1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Harwood-Johnson E, Leis KS, Hanson J, Olfert J, Blonde Y, Brindamour M. Community treatment of latent tuberculosis in child and adult refugee populations: outcomes and successes. Front Public Health 2023; 11:1225217. [PMID: 37942244 PMCID: PMC10629593 DOI: 10.3389/fpubh.2023.1225217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Tuberculosis (TB) is the world's leading infectious cause of death, killing millions every year. In Canada, considered a low-incidence country for TB, the burden of the disease is unequally distributed, with most cases of latent tuberculosis infection (LTBI) experienced by newcomers from endemic regions. The purpose of this study was to measure LTBI treatment acceptance and completion outcomes of LTBI treatment at the REACH clinic in Saskatoon, a local refugee clinic providing primary care-based LTBI management. Methods A retrospective case series by sampling methodology was applied to review patients who visited the REACH clinic between January 2017 and June 2021 and who had an interferon-gamma release assay (IGRA) or tuberculin skin test (TST) done for LTBI screening. Those with positive results were retained for analysis. The LTBI treatment acceptance and completion groups were compared according to demographic variables, WHO regions of origin, year of arrival to Canada, and LTBI treatment regimen. Results A total of 523 patients were screened for LTBI, of whom 125 tested positive, leading to a test positivity of 23.9%. The treatment acceptance rate was 84.8%, and the treatment completion rate was 93.3%. All of those who declined treatment were more than 18 years of age (p = 0.02). Otherwise, treatment acceptance and completion rates did not vary significantly in association with gender, categories of refugees, WHO region of origin, year of arrival to Canada, or LTBI treatment regimen used. Discussion The refugee clinic acceptance and completion rates in this study are high and meet Canadian TB standards of care. The multidisciplinary clinic model and community support are important facilitators, which, in combination with shorter treatment regimens, offer a path forward for LTBI management among refugees resettling in low-incidence countries.
Collapse
Affiliation(s)
| | - Karen S. Leis
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jacelyn Hanson
- Department of Family Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jordan Olfert
- Department of Respirology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Yvonne Blonde
- Department of Academic Family Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahli Brindamour
- Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| |
Collapse
|
3
|
Basham CA, Karim ME, Johnston JC. Multimorbidity prevalence and chronic disease patterns among tuberculosis survivors in a high-income setting. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2023; 114:264-276. [PMID: 36459364 PMCID: PMC10036698 DOI: 10.17269/s41997-022-00711-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/07/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES Multimorbidity is the presence of two or more chronic health conditions. Tuberculosis (TB) survivors are known to have higher prevalence of multimorbidity, although prevalence estimates from high-income low-TB incidence jurisdictions are not available and potential differences in the patterns of chronic disease among TB survivors with multimorbidity are poorly understood. In this study, we aimed to (1) compare the prevalence of multimorbidity among TB survivors with matched non-TB controls in a high-income setting; (2) assess the robustness of aim 1 analyses to different modelling strategies, unmeasured confounding, and misclassification bias; and (3) among people with multimorbidity, elucidate chronic disease patterns specific to TB survivors. METHODS A population-based cohort study of people immigrating to British Columbia, Canada, 1985-2015, using health administrative data. Participants were divided into two groups: people diagnosed with TB (TB survivors) and people not diagnosed with TB (non-TB controls) in British Columbia. Coarsened exact matching (CEM) balanced demographic, immigration, and socioeconomic covariates between TB survivors and matched non-TB controls. Our primary outcome was multimorbidity, defined as ≥2 chronic diseases from the Elixhauser comorbidity index. RESULTS In the CEM-matched sample (n=1962 TB survivors; n=1962 non-TB controls), we estimated that 21.2% of TB survivors (n=416), compared with 12% of non-TB controls (n=236), had multimorbidity. In our primary analysis, we found a double-adjusted prevalence ratio of 1.74 (95% CI: 1.49-2.05) between TB survivors and matched non-TB controls for multimorbidity. Among people with multimorbidity, differences were observed in chronic disease frequencies between TB survivors and matched controls. CONCLUSION TB survivors had a 74% higher prevalence of multimorbidity compared with CEM-matched non-TB controls. TB-specific multimorbidity patterns were observed through differences in chronic disease frequencies between the matched samples. These findings suggest a need for TB-specific multimorbidity interventions in high-income settings such as Canada. We suggest TB survivorship as a framework for developing person-centred interventions for multimorbidity among TB survivors.
Collapse
Affiliation(s)
- C Andrew Basham
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluative and Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - James C Johnston
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| |
Collapse
|
4
|
Pépin J, Desjardins F, Carignan A, Lambert M, Vaillancourt I, Labrie C, Mercier D, Bourque R, LeBlanc L. Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada. PLoS One 2022; 17:e0267781. [PMID: 35587499 PMCID: PMC9119458 DOI: 10.1371/journal.pone.0267781] [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] [Received: 11/05/2021] [Accepted: 04/14/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction
The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the ‘cascade of care’ and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management.
Methods
Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009–2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010–14 (n = 1906) and 2018–19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997–2008) and after (2009–2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured.
Results
Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997–2008) to 26.3 per 100,000 person-years (2009–2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change.
Conclusions
Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.
Collapse
Affiliation(s)
- Jacques Pépin
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
- * E-mail:
| | - France Desjardins
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Michel Lambert
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Isabelle Vaillancourt
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Christiane Labrie
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Dominique Mercier
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Rachel Bourque
- Clinique des Réfugiés, Centre Local de Services Communautaires, Sherbrooke, Québec, Canada
| | - Louiselle LeBlanc
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, Québec, Canada
| |
Collapse
|
5
|
The Role of Immigrant Admission Classes on the Health and Well-being of Immigrants and Refugees in Canada: A Scoping Review. J Immigr Minor Health 2022; 24:1045-1060. [PMID: 35303219 DOI: 10.1007/s10903-022-01352-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 10/18/2022]
Abstract
Many countries offer different pathways through which migrants can enter a new country. In Canada, there are three main immigrant admission classes: economic, family, and refugee. Previous research suggests that there are differences in health outcomes among various subgroups of migrants. A scoping review was conducted to characterize the role of immigrant admission classes on the health and well-being of immigrants and refugees in Canada. MEDLINE, Embase, PsycINFO, Sociological Abstracts, and EconLit databases were searched for quantitative studies published in English after 1990. The screening and selection process identified 27 relevant studies. Studies were categorized into four key reported outcomes: health care and services utilization, self-rated health and mental health, medical conditions and chronic illnesses, and social integration and satisfaction. Findings confirm that certain subgroups have worse health outcomes after arrival, particularly refugees, family class and other dependent immigrants. Health outcomes vary significantly across immigrant subgroups defined by the admission class through which they entered Canada.
Collapse
|
6
|
Campbell JR, Schwartzman K. Invited Commentary: The Role of Tuberculosis Screening Among Migrants to Low-Incidence Settings in (Not) Achieving Elimination. Am J Epidemiol 2022; 191:271-274. [PMID: 34216207 DOI: 10.1093/aje/kwab193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 01/01/2023] Open
Abstract
The cost-effectiveness of migrant tuberculosis prevention programs is highly relevant to many countries with low tuberculosis incidence as they attempt to eliminate the disease. Dale et al. (Am J Epidemiol. 2022;191(2):255-270) evaluated strategies for tuberculosis infection screening and treatment among new migrants to Australia. Screening for infection before migration, and then administering preventive treatment after arrival, was more cost-effective than performing both screening and treatment after arrival. From the Australian health payer perspective, the improved cost-effectiveness of premigration screening partly reflected the shift of screening costs to migrants, which may raise ethical concerns. Key sensitivity analyses highlighted the influence of health disutility associated with tuberculosis preventive treatment, and of posttreatment sequelae of tuberculosis disease. Both considerations warrant greater attention in future research. For all strategies, the impact on tuberculosis incidence among migrants was modest (<15%), suggesting enhanced migrant screening will not achieve tuberculosis elimination in low-incidence settings. This emphasizes the need to increase investment and effort in global tuberculosis prevention and care, which will ultimately reduce the prevalence of tuberculosis infection and therefore the risk of tuberculosis disease among migrants. Such efforts will benefit high and low tuberculosis incidence countries alike, and advance all countries further toward tuberculosis elimination.
Collapse
|
7
|
Puyat JH, Shulha HP, Balshaw R, Campbell JR, Law S, Menzies R, Johnston JC. How Well Does TSTin3D Predict Risk of Active Tuberculosis in the Canadian Immigrant Population? An External Validation Study. Clin Infect Dis 2021; 73:e3486-e3495. [PMID: 32556316 PMCID: PMC8631069 DOI: 10.1093/cid/ciaa780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/13/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The online Tuberculin Skin Test/Interferon Gamma Release Assay (TST/IGRA) Interpreter V3.0 (TSTin3D), a tool for estimating the risk of active tuberculosis (TB) in individuals with latent TB infection (LTBI), has been in use for more than a decade, but its predictive performance has never been evaluated. METHODS People with a positive TST or IGRA result from 1985 to 2015 were identified using a health data linkage that involved migrants to British Columbia, Canada. Comorbid conditions at the time of LTBI testing were identified from physician claims, hospitalizations, vital statistics, outpatient prescriptions, and kidney and HIV databases. The risk of developing active TB within 2 and 5 years was estimated using TSTin3D. The discrimination and calibration of these estimates were evaluated. RESULTS A total of 37 163 individuals met study inclusion criteria; 10.4% were tested by IGRA. Generally, the TSTin3D algorithm assigned higher risks to demographic and clinical groups known to have higher active TB risks. Concordance estimates ranged from 0.66 to 0.68 in 2- and 5-year time frames. Comparing predicted to observed counts suggests that TSTin3D overestimates active TB risks and that overestimation increases over time (with relative bias of 3% and 12% in 2- and 5-year periods, respectively). Calibration plots also suggest that overestimation increases toward the upper end of the risk spectrum. CONCLUSIONS TSTin3D can discriminate adequately between people who developed and did not develop active TB in this linked database of migrants with predominately positive skin tests. Further work is needed to improve TSTin3D's calibration.
Collapse
Affiliation(s)
- Joseph H Puyat
- School of Population and Public Health, Faculty of Medicine, University
of British Columbia, Vancouver, British Columbia, Canada
| | - Hennady P Shulha
- BC Centre for Disease Control, Vancouver, British
Columbia, Canada
| | - Robert Balshaw
- George & Fay Yee Centre for Healthcare Innovation,
Winnipeg, Manitoba, Canada
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics, and Occupational Health,
Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Stephanie Law
- Department of Global Health and Social Medicine, Harvard Medical
School, Boston, Massachusetts, USA
| | - Richard Menzies
- Department of Medicine, Faculty of Medicine, McGill
University, Montreal, Quebec, Canada
| | - James C Johnston
- School of Population and Public Health, Faculty of Medicine, University
of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control and Division of Respiratory Medicine,
Faculty of Medicine, University of British Columbia, Vancouver,
British Columbia, Canada
| |
Collapse
|
8
|
Basham CA, Karim ME, Cook VJ, Patrick DM, Johnston JC. Tuberculosis-associated depression: a population-based cohort study of people immigrating to British Columbia, Canada, 1985-2015. Ann Epidemiol 2021; 63:7-14. [PMID: 34146707 DOI: 10.1016/j.annepidem.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/28/2021] [Accepted: 06/06/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To estimate the risk of tuberculosis (TB)-associated depression. A second aim was to estimate the extent to which any increased risk of depression among TB patients may be mediated by the length of hospital length stay (LOS) METHODS: Retrospective cohort study of linked healthcare claims and public health surveillance data. Our primary outcome, time-to-depression, was analyzed using Cox proportional hazards (PH) regressions. Causal mediation analysis was used to estimate the natural direct and indirect effect of TB mediated by hospital LOS. RESULTS Among 755,836 participants (52.2% female, median age=35 years, median follow-up=8.75 years), 2295 were diagnosed with TB (exposure), and 128,963 were diagnosed with depression (outcome). We observed a covariate-adjusted hazard ratio (aHR) of 1.24 (95% CI, 1.14-1.34) for depression by TB. The total effect of TB on depression was decomposed into a natural direct effect of TB of aHR=1.11 (95% CI, 1.02-1.21) and an indirect effect through hospital LOS of aHR=1.11 (95% CI, 1.10-1.12), indicating that TB's total effect was mediated by 50% (95% CI, 35-82%) through hospital LOS. CONCLUSIONS TB patients had a 24% higher risk of developing depression. TB's effect was mediated substantially by hospital LOS, requiring further study. Depression screening among TB patients is warranted.
Collapse
Affiliation(s)
- C Andrew Basham
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada.
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; Centre for Health Evaluative and Outcome Sciences, University of British Columbia, Vancouver, Canada
| | - Victoria J Cook
- British Columbia Centre for Disease Control, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - David M Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - James C Johnston
- School of Population and Public Health, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| |
Collapse
|
9
|
Basham CA, Karim ME, Cook VJ, Patrick DM, Johnston JC. Post-tuberculosis mortality risk among immigrants to British Columbia, Canada, 1985-2015: a time-dependent Cox regression analysis of linked immigration, public health, and vital statistics data. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2021; 112:132-141. [PMID: 32666352 PMCID: PMC7851220 DOI: 10.17269/s41997-020-00345-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/14/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare non-tuberculosis (non-TB)-cause mortality risk overall and cause-specific mortality risks within the immigrant population of British Columbia (BC) with and without TB diagnosis through time-dependent Cox regressions. METHODS All people immigrating to BC during 1985-2015 (N = 1,030,873) were included with n = 2435 TB patients, and the remaining as non-TB controls. Outcomes were time-to-mortality for all non-TB causes, respiratory diseases, cardiovascular diseases, cancers, and injuries/poisonings, and were ascertained using ICD-coded vital statistics data. Cox regressions were used, with a time-varying exposure variable for TB diagnosis. RESULTS The non-TB-cause mortality hazard ratio (HR) was 4.01 (95% CI 3.57-4.51) with covariate-adjusted HR of 1.69 (95% CI 1.50-1.91). Cause-specific covariate-adjusted mortality risk was elevated for respiratory diseases (aHR = 2.96; 95% CI 2.18-4.00), cardiovascular diseases (aHR = 1.63; 95% CI 1.32-2.02), cancers (aHR = 1.40; 95% CI 1.13-1.75), and injuries/poisonings (aHR = 1.85; 95% CI 1.25-2.72). CONCLUSIONS In any given year, if an immigrant to BC was diagnosed with TB, their risk of non-TB mortality was 69% higher than if they were not diagnosed with TB. Healthcare providers should consider multiple potential threats to the long-term health of TB patients during and after TB treatment. TB guidelines in high-income settings should address TB survivor health.
Collapse
Affiliation(s)
- C Andrew Basham
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
- British Columbia Centre for Disease Control, 655 W 12th Ave., Vancouver, BC, V5Z 4R4, Canada.
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcomes Science, University of British Columbia, Vancouver, BC, Canada
| | - Victoria J Cook
- British Columbia Centre for Disease Control, 655 W 12th Ave., Vancouver, BC, V5Z 4R4, Canada
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David M Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, 655 W 12th Ave., Vancouver, BC, V5Z 4R4, Canada
| | - James C Johnston
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- British Columbia Centre for Disease Control, 655 W 12th Ave., Vancouver, BC, V5Z 4R4, Canada
- Division of Respiratory Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
10
|
Emery JC, Richards AS, Dale KD, McQuaid CF, White RG, Denholm JT, Houben RMGJ. Self-clearance of Mycobacterium tuberculosis infection: implications for lifetime risk and population at-risk of tuberculosis disease. Proc Biol Sci 2021; 288:20201635. [PMID: 33467995 PMCID: PMC7893269 DOI: 10.1098/rspb.2020.1635] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023] Open
Abstract
Background: it is widely assumed that individuals with Mycobacterium tuberculosis (Mtb) infection remain at lifelong risk of tuberculosis (TB) disease. However, there is substantial evidence that self-clearance of Mtb infection can occur. We infer a curve of self-clearance by time since infection and explore its implications for TB epidemiology. Methods and findings: data for self-clearance were inferred using post-mortem and tuberculin-skin-test reversion studies. A cohort model allowing for self-clearance was fitted in a Bayesian framework before estimating the lifetime risk of TB disease and the population infected with Mtb in India, China and Japan in 2019. We estimated that 24.4% (17.8-32.6%, 95% uncertainty interval (UI)) of individuals self-clear within 10 years of infection, and 73.1% (64.6-81.7%) over a lifetime. The lifetime risk of TB disease was 17.0% (10.9-22.5%), compared to 12.6% (10.1-15.0%) assuming lifelong infection. The population at risk of TB disease in India, China and Japan was 35-80% (95% UI) smaller in the self-clearance scenario. Conclusions: the population with a viable Mtb infection may be markedly smaller than generally assumed, with such individuals at greater risk of TB disease. The ability to identify these individuals could dramatically improve the targeting of preventive programmes and inform TB vaccine development, bringing TB elimination within reach of feasibility.
Collapse
Affiliation(s)
- Jon C. Emery
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Alexandra S. Richards
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Katie D. Dale
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, Victoria, Australia
- Department of Microbiology and Immunology, The University of Melbourne, Melbourne, Victoria, Australia
| | - C. Finn McQuaid
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Richard G. White
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Justin T. Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, Victoria, Australia
| | - Rein M. G. J. Houben
- TB Modelling Group, TB Centre and Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| |
Collapse
|
11
|
Dale KD, Trauer JM, Dodd PJ, Houben RMGJ, Denholm JT. Estimating Long-term Tuberculosis Reactivation Rates in Australian Migrants. Clin Infect Dis 2021; 70:2111-2118. [PMID: 31246254 DOI: 10.1093/cid/ciz569] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/25/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The risk of progression to tuberculosis (TB) disease is greatest soon after infection, yet disease may occur many years or decades later. However, rates of TB reactivation long after infection remain poorly quantified. Australia has a low incidence of TB and most cases occur among migrants. We explored how TB rates in Australian migrants varied with time from migration, age, and gender. METHODS We combined TB notifications in census years 2006, 2011, and 2016 with time- and country-specific estimates of latent TB prevalences in migrant cohorts to quantify postmigration reactivation rates. RESULTS During the census years, 3246 TB cases occurred among an estimated 2 084 000 migrants with latent TB. There were consistent trends in postmigration reactivation rates, which appeared to be dependent on both time from migration and age. Rates were lower in cohorts with increasing time, until at least 20 years from migration, and on this background there also appeared to be increasing rates during youth (15-24 years of age) and in those aged 70 years and above. Within 5 years of migration, annual reactivation rates were approximately 400 per 100 000 (uncertainty interval [UI] 320-480), dropping to 170 (UI 130-220) from 5 to 10 years and 110 (UI 70-160) from 10 to 20 years, then sustaining at 60-70 per 100 000 up to 60 years from migration. Rates varied depending on age at migration. CONCLUSIONS Postmigration reactivation rates appeared to show dependency on both time from migration and age. This approach to quantifying reactivation risks will enable evaluations of the potential impacts of TB control and elimination strategies.
Collapse
Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia
| | - James M Trauer
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Peter J Dodd
- School of Health and Related Research, University of Sheffield, United Kingdom
| | - Rein M G J Houben
- Tuberculosis Modelling Group, Tuberculosis Centre, London School of Hygiene and Tropical Medicine, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Justin T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia.,Department of Microbiology and Immunology, The University of Melbourne, Victoria, Australia
| |
Collapse
|
12
|
Ronald LA, Campbell JR, Rose C, Balshaw R, Romanowski K, Roth DZ, Marra F, Schwartzman K, Cook VJ, Johnston JC. Estimated Impact of World Health Organization Latent Tuberculosis Screening Guidelines in a Region With a Low Tuberculosis Incidence: Retrospective Cohort Study. Clin Infect Dis 2020; 69:2101-2108. [PMID: 30856258 DOI: 10.1093/cid/ciz188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/05/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Latent tuberculosis infection (LTBI) screening and treatment is a key component of the World Health Organization (WHO) EndTB Strategy, but the impact of LTBI screening and treatment at a population level is unclear. We aimed to estimate the impact of LTBI screening and treatment in a population of migrants to British Columbia (BC), Canada. METHODS This retrospective cohort included all individuals (N = 1 080 908) who immigrated to Canada as permanent residents between 1985 and 2012 and were residents in BC at any time up to 2013. Multiple administrative databases were linked to identify people with risk factors who met the WHO strong recommendations for screening: people with tuberculosis (TB) contact, with human immunodeficiency virus, on dialysis, with tumor necrosis factor-alpha inhibitors, who had an organ/haematological transplant, or with silicosis. Additional TB risk factors included immunosuppressive medications, cancer, diabetes, and migration from a country with a high TB burden. We defined active TB as preventable if diagnosed ≥6 months after a risk factor diagnosis. We estimated the number of preventable TB cases, given optimal LTBI screening and treatment, based on these risk factors. RESULTS There were 16 085 people (1.5%) identified with WHO strong risk factors. Of the 2814 people with active TB, 118 (4.2%) were considered preventable through screening with WHO risk factors. Less than half (49.4%) were considered preventable with expanded screening to include people migrating from countries with high TB burdens, people who had been prescribed immunosuppressive medications, or people with diabetes or cancer. CONCLUSIONS The application of WHO LTBI strong recommendations for screening would have minimally impacted the TB incidence in this population. Further high-risk groups must be identified to develop an effective LTBI screening and treatment strategy for low-incidence regions.
Collapse
Affiliation(s)
- Lisa A Ronald
- British Columbia Centre for Disease Control, Vancouver
| | | | - Caren Rose
- British Columbia Centre for Disease Control, Vancouver.,School of Public and Population Health, University of British Columbia, Vancouver
| | - Robert Balshaw
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg
| | | | - David Z Roth
- British Columbia Centre for Disease Control, Vancouver
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver
| | - Kevin Schwartzman
- McGill International Tuberculosis Centre, Montreal.,Respiratory Division, Montreal Chest Institute, Respiratory Epidemiology and Clinical Research Unit, McGill University, Vancouver, Canada
| | - Victoria J Cook
- British Columbia Centre for Disease Control, Vancouver.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - James C Johnston
- British Columbia Centre for Disease Control, Vancouver.,McGill International Tuberculosis Centre, Montreal.,School of Public and Population Health, University of British Columbia, Vancouver.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| |
Collapse
|
13
|
Langholz Kristensen K, Lillebaek T, Holm Petersen J, Hargreaves S, Nellums LB, Friedland JS, Andersen PH, Ravn P, Norredam M. Tuberculosis incidence among migrants according to migrant status: a cohort study, Denmark, 1993 to 2015. ACTA ACUST UNITED AC 2020; 24. [PMID: 31690363 PMCID: PMC6836680 DOI: 10.2807/1560-7917.es.2019.24.44.1900238] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Migrants account for the majority of tuberculosis (TB) cases in low-incidence countries in western Europe. TB incidence among migrants might be influenced by patterns of migration, but this is not well understood. Aim To investigate differences in TB risk across migrant groups according to migrant status and region of origin. Methods This prospective cohort study included migrants ≥ 18 years of age who obtained residency in Denmark between 1 January 1993 and 31 December 2015, matched 1:6 to Danish-born individuals. Migrants were grouped according to legal status of residency and region of origin. Incidence rates (IR) and incidence rate ratios (IRR) were estimated by Poisson regression. Results The cohort included 142,314 migrants. Migrants had significantly higher TB incidence (IR: 120/100,000 person-years (PY); 95% confidence interval (CI): 115–126) than Danish-born individuals (IR: 4/100,000 PY; 95% CI: 3–4). The IRR was significantly higher in all migrant groups compared with Danish-born (p < 0.01). A particularly higher risk was seen among family-reunified to refugees (IRR: 61.8; 95% CI: 52.7–72.4), quota refugees (IRR: 46.0; 95% CI: 36.6–57.6) and former asylum seekers (IRR: 45.3; 95% CI: 40.2–51.1), whereas lower risk was seen among family-reunified to Danish/Nordic citizens (IRR 15.8; 95% CI: 13.6–18.4) and family-reunified to immigrants (IRR: 16.9; 95% CI: 13.5–21.3). Discussion All migrants had higher TB risk compared with the Danish-born population. While screening programmes focus mostly on asylum seekers, other migrant groups with high risk of TB are missed. Awareness of TB risk in all high-risk groups should be strengthened and screening programmes should be optimised.
Collapse
Affiliation(s)
- Kristina Langholz Kristensen
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Troels Lillebaek
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | | | - Sally Hargreaves
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Jon S Friedland
- Institute for Infection & Immunity, St. George's, University of London, London, United Kingdom
| | - Peter Henrik Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Pernille Ravn
- Department of Medicine, Infectious Disease Section, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Marie Norredam
- Department of Infectious Diseases, Section of Immigrants Medicine, University Hospital Hvidovre, Hvidovre, Denmark.,Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
14
|
Affiliation(s)
- C Andrew Basham
- University of British Columbia, British Columbia Centre for Disease Control, Vancouver V5Z 4R4, BC, Canada.
| | - Brenda Elias
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Pamela Orr
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
15
|
Campbell JR, Dowdy D, Schwartzman K. Treatment of latent infection to achieve tuberculosis elimination in low-incidence countries. PLoS Med 2019; 16:e1002824. [PMID: 31170161 PMCID: PMC6553715 DOI: 10.1371/journal.pmed.1002824] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In a Perspective for the Tuberculosis Special Issue, Kevin Schwartzman and colleagues discuss the choices and implications for personal versus public health benefits when pursuing tuberculosis elimination in low-incidence countries.
Collapse
Affiliation(s)
- Jonathon R. Campbell
- McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, Québec, Canada
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kevin Schwartzman
- McGill International TB Centre, McGill University, Montréal, Québec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Montréal Chest Institute, McGill University Health Centre, Montréal, Québec, Canada
| |
Collapse
|
16
|
Guthrie JL, Ronald LA, Cook VJ, Johnston J, Gardy JL. The problem with defining foreign birth as a risk factor in tuberculosis epidemiology studies. PLoS One 2019; 14:e0216271. [PMID: 31039191 PMCID: PMC6490926 DOI: 10.1371/journal.pone.0216271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/17/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine how stratifying persons born outside Canada according to tuberculosis (TB) incidence in their birth country and other demographic factors refines our understanding of TB epidemiology and local TB transmission. BACKGROUND Population-level TB surveillance programs and research studies in low incidence settings often report all persons born outside the country in which the study is conducted as "foreign-born"-a single label for a highly diverse population with variable TB risks. This may mask important TB epidemiologic trends and not accurately reflect local transmission patterns. METHODS We used population-level data from two large cohorts in British Columbia (BC), Canada: an immigration cohort (n = 337,492 permanent residents to BC) and a genotyping cohort (n = 2290 culture-confirmed active TB cases). We stratified active TB case counts, incidence rates, and genotypic clustering (an indicator of TB transmission) in BC by birth country TB incidence, age at immigration, and years since arrival. RESULTS Persons from high-incidence countries had a 12-fold higher TB incidence than those emigrating from low-incidence settings. Estimates of local transmission, as captured by genotyping, versus reactivation of latent TB infection acquired outside Canada varied when data were stratified by birthplace TB incidence, as did patient-level characteristics of individuals in each group, such as age and years between immigration and diagnosis. CONCLUSION Categorizing persons beyond simply "foreign-born", particularly in the context of TB epidemiologic and molecular data, is needed for a more accurate understanding of TB rates and patterns of transmission.
Collapse
Affiliation(s)
- Jennifer L. Guthrie
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Lisa A. Ronald
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Victoria J. Cook
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - James Johnston
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jennifer L. Gardy
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Disease Control, Vancouver, Canada
| |
Collapse
|
17
|
Bozorgmehr K, Preussler S, Wagner U, Joggerst B, Szecsenyi J, Razum O, Stock C. Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015. BMC Infect Dis 2019; 19:304. [PMID: 30943917 PMCID: PMC6448304 DOI: 10.1186/s12879-019-3902-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/13/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of screening yield. METHODS We combined individual data of 119,037 asylum seekers screened for TB in Germany (2002-2015) with TB estimates of the World Health Organization (WHO) (1990-2014) for their 81 countries of origin. Adjusted rate ratios (aRR) and 95% credible intervals (CrI) of the observed yield of screening were calculated in Bayesian Poisson regression models by categories of WHO-estimated TB incidence. We assessed changes in sensitivity depending on screening thresholds, used WHO TB estimates as prior information to predict TB in asylum seekers, and modelled country-specific probabilities of numbers needed to screen (NNS) conditional on different screening thresholds. RESULTS The overall yield was 82 per 100,000 and the annual yield ranged from 44.1 to 279.7 per 100,000. Country-specific yields ranged from 10 (95%- CrI: 1-47) to 683 (95%-CrI: 306-1336) per 100,000 in Iraqi and Somali asylum seekers, respectively. The observed yield was higher in asylum seekers from countries with a WHO-estimated TB incidence > 50 relative to those from countries ≤50 per 100,000 (aRR: 4.17, 95%-CrI: 2.86-6.59). Introducing a threshold in the range of a WHO-estimated TB incidence of 50 and 100 per 100,000 resulted in the lowest "loss" in sensitivity. WHO's TB prevalence estimates improved prediction accuracy for eight of the 11 countries, and allowed modelling country-specific probabilities of NNS. CONCLUSIONS WHO's TB data can inform the estimation of screening yield and thus be used to improve screening efficiency in asylum seekers. This may help to develop more targeted screening strategies by reducing uncertainty in estimates of expected country-specific yield, and identify thresholds with lowest loss in sensitivity. Further modelling studies are needed which combine clinical, diagnostic and country-specific parameters.
Collapse
Affiliation(s)
- Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, INF 130.3, 69120 Heidelberg, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Stella Preussler
- Institute of Medical Biometry and Informatics (IMBI), University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrich Wagner
- Public health authority, Section for Disease Control, Landkreis Karlsruhe, Karlsruhe, Germany
| | | | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, INF 130.3, 69120 Heidelberg, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics (IMBI), University Hospital Heidelberg, Heidelberg, Germany
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, DKFZ, Heidelberg, Germany
| |
Collapse
|
18
|
Long R, Asadi L, Heffernan C, Barrie J, Winter C, Egedahl ML, Paulsen C, Kunimoto B, Menzies D. Is there a fundamental flaw in Canada's post-arrival immigrant surveillance system for tuberculosis? PLoS One 2019; 14:e0212706. [PMID: 30849130 PMCID: PMC6407769 DOI: 10.1371/journal.pone.0212706] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/08/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND New immigrants to Canada with a history of tuberculosis or evidence of old healed tuberculosis on chest radiograph are referred to public health authorities for medical surveillance. This ostensible public health protection measure identifies a subgroup of patients (referrals) who are at very low risk (compared to non-referrals) of transmission. METHODS To assess whether earlier diagnosis or a different phenotypic expression of disease explains this difference, we systematically reconstructed the immigration and transmission histories from a well-defined cohort of recently-arrived referral and non-referral pulmonary tuberculosis cases in Canada. Incident case chest radiographs in all cases and sequential past radiographs in referrals were re-read by three experts. Change in disease severity from pre-immigration radiograph to incident radiograph was the primary, and transmission of tuberculosis, the secondary, outcome. RESULTS There were 174 cohort cases; 61 (35.1%) referrals and 113 (64.9%) non-referrals. Compared to non-referrals, referrals were less likely to be symptomatic (26% vs. 80%), smear-positive (15% vs. 50%), or to have cavitation (0% vs. 35%) or extensive disease (15% vs. 59%) on chest radiograph. After adjustment for referral status, time between films, country-of-birth, age and co-morbidities, referrals were less likely to have substantial changes on chest radiograph; OR 0.058 (95% CI 0.018-0.199). All secondary cases and 82% of tuberculin skin test conversions occurred in contacts of non-referrals. CONCLUSIONS Phenotypically different disease, and not earlier diagnosis, explains the difference in transmission risk between referrals and non-referrals. Screening, and treating high-risk non-referrals for latent tuberculosis is necessary to eliminate tuberculosis in Canada.
Collapse
Affiliation(s)
- Richard Long
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Leyla Asadi
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Courtney Heffernan
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - James Barrie
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher Winter
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mary Lou Egedahl
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Paulsen
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brenden Kunimoto
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
19
|
Abstract
Migration is increasing and practitioners need to be aware of the unique health needs of this population. The prevalence of infectious diseases among migrants varies and generally mirrors that of their countries of origin, but is modified by the circumstance of migration, the presence of pre-arrival screening programs and post arrival access to health care. To optimize the health of migrants practitioners; (1) should take all opportunities to screen migrants at risk for latent infections such as tuberculosis, chronic hepatitis B and C, HIV, strongyloidiasis, schistosomiasis and Chagas disease, (2) update routine vaccines in all age groups and, (3) be aware of "rare and tropical infections" related to migration and return travel.
Collapse
Affiliation(s)
- Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, Room E0057, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, 3755 Côte Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada; J.D. MacLean Center for Tropical Diseases at McGill, McGill University Health Centre, Glen Site, 1001 Décarie Boulevard, Montreal, Quebec H4A 3J1, Canada.
| | - Francesco Castelli
- University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Piazza del Mercato, 15, Lombardy, Brescia 25121, Italy; UNESCO Chair "Training and Empowering Human Resources for Health Development in Resource-Limited Countries", University of Brescia, Brescia, Italy
| |
Collapse
|
20
|
Greenaway C, Castelli F. Infectious diseases at different stages of migration: an expert review. J Travel Med 2019; 26:5307656. [PMID: 30726941 DOI: 10.1093/jtm/taz007] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Human migration is increasing in magnitude and scope. The majority of migrants arriving in high-income countries originate from countries with a high prevalence of infectious diseases. The risk and burden of infectious diseases are not equally distributed among migrant groups and vary with migration stage. METHODS A broad literature review was conducted on the drivers for infectious diseases and associated health outcomes among migrants across different stages of migration. The aim was to provide practitioners with an overview of the key infectious disease risks at each stage to guide health promotion strategies. RESULTS A complex interaction of factors leads to infectious diseases and associated poor health outcomes among migrants. The most important drivers are the epidemiology of infectious diseases in their countries of origin, the circumstances and conditions of the migration journey and barriers accessing healthcare post-arrival. During the recent large waves of forced migration into Europe, the primary health concerns on arrival were psychological, traumatic and chronic non-communicable diseases. In the early settlement period, crowded and unhygienic living conditions in reception camps facilitated outbreaks of respiratory, gastrointestinal, skin infections and vaccine preventable diseases. After re-settlement, undetected and untreated latent infections due to tuberculosis, viral hepatitis, HIV, chronic helminthiasis and Chagas' disease led to poor health outcomes. Migrants are disproportionally affected by preventable travel-related diseases such as malaria, typhoid and hepatitis due to poor uptake of pre-travel prophylaxis and vaccination. Infectious diseases among migrants can be decreased at all migration stages with health promotion strategies adapted to their specific needs and delivered in a linguistically and culturally sensitive manner. CONCLUSIONS Tailored health promotion and screening approaches and accessible and responsive health systems, regardless of legal status, will be needed at all migration stages to limit the burden and transmission of infectious diseases in the migrant population.
Collapse
Affiliation(s)
- Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.,JD MacLean Centre for Tropical Diseases at McGill, McGill University Health Centre, McGill University, Montreal, Canada
| | - Francesco Castelli
- JD MacLean Centre for Tropical Diseases at McGill, McGill University Health Centre, McGill University, Montreal, Canada.,University Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili, Brescia, Italy.,UNESCO Chair 'Training and Empowering Human Resources for Health Development in Resource-Limited Countries', University of Brescia, Brescia, Italy
| |
Collapse
|
21
|
Campbell JR, Johnston JC, Ronald LA, Sadatsafavi M, Balshaw RF, Cook VJ, Levin A, Marra F. Screening for Latent Tuberculosis Infection in Migrants With CKD: A Cost-effectiveness Analysis. Am J Kidney Dis 2018; 73:39-50. [PMID: 30269868 DOI: 10.1053/j.ajkd.2018.07.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/20/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE In countries with a low tuberculosis (TB) incidence, TB disproportionately affects populations born abroad. TB persists in these populations through reactivation of latent TB infection (LTBI) acquired before immigration. Those with chronic kidney disease (CKD) are at increased risk for reactivation and may benefit from LTBI screening and treatment. STUDY DESIGN Health administrative data from British Columbia, Canada, were used to inform a cost-effectiveness analysis evaluating LTBI screening in those diagnosed with stage 4 or 5 CKD not requiring dialysis (late-stage CKD) and those who began dialysis therapy. SETTING & POPULATION Permanent residents establishing residency in British Columbia, Canada, between 1985 and 2012 who had late-stage CKD diagnosed or began dialysis therapy. INTERVENTIONS Screening with the tuberculin skin test or interferon-gamma release assay (IGRA) compared to no LTBI screening at the time of late-stage CKD diagnosis and time of dialysis therapy initiation. Treatment for those who tested positive was isoniazid for 9 months. OUTCOMES Costs (2016 Can $), TB cases, and quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio for QALYs gained was calculated. MODEL, PERSPECTIVE, & TIMEFRAME Discrete event simulation model using a health care system perspective, 1.5% discount rate, and 5-year time horizon. RESULTS Screening with IGRA was superior to the tuberculin skin test in all situations. Screening with IGRA was less expensive and resulted in better outcomes compared to no screening in those initiating dialysis therapy from countries with an elevated TB incidence. In individuals with late-stage CKD, screening with IGRA was only cost-effective in those 60 years or older (cost per QALY gained, <$48,000) from countries with an elevated TB incidence. LIMITATIONS This study has limitations in generalizability to different epidemiologic settings and in modeling complicated clinical decisions. CONCLUSIONS LTBI screening should be considered in non-Canadian-born residents initiating dialysis therapy and those with late stage CKD who are older.
Collapse
Affiliation(s)
- Jonathon R Campbell
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - James C Johnston
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada
| | - Lisa A Ronald
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Robert F Balshaw
- British Columbia Centre for Disease Control, Vancouver, Canada; George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Victoria J Cook
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; British Columbia Centre for Disease Control, Vancouver, Canada
| | - Adeera Levin
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; British Columbia Provincial Renal Agency, Vancouver, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
22
|
Tuberculosis Specific Interferon-Gamma Production in a Current Refugee Cohort in Western Europe. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15061263. [PMID: 29904012 PMCID: PMC6025316 DOI: 10.3390/ijerph15061263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/06/2018] [Accepted: 06/11/2018] [Indexed: 12/21/2022]
Abstract
Background: In 2015, a high number of refugees with largely unknown health statuses immigrated to Western Europe. To improve caretaking strategies, we assessed the prevalence of latent tuberculosis infection (LTBI) in a refugee cohort. Methods: Interferon-Gamma release assays (IGRA, Quantiferon) were performed in n = 232 inhabitants of four German refugee centers in the summer of 2015. Results: Most refugees were young, male adults. Overall, IGRA testing was positive in 17.9% (95% CI = 13.2–23.5%) of subjects. Positivity rates increased with age (0% <18 years versus 46.2% >50 years). Age was the only factor significantly associated with a positive IGRA in multiple regression analysis including gender, C reactive protein, hemoglobin, leukocyte, and thrombocyte count and lymphocyte, monocyte, neutrophil, basophil, and eosinophil fraction. For one year change in age, the odds are expected to be 1.06 times larger, holding all other variables constant (p = 0.015). Conclusion: Observed LTBI frequencies are lower than previously reported in similar refugee cohorts. However, as elderly people are at higher risk for developing active tuberculosis, the observed high rate of LTBI in senior refugees emphasizes the need for new policies on the detection and treatment regimens in this group.
Collapse
|