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Tuberculosis Prevention, Diagnosis, and Care in Manitoba, 2008-2010

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Tuberculosis Prevention, Diagnosis, and Care in Manitoba, 2008-2010 Tuberculosis Prevention, Diagnosis, and Care in Manitoba, 2008-2010: A Performance Analysis by C. Andrew Basham A Thesis submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfilment of the requirements for the degree of MASTER OF SCIENCE Department of Community Health Sciences University of Manitoba Winnipeg Copyright © 2016 by C. Andrew Basham ABSTRACT A cross-sectional study of Manitoba TB Registry data was conducted using a set of performance measures based on the US Centers for Disease Control and Prevention TB Performance Objectives and Targets framework. The study investigated all cases of TB diagnosed in Manitoba during the period of 2008 to 2010 (inclusive), and their contacts. Seven performance measures (PMs) were analyzed: treatment completion/cure, early diagnosis, HIV testing/reporting, paediatric cases, retreatment cases, contact elicitation, and contact assessment. Ethnic-origin, age, sex, geographic, and treatment history groups were compared on these PMs through log-binomial and robust Poisson regression analyses, implemented through a generalized estimating equations (GEE) modelling approach. An updated epidemiological profile is provided, along with a baseline of performance in TB prevention, diagnosis, and care in Manitoba. Significant differences were found between Manitoba sub-populations in the PMs. The PM framework developed in this study provided valuable information for TB program planning and evaluation. i ACKNOWLEDGEMENTS I would like to thank my Thesis Committee, and in particular Drs. Elias and Orr, for their commitment of time and energy towards this study. I would also like to acknowledge the Western Regional Training Centre in Health Services and Policy Research (WRTC) for providing me the funding to enter the M.Sc. Program in Community Health Sciences along with the Network Environment for Aboriginal Health Research (NEAHR) who supplemented my initial scholarship from WRTC. I acknowledge the Manitoba Health Research Council (MHRC) for providing scholarship funding to me in my second year, supported my studies. Funding from the Canadian Institutes of Health Research (Dr. Brenda Elias – CIHR HOA 80062) enabled me to complete this study. I would like to acknowledge the Manitoba Keewatinowi Okimakanak (MKO) for their work on TB in Northern Manitoba, from which this project originated. I would like to acknowledge the Assembly of Manitoba Chiefs' Health Information and Research Governance Committee (AMC-HIRGC), including both its membership and administration, for reviewing my research proposal as it involved First Nations (FN) people. I also acknowledge the work of people at Manitoba Health, Public Health Division, who reviewed, approved, and executed the data extraction necessary for this study. I appreciate Drs. Nancy Yu and Jamie Blanchard for hosting me during the data analysis, which was conducted at the Centre for Global Public Health (CGPH), Applied Public Health Evaluation and Research Unit (APHERU). I also appreciate advice from Dr. Depeng Jiang, Biostatistical Consulting Unit, Department of Community Health Sciences, regarding statistical methods. ii Table of Contents 1. INTRODUCTION................................................................................................................................1 Study Rationale.................................................................................................................................3 Study Purpose...................................................................................................................................9 Research Questions...........................................................................................................................9 Study Objectives...............................................................................................................................9 2. LITERATURE REVIEW..................................................................................................................11 PART I. TUBERCULOSIS IN CANADA: HISTORY, EPIDEMIOLOGY, AND PRINCIPLES FOR PREVENTION, DIAGNOSIS, AND CARE...........................................................................................................................11 History of TB Prevention, Diagnosis, and Care in Canada............................................................13 Manitoba TB Prevention, Diagnosis, and Care..............................................................................16 Modern TB Prevention, Diagnosis, and Care.................................................................................19 Social Determinants of TB.............................................................................................................23 Epidemiology of TB in Canada......................................................................................................27 Epidemiology of TB in Manitoba...................................................................................................31 Drug-Resistant TB in Manitoba..................................................................................................35 PART II. PERFORMANCE MEASUREMENT IN TB PREVENTION, DIAGNOSIS, AND CARE..................37 From Neglect to Performance Measurement: TB Elimination in the United States...................38 Performance Measures Used in TB Prevention, Diagnosis, and Care...........................................42 Early Detection of Pulmonary TB: Smear Negative at Diagnosis..............................................42 Human Immunodeficiency Virus (HIV) Testing & Reporting......................................................43 Contact Investigation and Latent TB Infection Diagnosis and Treatment..................................46 Treatment Completion.................................................................................................................50 Paediatric Cases..........................................................................................................................51 Re-Treatment Cases.....................................................................................................................53 Laboratory Reporting..................................................................................................................53 Treatment Initiation.....................................................................................................................54 Directly Observed Treatment.......................................................................................................54 Sputum-Culture Conversion........................................................................................................55 Examples of Performance Measurement in Canadian TB Prevention, Diagnosis, and Care.........56 Summary of Literature Review......................................................................................................65 3. METHODOLOGY.............................................................................................................................69 Research Questions Revisited........................................................................................................69 Study Design...................................................................................................................................70 Study Population.............................................................................................................................71 Data Source.....................................................................................................................................72 Performance Measures – Towards a Framework............................................................................74 Dependent Variables.......................................................................................................................75 Independent Variables.....................................................................................................................76 Demographic Groups..................................................................................................................78 Ethnic-Origin Group.............................................................................................................79 Age Group.............................................................................................................................80 Sex.........................................................................................................................................81 Geography...................................................................................................................................81 Bacterial Status...........................................................................................................................82 STATISTICAL ANALYSIS.......................................................................................................................82 Odds Ratios versus Prevalence/Probability Ratios.........................................................................83 Log-Binomial Regression............................................................................................................85 Robust Poisson Regression..........................................................................................................86 Analysis of Performance Measures................................................................................................87
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