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Jordan AE, Nsengiyumva NP, Houben RMGJ, Dodd PJ, Dale KD, Trauer JM, Denholm JT, Johnston JC, Khan FA, Campbell JR, Schwartzman K. The prevalence of tuberculosis infection among foreign-born Canadians: a modelling study. CMAJ 2023; 195:E1651-E1659. [PMID: 38081633 PMCID: PMC10718277 DOI: 10.1503/cmaj.230228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The prevalence of tuberculosis infection is critical to the design of tuberculosis prevention strategies, yet is unknown in Canada. We estimated the prevalence of tuberculosis infection among Canadian residents born abroad. METHODS We estimated the prevalence of tuberculosis infection by age and year of migration to Canada for people from each of 168 countries by constructing country-specific and calendar year-specific trends for annual risk of infection using a previously developed model. We combined country-specific prevalence estimates with Canadian Census data from 2001, 2006, 2011, 2016 and 2021 to estimate the overall prevalence of tuberculosis infection among foreign-born Canadian residents. RESULTS The estimated overall prevalence of tuberculosis infection among foreign-born people in Canada was 25% (95% uncertainty interval [UI] 20%-35%) for census year 2001, 24% (95% UI 20%-33%) for 2006, 23% (95% UI 19%-30%) for 2011, 22% (95% UI 19%-28%) for 2016 and 22% (95% UI 19%-27%) for 2021. The prevalence increased with age at migration and incidence of tuberculosis in the country of origin. In 2021, the estimated prevalence of infection among foreign-born residents was lowest in Quebec (19%, 95% UI 16%-24%) and highest in Alberta (24%, 95% UI 21%-28%) and British Columbia (24%, 95% UI 20%-30%). Among all foreign-born Canadian residents with tuberculosis infection in 2021, we estimated that only 1 in 488 (95% UI 185-1039) had become infected within the 2 preceding years. INTERPRETATION About 1 in 4 foreign-born Canadian residents has tuberculosis infection, but very few were infected within the 2 preceding years (the highest risk period for progression to tuberculosis disease). These data may inform future tuberculosis infection screening policies.
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Affiliation(s)
- Aria Ed Jordan
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Ntwali Placide Nsengiyumva
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Rein M G J Houben
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Peter J Dodd
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Katie D Dale
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - James M Trauer
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Justin T Denholm
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - James C Johnston
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Faiz Ahmad Khan
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que.
| | - Kevin Schwartzman
- Department of Epidemiology, Biostatistics, and Occupational Health (Jordan), McGill University; McGill International Tuberculosis Centre (Jordan, Nsengiyumva, Ahmad Khan, Campbell, Schwartzman); Respiratory Epidemiology and Clinical Research Unit (Nsengiyumva, Ahmad Khan, Campbell, Schwartzman), Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montréal, Que.; Department of Infectious Disease Epidemiology and Tuberculosis Centre (Houben), Tuberculosis Modelling Group, London School of Hygiene and Tropical Medicine, London, UK; School of Health and Related Research (Dodd), University of Sheffield, Sheffield, UK; Victorian Tuberculosis Program (Dale, Denholm), Melbourne Health, at the Peter Doherty Institute for Infection and Immunity; School of Public Health and Preventive Medicine (Trauer), Monash University; Department of Infectious Diseases (Denholm), University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; British Columbia Centre for Disease Control (Johnston); Department of Medicine (Johnston), University of British Columbia, Vancouver, BC; Departments of Medicine and of Global and Public Health (Campbell), McGill University, Montréal, Que.
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Shamputa IC, Law MA, Kelly C, Nguyen DTK, Burdo T, Umar J, Barker K, Webster D. Tuberculosis related barriers and facilitators among immigrants in Atlantic Canada: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001997. [PMID: 37276222 DOI: 10.1371/journal.pgph.0001997] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
Tuberculosis (TB) is a disease caused by the bacterium Mycobacterium tuberculosis and affects approximately one-quarter of the world's population. Immigrant populations in Canada are disproportionately affected by TB. Canada's immigration medical examinations include screening for active TB but not latent TB infection (LTBI). In LTBI, the bacterium remains dormant within the host but can reactivate and cause disease. Once active, TB can be transmitted to close contacts sharing confined spaces leading to the possibility of outbreaks in the broader community. This study aimed to 1) assess the current TB knowledge, perceived risk, and risk behaviors of immigrants in Atlantic Canada as well as 2) identify barriers and facilitators to testing and treatment of TB among this population. Three focus group discussions were conducted with a total of 14 non-Canadian born residents of New Brunswick aged 19 years and older. Data were analyzed using inductive thematic analysis. Four themes were identified from the data relating to barriers to testing and treatment of LTBI: 1) Need for education, 2) stigma, 3) fear of testing, treatment, and healthcare system, and 4) complacency. Results included reasons individuals would not receive TB testing, treatment, or seek help, as well as facilitators to testing and treatment. These findings may inform the implemention of an LTBI screening program in Atlantic Canada and more broadly across the country.
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Affiliation(s)
- Isdore Chola Shamputa
- Department of Nursing & Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Moira A Law
- Department of Psychology, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Clara Kelly
- Department of Nursing & Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Duyen Thi Kim Nguyen
- Government of New Brunswick, Department of Health, Saint John, New Brunswick, Canada
- Faculty of Business, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Tatum Burdo
- Dalhousie University New Brunswick, MD Program, Saint John, New Brunswick, Canada
| | - Jabran Umar
- Dalhousie University New Brunswick, MD Program, Saint John, New Brunswick, Canada
| | - Kimberley Barker
- Government of New Brunswick, Department of Health, Saint John, New Brunswick, Canada
| | - Duncan Webster
- Division of Microbiology, Department of Laboratory Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
- Dalhousie Medicine New Brunswick, Faculty of Medicine, Dalhousie University, Saint John, New Brunswick, Canada
- Division of Infectious Diseases, Department of Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada
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Russo G, Marchese V, Formenti B, Cimaglia C, Di Rosario G, Cristini I, Magro P, El-Hamad I, Cirillo DM, Girardi E, Matteelli A. Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context. Antibiotics (Basel) 2023; 12:antibiotics12040631. [PMID: 37106992 PMCID: PMC10135261 DOI: 10.3390/antibiotics12040631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Screening of tuberculosis infection (TBI) among migrants from high-incidence countries is a cornerstone of tuberculosis control in low-incidence countries. However, the optimal screening strategy has not been defined yet. METHODS A quasi-experimental study involving migrants residing in the province of Brescia was carried out that aimed at assessing the completion rate, time to completion, preventive treatment initiation rate, and cost-effectiveness of two strategies for TBI screening. They underwent TBI screening with the IGRA-only strategy (arm 1) or with the sequential strategy (tuberculin skin test, TST, followed by IGRA in case of a positive result-arm 2). The two strategies were compared in terms of screening completion, time to complete the screening process, therapy initiation, and cost-effectiveness. RESULTS Between May 2019 and May 2022, 657 migrants were evaluated, and 599 subjects were included in the study, with 358 assigned to arm 1 and 237 to arm 2. Screening strategy was the only factor associated with screening completion in a multivariable analysis, with the subjects assigned to the IGRA-only strategy more likely to complete the screening cascade (n = 328, 91.6% vs. n = 202, 85.2%, IRR 1.08, 95% CI (1.01-1.14), p = 0.019). The time to complete the screening process was significantly longer for patients assigned to the sequential strategy arm (74 days vs. 46 days, p = 0.002). Therapy initiation did not significantly differ between the two arms, and cost-effectiveness was higher for the sequential strategy. CONCLUSION Sequential strategy implementation for TBI screening among migrants may be justified by its higher cost-effectiveness in spite of the lower completion of the screening cascade.
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Affiliation(s)
- Giulia Russo
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Valentina Marchese
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
- Department of Clinical and Experimental Sciences, WHO Collaborating Centre for Tuberculosis Prevention, University of Brescia, 25123 Brescia, Italy
- Department of Infectious Diseases Epidemiology, Bernhard Nocht Institute for Tropical Medicine (BNITM), 20359 Hamburg, Germany
| | - Beatrice Formenti
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
- UNESCO Chair "Training and Empowering Human Resources for Health Development in Resource-Limited Countries", Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy
| | - Claudia Cimaglia
- Clinical Epidemiology Unit, Lazzaro Spallanzani National Institute for Infectious Diseases-IRCCS, 00149 Rome, Italy
| | - Gianluca Di Rosario
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Irene Cristini
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Paola Magro
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Issa El-Hamad
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Enrico Girardi
- Clinical Epidemiology Unit, Lazzaro Spallanzani National Institute for Infectious Diseases-IRCCS, 00149 Rome, Italy
| | - Alberto Matteelli
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
- Department of Clinical and Experimental Sciences, WHO Collaborating Centre for Tuberculosis Prevention, University of Brescia, 25123 Brescia, Italy
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Marx FM, Hauer B, Menzies NA, Haas W, Perumal N. Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis. BMC Public Health 2021; 21:2172. [PMID: 34836526 PMCID: PMC8622109 DOI: 10.1186/s12889-021-12142-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Enhancing tuberculosis (TB) prevention and care in a post-COVID-19-pandemic phase will be essential to ensure progress towards global TB elimination. In low-burden countries, asylum seekers constitute an important high-risk group. TB frequently arises post-immigration due to the reactivation of latent TB infection (LTBI). Upon-entry screening for LTBI and TB preventive treatment (TPT) are considered worthwhile if targeted to asylum seekers from high-incidence countries who usually present with higher rates of LTBI. However, there is insufficient knowledge about optimal incidence thresholds above which introduction could be cost-effective. We aimed to estimate, among asylum seekers in Germany, the health impact and costs of upon-entry LTBI screening/TPT introduced at different thresholds of country-of-origin TB incidence. Methods We sampled hypothetical cohorts of 30–45 thousand asylum seekers aged 15 to 34 years expected to arrive in Germany in 2022 from cohorts of first-time applicants observed in 2017–2019. We modelled LTBI prevalence as a function of country-of-origin TB incidence fitted to data from observational studies. We then used a probabilistic decision-analytic model to estimate health-system costs and quality-adjusted life years (QALYs) under interferon gamma release assay (IGRA)-based screening for LTBI and rifampicin-based TPT (daily, 4 months). Incremental cost-effectiveness ratios (ICERs) were calculated for scenarios of introducing LTBI screening/TPT at different incidence thresholds. Results We estimated that among 15- to 34-year-old asylum seekers arriving in Germany in 2022, 17.5% (95% uncertainty interval: 14.2–21.6%) will be latently infected. Introducing LTBI screening/TPT above 250 per 100,000 country-of-origin TB incidence would gain 7.3 (2.7–14.8) QALYs at a cost of €51,000 (€18,000–€114,100) per QALY. Lowering the threshold to ≥200 would cost an incremental €53,300 (€19,100–€122,500) per additional QALY gained relative to the ≥250 threshold scenario; ICERs for the ≥150 and ≥ 100 thresholds were €55,900 (€20,200–€128,200) and €62,000 (€23,200–€142,000), respectively, using the next higher threshold as a reference, and considerably higher at thresholds below 100. Conclusions LTBI screening and TPT among 15- to 34-year-old asylum seekers arriving in Germany could produce health benefits at reasonable additional cost (with respect to international benchmarks) if introduced at incidence thresholds ≥100. Empirical trials are needed to investigate the feasibility and effectiveness of this approach.
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Affiliation(s)
- Florian M Marx
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany. .,Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. .,DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Barbara Hauer
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Walter Haas
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nita Perumal
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany.,Immunization Unit, Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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