Leadership and political will are needed to address tuberculosis in Canada

Key points

• Although tuberculosis (TB) disease is preventable and curable, it affects nearly 11 million people worldwide each year, more than 2000 of whom live in Canada.

• In Canada, TB overwhelmingly affects Indigenous people and those born outside the country.

• To facilitate progress to TB elimination, political will and leadership should support the implementation of 4 key solutions: creation of a national body to lead the TB response; improved availability and usability of national TB surveillance data; increased access to essential TB medications; and better funding for TB research and development both domestically and internationally.

Despite being preventable and curable, tuberculosis (TB) disease affects nearly 11 million people worldwide per year, more than 2000 of whom live in Canada.^1,2 In 2014, the World Health Organization (WHO) released the End TB Strategy, an ambitious plan for global elimination that has resulted in impressive breakthroughs, including shortened treatment and meeting global targets for disease prevention in people living with HIV.^3,4 Steady reductions in incidence followed; however, this trajectory was challenged by the diversion of resources to address COVID-19. Now the global TB burden is projected to skyrocket following withdrawals of United States Agency for International Development funding, making this a critical juncture for collective elimination efforts.⁵

Canada endorsed End TB targets and committed to achieving domestic pre-elimination (< 1 case/100 000 population) by 2035.⁶ With less than a decade to achieve this goal, the country is headed in the wrong direction. In 2023, the crude TB rate, at 5.5 cases/100 000 population, was the highest recorded since 2001.^2,7 Moreover, Canada was the only G7 nation with an incidence increase of more than 20% between 2015 and 2023. The United Kingdom, Germany, Italy, and Japan all showed a 10% to 19% decrease over the same period.¹ We discuss why Canada needs better leadership and political will to address TB, and offer several suggestions.

Tuberculosis services in Canada, including screening for newcomers, are largely delivered by provincial and territorial governments, with federal funding for select populations (e.g., Indigenous people living on reserve, federal inmates, refugee claimants). This multijurisdictional system often leads to fragmented responsibilities, variable standards of care, and slow collective action. In Canada, TB remains largely a population health challenge, raising important questions about equity for key affected groups. The last year of publicly reported data (2023) shows that although pre-elimination has all but been achieved within the Canadian-born, non-Indigenous population, 80% of those affected by TB were born outside Canada.² Indigenous people experienced 16% of new TB diagnoses, whereas they comprise about 5% of the population.² Addressing these disparities will require focused support for communities at risk, which includes scaling up screening and treatment for TB infection and positively affecting root causes, such as poverty, racism, and poor health care access. Such campaigns require political prioritization, investment, and multisectoral collaboration.

In 2024, recognizing the need for action, national policy-makers convened a time-limited task group within the Pan-Canadian Public Health Network, consisting of Indigenous, federal, provincial, and territorial partners, and charged the group with developing a TB elimination plan. In parallel, nationwide consultations of key groups culminated in the release of the Government of Canada’s Tuberculosis Response;⁶ although welcome, the document fails to describe critical implementation considerations, including funding and accountability.

Several important issues must be addressed for Canada to progress toward TB elimination. Indigenous, federal, provincial, and territorial TB programs currently work in silos, without a collective voice. Volunteer networks such as the Canadian TB Elimination Network and Stop TB Canada coordinate and advocate for change but lack resources and authority. Canada’s TB data-collection system is slow and produces simplistic, outdated metrics that do not shed light on current problems,⁸ including catastrophic costs experienced by people born outside Canada, some of whom lack health insurance. In addition, TB physicians in Canada must navigate a complex regulatory framework to access many WHO-recommended TB medications that are not licensed here but improve TB outcomes. Examples include bedaquiline for drug-resistant disease, rifapentine for shortening preventive therapy, and formulations designed to more effectively treat children.⁹ Finally, dedicated funding for TB research and development is lacking, resulting in missed opportunities to benefit from innovation. We offer 4 solutions to address longstanding concerns in support of TB elimination efforts in Canada.

First, a national body should be created to champion Canada’s TB response. Aligned with the recommendations of TB scholars,¹⁰ Canada needs a standing committee on TB to advocate for much-needed resources, create accountability mechanisms for reaching elimination targets, and amplify concerns of key partners (e.g., Indigenous leaders, newcomer or ethnocultural groups, public health officials). Such a body would report to Parliament through the Communicable and Infectious Disease Steering Committee but could also advocate for the creation of an additional operational unit, housed within the Public Health Agency of Canada, to strengthen the delivery of national TB care. An operations unit could improve TB care nationwide by coordinating care across jurisdictions, supporting implementation of diagnostic and treatment innovations, and strengthening workforce training for culturally appropriate, community-driven services.

Second, the availability and usability of Canadian TB data should be increased. Data on the determinants of TB and distinct epidemiologic trends among Indigenous communities and people born outside Canada are needed to drive effective community-based responses. Ensuring TB is a priority within the Pan-Canadian Health Data Strategy would facilitate Indigenous-led and multisectoral action based on indicators from reliable, timely, linked data sets. In the same way that countries such as the US have benefited from concerted efforts to improve TB surveillance, Canada can use whole genome sequencing data to better respond to outbreaks, and track trends on risk factor prevalence to better guide primary prevention.¹¹

Third, improved access to essential TB medications is needed. Canada’s drug approval process and relatively small global market share may disincentivize manufacturers from seeking regulatory approval for newer TB medications. Canadian regulators should implement solutions that incentivize manufacturers to submit new medications for approval. Other policy interventions could improve access to essential TB medications. For example, a national stockpile of medications to treat drug-resistant TB would substantially improve care for many people born outside Canada. Removing regulatory barriers to the purchase of child-friendly formulations from the Global Drug Facility, as has been done in countries such as Spain,¹² is critical to preventing serious childhood TB illness.

Fourth, domestic and international TB research and development must be funded strategically. Elimination of TB will require biomedical, technological, and health system innovation. Canada has not developed its full potential to be a scientific leader on TB, which requires increased spending. Domestic TB elimination can be advanced with research to support the scale and spread of effective interventions. Promising examples include Ontario’s TB Diagnostic and Treatment Services for Uninsured Persons (TB-UP) program, which funds necessary care for uninsured people, and Taima TB, which has successfully reduced stigma and other barriers to TB preventive treatment in Nunavut.^13,14 Canada should also increase spending on implementation studies for effective TB interventions in high-burden countries. Not only is this Canada’s responsibility as a high-income nation, but modelling shows that supporting international efforts may be the most effective way to reduce TB at home.¹⁵

Implementing these recommendations will not occur without leadership, coordination, and accountability. Canada has the resources required to reverse current trends and move toward TB elimination, but political prioritization and collective action are needed to use resources effectively.

See related editorial at www.cmaj.ca/lookup/doi/10.1503/cmaj.252036