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Volume 11, Number 1Volume 11, Number 1Volume 11, Number 1Volume 11, Number 1Volume 11, Number 1 January 28, 2000January 28, 2000January 28, 2000January 28, 2000January 28, 2000

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Epidemiology of Tuberculosis inEpidemiology of Tuberculosis inEpidemiology of Tuberculosis inEpidemiology of Tuberculosis inEpidemiology of Tuberculosis inOntario: Update 1998Ontario: Update 1998Ontario: Update 1998Ontario: Update 1998Ontario: Update 1998

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StatisticsStatisticsStatisticsStatisticsStatistics• November 1999• Rabies Report, 3rd Quarter, 1999

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Public Health andEpidemiology Report Ontario��

M i n i s t r y o f

Health and Long-Term Care

01/28/0001/28/0001/28/0001/28/0001/28/0022222PHEROPHEROPHEROPHEROPHERO

EPIDEMIOLOGY OFEPIDEMIOLOGY OFEPIDEMIOLOGY OFEPIDEMIOLOGY OFEPIDEMIOLOGY OFTUBERCULOSIS IN ONTTUBERCULOSIS IN ONTTUBERCULOSIS IN ONTTUBERCULOSIS IN ONTTUBERCULOSIS IN ONTARIO:ARIO:ARIO:ARIO:ARIO:UPDAUPDAUPDAUPDAUPDATE 1998TE 1998TE 1998TE 1998TE 1998

IntroductionIntroductionIntroductionIntroductionIntroductionAt the beginning of the 20th century, tuberculosis (TB)was the leading cause of death due to infectious disease1.Although improvements in public health and discoveryof antituberculous drugs led to a decline in the incidenceof TB and to a vision of TB elimination, the incidenceof TB began to climb again in Ontario in the 1980s.Factors responsible for this included increasedimmigration from countries with high TB rates, HIV,and the emergence of drug-resistant TB. Now with theadvent of the 21st century, TB has reemerged as animportant public health issue.

Currently, the World Health Organization (WHO)estimates that one-third of the world’s population isinfected with Mycobacterium tuberculosis and, in 1993,the WHO declared TB a global emergency.

Despite the vast amount of information available on theetiology, treatment, and prophylaxis of the disease,modeling data has shown that the global incidence ofTB is expected to increase from 8.8 million cases in1995 to 10.2 million cases by the year 2000 and up to11.9 in 2005. In addition to this, if it is assumed that thelevel of effectiveness and availability of treatmentprograms remain the same, 3.5 million deaths areexpected for the year 2000, an increase from3 million in 1995 2.

In Canada, while the incidence of TB hasdeclined over the past few decades, this rateof decline has leveled off with approximately2000 new cases and more than 100 deathsreported annually3. Although the rate of TBin Canada is one of the lowest in the world atabout 7 per 100,000 population per year, theTB rates in sub-populations still vary. Whilethe rate of TB among Canadian-born non-aboriginal people is approximately 1 per100,000, rates of TB among aboriginal peopleare still high at 70 per 100,0004. In additionto this, there are a large number of immigrants,refugees and visitors arriving in Canada eachyear from countries with high rates of TB.The risk of reactivation of disease in persons

who have had previous TB disease is increased in theforeign-born group4. The ten countries with the highestincidence rates for TB are presented in Table 15.

In 1996, 76% of TB cases reported in Canada occurredin Ontario, Quebec, and British Columbia (Figure 1).The rate of TB was highest in the Northwest Territoriesat 53.9 cases per 100,000 which is attributed to highrates among the mainly aboriginal population3. Ontarioaccounted for the highest number of cases acrossCanada representing 41.4% of all Canadian TB casesand 36.2% of the Canadian population.

In order to more closely examine the emergent TBissues in Ontario, a descriptive analysis of the 1996 to1998 Ontario TB data as well as an in-depth look at thetrends in drug-resistant TB from 1990 to 1998 wereundertaken. This report is an update of the descriptiveepidemiology of TB in Ontario based on the format ofprevious reports published in PHERO6, 7, 8.

MethodsMethodsMethodsMethodsMethodsUnder the Health Protection and Promotion Act(HPPA), all new active and reactivated cases of TB areto be reported to the local medical officer of health.These reports are then transmitted, on a non-nominalbasis, to the Public Health Branch (PHB), OntarioMinistry of Health and Long-Term Care. Since 1990,TB cases have been reported electronically through theReportable Diseases Information System (RDIS) eachweek. For this report, records for TB cases withepisode dates from January 1, 1990 to December 31,

Top Ten countries of TB incidence Table 1

Source: Dye C, Scheele S, Dolin P, Pathania V, Raviglione M. Global Burden of Tuberculosis. JAMA. 1999; 282:677-686.

Country Rate/100,000Cambodia 539Zimbabwe 538

South Africa 392Afghanistan 333

Uganda 320Philippines 314Tanzania 308

Kenya 297Indonesia 285Ethiopia 260

3333301/28/0001/28/0001/28/0001/28/0001/28/00 PHEROPHEROPHEROPHEROPHERO

1998 were extracted from RDIS (inDecember 1999) and analyzed using Epi-Info (Centers for Disease Control andPrevention, Atlanta, Georgia). Cases from1996 to 1998 were analyzed for general TBtrends while all cases from 1990 to 1998were analyzed for trends in drug-resistantTB.

While this analysis looked at the descriptiveepidemiology of TB from 1996 to 1998, forspecific variables where the trends haveremained virtually unchanged over thisperiod, the data from the most recent year(1998) were presented. Where the numberswere small, particularly for analysesincluding the aboriginal population,aggregate data from 1996 to 1998 wereused.

The RDIS case definition for the reporting of TB is:

a) Mycobacterium tuberculosis complex (e.g., M. tu-berculosis, M. bovis (excluding BCG), or M.africanum) demonstrated on culture from sputum,body fluids, or tissues

or

b) without bacteriological proof but with clinical symp-toms or signs, radiological or pathological evidenceof active pulmonary or nonpulmonary disease, pref-erably with:i) a positive tuberculin skin test (as defined by theprovincial guidelines) and/or

ii) demonstration of acid-fast bacilli in smears fromsputum or other body fluids or tissues and/or

iii) response to antituberculosis treatment

For RDIS reporting, “new active” cases are defined ashaving no documented evidence or history of previousepisodes of active TB; “reactivated” cases are personswith active TB who have documented evidence orhistory of active TB which had become inactive.“Inactive” cases are those for whom cultures forMycobacterium tuberculosis have been negative for atleast 6 months, or if culture results are not available,where chest (or other) x-rays have been stable for atleast 6 months. Cases reported in RDIS as havinginactive TB were not included in this analysis.

For this analysis, primary pulmonary and pulmonaryTB were combined into one category of pulmonary TB.Respiratory TB includes pulmonary TB and otherrespiratory (e.g., laryngeal) TB but not pleural or miliaryTB.

In the RDIS reporting system, cases are classified bycountry of origin into three mutually exclusivecategories: 1) Canadian-born (does not includeaboriginal cases); 2) persons born outside Canada(foreign-born); and 3) aboriginal people, which includesregistered Indians, unregistered Indian/Metis, and Inuit.Cases in which the origin was missing or entered as“unspecified” accounted for 32 (1.4%) of all TB casesreported in the 1996 to 1998 period. It was assumed thatthese cases were comparable to the population analyzedand these cases were not included in any analysesincluding the origin variable.

1996 population census data for Ontario (StatisticsCanada) were used to calculate incidence rates for TB.

Data on drug-resistant TB were based on the informationavailable from the RDIS case reports. These data maydiffer slightly from drug sensitivity data based onlaboratory reports due to delays in reporting or enteringdata, or differences in case classification by year ofisolation or year specimen was received (laboratoryreports) versus year of symptom onset (RDIS data).Laboratory data may also reflect isolates rather thanindividual cases.

Incidence of Tuberculosis by Province/Territory

Canada 1996

Source: Laboratory Centre for Disease Control, Health Canada, 1999*Ontario data w as updated to reflect data from RDIS

4.22.2 1.6 2

4.57.2 8.5

11.1

58.2

19.1

53.9

6.3

NF PEI NS NB QC ON MB SK AB BC YT NWT Canada

Province

0

10

20

30

40

50

60Rate/100,000

0

10

20

30

40

50

60

Figure 1


ResultsResultsResultsResultsResultsIncidenceThe trends in the incidence of TB over the past 53 yearsfrom 1945 to 1998 are depicted in Figure 2. During theperiod from 1960 to 1988, a total of 32,351 cases ofactive TB were reported. The trend during this timeperiod shows a relatively steady decrease in the numberof reported TB cases from a peak of 2030 cases of TBin 1960, to 644 cases in 1988. The average number ofcases per year declined from 1,100 per year in the 1970sto approximately 700 per year in the 1980s 8.

The increase in cases of TB from 1988 to 1989 was, inpart, due to a change in the Ontario reportingsystem for TB which resulted in cases beingclassified by year of onset starting in 1990.Prior to 1990, cases reported through thepaper-based system were classified by datethat the case report was received at the healthunit. This change, in part, accounts for the10% increase in cases of TB from 1988 to1989, as some cases reported in 1990 wereclassified as 1989 cases based on their dateof onset.

This was followed by a slight increase inrates from 1989 to 1995. From 1990 to 1998,the average number of cases increased to800 cases annually (7.4/100,000 population).

Within Ontario, the geographic distributionof TB varies among health units (Figure 3).

In 1998, the highest incidence rates occurredin the amalgamated City of Toronto (17.0/100,000) followed by Ottawa-Carleton(10.1/100,000) and Hamilton-Wentworth(6.8 cases/100,000). Within theamalgamated Toronto, the highest rates ofTB occurred in the former: City of Toronto(20.7/100,000), Borough of East York(17.6/100,000), and City of Scarborough(17.5/100,000).

Consistent with previous years 8, the majorityof TB cases reported in 1998 resided inurban centres that tend to have higherconcentrations of new immigrants andrefugees. As depicted in Figure 4, the 6health units that now make up the

amalgamated City of Toronto, followed by Peel Regionand Ottawa-Carleton health units reported the highestnumber of cases in 1998.

A high incidence of TB was also reported by theNorthwestern health unit (9.1/100,000), where all 8reported TB cases in 1998 were of aboriginal origin.

DemographicsIn 1998, 53.8% of TB cases were males while 46.2%were female. Figure 5 shows the number of cases andage-specific rates of TB by sex for 1998. The mean ageof TB cases was 47 years.

Tuberculosis Cases by Health UnitOntario 1998

*As of Jan. 1, 1998, these health units became the amalgamated City of Toronto health unit.Data in this graph are presented according to former boundaries.

135

98

85

79

73

48

47

32

22

20

19

82

*Toronto*Scarborough

*North YorkPeel

Ottawa-Carleton*Etobicoke

York RegionHamilton-Wentworth

Waterloo*York City

*East York

Remaining Health Units

Health Unit

0 20 40 60 80 100 120 140 160

Number of Cases

Figure 4

Tuberculosis

Ontario, 1945-1998

!!

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

,

,

, , , , , , , , , ,, , , , , , , ,

, , , , , , , , , , , , , , , , , ,

1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995

Year

0

500

1000

1500

2000

2500

3000Number of Cases

Tuberculosis (Total) New Active Reactivated, !

Figure 2


For males, the age-specific rate of TB ranged from 1.1/100,000 in the 10-14 year age group to 24.9 per 100,000the 70+ year age group, reflecting the trend in previousyears8. Similarly, for females, the rates ranged from1.1/100,000 in the 5-9 year age group to 10.9/100,000in the 70+ age group. The age-specific rates are slightlyhigher for females in the 10-29 year age groups, afterwhich the age-specific rates are consistently higher formales. The largest difference between sex-specificrates occurred in the 70+ age group.

Of those TB cases aged 0-4 years that occurred between1996 and 1998, the majority (68%) were Canadian-born children. A prior survey of pediatriccases in Ontario9 found that the majority ofthese are first-generation Canadians livingin immigrant households (i.e., born toimmigrant parents). In the 5-19 age group,the majority of cases continue to occur inforeign-born children.

Figure 6 shows the age distribution of TBcases by origin. The mean age of Canadian-born cases was 47.6 years; for aboriginalcases the mean age was 45.7 years. Similarto previous years, the mean age for foreign-born cases was younger at 41.5 years. Forforeign-born cases, the number of casesreported peaked in the 25 to 39 year agegroups with a second peak occurring incases 60 to 79 years of age. For the Canadian-

born cases, the highest number of casesoccurred in those aged 70 to 79 years with asmaller peak in those under 4.

Between 1996 and 1998, 37.2% of caseswere less than 35 years, the age below whichthere is little concern about isoniazidhepatotoxicity and need for close monitoring.In the period from 1996 to 1998, of the 853cases in the under 35 year age group, 86.6%were foreign-born, 10.1% were Canadian-born, 2.7% of cases were aboriginal, and 5cases had missing or unspecified data fororigin. A large number of these cases weretherefore potentially preventable cases ofTB.

OriginBetween 1996 and 1998, 84.6% of all TB cases occurredin foreign-born individuals, 12.9% in Canadian-born,and 2.4% in aboriginal people.

As demonstrated in previous reports, for foreign-bornpersons, recent arrival in Canada is a risk factor for thedevelopment of active disease. In 1998, 36.4% of theforeign-born cases were diagnosed with active diseasewithin the first 2 years of arriving in Canada and a totalof 42.9% diagnosed within 5 years of arrival. Another36.0% had been in Canada between 5 and 15 years ofarrival. Overall, the mean time from arrival in Canada

Tuberculosis Cases by Age and SexOntario, 1998

&

&

& && &

& && &

&!

!

! !! !

! ! ! !!

0-4 5-9 10-14 15-19 20-24 25-29 30-39 40-49 50-59 60-69 70+

Age group (years)

0

20

40

60

80

100Number of Cases

0

10

20

30

40

50Rate per 100,000

Male Cases Female Cases Male Rate Female Rate! &

Figure 5

Tuberculosis by Age and OriginOntario 1996-1998

*excluding 32 of 2291 cases w here origin w as missing or unspecified

0-0

12/

45-

910

-1415

-1920

-2425

-2930

-3435

-3940

-4445

-4950

-5455

-5960

-6970

-79

80+

Age group (years)

0

50

100

150

200

250

300Number of Cases

Canadian-born

Foreign-born

Aboriginal

Figure 6


to date of diagnosis of TB was 10.4 years for foreign-born cases diagnosed in 1998; the mean age of thesecases at time of diagnosis was 46.3 years.

The interval between arrival in Canada andonset of TB, however, varied by age. For theage group up to 39 years, 50.0% of caseswere diagnosed within the first two years ofarrival and a total of 58.1% of cases in thefirst five years. In the 40 years and over agegroup, only 28.9% of cases occurred withinthe first five years of arrival to Canada.Therefore, the first 5 years after arrivalappears to be the highest risk period fordevelopment of active TB, particularly forthe younger age groups. These statisticsreinforce the need for appropriate assessmentand treatment or prophylaxis of these high-risk groups.

Figure 7 shows foreign-born cases by countryof origin and the mean age of these cases.

Status, Site and Risk FactorsIn 1998, 89.5% of all reported TB cases were classifiedas new active and 9.7% as reactivated; 0.8% of cases

Tuberculosis Cases by Anatomical SiteOntario 1998

Site w as reported for 736 of 740 casesMore than one site may be reported for each case and all sites reported are presented here

474

149

32

23

17

14

13

10

4

3

35

Pulmonary

Lymph Node

Pleurisy

Bone and Joint

Genitourinary

Abdominal

CNS

Miliary

Other Respiratory

Skin

Other

0 100 200 300 400 500 600

Number of Cases

Figure 8

Foreign-born Tuberculosis Casesby country of birth, age, and interval between arrival and onset of TB

Ontario 1998

Date of arrival w as reported for 583 of 608 foreign-born cases *Interval betw een date of arrival and diagnosis date

78

76

61

55

36

32

27

20

17

12

10

10

8

8

7

7

6

6

6

99

ChinaIndia

PhilippinesVietnamSomalia

Hong KongEthiopiaPakistan

Sri LankaRomania

Yugoslav iaSouth Korea

UKKenya

GuyanaItaly

PolandIran

JamaicaOthers

0 20 40 60 80 100

Number of Cases

Age (yrs) Interval (yrs)mean median mean median57.1 61.0 11.2 9.047.8 43.5 7.6 4.744.6 42.0 9.3 7.043.2 38.0 9.2 8.029.3 28.5 4.2 3.044.8 40.5 8.3 6.031.0 32.0 6.0 5.043.4 37.0 6.5 5.042.9 44.0 5.6 4.037.3 33.5 3.2 2.059.4 61.0 20.2 8.557.6 62.5 10.9 9.061.5 65.0 39.1 38.529.0 21.5 8.1 3.055.9 58.0 8.7 7.066.0 61.0 37.4 35.070.9 73.5 31.8 33.554.3 58.0 3.5 1.545.8 39.5 12.5 8.046.3 41.0 13.5 7

Figure 7


were missing data on the staging of disease. Thisdistribution is similar to that of foreign-born cases. ForCanadian-born cases, however, a higher proportion ofcases are reported as “new active” (93.1%).

For 1998, 61.4% of the cases were reported as respiratory,38.6% were non-respiratory and 0.5% of cases had theanatomical site listed as “unknown”. The distribution ofTB cases by site is presented in Figure 8. This distributionis consistent with the sites reported for TB cases overthe past 10 years. From 1996 to 1998, respiratory casesof TB represented a larger proportion of cases amongthe aboriginal (81.8%) and Canadian-born cases (79.2%)compared to the foreign-born cases (57.5%) (Figure 9).

The most common non-respiratory sites of active TB

were the lymph nodes (49.7%), pleura(7.3%), and bones and joints (5.2%).Specific sites of non-respiratory TB byorigin for 1996 to 1998 are presented inFigure 10.

Tables 2 and 3 present the risk settings andrisk factors for TB cases. Risk setting waslisted for 99.3% of cases and risk factor for98.9% of cases. More than one risk settingor risk factor could be reported for each case.Comparable to the results of previous years,travel or living in a TB endemic countryremained a significant risk setting and wasreported for 71.8% of cases. Risk factor wasreported as “unknown” for 52.6% of thecases. Where a specific risk factor wasdocumented, presence of an underlying

medical condition and close contact with a case remainedthe two most commonly reported risk factors for TB(9.5% and 9.3% respectively).

Case ascertainmentFor the period 1996 to 1998, 82.2% of TB cases weredetected by symptoms, 5.2% by routine screening,3.5% by immigration surveillance, 3.3% by contacttracing, and 0.6% post-mortem. For the time periodfrom 1990 to 1998, 76.5% of TB cases had a positiveculture result.

Hospitalization and MortalityBetween 1996 and 1998, 2291 TB cases were reported.Approximately 45% (n=814) of the cases for whichhospitalization data was reported (n=1823), were

Site of Tuberculosis by OriginOntario 1996-1998

*excluding 32 of 2291 cases w here origin w as missing or unspecif ied and 0.5% of cases w here site w as missing or unspecif ied

81.8%

57.5%

79.2%

16.4%

42.1%

19.5%

1.8%

0.5%

1.4%

Aboriginal

Foreign-born

Canadian-born

Origin

0% 20% 40% 60% 80% 100%

Percent of Cases

Respiratory

Non-RespiratoryUnknown

Figure 9

Risk Settings Recorded on RDIS for Cases of Tuberculosis

Ontario 1996-1998

*more than one setting may be reported per case

Risk Setting Number of Cases Percent of Cases

Travel/Living in Endemic Country 1644 71.8%

Home 261 11.4%

Shelter 27 1.2%

Workplace 23 1%

Correctional Facility 21 0.9%

Residential Facility 21 0.9%

Hospital 14 0.6%

School 4 0.2%

Other 1995 87.1%

Unknown/Unspecified 225 9.8%

Table 2

Risk Factors Recorded on RDIS for Tuberculosis Cases

Ontario 1996-1998

*more than one risk factor may be reported per case

Risk Factor Number Percent of Cases

Underlying medical condition 231 9.5%

Close Contact 226 9.3%

Low Income 93 3.8%

Inactive Disease 91 3.7%

Alcoholism 55 2.3%

HIV/AIDS 52 2.1%

Health Care Worker 24 1%

Homeless 17 0.7%

IVDU 8 0.3%

Other 356 14.6%

Unknown 1279 52.6%

Table 3


hospitalized for treatment of their TB. Of the 2291cases, 186 died, representing 8.1% of all reported casesduring this time period and a mean of 62 deaths annually.Categorized by origin, there were 134 reported deathsamong foreign-born cases for a case fatality rate of

7.0% over this time period; 35 (11.9%) deaths inCanadian-born cases, and 8 (14.5%) deaths amongaboriginal cases. The mean age of the cases who diedwas 69.5 years (median 74 years).

Drug-ResistanceSensitivity data were available on 4383 ofthe 5468 culture confirmed cases (of theremaining cases, 943 had sensitivity resultsdocumented as “unspecified” and 142 weremissing any documentation). For the periodfrom 1990 to 1998, 580 cases were reportedas being resistant to one or moreantituberculous drugs. Eight of the 580cases did not have a culture positive resultdocumented on RDIS; these may representcases in which resistance status wasdetermined in a jurisdiction outside Ontario.The proportion of the 580 cases withresistance to one or more drugs increasedfrom 4.2% in 1990 to a high of 13.9% in1997 (Figure 11).

Culture-Positive TB Cases by Resistance StatusOntario 1990 - 1998

Note: Clinical cases or cases in w hich no culture w as obtained w ere excluded. 76.5% of cases reported betw een 1990 and 1998 w ere culture positive.

&

&

&

&&

&& &

&

90 91 92 93 94 95 96 97 98Episode year

0

150

300

450

600

750Number of cases

0%

5%

10%

15%

20%

25%Proportion drug resistant

Resistant to 1 or more drugs

Sensitive

Unspecified/Missing

Proportion of cases w ith any drug resistance

&

Figure 11

Site of Non-Respiratory Tuberculosis by OriginOntario 1996-1998

*Other includes CNS, miliary, skin, and 'other' sites as listed in RDIS

11.1%

49.7%

29.6%

44.4%

10.9%

9.9%

0%

5.3%

11.3%

11.1%

8.3%

5.6%

0%

5.6%

7%

33.3%

20.2%

36.6%

Aboriginal

Foreign-born

Canadian-born

Origin

0% 10% 20% 30% 40% 50% 60%

Percent of Non-Respiratory TB

Lymph Node

Pleurisy

Genitourinary

Bone and Joint

Abdominal

Other*

Figure 10


The mean age for cases that were drug-resistant was42.5 years (median 40 years) compared to 48.6 years(median 43 years) for cases sensitive to all first-lineantituberculous drugs.

Between 1990 and 1998, 44.1% of the 580 resistant

cases were reported as resistant to isoniazid alone. Thisrepresented the vast majority of cases with single drugresistance. During the same period, 34.1% of resistantcases were reported as resistant to two or more drugs.

Trends in single drug-resistance have been most variablefor isoniazid (Figure 12). The proportion ofTB cases resistant to isoniazid ranged from1.5% in 1990, to a peak of 5.6% in 1994.This proportion generally increased between1990 and 1996 but did decline in 1997 and1998.

Multidrug resistant TB (MDR-TB), definedas drug resistance to at least isoniazid andrifampin, increased between 1990 and 1991and has consistently representedapproximately 1% of TB cases since 1991(Figure 12).

The vast majority (67.6%) of resistant TBcases reported between 1990 and 1998resided in the 6 health unit areas which nowmake up the amalgamated City of Toronto(Figure 13).

Distribution of Resistant TB Cases by Health UnitOntario 1990-1998

Source: RDIS

amalgamated Toronto 67.6%

Peel 10.8%All Others 10.4%

Ottawa- Carleton 6.5%

Hamilton-Wentworth 2.4%York Region 2.4%

Figure 13

Trends in Drug Resistance

Ontario 1990-1998

Source: RDIS data

90 91 92 93 94 95 96 97 98

Episode date

0%

1%

2%

3%

4%

5%

6%Proportion of all annual TB cases

Isoniazid only Streptomycin only Rifampin only MDR-TB

Figure 12


Of all drug-resistant cases reported between 1990 and1998, 91.2% were foreign-born, 6.0% were Canadian-born, and 0.52% were of aboriginal origin. Thirteendrug-resistant cases had origin listed as either “missing”or “unspecified”.

The countries of origin for cases with resistance to atleast one antituberculous drug are presented in Figure14. The highest number of drug-resistant cases were ofVietnamese origin, however, the highest proportion ofcases with drug resistance were from Kenya.

DiscussionDiscussionDiscussionDiscussionDiscussionOver the past decade, the epidemiology of TB in Ontariohas not changed dramatically. Incidence rates continueto hover at approximately 7 cases per 100,000population, with approximately 80% of cases occurringin foreign-born individuals. Recent arrival in Canadacontinues to stand out as a risk factor for active diseasein young foreign-born individuals. Consequently TBremains a key issue for selected health units in whichthere are high concentrations of new immigrants orrefugees. These health units also tend to have higher

concentrations of other risk groups including thehomeless and those with HIV infection. TB alsoremains a key issue for health units with a high proportionof aboriginal people.

�

SOURCE

Monali Varia, MHSc, BScProject EpidemiologistVaccine Preventable Diseases and Tuberculosis ControlDisease Control ServicePublic Health Branch

Jill Sciberras, RN, BNSc, MHScNurse EpidemiologistVaccine Preventable Diseases and Tuberculosis ControlDisease Control ServicePublic Health Branch

CONTACT

Barbara Kawa, MD, DPHSenior Medical ConsultantVaccine Preventable Diseases and Tuberculosis ControlDisease Control ServicePublic Health Branch

Country of Origin for Cases with Resistance to One or More Antituberculosis Drugs

Ontario 1990-1998

Source: RDIS*Proportion of resistant cases did not exceed 5% for countries not presented.

Country of Origin Number of resistant cases Number of TB cases

Proportion of cases resistant to one or

more drugs

Kenya 6 27 22.2%Vietnam 125 672 18.6%

Philippines 76 563 13.5%South Korea 12 96 12.5%

Somalia 62 519 11.9%Haiti 3 27 11.1%

Portugal 11 102 10.8%North Korea 4 39 10.3%

China 55 550 10%Thailand 1 10 10%Romania 4 41 9.8%Pakistan 10 114 8.8%Ethiopia 16 208 7.7%

Hong Kong 27 360 7.5%India 34 563 6%

Guyana 3 52 5.8%Italy 5 100 5%

Canada 38 1257 3%

*All other countries 88 1825 4.8%

Figure 14


REFERENCES1. Walkenstein MD. “Tuberculosis”. <Website: http://

blue.temple.edu/~pathphys/ pulmonary/tuberculosis.html>.Accessed January 7, 2000.

2. Pilheu J.A. Tuberculosis 2000: problems and solutions. Int JTuberc Lung Dis. 2(9):696-703.

3. Long R, Njoo H, Hershfield E. Tuberculosis: 3. Epidemiologyof the disease in Canada. CMAJ. 1999; 160:1185-90.

4. Fanning A. Tuberculosis: 1. Introduction. CMAJ. 1999;160:837-9.

5. Dye C, Scheele S, Dolin P, Pathania V, Raviglione M. GlobalBurden of Tuberculosis. JAMA. 1999; 282:677-686.

6. Naus M. Epidemiology of Tuberculosis in Ontario in 1989.Public Health and Epidemiology Report Ontario. 1990;1(7):102-107.

7. Troy CJ. Epidemiology of Tuberculosis in Ontario, 1989-1992. Public Health and Epidemiology Report Ontario. 1993;5(3):63-71.

8. Kerbel D. Epidemiology of Tuberculosis in Ontario, 1995.Public Health & Epidemiology Report Ontario. 1997; 8(4):81-93.

9. Kerbel D. (unpublished data, Ontario Ministry of Health)

10. Correspondence: Howard Ngoo, Laboratory Centre for DiseaseControl. Dec 23, 1999.

11. Simone P, and Dooley S. (1994). “Multidrug-ResistantTuberculosis”. Centres for Disease Control and Prevention.<Website: http://www.cdc.gov/nchstp/tb/pub/ mdrtb/mdrtb/mdrtb.htm>. Accessed January 7, 2000.

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DISEASE CONTROL SERDISEASE CONTROL SERDISEASE CONTROL SERDISEASE CONTROL SERDISEASE CONTROL SERVICEVICEVICEVICEVICECOMMENTCOMMENTCOMMENTCOMMENTCOMMENTIt has been estimated that as many as 50 million peoplearound the world are infected with tuberculosis strainsthat are resistant to at least one antituberculous drug10.Groups at risk for drug resistance include persons whohave been treated with antituberculous drugs in the past,contacts of persons who are known to have drug-resistant TB, and foreign-born individuals from areaswith a high prevalence of drug-resistant TB. This includesLatin America, Asia and Africa11.

In 1998, MDR-TB cases represented 1.1% of all reportedTB cases in Ontario. Increases in drug resistance are inpart due to the high number of persons arriving inCanada from countries with a high prevalence of drugresistance, but are also occurring as a result ofinappropriate or interrupted treatment here in Canada.Further analysis of this issue is currently underway.

Physicians need to be made aware of the increasingconcern around drug resistant TB. Patients with TB

should be started on 4-drug therapy; sensitivity resultsmust be followed-up and acted on appropriately ifresistance is present. Although the number of cases inwhich resistance status was reported as eitherunspecified or missing in RDIS has decreased since1992, health units need to continually monitor theircases to ensure that sensitivity results are being reviewedand effective treatment is being ordered.

MDR-TB is associated with high mortality rates andextremely high costs due to prolonged hospitalizationand use of second line drugs. In Ontario, treatment isavailable and mortality due to this infection can usuallybe prevented if the case, and contacts, are detected in atimely manner and followed-up appropriately.

In order to decrease and, ultimately, eliminate TB fromOntario, surveillance, education of health careprofessionals, high risk groups and the general public, andeffective prevention and control programs are necessary.

Awareness is the first step to improving not onlyeducation but also the effectiveness of surveillanceactivities. Physicians need to consider TB in theirdifferential diagnosis not only with young foreign-born individuals but also in the elderly population whomay develop reactivated disease, especially if theirimmune system is compromised. In addition they needto know how to proceed with confirmatory testing(culture and sensitivity), and be aware of the importanceof doing so. The importance of timely reporting ofcases to the health unit should also be emphasized.These activities will prevent delays in the diagnosis ofTB and contact follow-up.

Health care facilities and other occupational settingswhere staff are at increased risk for TB exposure needto be aware of the value of baseline and ongoing skintesting surveillance programs.

Case management of active disease may be improvedby reducing diagnostic delays through awareness,education, and ensuring adherence to treatment bydirectly observed therapy (DOT). Once a case of activedisease has been detected, effective control measuresmust be implemented as soon as possible. For the mostpart TB is a treatable and curable disease. Earlydiagnosis is one of the most important factors in reducingmorbidity and preventing the spread of disease toexposed contacts. The second part of this equation iscompliance with an appropriate antituberculous drug


1. “Salmonella typhimurium Definitive Type104 in Ontario, 1997-1998: One Example ofan Antimicrobial Resistant Organism”(PHERO Volume 10, Number 11, November26, 1999).The following author should have beenincluded as one of the sources:Shelley Deeks, MD, MHSc, FRCPC,Completed while a Federal FieldEpidemiologist, Ontario Ministry of Health

2. The following laboratory should have beenacknowledged for performing the phagetyping that defined all strains as ST DT 104:National Laboratory for Enteric Pathogens,Laboratory Centre for Disease Control,Winnipeg, Manitoba

PHERO would like to apologize for theseomissions.

ERRAERRAERRAERRAERRATUMTUMTUMTUMTUMregimen. Poor adherence to treatment is one of themajor barriers to the elimination of TB and the singlemost important factor in the development of secondarydrug resistance.

Directly observed therapy (DOT) remains one of themost effective measures to improve compliance withdrug therapy. The success of DOT as an intervention isdependent not only on the individual DOT worker’sability to sustain a relationship with the client for theduration of their therapy but also on the availability ofresources to implement this intervention.

The identification and prophylaxis of individuals withlatent infection is much more complex. Infected personsmay be identified through contact follow-up of a case,routine surveillance of high risk groups, or medicalsurveillance of immigrants and refugees. Theseindividuals need to be informed of the importance,implications and process for surveillance of latentinfection in an effective, culturally appropriate manner.This activity is usually left up to the health unit staff,who may represent the first contact with the health caresystem for some of these individuals. Activities areongoing at all levels of government to improve,specifically, the immigration medical surveillancesystem.

Tuberculosis is a disease which has re-emerged as asignificant cause of mortality and morbidity indeveloped, as well as developing, countries over thelast decade. In Ontario, the disease has not beeneliminated, but has remained stable in recent years at arate of approximately 7 cases per 100,000 population.While the rate of TB has not increased lately, theproportion of cases which are resistant to one or moreantituberculous drugs has increased over the past decade,highlighting the need for continued vigilance in theearly identification of cases and in ensuring prompt,appropriate and complete treatment of cases.

Resource allocation to deal with this issue is in partdependent on awareness of the problem and knowledgeof the actual and potential impact of the problem. Thiscan be achieved through ongoing feedback ofsurveillance and epidemiological data to decision makersto facilitate comparison with competing priorities. Thisreport is designed to provide feedback based onprovincial data thereby facilitating decision-making atboth the municipal and provincial level.

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BENCHMARKING PILOT PROJECTBENCHMARKING PILOT PROJECTBENCHMARKING PILOT PROJECTBENCHMARKING PILOT PROJECTBENCHMARKING PILOT PROJECT:::::TESTING THE CONCEPT IN PUBLICTESTING THE CONCEPT IN PUBLICTESTING THE CONCEPT IN PUBLICTESTING THE CONCEPT IN PUBLICTESTING THE CONCEPT IN PUBLICHEALHEALHEALHEALHEALTHTHTHTHTH

IntroductionIntroductionIntroductionIntroductionIntroductionThe purpose of this article is to provide a brief overviewof the achievements of the three initial benchmarkingpilot projects. The discussion will include a briefsummary of the pilot process and some key results ofthese pilots. One element of the Ontario Public HealthBenchmarking Partnership’s pilot projects was designedto test the concept of benchmarking* in public healthpractice. The Ontario Public Health BenchmarkingPartnership is a joint initiative of the Association ofLocal Public Health Agencies (alPHa), the OntarioCouncil on Community Health Accreditation (OCCHA),the Public Health Branch, Ontario Ministry of Healthand Long-Term Care, and the Public Health Research,Education and Development (PHRED) Program. Abasic outline for the pilot was proposed in the Stewartand Sales (1998) report1. Using the recommendationsof the report, the Benchmarking Steering Committeedeveloped a workplan to guide the implementation ofthe pilot projects in three areas of health protection. Asthe pilot projects progressed, the timelines and otheraspects of the original workplan were adjusted to conformto the realities of managing the pilot.

Selection of TopicsSelection of TopicsSelection of TopicsSelection of TopicsSelection of TopicsAn important consideration in designing the pilot projectswas the need for early success. The BenchmarkingSteering Committee chose three specific areas that hada reasonable chance of showing concreteresults within a short time period (i.e.,Food Premises Inspection, ImmunizationRecord Process, and STD ContactTracing). Another factor in the selectionwas that extensive background materialabout practices in these areas wasavailable (e.g. CPHA Journal 1994 July/

August Supplement). As well, some health units hadbegun work on performance measures in these areas.

Selection of Pilot SitesSelection of Pilot SitesSelection of Pilot SitesSelection of Pilot SitesSelection of Pilot SitesParticipation in the pilot projects required thedesignation of one or two participants from each healthunit who would take the lead in benchmarking. Therewas a total of nine participating health units. EasternOntario, Elgin-St.Thomas, Timiskaming, Waterloo,and York Region were selected as exemplifying a goodcross-section of Ontario’s health units. In addition,four PHRED programs were pilot sites: Middlesex-London, Ottawa-Carleton, Sudbury and Toronto.Toronto was in the midst of amalgamation, however,since the process was not yet complete, they participatedas six health units in the pilot. Consequently, a variationin the number of pilot health units represented in thegraphs is evident. Furthermore, not all of the healthunits participated in each of the three pilot projects.

Selection of ComparatorsSelection of ComparatorsSelection of ComparatorsSelection of ComparatorsSelection of ComparatorsThe pilot projects demonstrated the importance ofchoice of comparators that could vary from issue toissue. One of the challenges of benchmarking in publichealth will be distinguishing differences in performanceand practice from differences in context. Therefore,the interpretation of results must take into considerationthe variations in context. Comparing health unitsacross the province requires an understanding of therealities faced by each health unit. Demographics,geographic dispersion, and political realities, such asthe amalgamation of metro Toronto, are examples offactors that can influence results.

*Benchmarking - “The process ofconsistently researching for new ideasfor methods, practices, processes, and ofeither adopting the practices or adaptingthe good features, and implementing themto become the best of the best.”

Figure 1Critical Food Infractions per 10 Routine Inspections

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Data Collection and AnalysisData Collection and AnalysisData Collection and AnalysisData Collection and AnalysisData Collection and AnalysisData collection consisted of the development of programlogic models, performance measurements for programcomponents, and survey questionnaires. Each approachwill be briefly described in the following section.

Program Logic ModelA necessary step in the benchmarking pilots was thepreparation of a program logic model (using the ProgramEvaluation Tool Kit, developed by Porteous, Sheldrick,and Stewart, 19972) and the identification of programcomponents and activities. Program components needto be few (i.e., 2-4) and have identifiable performanceindicators. For instance, Food Premises Inspectionactivity is grouped into three areas: (1) evaluation of thefood remises [surveillance andmonitoring], (2) managementconsultation and education, and (3)enforcement. Immunization RecordProcess activity is grouped into twomain areas: (1) obtaininginformation from new schoolenterers and transfers, and (2)assessing and reviewing existingrecords. Partner Notification forChlamydia is grouped under twomain headings: (1) contact withindex case and (2) contact withpartners.

Performance Measures*Performance measures for each programneeded to be developed before surveytools could be prepared. The pilot healthunits developed performance measuresfor each component and then preparedquestionnaires. This process requiredmany reviews and revisions bybenchmarking pilots (e.g., definingissues, collecting data in a clear andunambiguous way). Tables 1, 2, and 3show the performance measurementsidentified for the program componentsof each pilot project: Food Premises

Inspection, Immunization Record Process, and PartnerNotification for Chlamydia, respectively.

Survey ToolsThe design of the surveys was determined by the need tocollect both the quantitative data for measures ofeffectiveness and efficiency, and the qualitative data thatwould allow the comparison of practices in each area.Another important factor in the design of survey tools isthat data should be available without much effort. Also,clear and consistent definitions ensure questions allowfor development of indicators. The complete surveywas comprised of five components: a Health UnitProfile generic questionnaire that allowed comparisonof health units on demographic characteristics,

*Performance Measure - “A unitused to assess an activity’s progresstoward its intended results.”

Figure 2PHIs per 1,000 Food Premises

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individual questionnaires for Food Premises Inspectionand Immunization Record Process, and twoquestionnaires for Partner Notification for Chlamydia.

Benchmarking Pilot Project ResultsBenchmarking Pilot Project ResultsBenchmarking Pilot Project ResultsBenchmarking Pilot Project ResultsBenchmarking Pilot Project ResultsThe following section will present a selection of resultsfrom each pilot project to demonstrate the variability inthe pilot results. The health units’ identities in thefollowing figures have been altered to protect theidentification of the participating health units.

Food Premise InspectionFigures 1 and 2 depict the result for the effectivenessindicator related to surveillance and monitoring. It isimportant to note the variability between health unitsin each instance. Figure 1, in particular, shows onehealth unit with markedly different results than theother health units. A probable reason for the differenceshown is that, for the past two years, this health unithas been tracking its critical food infractions in anattempt to standardize how Public Health Inspectorsrecord infractions. Similar variation in results wasseen in other key measures, for example, re-inspectionsby type of risk premise (not shown).

In Figure 3, the use of Medical Officer of Health(MOH)/Public Health Inspection (PHI) orders,Provincial Offences Acts (POAs), and the number ofcharges laid for repeat infractions of critical control

points (CCP) are shown per 1000food premises. Three health units usemore enforcement interventions thando the other health units.

At the completion of the pilot therewas agreement among theparticipating health units that the bestoverall effectiveness measure for FoodPremise Inspection is the number ofcritical food infractions/10 routineinspections. The incidence of food-borne infections was notrecommended as an effectivenessmeasure because most infections arenot related to food premises. Therewas some discrepancies among healthunits in the way the number of criticalinfractions was recorded, however,standardization of this can be readily

achieved.

Immunization Record ProcessThe overall effectiveness indicator selected was thedifference between the percentage of incomplete recordsin October and June as shown in Figure 4. Health unitsthat had a low number of incomplete records in Octoberhad very little change in their incomplete rate in June.More variability in results was seen with health unitsthat had a higher number of incomplete records inOctober. This indicator could be improved if entererscould be identified in IRIS in October and the status ofincompletes tracked through the school year.

Figure 5Staffing Efficiency

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Figure 4Comparison of % Incomplete Immunization

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The result of the efficiency indicatorpertaining to staffing FTEs/10,000Immunization Records is shown inFigure 5. Staffing ratios alsoresulted in significant variabilityamong pilot health units. Adenominator, which better reflectsworkload, would be the sum ofenterers and incomplete in October.This is not currently available inImmunization Record InformationSystem (IRIS).

Figure 6 shows the efficiencyindicator which examines thedifference between the number ofincomplete records in October andJune with respect to the totalnumber of records reviewed. What this graph does notshow is the variations in the number of records healthunits reviewed. In the graph, it appears that health unitE was the most efficient, however in actual fact, theyreviewed only 10% of their records in comparison toother health units that reviewed 100%.

Partner Notification for ChlamydiaThis pilot was the most complex of the three pilotsbecause the practices of health unitsin this area differ dramatically, withsome health units doing mostcontact tracing while others leavethis role primarily to clients andother health practitioners. Thispilot decided to focus oncomparing the differentapproaches to health unit follow-up. Since data to supportperformance measurement inpartner notification is currently notroutinely collected by health units,data forms were developedespecially to follow individualcases and contacts for the pilot.Elapsed time indicators, instead ofthe measurement of staff time, werechosen as the measure ofefficiency. Most health units have

the same staff do partner follow-up for all STD’s andhave difficulty separating out time spent on any particulardisease.

The first effectiveness indicator for activities related toPartner Notification and Follow-up is the proportion ofnamed partners followed by the health unit who aresuccessfully reached. The denominator for this indicatorconsists of all partners in the health unit’s jurisdiction

Figure 7Percentage of Named Partners Successfully Reached by

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plus those for which the jurisdiction was unknown. The“Unknown Jurisdiction” partners were included becausemost health units attempted some follow-up. Thenumerator consists of the number of partners who aresuccessfully reached. As shown in Figure 7, most healthunits attained 80% or better.

Figure 8 shows the average time from naming partner toinitiation of contact attempts for pilot sites. There isconsiderable diversity of practice with some healthunits initiating follow-up the same day and others takingmore than a week to initiate follow-up. Note that thenumber of cases and the proportion of cases followed upby the health unit should be considered in interpretingthese comparisons. Despite the data problems and thedramatically different practices among health units,Figures 7 and 8 show the types of indicator which can beused to monitor performance.

Lessons LearnedLessons LearnedLessons LearnedLessons LearnedLessons LearnedBenchmarking in public health practice is new anduncharted territory. The pilot projects have proven thatdespite the complexity of public health practice and theconstantly changing environment, it is possible to applythis methodology to our service delivery in publichealth. The pilot projects have made a good beginningin testing the concept, and in providing valuable lessonsfor future projects. As with any new venture, it is notpossible to foresee all the challenges, therefore welearned to expect the unexpected. Summarized beloware some of the lessons of the pilot project componentof the benchmarking project:

Figure 8Average Time in days to Initiate Follow-up

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s• Benchmarking projects that use available sources

of data are easier to implement than those thatrequire the collection of primary data.

• Development of performance measures takes time.• Standardization of data collection is crucial to the

benchmarking process, otherwise, inter health unitcomparisons cannot be made. The pilot processdemonstrated that differences currently exist evenfor activities that are well established in publichealth practice. The process of agreeing on indicatorsand making comparisons is essential to achievestandardization.

• The reliability of the data is enhanced if cleardefinitions, collection procedures and guidelinesare provided. In some instances province-widetraining will be required. This would cut down onthe variation in data collection due to differentinterpretations of the questions in a survey.

• Surveys are one method of collecting data for abenchmarking project, but other methods such assite visits may offer more in-depth information. Acombination of a short survey followed by an on-site visit may be a more satisfactory means ofidentifying best practices than a survey alone.

• The determination of best practices* is challengingbecause of the complexity of public health practice.It is also context dependent and needs to beempirically based, blending literature and evidencewith actual practice. Synergistic collaborationbetween PHRED projects that approach theidentification of best practices in different ways hasthe potential to enhance public health practice.

• The project has demonstrated that analyzingprograms from the perspective of PerformanceMeasurement does generate very useful newinformation about program performance.Identifying best practice is not simple. Even withreliable, valid and generally accepted indicatorsfor comparison, best practice is highly contextdependent. Health units must choose comparatorscarefully and be very selective in appropriatingpractices for their particular context.

*Best Practice - “A method or process of doingbusiness that achieves better results and/or moreefficient use of resources.”


The Public Health staff that was involved in the threepilot projects showed enthusiasm towards benchmarkingand commitment to seeing the projects through tocompletion despite the uncertainty experienced whenventuring into uncharted territory and the demands ontheir time and resources.

Benchmarking Pilot OutcomesBenchmarking Pilot OutcomesBenchmarking Pilot OutcomesBenchmarking Pilot OutcomesBenchmarking Pilot OutcomesFood Premises InspectionIn this project we have identified a key outcome indicatorof critical infractions per ten food premise inspected.The findings of this project will be presented to theAssociation of Supervisors of Public Health Inspectorsof Ontario (ASPHIO) and the Ministry by the end of1999. Ideally standardized data for benchmarking willbegin to be collected across the province in 2000.

ImmunizationThis pilot has been able to generate a very useful

benchmarking package which consists of a number ofindicators which can readily be generated from IRIS aswell as an inventory of practices which could influencethose indicators. The immunization working grouphave identified some minor modifications to IRIS whichthey feel could enable the generation of greatly improvedindicators for both the Ministry of Health and Long-Term Care and program management. We again hopeto initiate province-wide data collection for the 2000-2001 school year.

Chlamydia Contact TracingThis is the pilot where it is less clear how we moveforward. There are enormous differences among healthunits in what proportion of cases they follow upthemselves, and the degree to which they promotenotification by the client. Because in most health unitsan information system is not in place, for benchmarking

to move forward, healthunits would have to adopta uniform recordingsystem. Given therelatively low priorityaccorded to this activityin many health units, it isunclear that such aninitiative would be wellutilized. The issue in thisarea would seem to be thegreat diversity of practiceacross the province. Thiswould need to beaddressed at the level ofall STD contact tracing.We are discussing thepossibility of a provincialmeeting to look at thepolicy issues that arise outof this pilot.

Future InitiativesThe Steering Committeeof the Ontario PublicHealth BenchmarkingPartnership recognizes theneed to begin to addressthe challenge ofbenchmarking within the

Table 1Food PrFood PrFood PrFood PrFood Premises Inspection - Performance Measuremises Inspection - Performance Measuremises Inspection - Performance Measuremises Inspection - Performance Measuremises Inspection - Performance Measurementsementsementsementsements

Evaluation of the Status of the PrEvaluation of the Status of the PrEvaluation of the Status of the PrEvaluation of the Status of the PrEvaluation of the Status of the Premiseemiseemiseemiseemise

(a) Effectiveness Indicators

• # high-risk food premises re-inspected / # of high-risk premises• # medium-risk food premises re-inspected / # of medium-risk premises• # low-risk food premises re-inspected / # of low-risk premises(b) Efficiency Indicators

• # Public Health Inspectors / 1000 premises• # routine inspections in high-risk premises / # high-risk premises• # routine inspections in medium-risk premises / # medium-risk premises• # routine inspections in low-risk premises / # low-risk premises

Management/Consultation/EducationManagement/Consultation/EducationManagement/Consultation/EducationManagement/Consultation/EducationManagement/Consultation/Education

(a) Effectiveness Indicator

• # of food handlers certified / total # of food premises

EnforEnforEnforEnforEnforcementcementcementcementcement


• # of orders / # of high-risk food premises• # high-risk food premises re-inspected / # high-risk food premises• # medium-risk food premises re-inspected / # medium-risk food premises• # low-risk food premises re-inspected / # low-risk food premises

Overall EfOverall EfOverall EfOverall EfOverall Effectiveness Indicatorfectiveness Indicatorfectiveness Indicatorfectiveness Indicatorfectiveness Indicator

• # of critical food infractions / # of routine inspectionsOverall EfOverall EfOverall EfOverall EfOverall Efficiency Indicatorficiency Indicatorficiency Indicatorficiency Indicatorficiency Indicator

• # of Public Health Inspectors / 1000 food premises


Table 2Immunization RecorImmunization RecorImmunization RecorImmunization RecorImmunization Record Prd Prd Prd Prd Process – Performance Measurocess – Performance Measurocess – Performance Measurocess – Performance Measurocess – Performance Measurementsementsementsementsements

Updating & Maintaining Existing Immunization RecorUpdating & Maintaining Existing Immunization RecorUpdating & Maintaining Existing Immunization RecorUpdating & Maintaining Existing Immunization RecorUpdating & Maintaining Existing Immunization Recordsdsdsdsds


• % of records reviewed

• # of suspension orders from Medical Officer of Health / # reviewed incomplete records as of October 1st.

Overall MeasuresOverall MeasuresOverall MeasuresOverall MeasuresOverall Measures


• % of students with acceptable immunization status on June 30th.

• Difference between % Incomplete records in October and June(b) Efficiency Indicators

• Difference between # of incomplete records in October and June / Total # of reviewed records

Table 3Partner Notification of Chlamydia – Performance Measurements

Communication with Index Cases in Jurisdiction for Partner IdentificationCommunication with Index Cases in Jurisdiction for Partner IdentificationCommunication with Index Cases in Jurisdiction for Partner IdentificationCommunication with Index Cases in Jurisdiction for Partner IdentificationCommunication with Index Cases in Jurisdiction for Partner Identification


• % of clients referred to health unit

• % of health unit managed index cases successfully contacted

• % of health unit managed index cases identifying partners sufficiently for follow-up

• average # of contacts identified per case(b) Efficiency Indicators

Elapsed time between:

• date of testing

• date health unit received lab report

• date index case referred to health unit for follow-up

• date health unit obtained names of partners

Partner Notification and Follow-up for Partners Managed by Health UnitPartner Notification and Follow-up for Partners Managed by Health UnitPartner Notification and Follow-up for Partners Managed by Health UnitPartner Notification and Follow-up for Partners Managed by Health UnitPartner Notification and Follow-up for Partners Managed by Health Unit


• % of named partners receiving treatment

(b) Efficiency Indicators

Elapsed time between:

• date health unit obtained partner name

• date health unit first attempted to notify partner

• date health unit actually notified partner

• number of methods used (including repeats of same methods) in attempts to notify partner


health promotion and disease prevention mandatoryprograms, such as Chronic Disease Prevention andFamily Health. They have identified two new pilotprojects based on the priorities identified by health unitsin the benchmarking survey, as well as, the practicallessons learned in the first three pilots. The first newpilot is heart health coalitions in which almost all healthunits are currently involved. The second is breastfeeding,Requirement 4 (a-e) of Child Health Mandatory Program.Several health units have volunteered to participate inthe new pilots and are representative of the diversityacross Ontario. Both projects, while challenging, willbe of great value to public health units and shouldprovide lessons and templates which can be readilygeneralized to other parts of the Mandatory Programs.

ACKNOWLEDGEMENTS

The success of the pilot projects would not have been possiblewithout the ongoing support, committment and contribution by thefollowing: Eastern Ontario Health Unit (Doreen Blais, GiseleMartin, Suzanne Ross), Elgin-St.Thomas Health Unit (LauraMcLachlin), Region of Hamilton-Wentworth Social Services andPublic Health Services Department (Dan McInnis), Middlesex-London Health Unit (Charlene Beynon), Region of Ottawa-CarletonHealth Department (Mary McNamara), Sudbury and District HealthUnit (Cheryl Dovigi, Louise Picard, Ido Vettoretti), TimiskamingHealth Unit (Lynn Landriault, Esther Millar), Toronto PublicHealth ( John Dwyer, Marjolyn Pritchard, Pam Scharfe), RegionalMunicipality of Waterloo, Community Health Department (BobHart, Karen Verhoeve), York Region Health Services Department(Karim Kurji, Marie Muir), alPHa, and OCCHA. within the OntarioPublic Health Benchmarking Partrnership

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CONTACTS AND SOURCEDr. Geoff Dunkley, Deputy Medical Officer of HealthVerna Wilson, Benchmarking Pilot Project ManagerMonique Stewart, Program Planning & Evaluation Officer

PHRED ProgramRegion of Ottawa-Carleton Health Department

REFERENCES1. Stewart P, Sales P. A benchmarking process for public health

programs in Ontario: A development plan. Ottawa: Paula J.Stewart & Associates Community Health Consulting, 1998.

2. Porteous N, Sheldrick B, and Stewart P. Program evaluationtool kit: A blueprint for public health management. Ottawa:PHRED Program, Ottawa-Carleton Health Department, 1997.

3. Balm, G. J. Benchmarking: A practitioner’s guide for becomingand staying best of the best. Schaumburg, Illinois: QPMAPress, 1992; 16.

4. Sales, P. and Stewart, P. Benchmarking Tool Kit: A blueprintfor public health practice. Middlesex-London Health Unit,1998; 88-89.


Summary of Reportable Diseases in Ontario - NovemberSummary of Reportable Diseases in Ontario - NovemberSummary of Reportable Diseases in Ontario - NovemberSummary of Reportable Diseases in Ontario - NovemberSummary of Reportable Diseases in Ontario - November, 1999, 1999, 1999, 1999, 1999

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1996 M umps Per tussis R ubella Salmon. Shigel losis Syphil is V T EC Health Units by R egion Population (Pr im/Sec)

A lgoma 123,953 3

* N orth Bay 93,841

N orthw estern 80,235 3 2

Porcup ine 97,437 1

Sudbury 201,154 2

T hunder Bay 161,187 2

T imiskaming 38,847

T otal - Nor ther n 796,654 8 3 2

Eastern Ontario 185,314 1 1 3

H ast ings-Prince Edw ard 143,790 7

K ingston -Fron tenac 175,568 6 1

Leeds-Grenv il le 156,129 1 2

Ottaw a-Carleton 721,136 8 10 4

Renfrew 97,634

T otal- Easter n 1,479,571 1 15 1 23 4

D urham Reg ion 458,616 1 5

East York 107,822 3

Etobicoke 328,718 1 2 1

H aliburton-K aw artha 165,039 2 2 1 2

M uskoka-Parry Sound 78,675 1 1 1

N orth York 589,653 4 10 3 3

Peel Reg ion 852,526 1 2 19 1

Peterborough 123,448 1 5

Scarborough 558,960 6 7 1

Simcoe Coun ty 329,865 2 2

T oronto City 653,734 3 6 2

York City 146,534 1 4

York Region 592,445 1 4 7 1 4

T otal - Centr al East 4,986,035 4 36 63 9 1 10

Bruce, Grey -Ow en Sound 153,312 9 1 1

Elg in-St . T homas 79,159 1

H uron 60,220 1 5

Chatham-K ent 109,650

Lambton 128,975 1 2

M iddlesex-London 389,616 5 2 1 4

Oxford 97,142

Perth 72,106 1

W indsor-Essex 350,329 1 1 1 1 1

T otal - Southwest 1,440,509 1 17 12 2 7

Brant 114,564 3 1

H ald imand-N orfo lk Region 102,575 1

H alton Region 339,875 2 4

H amilton-W entw orth 467,799 1 6 2

N iagara Region 403,504 2 5 2

W aterloo Reg ion 405,435 14 5 3

W elling ton-D uf ferin 217,052

T otal - Centr al W est 2,050,804 3 20 20 8

N ovember 1999 10 ,753 ,573 9 96 1 121 11 1 31

T otal YT D 1999 - 40 1,181 7 2,176 261 22 373

* * T otal YT D 1998 - 29 1,654 15 3,080 383 26 390

* D at a incom p let e f o r t he m ont h o f N ov em ber 1999 f rom heal t h U n i t : N or t h Bay

* * A djust ed f or delet i ons and lat e repor t s.

epidemiology report ontario - ministry of health and long-term … · 2012. 6. 27. · fax: (905)...

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