Pediatrician Mahli Brindamour knows of parents and nurses in northern Saskatchewan who spend hours every day begging reluctant children to take their daily antibiotics for tuberculosis.
They crush pills meant for adults and hide them in yogurt, apple sauce or syrupy liquids, but those tricks rarely mask the bitter taste of drugs that children usually must take for six months to cure their potentially lethal disease.
“I’ve had kids who have just refused to eat anything subsequent to this trauma of having to take this medication,” said Dr. Brindamour, who works with the Saskatchewan tuberculosis prevention and control program. In the most extreme cases, she added, children with TB in her province have been admitted to hospital so tubes could be put in their noses to deliver antibiotics they refuse to swallow.
There is a solution to this problem, Dr. Brindamour said. Child-friendly formulations of TB medications that dissolve in water and taste good are widely available in countries where tuberculosis is more common than it is in Canada. But they aren’t available here, according to a new report that reveals the extent to which essential medications for TB are difficult to obtain in Canada.
The report, prepared by the advocacy group Stop TB Canada and released Thursday, surveyed 71 Canadian physicians, nurses and other health workers about the availability of antibiotics for TB.
The respondents noted that three new and crucial antibiotics for drug-resistant TB – bedaquiline, delamanid and pretomanid – are not approved by Health Canada because the companies that make them have declined to apply to sell them in a market where TB is rare, and where they would be unlikely to turn a profit.
The same is true of child-friendly formulations of TB antibiotics that Health Canada has already authorized for adults, the survey respondents indicated.
Tuberculosis is caused by airborne bacteria that most often lodge in the lungs, where they can cause weight loss, sweating, fever, fatigue and a relentless, sometimes bloody cough. TB can be fatal if left untreated.
Although the infectious disease is rare among non-Indigenous people born in Canada, it is a scourge in some Indigenous communities. In 2022, the most recent year for which the Public Health Agency of Canada has published data, the overall rate of tuberculosis disease in Canada was 5.1 cases per 100,000 people. The rate was 136.7 per 100,000 among Inuit, 21.4 among First Nations, and 14.4 among people born outside Canada, who can pick up latent, or silent, infections in countries where TB is endemic.
Nunavut is currently battling long-lasting TB outbreaks in three communities. Northern Saskatchewan has also seen an uptick of TB cases in First Nations communities in recent years, particularly among children, according to a study published in December.
Toronto, meanwhile, recorded 375 cases of TB last year, the most in at least a decade.
The new report noted that some Health Canada-approved TB drugs are frequently in shortage. Rifapentine, a TB drug that is not Health Canada-approved but is regularly imported through a special federal pathway, is currently in shortage, according to an e-mail from the Public Health Agency of Canada obtained by The Globe and Mail on Wednesday.
Health Canada has another mechanism for allowing unapproved drugs into Canada called the Special Access Program. However, respondents to the survey said the program was cumbersome and slow, in part because physicians must fill out extensive paperwork for every patient with tuberculosis.
“Imagine if you’re the patient waiting for those life-saving drugs,” said Elizabeth Rea, a Toronto associate medical officer of health with the tuberculosis program. “The TB is still sitting in you doing its thing, and you’re on these older medications which have far more side effects.”
Dr. Rea and Dr. Brindamour are both on the steering committee for Stop TB Canada.
André Gagnon, a spokesman for Health Canada, said by e-mail that the regulator cannot compel pharmaceutical companies to seek approval for specific drugs here. However, he said TB drugs without Health Canada authorization are regularly brought into Canada through the Special Access Program and other pathways.
“Health Canada is taking action to support access to drugs, including those for TB, by collaborating with national and international partners and stakeholders, approving clinical trials for investigational drugs and taking a leadership role in mitigating the impact of drug shortages,” he added.
The new report urges Ottawa to tap the Global Drug Facility, an initiative of the United Nations-affiliated Stop TB Partnership, as one option for purchasing essential TB medications that pharmaceutical companies decline to market in Canada, including child-friendly formulations.
One respondent to the survey described the toll of the current practice of crushing adult pills for a child prescribed 3HP, an antibiotic regimen for latent TB, a silent infection that can turn into active disease.
“Collectively, my colleagues and I (8 nurses total) spent the entirety of the allowable 16 weeks trying to convince an 8-year-old to take 3HP. We tried mixing it with all typical foods... and tried crushed pills as well as liquid [medications] – in the end, she would flat out refuse, and her grandma would try to pin her down and force it in her mouth. Each encounter took hours, and left all parties involved in tears... Something [has] to change.”