Meeting Provincial Standards Across the City

for Selected Public Health Programs and Services

The Board of Health recommends the adoption of Recommendations Nos. (5) and (6) embodied in the report dated January 18, 1999, from the Medical Officer of Health, viz:

"(5)the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(6) the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date."

The Board of Health reports, for the information of Council, having:

(1)approved in principle Options (a) of Recommendations Nos. (1), (2) and (4), with a request that the Medical Officer of Health submit a report to the Board at its next meeting, scheduled to be held on February 22, 1999, on additional cost implications for the selected options in the context of the 1999 budget submission for public health;

(2)recommended the adoption of Recommendation No. (3) to the Community and Neighbourhood Services Committee; and

(3)requested the Chair of the Board of Health, the Medical Officer of Health and the Commissioner of Community and Neighbourhood Services to review the Board of Health's position on service harmonization, and report back thereon to the Board at its next meeting.

The Board of Health submit the following report (January 18, 1999) from the Medical Officer of Health:

Purpose:

To inform the Board of Health of the costs of service options for meeting new provincial standards across the City in three program areas in 1999 and beyond.

Financial Implications:

Recognizing the City's budget constraints, a range of service level options is identified for each program (Table 1). These options correspond to a range of financial impacts (Table 2). No source of funds has been identified. The estimated costs for meeting the new standards in these three program areas cannot be achieved within the current budget without service impacts in other areas. These cost estimates are based on current program configurations. Further analysis and refinement of these estimates is continuing to ensure efficiency and cost-effectiveness in the delivery of these services.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service level options for the Food Safety Program and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $646,411.00 in 1999 (including a one-time cost of $61,000.00), and $1,756,234.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $406,630.00 in 1999 (including a one-time cost of $39,900.00), and $1,100,189.00 in 2000 and subsequent years;

(2)the Board of Health select one of the following service options for tuberculosis (TB) control and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $726,159.00 in 1999 (including one-time costs of $100,000.00) and $1,878,478.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $567,572.00 in 1999 (including one-time costs of $87,000.00) and $1,441,715.00 in 2000 and subsequent years;

(3)the Board of Health request Council through the Community and Neighbourhood Services Committee to advocate with the Board of Health and local hospitals for provincial funding to provide appropriate accommodation for people without housing who have active TB, in order to reduce disease transmission and promote a stable environment which will assist them to regain their health;

(4)the Board of Health select one of the following service options for needle exchange for the purposes of HIV prevention and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $227,878.00 in 1999 (including one-time costs of $41,000.00 in 1999) and $560,634.00 in 2000 and subsequent years plus one-time capital costs of $82,000.00 in 2000; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $180,565.00 in 1999 (including one-time costs of $41,000.00) and $418,696.00 in 2000 and subsequent years.

(5)the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(6) the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date.

Background:

As described in the March 1998 report to the Board of Health entitled "Investing in Public Health", the goals of Toronto Public Health are to make public health programs and services accessible across the city and responsive to diverse needs, to improve the equity of health outcomes and the overall health of the population, and to maximize efficiency in the delivery of public health services. That report also described the potential impact on current services and resources as a result of the new provincial standards outlined in the Mandatory Health Programs and Services Guidelines, which were received from the Province in early 1998.

In August 1998, a preliminary budget forecast was submitted to the Chief Administrative Officer regarding estimated costs to meet these new provincial standards in relation to the following mandatory programs: Food Safety, Tuberculosis Control, and the needle exchange component of the Sexually Transmitted Diseases (including HIV/AIDS) program.

On October 13, 1998, the Board of Health adopted a report entitled "Issues Related to the 1999 Budget Supplementary Report". That report outlined the key directions being proposed by the Medical Officer of Health regarding next year's budget, including these priorities for mandatory program harmonization in relation to the new standards.

Comments:

Legal Framework:

The fundamental role of the Toronto Board of Health is to promote and protect the health of the City's population. Health units across the province are regulated by provincial legislation. The Health Protection and Promotion Act, c.H. 7, R.S.O. 1990, the Regulations made pursuant to that Act, and the Mandatory Health Programs and Services Guidelines published by the Minister of Health, prescribe the duties and responsibilities of local health units. The Health Protection and Promotion Act states that every Board of Health shall comply with the mandatory guidelines. Should the Minister of Health determine that a health unit has failed to meet the prescribed standards, the Minister has broad powers to ensure the provision of these mandatory programs, the costs of which may be treated as a debt to the Province of Ontario by the obligated municipality in the health unit concerned. The Province also expects all boards of health to deliver additional programs and services in response to local needs and subject to municipal approval.

Framework for New Standards:

In 1997, the Province made a series of "Who Does What" decisions that re-aligned financing responsibilities between the Province and local municipalities, a process commonly referred to as downloading. Public Health had previously been cost-shared between the Province and the former six municipalities in Toronto on a 40:60 ratio, respectively. In addition, the Province paid 100percent of the cost of certain programs that reflected provincial priorities. Most of these programs and services were downloaded to the local level effective January 1, 1998. The Province still pays 100 percent of the cost for a few programs and services, the details of which will be contained in the February report to the Board regarding the proposed 1999 Operating Budget.

The harmonization of public health programs is complicated by the Province's introduction of new program standards in parallel with both downloading and amalgamation. The Mandatory Health Program and Services Guidelines were first promulgated in 1984 and substantially revised in 1989, the version that was in effect in the year preceding amalgamation. These were again revised effective December 1997 (accompanying downloading amendments to the Health Protection and Promotion Act) to ensure that the duties and responsibilities of local boards were clearly spelled out, that the implementation of mandatory programs and services was amenable to monitoring and enforcement by the Ministry, and to ensure that local municipalities paid the expenses incurred by local boards of health in the performance of their duties.

Public Health staff from Toronto and across the province participated in the development of these new standards, although final decisions were subject to the approval of the Minister of Health and Cabinet. The criteria used by the Ministry to develop these standards included:

(a)consideration of the health needs across the province;

(b)the effectiveness of interventions to reduce these needs;

(c)whether it was appropriate for local boards of health to undertake this work; and

(d)whether local boards of health had the capacity to provide or ensure the provision of these programs and services.

Compared with the previous 1989 edition, the new standards are considerably more detailed and prescriptive, leaving little room for discretion in some cases. By contrast, the old guidelines left more opportunity for varying interpretations of the standard. This had resulted in varying levels of program implementation across the former six health units in Toronto. Even without new standards in place, this variation in service level would have had to be addressed by the current Board of Health. Staff are attempting to develop preliminary estimates of the costs for service harmonization had there been no new standards, as compared with the costs of complying with the new standards.

However, it must be noted that the Province gave explicit consideration to the scientific literature and best practices as of 1997, including new and emerging health issues that exist in Toronto and elsewhere. Therefore, the new standards reflect a level of programming that staff could have recommended as the optimal level even if the new standards had not been in place.

Policy Setting Process:

Pursuant to direction received from City Council in November, the Chief Administrative Officer is preparing a city-wide report on service level harmonization to the Strategic Policies and Priorities Committee, which will be referred for comments to local Community Councils and then to Standing Committees. This report will include information on the harmonization options contained in this report. It is generally recognized that harmonization will be a multi-year undertaking and that priorities will have to be established for the overall approach and sequencing of programs to be reviewed. Priorities for 1999 will include consideration of service levels for roads, sanitation, libraries and public health. As such, the Board's position on public health service level options should be conveyed to the Chief Administrative Officer as soon as possible. A detailed report on the public health component of the CAO's recommended operating budget will be presented to the Board of Health at its next meeting on February 22, 1999.

The options for service harmonization contained in this report are set out in relation to the City's health needs, evidence-based research, and the Board's legal duty to provide at least the minimum standard of provincially mandated programs. These options describe alternate levels of service which could be provided and which also comply with the prescribed standards under applicable legislation. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Once these programs have been harmonized, they will be monitored and evaluated to assess the impacts of the service level and funding decisions that have been made and the results will be reported to the Board.

Finally, it must be reiterated that the programs described in this report are the priorities for revision in 1999, not the full scope of public health programs requiring revision or enhancements to bring them into compliance with new provincial standards. As planning and amalgamation work proceeds, service level options for additional programs (e.g., in the Family Health and Lifestyles areas) will be brought forward for consideration in the Year 2000 budget cycle and beyond.

In addition to the programs dealt with in this report, options to harmonize selected local programs are described in companion reports appearing on this agenda including "Harmonization of Dental and Oral Health Services" and "Harmonization of Food Access Grants". Harmonization options for services for the homeless and options to harmonize ETS By-laws will be the subject of separate reports to the Board of Health at its February 22, 1999 meeting. Harmonization of the Animal Control By-law appears elsewhere on this agenda and harmonization options for Animal Services in general will be reported to the Board of Health later in the year for consideration in the 2000 budget cycle.

Description of Harmonization Options:

This report uses report-style appendices to explain the rationale for service harmonization in each area and to present two options for the Board's consideration.

Three of the 14 provincially mandated programs are prioritized for harmonization in 1999:

Food SafetyAppendix A

Tuberculosis ControlAppendix B

Needle Exchange Appendix C

For each program, Option A represents the optimal approach in health terms. This option is based on a combination of information on the City's health needs, evidence-based research, and the Ministry of Health's Mandatory Program and Services Guidelines, 1997. In each case, Option A is the one which as Medical Officer of Health I must endorse from a Public Health perspective.

These options are supported because they:

(1)meet legislated requirements;

(2)respond to changing and increasing local needs;

(3)use strategies considered to be "best practice" substantiated by research evidence;

(4)provide coverage that enables achievement of effective prevention in the target or risk groups; and

(5)achieve geographic equity in access to services according to the distribution of need.

Option B represents an alternative approach that is not optimal in health terms but provides some service delivery at lower cost when compared with Option A. For each mandatory program, Option B represents the minimum level of service required by the Ministry of Health. All boards of health in Ontario must provide or ensure the provision of at least this level of service.

Options A and B are also compared with the outcome of a policy decision not to increase program resources. In the case of mandatory programs, the current envelope of funds would be re-distributed to provide a consistent level of service relative to the distribution of health needs across the City, recognizing that this level will fall below the minimum requirement. Redeployment of existing resources to serve the entire City will result in service reductions in one or more regions, with the threshold for service being raised in order to address only those with the highest needs.

Conclusions:

Starting in the fall of 1997, Public Health has consistently indicated that additional resources will be required to harmonize services, to meet health needs in cost effective ways, and to achieve compliance with provincially legislated and regulated requirements. The program options put forward for harmonization in 1999 must be considered in light of available information on health needs, the effectiveness of preventive measures, and the future costs of preventable illness and death. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Contact Name:

Dr. Sheela Basrur, Medical Officer of Health

Tel: 392-7402; Fax: 392-0713

Connie Clement, Director, Public Health Planning and Policy

Tel: 392-7463; Fax: 392-0713

Table 1

Summary of Service Impact of Program Options

Appendix A

Food Safety Program

Purpose:

To inform the Board of Health about options for meeting provincial standards for food safety across the City.

Recommendation:

(1)It is recommended that the Board of Health select one of the following service level options for the Food Safety Program and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $646,411.00 in 1999 (including a one-time cost of $61,000.00), and $1,756,234.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province at an additional cost of $406,630.00 in 1999 (including a one-time cost of $39,900.00), and $1,100,189.00 in 2000 and subsequent years.

Background:

For the Food Safety Program, Mandatory Health Programs and Services have very specific program standards and requirements and therefore, there is little flexibility or discretion in terms of interpreting the minimum standards.

Need:

It is estimated that one in six or 1.5 million people in Ontario suffer from food-borne illnesses every year, at a medical cost alone of about half a billion dollars. The nature and scope of food-borne diseases are rapidly changing, resulting in greater public risk. Examples include:

(a)widespread food-borne outbreaks in industrialized countries from agents previously unrecognized as food-borne pathogens (e.g., E.coli O157:H7, Salmonella typhimurium DT104, Cyclospora);

(b)increasing prevalence and virulence of well recognized food-borne pathogens (e.g., Listeria monocytogenes is currently implicated in an outbreak involving 35 cases and 4 deaths across nine U.S. states);

(c)increasing number of previously unrecognized "hazardous" foods (e.g., outbreaks of E.coli caused by fresh-pressed apple cider, bean sprouts, and radish sprouts in North America and Japan);

(d)globalization of the food supply (e.g., three major Cyclospora outbreaks involving fresh Guatemalan raspberries between 1996-98 with over 300 cases reported in Toronto in spring 1998);

(e)new production technologies (e.g., aquaculture conditions suspected to be the source of the newly-identified Streptococcus iniae infection from Tilapia fish in Toronto 1995-96);

(f)increase in susceptible populations (e.g., the elderly constitute a growing percentage of the population, and are at higher risk of food-borne illness); and

(g)a general decline in safe food preparation skills in the home as a result of increasing reliance on convenience foods, take-out meals, and restaurant eating (31 percent of the food dollar in Canada is now spent out of the home).

Under-reporting of food-borne diseases is common. It is estimated that for every case of food-borne illness reported to a health agency, as many as 25 may go unreported. Consequently, the yearly average of 1,700 food-borne cases reported among residents of Toronto may actually represent up to 42,500 cases per year. Moreover, Toronto's non-resident population increases by several thousand daily; potentially hundreds of food-borne cases associated with food premises in Toronto may not be reflected in the Toronto totals, because the current surveillance system records cases based on city of residence rather than place of consumption. Even so, incidence rates of food-borne diseases in Toronto have consistently been 30 percent to 40 percent higher than the provincial rates throughout the 1990s.

Ontario surveillance data shows that most outbreaks of food-borne illness between 1993 and 1996 were associated with foods served in restaurants, catered events, and health care institutions, while "home" was the main source for single, sporadic cases. Toronto's 17,582 food premises employ over 40,000 food handlers, most of whom have no formal training in food safety.

Effective Prevention:

There is demonstrated evidence of the effectiveness of: (1) incorporating risk assessment and the Hazard Analysis Critical Control Point (HACCP) system into the conventional food premises inspection programs; (2) food handler training; and (3) community-based food safety programs. HACCP is a food quality assurance system addressing risk factors that are directly linked to food-borne illness (e.g., inadequate temperature control and cross-contamination). It is believed that HACCP provides greater assurance of food safety than any other preventive measure yet devised.

The provincial 1997 Mandatory Health Programs and Services Guidelines for Food Safety are consistent with this evidence and international standards. Minimum requirements require annual assessments of all food premises to determine their potential for causing food-borne illness. Based on this assessment, each premise is classified into one of three risk categories: high, medium or low. Mandated minimum inspection frequencies are three, two, and one per year for high, medium and low-risk premises, respectively. In addition, high-risk premises must receive at least one HACCP audit per year. The 1989 version of the Mandatory Programs and HACCP Protocol were not prescriptive with respect to minimum inspection frequencies as mandated in the 1997 version. This resulted in differences in scheduled inspection frequencies and HACCP audits between the former health units. Minimum inspection frequencies for many of the former health units were based on available public health inspector resources.

The revised Mandatory Programs also require all Boards of Health to: provide food safety information to consumers, non-profit community groups and schools; ensure the availability of certified food handler training; undertake food recalls; and respond to food-related complaints within 24 hours of notification.

Current Service Delivery Issues:

It would appear that none of the six former health units' current food safety programs fully meet the 1997 Mandatory Program requirements because the Guidelines establish more detailed requirements, in particular the minimum number of inspections based on risk category of food premises. There is also wide discrepancy among levels of services. In 1997, for example, inspection frequencies for high and medium risk services ranged from once a year or less in Toronto to four or more times a year in Etobicoke. Some offices conducted extensive HACCP audits, while others only conducted modified audits and some offices did not include HACCP audits as part of their inspections. There is also diversity in the type and amount of food handler training provided. Special events (e.g., Caribana, Molson-Indy, CNE) place a heavy demand on the Toronto office for approval and inspection. All six offices meet the Ministry's requirement for 24-hour response to any food-related complaints but are able to allocate only minimal resources for public education on food safety issues.

The number of food premises is expected to continue to rise. The concentration of ethnocultural foods in Toronto and increasing diversification of the food industry (e.g., doughnut shops operating as cafés selling sandwiches and soups; supermarkets offering "take-out" items) further increase the inspection workload.

Options for Harmonization:

Option A:Optimal Prevention:

With a food safety budget increase of 45 percent, Option A results in effective food safety programs throughout the City in compliance with minimum Mandatory Program requirements consisting of: inspection services, expanded community food safety initiatives, food handler training and certification programs, effective and efficient response to consumer complaints and enquiries; and an enhanced surveillance and monitoring system to identify and assess risks and prevent and control hazards that can lead to food-borne illness. Staffing levels will be adequate to meet the demands of special events and functions (food vendors at these events are not included in the total 17,582 premises). This level of service would ensure that each year all high risk premises are inspected three times (including one HACCP audit), all medium-risk premises two times and low-risk premises once.

The enhanced community food safety initiatives will include locally implementing public education campaigns such as "Fight BAC". This campaign launched by a unique national coalition of industry, government, environmental and consumer groups comes at a time when many Canadians have inadequate knowledge about basic food safety practices. Campaigns such as this will result in new partnerships with many food operators in a joint effort to reduce food-borne illness.

Expanding the partnership with the small business offices (such as present in Toronto) to the entire City will lead to increased opportunities to assist owners in safely designing and operating their new food business. Developing new and strengthening existing partnerships with community, cultural and business groups and associations will ensure equal access to food safety programs and services. An environmental epidemiologist dedicated to the Food Safety Program will permit detailed analysis of food-borne illness (i.e., sentinel physician reporting, analysis of hospital emergency room visits, etc.) to get a clear picture of food-borne illness in the City.

This will require additional public health staff such as health promotion specialists, an epidemiologist and environmental consultants outlined in the costs below. Approximately five staff currently provide this type of support to the Food Safety Program. These FTEs are not included as part of the existing 53.3 public health inspector FTEs in the Food Safety Program.

This option equalizes current programs and levels of service across the City, standardizing inspections and eliminating differences. Food premises in Etobicoke, York, East York and North York will see decreases from the number of inspections conducted in 1997 and inspections in Scarborough and Toronto will increase. The Toronto area, with approximately 45 percent of the food premises, will have the largest increase in number of inspections. Those with decreased numbers of inspections will benefit from the HACCP Protocol and increased implementation of non-inspection services as per the Mandatory Program requirements. Partnerships with the private sector and the community will be enhanced with the common goal of providing a safer food supply.

This additional cost of $1,756,234.00 annualized provides for an additional 20.7 public health inspectors, one manager, one epidemiologist, one health educator and two clerical support staff with implementation to begin in September 1999 ($585,411.00), a one-time cost of $61,000.00 in September 1999 and full implementation in 2000.

Option B:Minimum Mandatory Program Standards:

With a food safety budget increase of 28 percent, Option B results in effective food safety programs throughout the City in compliance with minimum Mandatory Program requirements consisting of: inspection services, community food safety initiatives, food handler training and certification programs, effective and efficient response to consumer complaints and enquiries; and a surveillance and monitoring system to identify and assess risks and prevent and control hazards that can lead to food-borne illness. Staffing levels will be adequate to meet the demands of special events and functions (food vendors at these events are not included in the total 17,582 premises). This level of service would ensure that each year all high risk premises are inspected three times (including one HACCP audit), all medium-risk premises two times and low-risk premises once.

This option equalizes current programs and levels of service across the City, standardizing inpsections and eliminating differences. Food premises in Etobicoke, York, East York and North York will see decreases from the number of inspections conducted in 1997 and inspections in Scarborough and Toronto will increase. The Toronto area, with approximately 45 percent of the food premises, will have the largest increase in number of inspections. Those with decreased numbers of inspections will benefit from the HACCP Protocol and increased implementation of non-inspection services as per the Mandatory Program requirements. Partnerships with the private sector and the community will be enhanced with the common goal of providing a safer food supply.

This additional cost of $1,100,189.00 annualized provides for an additional 14.7 public health inspectors and two clerical support staff with implementation to begin in September 1999 ($366,730.00) plus a one-time cost of $39,900.00 in September 1999, with full implementation in 2000. In my opinion, as Medical Officer of Health, the minimum mandatory requirements cannot be met without this additional staffing.

Implications of No Additional Funding:

If there is no increase in the current budget of $3,856,750.00, it is recommended that the level of service be standardized across Toronto. This would require a redistribution of existing staff resources based on need. A proportion of staff resources from all of the other offices would need to be reassigned to the Toronto office, which has 45 percent of the food premises, resulting in a significant reduction of the current service levels in the areas served by the other five offices.

This option will result in over 16,000 compliance inspections not being carried out and potentially hundreds of critical violations going unchecked, placing the Toronto community at greater risk for food-borne illness and disease.

This option provides a level of service where all high-risk premises would be inspected three times annually, 83 percent (7,113) of medium-risk premises would receive only one inspection per year and 17 percent (1,465) of the medium-risk and all 6,254 low-risk would not be inspected. The criteria for selecting those medium-risk premises that would not be inspected include the presence of internal responsibility systems, such as full implementation of HACCP, self-auditing of food preparation, food handler training/certification, etc.

In my opinion as Medical Officer of Health, the Toronto Board of Health would not be in compliance with the Mandatory Programs under this option.

This level of public health surveillance and monitoring of food premises may also result in a lower level of self-compliance by owners/operators of restaurants and other food premises. Reduced inspection levels in some areas may also result in an increased number of complaint investigations and reinspections to ensure critical hazards rectified, resulting in further inability to meet even the proposed inspection schedule.

Program Budget and Budget Options:

Conclusion:

A broad range of global and local factors is responsible for recent outbreaks, new food hazards and an increasing need for effective food safety programs world-wide and in Toronto. In response, industry and governments in Europe, North America (and Ontario) are implementing new standards based on evidence of effective interventions. These include: risk assessment and incorporating the Hazard Analysis Critical Control Point (HACCP) system into conventional food safety premises inspections programs; food handler training; and community-based safety programs. Effective food safety programs are essential to the health of the population and the ability of Toronto to maintain its reputation as a safe and healthy city for business, tourism and living. This report presents options for meeting provincial standards for effective food safety programs in Toronto. These options have different budget implications. The Board of Health (and ultimately City Council) has to make policy decisions, determined by health, financial, social and political factors and constraints as to which option is ultimately selected.

References:

Altekruse SF, Cohen ML, Swerdlow DL. Emerging Foodborne Diseases. Emerg Infect Dis 1997 Jul-Sep:3(3):285-93.4.

Campbell ME, Gardner CE, Dwyer JJ, et al. Effectiveness of Public Health Interventions in Food Safety: A Systematic Review. Canadian Journal of Public Health 1998;89(3):203-207.

FSnet Dec. 19, 1998 http://www.exnet.iastate.edu/Pages/families/fs/homepage.html.

Hauschild AHW, Bryan FL. Estimate of cases of food and waterborne illness in Canada and the United States. Journal of Food protection 1980; 43:4335-4440.

Institute of Medicine, National Research Council. Ensuring Safe Food: From Production to Consumption. Washington D.C. : National Academy Press, 1998; 51-59.

Meng J. Doyle MP. Emerging Issues in Microbiological Food Safety. Annu Rev Nutr 1997;17:255-75.

Ontario Ministry of Agriculture, Food and Rural Affairs (OMAFRA), 1994. Community Food Advisor Program Guidelines. OMAFRA, Toronto. Revised May 1994.

Ontario Ministry of Health. Public Health and Epidemiology Report Ontario (PHERO). 1998;9(5):109-112.

RDIS data 1995-1997, Toronto Public Health.

Rocourt J. Bille J. Foodborne Listeriosis World Health Stat Q 1997;50(1-2):67-73.

Silliker JH, Baird-Parker A, Bryan FL, et al. Report of the WGO/ICMSF Meeting on Hazard Analysis Critical Control Point System in Food Hygiene. World Health Organization, Geneva, Switzerland, 1982.

Sly T. Ryerson Polytechnic University, School of Occupational and Public Health. Personal Communication. December 20, 1998.

Toronto Board of Health. 1997. Is Food the Next Public Health Challenge? City Clerk, Toronto. September 5, 1997.

Toronto District Health Council. Toronto's Health System Report Card (Interim Report). November 1998 102-103.

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Appendix B

Tuberculosis Program

Purpose:

To inform the Board of Health about options for meeting provincial standards for tuberculosis control across the City.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service options for tuberculosis (TB) control and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto at an additional cost of $726,159.00 in 1999 (including one-time costs of $100,000.00) and $1,878,478.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $567,572.00 in 1999, (including one-time costs of $87,000.00) and $1,441,715.00 in 2000 and subsequent years; and

(2)the Board of Health request Council through the Community and Neighbourhood Services Committee to advocate with the Board of Health and local hospitals for provincial funding to provide appropriate accommodation for people without housing who have active TB in order to reduce disease transmission and promote a stable environment which will assist them to regain their health.

Background:

For the TB control program, there is a provincial protocol under the Mandatory Health Program and Service Guidelines which has specific program standards and requirements. Therefore, there is little flexibility or discretion in terms of interpreting the minimum standards.

Need:

There are approximately 2000 new cases of tuberculosis reported in Canada each year, including 800 in Ontario. The City of Toronto has 450 - 500 cases of TB per year with an incidence rate three times the provincial rate. Three key factors have contributed to the increased prevalence of TB in Toronto:

(1)Toronto experiences high immigration from countries where TB is endemic (over 90 percent of the TB cases in Toronto occur in the foreign-born). TB rates in some major source countries are 30 - 40 times the Toronto rate and 30 percent of all immigrants to Canada settle in Toronto, a city which has 6 percent of the Canadian population.

(2)Socio-economic factors - numbers of unemployed, low-income singles and families with children, people who are homeless - are all above the provincial average; poverty and crowded conditions increase the risk of acquiring and spreading TB among vulnerable groups.

(3)Toronto's HIV infection/AIDS incidence rate is three times the provincial rate. Having HIV greatly increases the risk of developing TB and prolongs the TB treatment period when TB does occur.

Drug resistant tuberculosis is of great concern and has been linked to outbreaks in cities such as NewYork and San Francisco. In 1996, 16 percent of Toronto cases demonstrated resistance to one or more antibiotics (compared to 8.7 percent nationally); multi-drug resistant (MDR-TB) cases reached 2.6 percent in 1996 compared to less than 1 percent for Canada as a whole. Mortality in drug resistant cases ranges between 18 - 70 percent. Drug resistant strains result primarily from incomplete or improper treatment; a drug resistant TB case costs $230,400.00 (U.S.) to treat compared to $14,500.00 (U.S.) for a case of nonresistant TB. TB prevention directly lowers future public health costs, while also reducing expenditures in other sectors (e.g., acute care hospitals).

Conversely, failure to invest in TB prevention can lead to escalating disease rates and associated costs, as occurred in New York City where complacency about declining numbers of TB cases led to cut-backs in the TB program during the 1980's. Within a short period of time, TB rates tripled and drug resistance increased to 23 percent, with mortality in resistant cases reaching more than 80percent. In response to this growing epidemic, the U.S. Center for Disease Control (CDC), expanded its budget to support TB programs from $25 million in 1991 to $104 million in 1993. With the additional funding, New York City embarked on a massive expansion of its Directly Observed Therapy (DOT) program, going from 137 persons on DOT in 1991 to 1282 DOT patients by 1993. That year the number of new TB cases fell for the first time in 15 years. This reversal was attributed to the expanded DOT program. In 1997, New York City had a population of 8.6 million and 1737 cases of TB, for an incidence rate of 21.6/100,000 population; it also required a $40 million TB program with over 500 staff. While it can be argued that the structure of the health care and social service systems are very different in the U.S., it is important to pay attention to the New York lesson and implement an effective TB program that will save lives and money in the long run.

TB is now regarded world-wide to be the leading cause of death among people who are HIV positive. In the City of Toronto in 1996, 4.2 percent of TB cases had HIV/AIDS listed as a risk factor, up from 3.7 percent for 1992-96. The mortality rate in persons who have TB and who are also HIV positive ranges between 20 percent to 35 percent, in part because TB accelerates the natural progression of HIV infection. Targeted programming and strategic interventions are required to prevent co-infection in Toronto.

Effective Prevention:

In 1993 the World Health Organization (WHO) declared TB a "global emergency". It recommended universal use of Directly Observed Therapy (DOT). DOT consists of closely supervised treatment by watching patients swallow their medication to make sure every dose is taken; it is the most effective way to cure TB as it ensures patients adhere to treatment. Non-adherence is difficult, if not impossible, to assess in advance and variables such as age, income, occupation, education do not reliably, consistently or accurately predict adherence to therapy. Incomplete treatment of TB is worse than no treatment at all because it leads to drug resistance. DOT is labour intensive but it works. The World Bank describes DOT as one of the most cost-effective health strategies.

The Canadian Expert Committee on Tuberculosis (ECOT), through the National Consensus Conference on Tuberculosis held in December 1997, made recommendations including:

(a)Directly Observed Therapy as the standard treatment;

(b)screening of high-risk groups for case finding and prophylaxis (e.g., drop-ins, homeless shelters, correctional facilities, alcohol and drug rehabilitation programs);

(c)improved communication and collaboration between AIDS and TB programs;

(d)case manager for each case of active TB (to monitor compliance, check drug toxicity monthly); and

(e)monitoring of clients on INH prophylaxis for toxicity.

The provincial Mandatory Health Programs and Services Guidelines (1997) state that the "Board of Health shall have in place an effective program for TB prevention and control which shall include case finding, case holding, treatment and follow-up". The minimum requirements outlined for TB prevention and control in Ontario, detailed in a provincial protocol, are consistent with the recommendations of the WHO, expert committees, and scientific research and experience concerning cost-effective TB prevention and control except in the case of DOT. The guidelines state that the Board of Health must "ensure that all persons with active tuberculosis complete the prescribed course of chemotherapy through the provision of DOT or another appropriate intervention." Other interventions are not described and to date no intervention has been shown to cure TB as cost-effectively as DOT. There may be strategies whereby DOT can be used in a modified manner but these have not been evaluated.

Current Service Issues:

There is considerable variation in the degree to which the new 1997 Mandatory Health Program and Services Guidelines are being met in the six former health units:

(a)Less than 20 percent of cases are followed with DOT (Toronto offers DOT to all cases, Etobicoke and North York offer DOT selectively; Scarborough, East York and City of York do not have DOT programs).

(b)Educational sessions and updates to physicians, other health care workers and high risk groups are provided only on as-time-permits basis (e.g., Toronto offers education to shelter and hostel staff; North York and Etobicoke offer education only upon request; and Scarborough cannot offer any educational sessions because of a lack of staff).

(c)Screening of high risk groups, other than contacts of active cases, is not available anywhere in the City.

(d)Monitoring of adherence to chemoprophylaxis is not available anywhere in the City.

(e)Monitoring of individuals on surveillance for inactive TB (Post Landing Surveillance of immigrants and refugees) varies from one contact only (Scarborough and City of York) to annual follow-up for five years (Toronto).

Options for Harmonizing the TB Program:

Option A:Optimal Prevention:

With the addition of 28 FTEs to the current 35.25 FTEs, Toronto will be able to provide DOT to all TB cases and select high risk contacts and provide TB education, including regular updates to physicians and other health care workers throughout the City. It will permit more careful monitoring of clients on chemoprophylaxis and screening of selected groups at high risk of developing TB (e.g.,injection drug users, English as a Second Language [ESL] students, homeless and underhoused persons living in shelters). The increase will enable Toronto to meet the requirements set out in the Mandatory Health Programs and Services Guidelines. It also provides equal access across the city to the most cost-effective form of treatment for active tuberculosis and the best protection against increasing TB drug resistance and preventable TB mortality. While DOT currently is primarily provided by RPNs (six to seven community visits per day), a variety of other strategies are currently being explored to provide DOT in the most cost-effective way possible (persons coming to the health unit or community clinic, contracting out, using non-professional staff for low-risk cases).

The additional budget required is $1,878,478.00 (a 90 percent increase in the current budget of $2,100,000.00 for a total budget of $3,978,478.00) to begin implementation in September 1999 with an increase in operational costs of $626,159.00 in 1999 plus one-time computer costs of $100,000.00.

Option B:Minimum Mandatory Program Standards:

With limited expansion (budget increase of 69 percent and 19.75 staff), full DOT will be available to only 40 percent of TB cases. This will be a reduction in the DOT program in the Toronto district while it increases the services available in other parts of the City. All new cases will start on DOT for the first month until treatment is well established. During this period the client will be assessed for risk factors commonly associated with non-adherence (e.g., failure to keep appointments) and a decision regarding the necessary support he/she requires will be made. The DOT program will be restricted to select high risk cases (e.g., persons who have drug resistant TB, persons who are co-infected with HIV, children and teenagers, persons who are homeless or under-housed, persons with substance abuse problems and individuals who are experiencing adverse reactions to TB medication). In other cases, an enhanced follow-up program will be used as a strategy to ensure adherence to treatment. Persons deemed to be at low risk can be followed at progressively longer intervals (e.g., initially weekly then tapering to monthly).

This expansion of the DOT program in some parts of the City will ensure improvement in completion of treatment and decline in relapse rates. This option also establishes enhancement to educational outreach as required in the new Mandatory Health Programs and Services Guidelines. Education will be available to targeted high-risk groups (e.g., new immigrant and refugee centres) and annual updates will be provided to health professionals. In addition, contact follow-up of new cases will be expanded to meet the new requirements. Limited screening of high risk groups (e.g., homeless shelters, ESL classes) will be undertaken and monitoring of individuals on chemoprophylaxis will be enhanced to the minimum level specified in the guidelines. Direct contact with individuals on post landing surveillance for inactive TB will be initiated.

This option increases access to DOT from the current 20 percent of cases to about 40 percent of cases. While it is anticipated that this option would comply with the minimum requirements of the 1997 Mandatory Health Programs and Services Guidelines, it would be difficult to provide the majority of persons with active TB with the treatment that has been proven to be most cost-effective. This requires a budget increase of $1,441,715.00 with implementation to begin in September 1999 with a budget increase of $480,572.00 for operational costs in 1999 plus one-time costs of $87,000.00.

Implications of No Additional Funding:

With no budget increase, existing resources would be redistributed to reflect patterns of health needs across the City. As a result, TB services would be decreased in the districts of Toronto, Etobicoke and North York, with expansion in Scarborough, East York and the City of York. DOT would only be available on a selected basis to high-risk pulmonary cases who are deemed to be most likely to be non-adherent to treatment.

Since it has been established that health care providers are unable to predict adherence to and completion of TB treatment, the incidence of non-adherence, acquired drug-resistance and TB mortality would be expected to rise. This would particularly occur in the districts where DOT services are cut back. Educational outreach would be limited to select high-risk settings on an as-time-permits basis which may have a negative impact on timely case identification and contact follow-up.

In my opinion, as Medical Officer of Health, many of the provisions specified in the Mandatory Guidelines would not be met. The dollars not invested in prevention and follow-up will put pressure on future budget requirements to treat cases that could have been prevented. This prediction is based on the American experience where it has been estimated that the health system cost of treating a single outbreak of drug resistant TB approaches $1,000,000.00 (U.S).

Program Budget and Budget Options:

* The cost of drugs for TB treatment and chemoprophylaxis is paid by the Province.

Conclusion:

Tuberculosis is a global emergency, a major cause of death in many countries and a leading cause of death among people who are HIV positive. Toronto has high immigration from many countries where TB is endemic. Drug resistant forms of TB are increasing world-wide and in Toronto. Other conditions for increasing TB are homelessness, poverty, substance abuse, crowded living conditions, and HIV.

Evidence of the cost effectiveness of TB prevention and control interventions is mounting and clear about the importance of infrastructure to ensure early identification of cases, directly observed therapy, follow up of all contacts and education for high-risk populations and health care providers. Experience is also clear in demonstrating that the costs of failure to invest in prevention are many times higher when a TB crisis results.

This report presents options for meeting provincial standards including optimal level to effectively prevent and control TB and minimal level to meeting provincial standards. The Board of Health (and ultimately City Council) has to make policy decisions determined by financial, economic, social and political factors and constraints as to which option is ultimately selected.

References:

Bayer R, Wilkinson D. Directly Observed Therapy for Tuberculosis: History of An Idea. The Lancet, Vol. 345, June 17, 1995. Pp. 1545-1548.

Chaulk CP, and Kazandjian VA. Directly Observed Therapy for Treatment Completion of Pulmonary Tuberculosis. JAMA, March 25, 1998, Vol. 279, p. 944.

Faning EA. Globalization of Tuberculosis [editorial comment]. CMAJ 1998; 158: Pp 611-2.

Moore RD, Chaulk CP, Griffiths R, Cavalcante S and Chaisson RE. Cost-Effectiveness of Directly Observed Versus Self-Administered Therapy for Tuberculosis. Am J Respir Crit Care med, 1996; Vol. 154, Pp. 1013-1019.

Park MM, Davis AL, Schluger NW, Cohen H and Rom WN. Outcome of MDR-TB Patients 1983 - 1993. Am J Respir Crit Care Med, 1996; Vol. 153, Pp. 317-324.

Prevention and Treatment of Tuberculosis Among Patients Infected with Human Immunodeficiency Virus: Principles of Therapy and Revised Recommendations, Morbidity and Mortality Weekly Report, October 30, 1998, Vol. 47, p. 7.

Report of the National Consensus Conference on Tuberculosis, held in Toronto December 3-5, 1997. Pp. 8-13.

Reported Tuberculosis in the United States, 1997. U.S. Department of Health and Human Services, Public Health Services, Centres for Disease Control and Prevention, National Centre for HIV, STD and TB Prevention, Division of Tuberculosis Elimination. Pg. 43.

TB Programme. TB a global emergency: WHO report on the TB epidemic Geneva. Switzerland: World Health Organization 1993 (WHO/TB 1993-177).

Weis SE, Slocum PC, Blais FX, King B, Nunn M, Matney GB, Gomez E and Foresman BH. The Effect of Directly Observed Therapy on the Rates of Drug Resistance and Relapse in Tuberculosis. The New England Journal of Medicine, Vol. 330, April 28, 1994, Pp. 1179-1184.

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Appendix C

Needle Exchange Services

Purpose:

To inform the Board of Health about options for meeting provincial standards for needle exchange services for the purposes of HIV prevention across the City.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service options for needle exchange for the purposes of HIV prevention and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $227,878.00 in 1999 (including one-time costs of $41,000.00 in 1999) and $560,634.00 in 2000 and subsequent years plus one-time capital costs of $82,000.00 in 2000; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $180,565.00 in 1999 (including one-time costs of $41,000.00) and $418,696.00 in 2000 and subsequent years;

(2)that the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(3) that the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date.

Background:

Need:

Injection drug use is the fastest rising risk factor for HIV, representing a significant need and opportunity for effective prevention.

(1)The number of injection drugs users in Toronto is estimated at 15,000. The largest concentration of AIDS/HIV among Ontario injection drug users continues to be in Toronto (half of all cases) and all the six former municipalities are among the 10 health units with the highest AIDS rates.

(2)The current HIV seroprevalence rate among injection drug users in Toronto is 9.5 percent, showing a steady increase since 1991 when the rate was less than 5 percent. Although the rate in Toronto is increasing, it is low compared to Montreal (20 percent) and Vancouver (25percent). Worldwide experience shows that once the HIV rate in a population reaches 10 percent, it can increase exponentially, making effective prevention programs in Toronto imperative.

(3)Conditions known to contribute to HIV transmission are increasing (e.g., lack of stable housing, transience, sharing needles, injecting cocaine). Anecdotal evidence indicates that crack injection is significant in Scarborough, East York, North York and Toronto.

(4)Street Youth are a growing risk group, with estimated HIV rates triple those of the general population; between 17 and 30 percent are estimated to be injection drug users and needle sharing is common.

(5)Research suggests that difficulty in obtaining sterile injecting equipment is the main reason that injection drug users share equipment.

(6)A recent scan to gather information about the need for increased services to injection drug users in Toronto revealed that all areas in the new City of Toronto are under-serviced, with the exception of the former City of Toronto.

Recognizing injection drug users as a priority group for AIDS prevention, the Ontario Ministry of Health recently created a mechanism to fund community outreach workers to work with injection drug users. Six workers will be hired in Toronto, with one position going to The Works (the former City of Toronto needle exchange program). The guidelines for this program clearly state that the workers must be "value added" and not duplicate or replace existing services and programs. The outreach workers are also expected to work towards reducing the isolation of injection drug users and should assist in reaching those presently not accessing services. There have already been preliminary discussions requesting supplies, training and support for the outreach workers in the Toronto area from The Works. It is therefore anticipated that this program will increase demand for needle exchange services and supplies in Toronto.

Effective Prevention:

The 1997 Provincial Mandatory Health Program and Services Guidelines state that "The Board of Health shall ensure that injection drug users can have access to sterile injection equipment by the provision of needle and syringe exchange programs as a harm reduction strategy to prevent the transmission of HIV, Hepatitis B, Hepatitis C and other blood-borne infections and associated diseases in areas where drug use is recognized as a problem in the community. The strategy shall also include counseling and education and referral to primary health services and addiction/ treatment services..."

The provision of sterile injection equipment is the most effective method for the prevention of HIV and other communicable diseases in injection drug users. A World Bank report found the former City of Toronto was one of five cities worldwide able to maintain a low HIV seroprevalance rate, primarily because the needle exchange programs started early and were multi-faceted. Research clearly demonstrates that a multi-faceted needle exchange service is a contributing factor to maintaining a low HIV rate. Multi-faceted needle exchange programs provide needles, condoms, instruction regarding safer drug use and safer sex, counselling regarding drug use, referrals to detox and drug treatment, assistance in accessing housing, food and clothing, testing for HIV, Hepatitis B and C, Hepatitis B vaccines, methadone and access to primary care and other health and social services.

Access to needle exchange services is enhanced through a combination of service sites.

(a) Mobile Service enables staff to reach a large geographic area, provide services to clients where they are and reach injection drug users who are concerned about anonymity.

(b) Fixed Site/Drop-in is a good venue for more in-depth service provision, including counselling, health testing (e.g., HIV and Hepatitis) and referrals to other services.

(c) Street Outreach introduces services to the target population in areas where there has not been service and educates injection drug users about the service and how to access it.

(d)Partnerships with community agencies enable provision of needle exchange for clients in an environment that they already trust and within which they feel comfortable.

Current Service Delivery Issues:

There is significant variation in the degree to which the 1997 Mandatory Health Program and Services Guidelines are being met in Toronto. The former City of Toronto appears to be the only district that meets the requirements. The former health units of Etobicoke and York offered a minimal level of service. Prior to amalgamation, the former North York was in the initial stages of developing a partnership with a community agency to provide basic needle exchange and condom distribution to injection drug users. The former municipalities of Scarborough and East York did not offer needle exchange services. Public Health staff in the Scarborough district are working closely with a community agency to expand other services for injection drug users.

The former City of Toronto funded a one-year methadone pilot project (called Methadone Works) in response to a recommendation arising from the Inquiry into Homelessness and Street Deaths (1996). Members of the Inquiry based this recommendation on research that clearly demonstrates a connection between drug use and homelessness. Methadone maintenance has also been shown to reduce the use of illicit drugs and criminal activity, improve mental and physical health and economic productivity, improve retention in addiction treatment, reduce needle sharing and reduce HIV ratesand transmission. The results of an evaluation of the program are expected in April 1999. Preliminary results reveal that many clients of Methadone Works have been able to reduce needle use and therefore needle sharing, and have been able to secure more stable housing.

The Toronto district needle exchange program operates Methadone Works in partnership with Breakaway Youth and Family Services in Etobicoke. There has been a substantial increase in methadone availability in Toronto in the recent past, mainly through private physicians who do not have comprehensive support services readily available for patients. Research demonstrates that successful methadone programs have a high level of optional support services. Methadone Works offers intensive support services and counselling and is the only low threshold harm reduction methadone program of its kind in Toronto. This program was designed for clients of The Works (many of whom are homeless or underhoused and have a variety of other service needs) who require counselling and would probably not remain on methadone without intensive support. Priority is given to clients who are HIV positive or pregnant. Methadone Works is co-located with The Works in an effort to increase accessibility to methadone for current injection drug users who have a positive history with a program that is non-judgemental and non-threatening. Clients without OHIP are also seen and the costs of methadone and other drugs prescribed by the methadone physician are covered in the methadone budget.

Methadone Works started in November 1997 as a pilot project with one-year funding from the former City of Toronto. A one-time grant from the Substance Abuse Bureau of the Ministry of Health willcontinue funding of the program until March 31, 1999. An application for continued annualized funding has been submitted, but is not expected to be approved due to financial constraints. A further application has been submitted to the Substance Abuse Bureau of the Ministry of Health for an additional two months of funding to carry the program until the end of May 1999, but a response has not yet been received. Applications will also be made to Health Canada and other federal funding sources.

Options for Harmonizing the Needle Exchange Program:

Option A: Optimal Prevention:

In this option, services would be enhanced to the level in the former City of Toronto to extend multifaceted needle exchange services across the city. Overall staffing and services would be almost doubled. A total of 5.8 Counsellors, three vans and one Clerk would be added and the Peer Outreach budget would be enhanced. Currently, 16 partnerships with community agencies and pharmacies for the provision of needle exchange services are in place, and Option A would see the number of partnerships increased to 30.

This level of service would comply with the Mandatory Health Programs and Services Guidelines and would have the greatest chance of ensuring the prevention of HIV, Hepatitis B and C and other communicable diseases in the injection drug using population in Toronto. This option has the potential for exchanging the largest number of needles; the one-time purchase of new vans (with capital expense spread over 1999 and 2000) is critical to the best practice nature of this option in that the existing two vans account for a major portion of needles currently exchanged. Vans are equipped with a stationary table and chairs, storage, needle disposal container, and a cab so that people can stand in the van as well as receive counselling, referral or health testing.

A total of $560,634.00 would be added to the annual base budget, bringing the total budget for needle exchange services to $1,185,634.00. In addition, a total of $123,000.00 in capital costs would be required for the purchase of three vans. Implementation of the needle exchange component would begin in September of 1999.

Option B: Minimum Mandatory Program Standards:

Services would be enhanced to the level of service delivery in the former City of Toronto, with the exception of the mobile component which would only be partially enhanced. This option would add four Counsellors, one van, one Clerk and an enhanced Peer Component and community agency partnership program. The focus of service delivery would be street outreach and support for peers and community agencies. The primary goal in the first year would be client finding.

It is anticipated that Option B would comply with the 1997 Mandatory Guidelines, however, limited availability of the mobile component in larger, more dispersed regions of the City will decrease efficiency and increase staff travel time, potentially decreasing access to needle exchange services to the most isolated clients.

A total of $418,696.00 would be added to the base budget (making the total budget for needle exchange services $1,043,696.00). A total of $41,000.00 in capital costs would be spent in 1999 to purchase one additional van. Implementation of Option B would begin in September of 1999.

Implications of No Additional Funding:

If resources remain the same, services would be redistributed to serve pockets of highest need across the City. This would reduce services provided to current clients in order to provide access to new clients in underserviced areas. The program would provide an inadequate level of prevention and HIV rates in the injection drug using population would likely increase. In my opinion as Medical Officer of Health, this level of service would not be a reasonable interpretation of the provincial standards given the conditions that exist in the City of Toronto.

Methadone Program:

If a funding commitment for continuation of the methadone component of The Works is not obtained before March 1999, we will work with clients on a case-by-case basis to determine the most appropriate option for discharge and referral. A methadone program with a harm reduction approach, in partnership with The Works with its multifaceted counselling, and support services, is an important component of the continuum of services for injection drug users in Toronto. Alternative funding or alternative service partnerships will be needed to provide access to comparable services if Methadone Works is terminated. The provision of methadone is not required in the provincial mandatory guidelines.

Program Budget and Budget Options:

Conclusion:

Experience world-wide and in other Canadian cities suggests the consequences of failure to provide comprehensive HIV prevention and harm reduction strategies for injection drug users have high human, social and treatment costs. Consequences include a rapid rise in HIV rates in this population; increasing HIV among women who contract HIV through needle sharing and among children who contract AIDS through perinatal transmission; increased spread of other communicable diseases such as Hepatitis B and C and preventable treatment costs of over $100,000.00 per case.

This report describes needle exchange services which represent optimal and minimum potential for preventing the spread of HIV among injection drugs users, their partners and children. Both meet the provincial standards for the provisions of needle exchange as part of a harm reduction strategy including counselling, education and referral to health care and addiction treatment services. The Board of Health (and ultimately City Council) has to make policy decisions, determined by health, financial, social and political factors and constraints as to which option is ultimately selected.

References:

Cavalieri et al, Proposal to the AIDS Bureau, Ministry of Health, Province of Ontario, for the Deployment of Four Outreach Workers to Provide Prevention, Education and Support Services to the IDU Community in the City of Toronto (Excluding Scarborough and North York).

DesJarlais et al. International Epidemiology of HIV and AIDS Among Injection Drug Users. AIDS, 1992, Volume 6 pp.1053-1068.

Jones, T. Steven and David Vlahov, Use of Sterile Syringes and Aseptic Drug Preparation are Important Components of HIV Prevention Among Injection Drug Users, Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 18(Suppl 1):S1-S5, 1998 Lippincott-Raven Publishers, Philadelphia.

Millson P., Myers T., Calzavera L., Major C., Fearon M., Wallace E., Rea E., Rankin J., Degani N., Chapman C., Rigby J. HIV Trends Among Injection Drug Users in Toronto, 1989-1997. Seventh Annual Canadian Conference on HIV/AIDS Research, Quebec City, May 1998. CanJ Infect Dis, 1998, 9, Suppl A, March/April, #276P.

Personal communication, 1998 Peer Program (The Works, Toronto Public Health).

Poulin, C. et al. The Epidemiology of Cocaine and Opiate Abuse in Urban Canada. Canadian Journal of Public Health. 1998. 89(4). 234-238.

Reed, S. et al, HIV Prevalence in Toronto Street Youth. Toronto Hospital For Sick Children. 1993.

Remis R. et al. Report on the HIV/AIDS Epidemic in Ontario. 1981 - 1996. Ministry of Health, 1998.

Research Group on Drug Use. Drug Use in Toronto, City of Toronto, 1998.

Roy, E. et al. Injection Drug Use Among Street Youth: A Dynamic Process. CJPH, July-Aug 1998 (239-240).

Schwartz RH. Syringe and Needle Exchange Programs: Part 1, Southern Medical Journal, 1993,86:318-22.

Swan, N., Research Demonstrates Long-Term Benefits of Methadone Treatment NIDA Notes, National Institute on Drug Abuse, November/December, 1994.

World Bank. Confronting AIDS Public Priorities in a Global Epidemic, A World Bank Policy Research Report, Oxford University Press, 1997.

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The Board of Health reports, for the information of Council, also having had before it during consideration of the foregoing matter the following communications:

(i)(January 22, 1999) from Ms. Anne Dubas, President, Canadian Union of Public Employees (CUPE) Local 79, urging Councillors to support the optimal approach to meeting provincial standards for food safety, tuberculosis control and needle exchange services; and

(ii)(January 21, 1999) from Ms. Rita Luty, Chair, Northern Health Area Community Health Board, advising that the Northern Health Area Community Health Board at its meeting held on January 21, 1999, adopted a motion in support of the selection of optimal service levels for the Food Safety Program, tuberculosis control and needle exchange for the purposes of HIV prevention, to be funded from new fiscal resources, and the pursuit of additional funding for methadone programs and services in Toronto.

Dr. Barbara Yaffe, Director, Communicable Disease Control, gave a presentation to the Board of Health on the foregoing report.

Mr. Dennis Casey, Vice-President, Canadian Union of Public Employees Local 79, appeared before the Board of Health in connection with the foregoing matter.