registered First Nations from 121.6 per 100,000 in 1975, to just under 50 cases per 100,000 in 1991 , this remained much higher than the Canadian population as a whole, which was 7.2 per 100,000 in 1991[2]. Further significant reductions among the Registered Indian population occurred between 1992 (incidence rate of 57.6 per 100,000) and 2008 (26.6 per 100,000). However, it is evident that for TB rates to be reduced even more, new approaches need to be developed. Consistent with the Committee’s recommendation, work to renew the National TB Elimination Strategy is being pursued on an accelerated basis in collaboration with FN/I partners, other federal departments, provincial and territorial governments, TB experts, and other stakeholders. 17. The Committee recommends an evaluation of past funding allocations to Health Canada’s National TB Program by the Office of the Auditor General (OAG). While it is beyond any Department’s power to direct the OAG’s evaluation and audit work, the renewal of the National TB Elimination Strategy will include enhanced indicators and targets, such as TB treatment completion rates, in line with the Committee’s recommendation, and will be informed by internal evaluation results including regularly collected information on activities such as: collaboration; community education and awareness; capacity building; and TB surveillance and research. 18. The GoC recognizes the need to focus on prevention and control activities in those FN communities that are considered hyper-endemic (i.e., continuing high rates over an extended period). The renewal of the 1992 National TB Elimination Strategy will describe new and improved approaches to target these communities. The new approaches will be based on results of TB monitoring in these communities, as well as program evaluations conducted in Manitoba, Saskatchewan, the two Regions with elevated rates of TB. 19. The renewed Strategy will capitalize on current best practices and ensure the most effective technologies and approaches in TB prevention and control are used to bring further reductions in TB in the FN/I populations. Consistent with the Committee’s recommendation, renewal will address gaps in the current data collection and sharing activities with First Nations, the Public Health Agency of Canada (PHAC), provinces and territories, and regional and/or local health authorities. 20. Health Canada’s renewed 1992 National TB Elimination Strategy will ultimately be an appendix to the PHAC’s overarching Canadian TB Prevention and Control Strategy. The strategies will complement each other and will include sections on TB indicators to facilitate better performance measurement and accountability. Implementation of both PHAC’s Canadian Strategy and Health Canada’s renewed 1992 National TB Elimination Strategy is expected to begin in 2011 using a phased in approach. 21. The Committee recommends that the GoC, through Health Canada, continue to engage FN/I, enhance local capacity and support grass-roots initiatives. FN/I engagement is the bedrock of TB programming. Community funding agreements are used to support integrated community planning based on individual community needs. Regional offices also continue to coordinate and support initiatives such as TB training for community health nurses and community health workers, as well as the Strategic Community Risk Assessment and Planning for the Enhanced TB Programming (SCRAP-TB), which has led to greater community ownership of TB programming. 22. SCRAP-TB, a tool piloted in British Columbia, was developed to enhance community capacity to develop TB programs. It was developed in partnership with Regional TB coordinators, TB nurses in the field, First Nations community representatives, TB experts and Health Canada officials. Several Health Canada Regions have adopted SCRAP-TB since its inception. An evaluation of the SCRAP-TB tool and its current dissemination in regions, utilization and utility has been completed. Health Canada is now considering the recommendations from the evaluation report as well as other new strategies to further support and promote the use of this community-based resource tool within Regional TB programs under the renewal of the 1992 National TB Elimination Strategy. 23. Health Canada, the Assembly of First Nations (AFN) and Inuit Tapiriit Kanatami (ITK) work in partnership on FN/I-focused TB prevention and control activities. Information is shared among all parties to ensure approaches to TB reduction are culturally appropriate and represent the needs of the recipients. 24. Health Canada provides ongoing capacity funding to the AFN and ITK to actively participate in joint TB initiatives. Funding is also provided by the GoC for specific initiatives. For example, Health Canada, PHAC and the Canadian International Development Agency provided financial assistance to support the 2008 Global Indigenous STOP TB Expert Meeting, co-hosted by AFN and ITK. This meeting brought together TB experts and Indigenous experts to develop an action plan to reduce the burden of TB within Indigenous populations globally. The plan complements the STOP TB Partnership’s Global Plan framework for Indigenous specific actions. 25. Health Canada, in partnership with AFN and ITK, brought together FN/I youth in December 2009 to create a series of storylines to help raise TB awareness in their respective populations. The materials have been professionally illustrated by a group of FN/I artists through a non-profit Aboriginal organization that specializes in delivering health messages through illustration. The materials, printed in poster and booklet format and distributed to FN/I communities, have been well received. COLLABORATION ACROSS JURISDICTIONS 26. The Committee made a number of recommendations related to increased collaboration across jurisdictions. The Canadian federal health system, by its very nature, relies on collaboration across jurisdictions. As described previously, addressing TB among First Nations and Inuit is an area of shared responsibility. The GoC supports a number of mechanisms to ensure effective cross-jurisdictional collaboration, including the activities of the CTC described above. 27. The Canadian Tuberculosis Standards, 6th edition is a joint production of the Canadian Lung Association, Canadian Thoracic Society and PHAC. The Standards are the definitive TB prevention and control guidelines for Canada. This publication draws upon current Canadian epidemiological, microbiological, respiratory medicine, infectious disease and public health expertise in TB. The Standards have a chapter dedicated to TB control among FN/I populations (used by Health Canada’s Regions in their TB efforts on reserve). 28. Health Canada’s Regional offices work actively with provincial and First Nations partners to ensure a coordinated and holistic approach to medical and public health interventions for on-reserve TB cases that meet up-to-date standards of care, and are consistent with best practices. For example, in Alberta, collaboration between the provincial government, Health Canada Region and First Nations contributed to a reduction in the rate of TB by 45 % from 1998 to 2008. In 2008 there were eight active cases of TB reported for on-reserve FN in Alberta. Despite these efforts, Health Canada will continue to collaborate with the province of Alberta to reduce the level of incidence nearer that of the general population. 29. In Manitoba, for example, co-ordination occurs as Health Canada’s Regional Office funds the Winnipeg Regional Health Authority (WRHA) to provide TB case and contact management services to persons living on reserve. They also provide direct support and services to First Nations communities affected by TB, including TB community health nurses, DOT workers, ongoing education, incentives, drugs and other services. The Province of Manitoba remains responsible for the overall direction of the TB program, the central TB data registry, support for regional health authorities, and development and maintenance of the Manitoba TB prevention and control program manual. 30. It is noteworthy that in Manitoba, the site of some of the First Nations communities most affected by TB, Health Canada’s invests more than $55,000 per on-reserve TB case through enhanced collaboration with First Nations and the Province. This is exclusive of funds to manage new outbreaks, and reflects the greater capacity of both provincial health entities and Health Canada’s Region to respond to TB needs. 31. The Committee recommends that Jordan’s Principle be adopted and applied in the context of TB prevention and treatment to ensure that the necessary care for First Nations children is not delayed or disrupted due to jurisdictional disagreements or disputes. There have been no reported cases to date of First Nations children having TB treatment delayed due to jurisdictional disputes, which is indicative of strong F∕P∕T collaboration. The federal response to Jordan’s Principle focuses on children with multiple disabilities requiring multiple service providers. TB cases do not typically fall into this category. Health Canada, PHAC and all partners involved in the treatment of TB will continue to work together to ensure that no First Nations child suffers from delays in TB treatment due to jurisdictional issues. SOCIAL DETERMINANTS OF HEALTH 32. The Committee recommended that the GoC address the Social Determinants of Health (SDOH), and specifically that it establish an interdepartmental committee on these important issues. The GoC has already taken action to address SDOH. For example, the Minister of Health proposed legislation to amend the Tobacco Act in 2009 that improved the protection from tobacco marketing aimed at Canadian youth. This Act received Royal Assent on October 8, 2009 and came fully into force on July 5, 2010. As well, Canada’s Economic Action Plan (CEAP) launched the Recreational Infrastructure Canada program (RInC) in May 2009, which provided $500 million in available funding to build new recreational facilities or renovate and repair old ones. The RInC initiative has allowed several First Nations communities to improve their physical activity infrastructure, which helps in improving SDOH. Understanding Determinants of Health 34. Some remote and isolated on-reserve FN/I communities face challenges due to inadequate housing and low incomes. Where there is poverty, overcrowding and inadequate housing, diseases such as diabetes and particularly HIV/AIDS increase the risk of contracting TB. In addition, the lack of ready access to a full range of medical services in some FN/I communities aggravates the problem. Finally, the unique cultural, educational and language differences that prevail in many Aboriginal communities can sometimes present barriers to receiving the most appropriate and effective health care. 35. Improving the underlying social and economic factors in FN/I communities is an important way of mitigating and preventing diseases, including TB. Health Canada works with its partners and with other government departments, such as Indian and Northern Affairs Canada (INAC), on the SDOH which affect susceptibility to TB, as described below. General Health 37. Safe drinking water is a key contributing factor to good health. The GoC has introduced the Safe Drinking Water for First Nations bill in Parliament to address the regulatory gap that exists for FN communities when it comes to safeguarding their drinking water. This proposed legislation follows from recommendations made by the Office of the Auditor General, the Expert Panel on Safe Drinking Water for First Nations and the Standing Committee on Aboriginal Peoples. Health Canada and INAC work in collaboration with First Nations communities to ensure that communities have access to safe drinking water. Health Canada has also made continuing significant investments since 2002, to increase capacity to sample and test drinking water quality. This includes verification monitoring of the overall quality of drinking water and providing public health inspections of community wastewater systems as well as advice, guidance and recommendations to FN/I communities to prevent drinking water contamination and waterborne illnesses. 38. PHAC is exploring, with federal partners, how to address the root causes of population health issues. PHAC also supports dialogue between health and non-health stakeholders outside government. For example, PHAC co-chairs and supports the operations of the Canadian Reference Group on Social Determinants of Health, engaging many sectors of government, civil society, business and academia in an effort to reduce health inequalities. In addition, PHAC participates in the Conference Board of Canada Expert Roundtable on Socio-Economic Determinants of Health, as a step to further engage the private sector in addressing these factors. 39. Health Canada and PHAC have programs that address broader social determinants of health, such as the Aboriginal Head Start Program, which prepare Aboriginal children from on-reserve, urban and Northern populations for success in school. In addition, the Community Action Program for Children and the Canada Prenatal Nutrition Program (of which there is a FN/I component) promote the health of and address the health inequalities affecting pregnant women, young children and their families. Food Security 41. A recently announced joint INAC-Health Canada program, Nutrition North Canada (NNC), will begin full implementation starting April 1, 2011. NNC will provide subsidies to retailers who, on the basis of competition and market forces, will determine cost-effective ways to transport healthy food to the North. In this program, Health Canada will partner with communities to offer culturally-appropriate nutrition and health promotion initiatives, including educational campaigns that will provide vital information on the use, marketing and preparation of nutritious foods to support healthy eating. Approximately 80 communities across the North, with an estimated total population of 90,000 will benefit from this program. Housing 43. Health Canada also relies on work such as the CTC’s Advisory Committee Statement published October, 2007, on Housing Conditions which Serve as Risk Factors for Tuberculosis Infection and Disease, as this is relevant to the issue of TB prevention and control in FN/I communities in terms of the development of strategies to reduce the incidence of TB. 44. Although the provision and management of housing on reserve lands is the responsibility of First Nations, INAC and CMHC provide support for the construction of about 2,300 new units and the renovation and repair of approximately 3,300 units per year, as well as various other housing initiatives. Through INAC’s funding alone, more than 2,100 units were built or renovated on reserve in 2009/2010. 45. In addition to this ongoing funding, Canada’s Economic Action Plan allocated a further $400 million over 2009/2010 and 2010/2011 for new on-reserve housing, social housing repair and renovation, remediation, lot servicing and to transition to market-based housing. An additional $200 million was dedicated for social housing, renovations and new construction in the North. 46. Under the renewed five year (2010-2015) Nunavik Housing Agreement (through the implementation of the James Bay and Northern Quebec Agreements) Canada will provide just over $17 million annually for the construction of social housing units for northern Quebec residents covered by the Agreements. Employment and Economic Development 48. To assist in building community economic capacity, Human Resources and Skills Development Canada (HRSDC) implements complementary national Aboriginal labour market programs to support the participation of Aboriginal people in the Canadian economy. These programs address skills development through partnership building and include: the Aboriginal Skills and Employment Training Strategy (2010-2015), the Aboriginal Skills and Employment Partnership, and the Aboriginal Skills and Training Strategic Investment Fund (2009/2011). 49. To assist Aboriginal Canadians in developing community economic and business development opportunities, INAC offers community economic development and business development programming to increase the participation of Aboriginal Canadians in the economy. These programs include the Community Economic Development Program, Aboriginal Business Canada, and the new Federal Framework for Aboriginal Economic Development. 50. Finally, INAC offers employment and education programming to FN/I youth, including: the First Nations and Inuit Youth Employment Strategy, the First Nations and Inuit Summer Work Experience Program, the First Nations and Inuit Skills Link Program, the Post-Secondary Education Program, and the Indian Studies Support Program. CONCLUSION 51. The GoC has long acknowledged the complexity of TB and the need for coordinated efforts by multiple partners to reduce the burden of this disease. Despite significant reductions in TB rates among First Nations over the past 30 years, more work needs to be done. Health Canada’s renewed 1992 National TB Elimination Strategy will target the small number of communities where TB has been found to be hyper-endemic; it will use indicators and evaluations to inform program decision making; and, it will be complementary to the PHAC National Strategy to reduce TB rates across Canada. Health Canada will ensure that interventions are effective and coordinated with First Nations and Inuit partners, and provincial, territorial, regional or local jurisdictions. 52. As noted by the Minister of Health in a presentation to the HESA on March 16, 2010, addressing the social determinants of health for First Nations is one of the most important ways to prevent disease, including TB. “We have invested significantly over the last three years to support the better health outcomes, and it’s not just in areas of treatment of tuberculosis... We’ve made significant investments in infrastructure, social housing, in First Nations communities and Inuit communities.” The Minister also noted that investments in healthy foods and the passage of tobacco legislation are other initiatives led by the federal government that address the underlying factors affecting high incidence rates of TB. 53. In addition to sustained TB programming, the GoC will continue to work on addressing the social determinants of health in a holistic and comprehensive manner. Addressing the SDOH will help to reduce the factors currently driving hyper-endemic TB in certain geographical areas, and further strengthen TB resistance of FN/I communities. 54. The GoC plays an important role in leadership, coordination, surveillance and capacity building within FN/I communities to address TB. This includes supporting knowledge development and exchange, as well as monitoring and evaluating interventions and innovations. The federal government will continue to work to improve knowledge on the influence of determinants of health on FN/I health and to continually improve policies and programming accordingly. Finally, the GoC will develop new strategies to better inform actions to address TB. 55. The GoC is committed to collaborating with Aboriginal organizations, advocacy groups, the private-sector, FN/I communities, regional offices and other stakeholders to reduce the incidence of TB in the Aboriginal populations of Canada. Health Canada is committed to ensuring that its 1992 National TB Elimination Strategy renewal is implemented collaboratively with the full range of its partners. [1] Reference located at: http://www.stoptb.org/global/plan/default.asp [2] The changes in the Inuit rate are harder to assess because reliable rates were not available until 2001.
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