Expansion of Hostel Services - Public Health

Initiatives to Reduce the Spread of

Communicable Diseases, In Particular TB

The Community and Neighbourhood Services Committee recommends the adoption of Recommendations Nos. (2) to (5) contained in the report dated March 26, 1999, from the Medical Officer of Health.

The Community and Neighbourhood Services Committee reports, for the information of Council, having received Recommendation No. (1), contained in the report of the Medical Officer of Health in that the Public Health's Operating Budget is being considered by Council on April 26 and27,1999, as part of the budget process.

The Community and Neighbourhood Services Committee submits the following report (March26, 1999) from the Medical Officer of Health:

Purpose:

To inform the Community and Neighbourhood Services Committee of the expansion of public health initiatives which would be required to reduce the spread of communicable diseases with an expansion of hostel services, in particular TB.

Financial Implications:

Tuberculosis (TB) in the homeless and underhoused population in the City of Toronto cannot be controlled unless there is a comprehensive TB control program for the entire population. Provision of this service level for the City would be at an additional cost of $634,830.00 in 1999 (including one-time costs of $103,377.00) and $1,594,358.00 in 2000 and subsequent years.

On March 23, 1999, the Province of Ontario announced that it will fund 50 percent of the cost of provincially-approved Mandatory Health Programs and Services retroactive to January 1, 1999. The actual impact of this announcement on Toronto's Public Health Budget is not known at the time of writing this report.

Recommendations:

It is recommended that:

(1)the Community and Neighbourhood Services Committee continue to support the optimal service level for Toronto Public Health's TB program;

(2)current Public Health initiatives pertaining to communicable diseases other than TB should be harmonized across the City and workloads associated with both the current and new hostels should be monitored with a view to considering provincial cost-sharing of hostel-specific public health services;

(3)prior to the construction of any new hostels, Toronto Public Health should be consulted regarding ways to minimize the risk of communicable diseases within the new environments;

(4)the Community and Neighbourhood Services Committee continue to advocate with the Province for provincial funding for appropriate accommodation for people without housing who have active TB in order to reduce disease transmission and promote stability and health, as requested by the Board of Health on January 25, 1999; and

(5)the Community and Neighbourhood Services Committee continue to support the recommendations in the Report of the Mayor's Homelessness Action Task Force, which state that no one should be discharged from an institution to the street and that the Ministry of Health should fund infirmary beds in appropriate locations for homeless people recovering from illness or surgery.

Background:

On February 11, 1999, the Community and Neighbourhood Services Committee recommended to Council that the commitment by the Community and Neighbourhood Services Department to expand hostel services by adding smaller full-standard facilities and developing a range of harm reduction shelters be supported. Also recommended was that the existing contract with the Salvation Army for the Lighthouse shelter at 37 Dundas Street East be increased by 30 beds on Monday, Tuesday, Wednesday and Thursday nights effective February 15, 1999 to April 14, 1999.

The Medical Officer of Health was directed to report back to the Community and Neighbourhood Services Committee on the expansion of public health initiatives to reduce the spread of communicable diseases, in particular TB, which should accompany an expansion of hostel services.

On January 25, 1999, the Board of Health approved, in principle, the provision of an optimal service level for TB control for the City of Toronto (see Appendix 1) and requested the Medical Officer of Health to submit a report to the Board at its next meeting on additional cost implications for the options in the context of the 1999 budget submission for Public Health. On February 22, 1999, the Board of Health gave final approval for the provision of optimal service levels in TB Control and recommended that the final costs for this program, which were not included in the 1999 Operating Budget request, be submitted to the Budget Committee for consideration. On March 24, 1999, the Community and Neighbourhood Services Committee supported in principle the service level recommended by the Board of Health for TB control.

Discussion:

The current number of homeless in the City of Toronto is not known. In 1996, almost 26,000 people used the hostel system in Toronto. This number underestimates the total number of homeless, as some people never use hostels. As of November 1998, there were approximately 4,000 beds in 46 shelters throughout the City. Between December 1 and March 31 yearly, a network of churches and other faith groups provide overnight shelter, drop-in services, and meals for homeless and socially isolated people through a program known as "Out of the Cold". There are 46 such facilities, of which 25 provide overnight services one or more nights a week, for between 150 and 400 youths and adults each night.

Homeless people are at higher risk of infectious diseases than the general population. They are also at an increased risk of suicide, mental health problems, chronic health problems, and substance abuse. This situation is exacerbated when people are living in circumstances which expose them to crowded conditions, poor ventilation, poor nutrition, lack of access to facilities to maintain adequate personal hygiene, and an increased likelihood of experiencing violence or trauma. All of these factors contribute to poor immunity and increased susceptibility to infectious diseases, such as respiratory diseases including TB, gastrointestinal diseases and skin infections and infestations.

Thirty to 40 percent of homeless individuals are infected with TB and are at a high risk of progression to active TB. Approximately 2 percent to 3 percent of Toronto's 450 to 500 active TB cases per year occur among persons who are homeless or underhoused. With respect to other infectious diseases, it is currently not known what proportion of Toronto's approximately 20,000 cases of communicable diseases (other than TB) each year occur in the homeless/underhoused population.

Shelter operators and staff are well aware of the health issues identified above. Shelters work in partnership with Public Health, local Community Health Centres, local hospitals and with individual physicians to provide the health services which shelter residents require. Nevertheless shelter operators indicate that it is still difficult for many shelter residents to access appropriate health care when they need it.

The City of Toronto Hostel Standards includes a section on Health and Safety which discusses the issue of communicable disease and appropriate staff training regarding various illnesses. It further requires shelters to develop clear policies and procedures for managing and treating communicable diseases. Hostel Services staff worked with Public Health on the development and distribution of handbooks on Infection Control and TB which were made available to services assisting homeless and underhoused people, as described below. At the present time, the Toronto Hostels Training Centre offers a course on Communicable Diseases and Prescription Drug Awareness. Additionally, a monthly course is offered on the Hostel Standards which involves a discussion of health and safety issues. Despite all of this, Hostel Services also recognizes that there are locations where crowded conditions exist and staff are working to address that issue.

Toronto Public Health provides services to the homeless and underhoused community to help control infectious diseases. These services are provided at various locations, including drop-in centres, shelters, and local area public health offices. All suspect/confirmed cases of communicable disease are investigated by the local area office to ensure that cases are diagnosed, treated, and isolated as appropriate; that potential contacts are identified and treated; and that all appropriate infection control measures are taken to reduce the spread of disease. Preventive education/outreach services for TB and infection control are generally provided upon request. Immunization clinics and infestation treatment are regularly offered in the former Toronto only.

Toronto Public Health is not currently able to meet the provincial mandatory requirements regarding TB control due to lack of resources and the volume of the problem. If anything less than the optimal service level for TB is approved, we will not be able to meet provincial standards in the current shelters within the City.

Below is an inventory of current public health initiatives related to communicable disease control for the homeless/underhoused population and comments as to whether these initiatives would need to be expanded to accommodate an expansion of hostel services.

(A)TB Control in Homeless/Underhoused Populations:

(i)Assess and investigate all reported active cases of TB. Provide directly observed therapy (DOT). Attempt to find stable housing for clients.

It is difficult to predict the impact of an expansion of hostel services on the number of cases of active TB.

(ii)Conduct contact tracing, including risk assessment and clinics at the facility involved, with education sessions and TB skin testing. Refer those who test positive for follow-up. Special arrangements have been made with a clinic at St.Michael's Hospital and a variety of community health centres for follow-up of clients without health cards.

An expansion of hostel services will have an impact on contact tracing clinics done by staff, as there would be more shelters where a case of TB may have spent time.

(iii)Advocate with hospitals on behalf of homeless/underhoused clients with TB to prevent premature discharge to high risk settings. This issue was addressed in the Report of the Mayor's Homelessness Action Task Force, which recommended that no one should be discharged from an institution to the street and that the Ministry of Health should fund infirmary beds in appropriate locations for homeless people recovering from illness or surgery. These advocacy positions will assist in the prevention of outbreaks of TB in crowded and poorly ventilated settings and the control of TB in individuals on treatment.

(iv)Provided a training session for shelter staff in 1996, with distribution of a comprehensive manual on TB prevention (former Toronto only).

With an expansion of hostel services, an updated manual and a full day training session should be provided to all new shelter staff throughout the City.

(v)Provide educational sessions every fall and January/February for "Out of the Cold" program volunteers throughout the City (six sessions in 1998). Additional sessions for shelter staff, volunteers and clients are given upon request as resources permit (18 sessions in 1998).

An expansion of hostel services would result in an increased number of requests for TB education sessions.

(vi)Routine screening for TB is currently not provided in the shelters, due to inadequate resources, despite being specifically required in the provincial Mandatory Health Programs and Services Guidelines.

If screening programs are implemented to meet Ministry requirements, increasing the number of shelters would result in an increased number of sites where screening would need to be undertaken.

(B)Control of Other Infectious Diseases in Homeless/Underhoused Populations:

(i)Assess and investigate all reports of suspect communicable disease (e.g., influenza, hepatitisA, invasive Group A Streptococcal disease).

An expansion of hostel services would likely increase the number of reportable disease investigations, because the total number of enclosed environments would increase and there would be a potential for increased exposure to communicable diseases due to the close living conditions within the shelters. Therefore, prior to the construction of any new hostels, Toronto Public Health should be consulted regarding ways to minimize the risk of communicable diseases within the new environments.

(ii)Offer monthly immunization clinics at two drop-in centres in the former Toronto. Routine immunizations, as well as hepatitis B, influenza and pneumococcal vaccines are available. These clinics are promoted throughout the former Toronto through the co-ordinators of the drop-in centres. There are preliminary plans to expand the number of clinics in the future to make the service more accessible to the homeless throughout the City.

An expansion of hostel services, would have limited impact on the immunization clinics as they are a centralized service.

(iii)Offer influenza and pneumococcal vaccines during influenza season at shelters and drop-in centres located in the former Toronto. During 1998, 868 people were immunized at 23 shelters. These clinics are promoted through posters at the shelters in the former Toronto. There are preliminary plans to increase the number of influenza clinics in the future to make the service more accessible to the homeless throughout the City.

With an expansion of hostel services, there would be an increased number of influenza clinics needed to provide influenza and pneumococcal vaccines at the new sites, or alternatively, there would need to be promotion of the current clinics at these new sites.

(iv)Provide an infestation control program targeting the homeless population and those who serve them, in partnership with Parks and Recreation, the Toronto Community Care Access Centre (CCAC) and two Community Health Centres. Two days a week treatment is offered for lice and scabies in a facility in the former Toronto. The site also offers participants facilities to wash their clothes.

An expansion of hostel services may have an impact on the infestation control program.

(v)Provided a training session for shelter staff in 1996, with distribution of a comprehensive manual on infection control (former Toronto only).

With an expansion of hostel services, an updated manual and training session would need to be provided to all new shelter staff throughout the City.

(vi)Assisted Metro Hostels and Salvation Army in development of a corporate manual distributed to all shelters.

(vii)Provide educational sessions to "Out of the Cold" volunteers (five sessions in 1998) and shelter staff (approximately 25 sessions in 1998) upon request (in former Toronto). Common concerns among the facilities were antibiotic resistance and body substance precautions.

An expansion of hostel services would likely result in an increased number of requests for infection control education sessions.

Conclusions:

Toronto Public Health is currently involved in a number of initiatives targeting the homeless/underhoused population. Public health initiatives focusing on the prevention of communicable diseases need to be harmonized across the City. Any expansion of hostel services should be accompanied by an expansion of public health initiatives to reduce the spread of communicable diseases within these environments. Also, in order to minimize the risk of communicable diseases within new shelter environments, Toronto Public Health should be consulted early in the site selection and construction stages when refinements are still possible.

The homeless/underhoused population is at an increased risk of many diseases, including TB. The conditions for a resurgence of TB exist in Toronto. TB in the homeless/underhoused cannot be controlled without a comprehensive TB control program for the entire population. TB screening in the current shelters, as required under the Ontario Ministry of Health's Mandatory Programs and Services Guidelines, is not carried out. In order for screening to be initiated, Toronto Public Health requires additional resources.

Preventive measures in this population should be considered cost effective in the long run. Not only will they reduce needless illness, suffering and premature death, but they will also save future expenditures on public health.

Contact Name:

Dr. Barbara Yaffe

Director, Communicable Disease Control and

Associate Medical Officer of Health

Toronto Public Health

Tel:392-7405/Fax: 392-0713

E-mail: byaffe@toronto.ca

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Appendix 1

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 New York 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 1980s. 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 1,282 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 1,737 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 3.7percent 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-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.