Towards TB elimination in Canada: Optimizing tuberculosis screening and prevention

The World Health Organization (WHO) aims to eliminate TB by 2050, but Canada is not on target to meet that goal. To reach our national TB elimination targets, we must reduce TB rates by 10% per year but we are only reducing TB rates by 2% per year. My research program is aimed at developing evidence to improve TB screening, prevention and treatment policies in order to accelerate TB elimination in British Columbia (BC) and Canada.  

In my primary research project, my team is using provincial health databases to describe TB epidemiology in the foreign-born population of Canada. Our goal is to develop a TB risk score and to create evidence that informs cost-effective TB screening policy. My team is also using TB genome sequencing data to understand TB transmission networks and to find areas for public health intervention. Lastly, we are developing evidence to improve treatment outcomes for people affected by TB.   

Examining how contextual factors and health equity considerations shape the implementation of an internet-based testing service for sexually transmitted and blood-borne infections

This study will examine how organizations are able to roll-out and improve GetCheckedOnline (GCO), an internet-based testing service for sexually and blood transmitted infections currently available in British Columbia.

Using the research approach of institutional ethnography, this study aims:

  1. to learn what it takes to implement and expand GCO in fair and sustainable ways, and
  2. to speak to healthcare and community stakeholders in British Columbia to understand the contextual obstacles and opportunities that have shaped the implementation of GCO.

This study's findings will help to inform how GCO can be improved to expand the service to new locations in British Columbia and potentially to the healthcare system in Toronto, Ontario. More generally, this project will offer insights into how sexual health services are implemented and how to promote the equitable growth of digital health interventions.

Utilizing a syndemic approach for population level prevention, care and treatment cascades of hepatitis C virus and related epidemics

Different distributions of social conditions, vulnerabilities, (e.g. drug use, mental illness) or other infections (HIV, HBV, TB), contribute to differences among populations affected by hepatitis C virus (HCV) infection. The different distribution of these comorbidities drives differences in cascades of care (diagnosis, initiation of treatment, cure and retention in care).

This study aims to improve HCV treatment and prevention by applying concepts of syndemic theory (how co-occuring conditions interact) to improve the integration and delivery of health services among populations affected by HCV infection, such as people born 1945-65 (“Baby Boomers”) and people who inject drugs (PWID). Using the British Columbia Hepatitis Testers Cohort (BC-HTC), which includes all individuals tested for HCV, HIV, HBV, sexually transmitted infections or TB since 1990, linked with administrative and healthcare data, the study will extend the HCV cascade of care to include prevention and care related to underlying syndemic factors (e.g. drug use, mental illness and other co-infections).

Identifying and investigating gaps in HCV care cascades, and syndemic factors associated with these gaps, will help identify avenues for shared and integrated interventions to improve prevention and care for HCV, and underlying substance use.

End of award update: December 2021

Following the end of her award term, Dr. Bartlett has provided the following brief update on this project’s progress.

Key impacts arising from fellowship program of work

Impact goal:
Help BC Centre for Disease Control analyze whether their investment in expensive hepatitis C medications are worthwhile.

Impact summary:
Dr. Bartlett’s research evaluated the impact of introducing new medications, called Direct Acting Antivirals (DAAs) used for treating HCV infection. It led to the only HCV care cascade in Canada in the DAA era and provided crucial data that can help drive policy changes aimed at eliminating HCV across the country. It also showed how useful linked administrative health data platforms are to improving the surveillance and monitoring of infections and chronic diseases, such as HCV.

Read more about the impact of Dr. Bartlett’s fellowship in the CIHR HSIF 2017-19 Embedded Research Impact Casebook.

At-home cervical cancer screening & strategies to enhance engagement with the care pathway for under-screened populations


  • Gina Ogilvie
  • Marette Lee
    BC Cancer

Executive sponsor:

  • Dirk van Niekerk
    BC Cancer

Cervical cancer is caused by persistent infection with human papillomavirus (HPV). It can be prevented with early detection through regular screening. Irregular or non-attendance to screening is one of the key barriers to further reducing cervical cancer rates in BC. HPV DNA testing is an evidence-based, highly sensitive, and effective way to screen for cervical cancer, where women can collect the sample for testing at home (HPV self-collection).

This project will look to HPV DNA testing as the best way to implement at-home cervical cancer screening for under-screened populations in BC.

Two implementation approaches will be used:

  1. CervixCheck, an online service for at-home cervical cancer screening for women who do not regularly attend screening, piloted in selected family medical clinics in Surrey, BC and in northern BC in partnership with Métis Nation BC.
  2. At-home screening piloted in First Nations community health centres in partnership with Carrier Sekani Family Services in rural northern BC.

By offering women an alternative to clinician collected samples for screening, this work can address many of the personal, geographic, historical and system-level barriers women face. However, as with other screening programs, HPV screening identifies women most at risk for progressing to cervical cancer, and is not a diagnostic tool in itself. Therefore, it is necessary to examine implementation and evaluate engagement in the full pathway of screening, diagnosis, treatment, and follow-up.

Through an implementation science approach, this project aims to:

  1. Determine strategies to optimally engage under-screened women through the full pathway of screening, diagnosis, treatment and follow-up, primarily with colposcopy.
  2. Assess the needs, gaps, and facilitators at the user, clinical, and health system levels to inform adaptability for other settings and contexts in the province.

Quantitative and qualitative methods will be applied, using the Quality Implementation Framework to inform evaluation design.

The outcomes for this project will be adoption, penetration, fidelity, and safety. Planning and development is already underway for the pilot implementation of CervixCheck. A critical aspect of this approach will be to assemble a team of stakeholders at the community level in pilot sites including patient advocates and physician and nursing leads, as well as at the health system level at the BC Cancer Cervical Cancer Screening Program and the BC Colposcopy Program. 

Population-level impact of hepatitis C virus (HCV) direct-acting antiviral therapies on extrahepatic manifestations

Hepatitis C virus is an important public health concern in Canada; however, there is limited information concerning the impact of new direct-acting antiviral therapies on manifestations outside the liver (extrahepatic manifestations, or EHMs), including chronic diseases, cancers, and health-care resource utilization in Canada.

This knowledge is important, as new HCV treatments are generally restricted to those with advanced liver disease and there are no estimates of the reductions in EHMs that can be achieved with expansion of therapy.

Using data from an administrative-linked population-based cohort in BC, Dr. Rossi will assess the impact that HCV treatments have on EHMs and associated health-care utilization.

Results from this study could lead to improved clinical and population health practices in BC by:

  1. Helping to inform targeted treatment strategies by identifying patients at the greatest risk of developing EHMs associated with HCV.
  2. Identifying areas where additional allocation of resources will be necessary to manage chronic comorbidities associated with aging.

This study will also provide a better understanding of the challenges and limitations associated with using administrative data for population health research.

The real-world effectiveness of hepatitis C virus (HCV) treatment on decompensated cirrhosis and hospitalizations

Between 230,000 to 450,000 Canadians are infected with hepatitis C virus (HCV). Most of these people were infected decades ago and remained untreated due to the severe side effects and low effectiveness of interferon-based treatment regimens. Therefore, HCV associated liver related morbidity and mortality are now on the rise, with substantial impact on health care utilization. 

Recently, highly effective interferon-free direct acting antiviral (DAA) treatments have started to become available. However, data on real-world effectiveness of DAAs in terms of hospitalization, cirrhosis, decompensation, hepatocellular carcinoma  and mortality is not yet available. 

Dr. Darvishian will address crucial knowledge gaps in the HCV response to DAAs. Specifically, her research will:

  1. Assess the real-world effectiveness of DAA treatments on overall and liver disease-related hospitalizations and the number of hospital admissions.
  2. Assess the real-world effectiveness of DAA treatments in preventing decompensated cirrhosis.
  3. Assess the potential modifying effect of metformin and/or statin on effect of DAAs and their synergestic effects on hospitalizations and decompensated cirrhosis.

The results of this study will be critical for designing an optimal strategy for HCV care and DAA treatment and refining HCV treatment guidelines and strategies.

Can specialized sexual health clinics address unmet mental health needs of sexual minorities?

Gay, lesbian and bisexual (GLB) Canadians are at higher risk of depression, anxiety, drug and alcohol use problems and suicide attempts, but there are few places where these mental health needs can be met in a way that is mindful of the judgment GLB people may fear on the basis of their sexuality. Many sexual health clinics already serve as GLB-sensitive points of care for diagnosing and treating sexually transmitted infections, including HIV. These clinics and their nursing staff could be supported in routinely offering assessment, referral, and counseling for mental health concerns; however, the extent to which this is needed and desired has not yet been explored. Dr. Salway will use a combination of data sources and methods to characterize the potential for such interventions.

This study will answer three questions:

  1. What are the unmet mental health service needs of GLB clients of sexual health clinics?
  2. How can these needs potentially be met through the sexual health clinics?
  3. What is the appeal of new approaches to meeting mental health needs through sexual health clinics?

Dr. Salway will use a large, linked data set to estimate how many sexual health clinic clients currently access mental health-related services from other hospitals or clinics. Interviews will be conducted with nurses and clients, and a survey will be administered at three sexual health clinics in Vancouver that predominantly serve GLB populations. 

Dr. Salway’s research will be conducted in collaboration with nurses, clinic managers, and policy-makers to ensure that results are applied to existing services. Through these collaborations, findings will be translated into clinical guidelines, training programs for clinicians, and policy recommendations. Ultimately, this study will provide evidence for promising strategies that will not only improve health care for sexual health clinic clients, but also contribute to reductions in mental health disparities that continue to affect GLB Canadians today.

Wealthy and healthy: Socioeconomic status (SES) and syndemics

Co-infections with sexually transmitted infections and blood borne infections (STIBBI) are common among people living with HIV. They occur because of shared risk behaviours and common social conditions. It is a significant public health issue because groups of people at high risk of acquiring and transmitting infections can spread them more readily to the broader population.

This study proposes to examine neighbourhood-level characteristics (e.g. socio-behavioural groupings, geographic areas) to describe how contextual variables and socioeconomic status contribute to STIBBI co-infection trends. We will use provincial surveillance, laboratory, and healthcare utilization data linkages.

Our goal is to shed light on whether real-time data linkage could improve delivery of health services to core groups of people living with HIV. Ultimately, this work could inform health service policies and procedures that improve quality of life and reduce the spread of STIBBI among the general population.

Risk Assessment and Prediction of Infectious Disease Outbreaks (RAPID): An integrated framework of quantitative public health policy design

Traditionally, British Columbia has played an important role in public health policy design in Canada. BC has a reputation for providing leadership in population health research aimed at improving the health of its residents. To continue providing leadership in this realm, BC needs to create a timely, quantitative framework to stifle the increasing threat of emerging and re-emerging infectious diseases. Despite medical advances, communicable diseases remain a major cause of death, disability and social and economic upheaval for millions around the world. Consequently, combating infectious diseases requires planning beyond individual-based interventions. Dr. Babak Pourbohloul is working to develop an integrated research, mentoring, education, and knowledge translation platform. He will create a quantitative risk assessment and predictive framework to understand the pattern of infectious disease spread, and will develop mathematical models to identify optimal, cost-effective control strategies against a wide variety of infections. This research will enable public health leaders to address six key areas: the most effective control strategies for emerging respiratory infectious diseases and influenza pandemic preparedness; vaccination program evaluation; public safety and bioterrorism; public health issues associated with infection control in marginalized populations; hospital infection prevention; and outbreak containment. Through Dr. Pourbohloul’s research, both the province and the BC Centre for Disease Control can maintain their vision and leadership in managing the complexity of infectious disease transmission with innovative and sophisticated quantitative tools – improving the health of all Canadians.

Molecular epidemiology of Giardia lamblia in British Columbia’s drinking water supplies

Giardia lamblia is a waterborne parasite that causes giardiasis, a diarrheal disease commonly called ""beaver fever”. Despite the comprehensive water quality management measures in B.C., this parasite is often detected in surface water supplies and is the second leading cause of gastrointestinal illness in the province. While current surveillance methods for G.lamblia in water supplies allows for enumeration of the parasite in water, the test cannot differentiate between infectious and non-infectious strains. Natalie Prystajecky is examining a library of archived water samples collected across B.C. over 13 years to determine if the strains in B.C. surface water are infectious to humans and how frequently, what the sources are, and where these strains are found. She is also assessing the effectiveness of control measures such as watershed protection and agricultural waste management best practices in protecting water quality. This information could lead to more effective environmental and health policies and public health interventions.