Standing at a crossroad, Toronto seeks budget hike
Foreign-born patients, homeless problems pile up
The city of Toronto is poised at a crossroad when it comes to TB control. In the midst of political changes designed to save money, public health officials are holding their breath to see whether a big budget increase they’ve requested will be approved. The purpose of the increase, TB experts say, is to facilitate the implementation of more directly observed therapy (DOT) in a more consistent fashion across the six outlying towns recently incorporated into the city.
Nor are plans to expand DOT the only reason TB controllers need the extra money, says Sharon Polluck, RN, manager of the Toronto Communi cable Disease Program. Among the city’s homeless and underhoused, molecular testing has shown clustering of cases, indicating ongoing transmission of disease, and skin-testing shows that 38% of the homeless population is latently infected with TB.
Instead of recent transmission, that figure represents the epidemiology of TB peculiar to this city, where 90% of TB cases occur among the foreign-born, who are well-represented among the homeless and underhoused, Polluck says.
The city’s melting pot of ethnic and racial groups includes a large Somali community where TB is regarded as a death sentence and a source of shame. Changing such attitudes is more challenging than usual, adds Polluck, since most Somalis remain illiterate in a language which existed only in oral form until 15 years ago when it was finally written down. (Because written material has limited applicability, TB controllers may make use of a training video that includes scenes of a Somali outreach worker speaking in her own tongue about treatment for the disease, she says.)
An overnight boom in the population
Then there is a third burden. TB controllers in Ontario, the province in which Toronto is located, every year must cope with about 6,000 notifications of what is known as "post-landing surveillance"— the follow-up mandated by terms of national immigration law for all foreign-born persons who arrive with evidence of skin-test positivity, changes in chest radiographs, or a history of prior treatment for TB.
"It’s a huge burden for our public health department," says Polluck. Here, as in the United States, a large percentage of latently infected immigrants and refugees who break down with active disease do so within five years of immigrating, she adds. So far, estimates are that only about 10% of candidates for prophylaxis are actually offered isoniazid. "So we obviously have a lot of work to do, but again, we lack the staff," she says.
When the city of Toronto decided to incorporate the surrounding district towns two years ago, one result was an instant population boom: From 600,000, the city’s numbers surged to 2.5 million people. No small part of the amalgamation process has been the challenge of trying to integrate six disparate TB control programs, all with varying degrees of resources at their command. One newly incorporated city, for example, had 112 cases of TB last year, but it only has three staff members available to the TB program. In pre-amalgamation days, Toronto boasted a relatively well-heeled TB program, one of the first in the region to embark on a program of DOT.
Still, there’s no fat to be trimmed from its budget. Because a principle motivation for the amalgamation was cost-savings, Polluck and others hope political leaders can be convinced they should make an exception when it comes to public health.
Recently, she took National Democratic Party leader Howard Hampton on a street tour to view some of the hostels and shelters where the city’s underhoused find refuge. Hampton concluded that "a raging TB epidemic" was looming, according to reports in the city’s newspaper.
Though perhaps not quite that bad, TB among the homeless "is certainly an area where we’re vulnerable," she says. Throughout Ontario, there are estimated to be between 25,000 and 50,000 homeless people, with cutbacks in social services probably boosting the numbers, experts here say. Every night, some 4,000 people seek refuge in one of Toronto’s 24 shelters, she adds. Churches in the city also take turns offering beds, especially when temperatures plummet to 50° C below and worse.
Along with many foreign-born residents, shelters and hostels house many members of the country’s aboriginal population; among them, co-infection is high, with HIV rates at about 12%.
Hey! That’s one of ours!’
When the city’s TB control division first decided to carry out DNA studies of isolates from the homeless population, initial results indicated no clustering, Polluck notes. Determined to make certain they hadn’t missed something, laboratory investigators went back and combed through cases recorded over the past year and a half, expanding the circle beyond the homeless to include underhoused residents as well. That’s where evidence of clustering, indicating recent transmission, turned up, she says.
When Toronto TB controllers presented the data at a recent conference in the United States, a New York City TB control worker recognized one of the banded patterns and cried, "Hey! That’s one of ours." Sure enough, when investigators went back and checked records, the Toronto patient was found to have spent time recently in the Big Apple.
That’s not the only time New York City has figured in the local conversation, Polluck adds. "We point to what happened when you cut back your public health infrastructure there and hold that up as an example," Polluck says. "We want people to realize it’s important not to make the same mistake here."
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