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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.
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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
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Kristensen KL, Ravn P, Petersen JH, Hargreaves S, Nellums LB, Friedland JS, Andersen PH, Norredam M, Lillebaek T. Long-term risk of tuberculosis among migrants according to migrant status: a cohort study. Int J Epidemiol 2021; 49:776-785. [PMID: 32380550 DOI: 10.1093/ije/dyaa063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The majority of tuberculosis (TB) cases in low-incidence countries occur in migrants. Only few studies have assessed the long-term TB risk in migrants after immigration, and datasets have not considered this across a range of diverse migrant groups. This nationwide study aimed to investigate long-term TB risk among migrants according to migrant status and region of origin. METHODS This cohort study included all migrants aged ≥ 18 years who obtained residence in Denmark from 1993 to 2015, with a mean follow-up of 10.8 years [standard deviation (SD) 7.3]. Migrants were categorized based on legal status of residence and region of origin. Incidence rates (IR) and rate ratios (IRR) were estimated by Poisson regression. RESULTS A total of 142 314 migrants were included. Across all migrants, the TB risk was highest during year 1 of residence (IR 275/100 000 person-years; 95% CI 249-305) followed by a gradual decline, though TB risk remained high for over a decade. Compared with the Danish-born population, the IRRs after 7-8 years were particularly higher among former asylum seekers (IRR 31; 95% CI 20-46), quota refugees (IRR 31; 95% CI 16-71), and family-reunified with refugees (IRR 22; 95% CI 12-44). Sub-Saharan African migrants also experienced elevated risk (IRR 75; 95% CI 51-109). The proportion of migrants with pulmonary TB was 52.4%. CONCLUSION All migrant groups experienced an initial high TB risk, but long-term risk remained high in key migrant groups. Most European countries focus TB screening on or soon after arrival. Our study suggests that approaches to TB screening should be adapted, with migrant populations benefiting from long-term access to preventive health services.
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Affiliation(s)
- Kristina Langholz Kristensen
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Department of Pulmonary and Infectious Diseases, Nordsjaellands Hospital, Hilleroed, Denmark
| | - Pernille Ravn
- Department of Medicine, Section of Infectious Diseases, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Sally Hargreaves
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Laura B Nellums
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jon S Friedland
- Institute for Infection & Immunity, St George's University of London, London, UK
| | - Peter Henrik Andersen
- Department of Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - Marie Norredam
- Research Centre for Migration, Ethnicity and Health, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Section of Immigrant Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark.,Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Dhawan V, Bown J, Lau A, Langlois-Klassen D, Kunimoto D, Bhargava R, Chui L, Collin SM, Long R. Towards the elimination of paediatric tuberculosis in high-income, immigrant-receiving countries: a 25-year conventional and molecular epidemiological case study. ERJ Open Res 2018; 4:00131-2017. [PMID: 29750144 PMCID: PMC5938491 DOI: 10.1183/23120541.00131-2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/09/2018] [Indexed: 11/21/2022] Open
Abstract
The epidemiology of tuberculosis (TB) in high-income countries is increasingly dictated by immigration. The influence of this trend on paediatric TB and TB elimination are not well defined. We undertook a 25-year conventional and molecular epidemiologic study of paediatric TB in Alberta, one of four major immigrant-receiving provinces in Canada. All isolates of Mycobacterium tuberculosis were DNA fingerprinted using standard methodology. Between 1990 and 2014, 176 children aged 0–14 years were diagnosed with TB. Foreign-born children or Canadian-born children of foreign-born parents accounted for an increasingly large proportion of total cases during the study period (from 32.1% to 89.5%). Of the 78 culture-positive cases, 35 (44.9%) had a putative source case identified by conventional epidemiology, with 34 (97.1%) having a concordant molecular profile. Of the remaining 43 culture-positive cases, molecular profiling identified spatially and temporally related sources in six cases (14.0%). These six children, along with four other children whose source cases were discovered through reverse-contact tracing, had a high morbidity and mortality. The increasing burden of paediatric TB in both foreign-born children and Canadian-born children of foreign-born parents calls for more timely diagnosis of source cases and more targeted screening for latent TB infection. Conventional and molecular epidemiology can inform paediatric TB elimination strategy in high-income countrieshttp://ow.ly/mwbn30iY1WF
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Affiliation(s)
- Vivek Dhawan
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Bown
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Angela Lau
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Dennis Kunimoto
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ravi Bhargava
- Dept of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Linda Chui
- Dept of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada.,Provincial Laboratory for Public Health, Alberta Health Services, Edmonton, AB, Canada.,Provincial Laboratory for Public Health, Alberta Health Services, Calgary, AB, Canada
| | - Simon M Collin
- Centre for Child and Adolescent Health, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard Long
- Dept of Medicine, University of Alberta, Edmonton, AB, Canada
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4
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Heffernan C, Doroshenko A, Egedahl ML, Barrie J, Senthilselvan A, Long R. Predicting pulmonary tuberculosis in immigrants: a retrospective cohort study. ERJ Open Res 2018; 4:00170-2017. [PMID: 29692996 PMCID: PMC5909047 DOI: 10.1183/23120541.00170-2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/28/2018] [Indexed: 12/30/2022] Open
Abstract
Our objective was to investigate whether pulmonary tuberculosis (PTB) can be predicted from features of a targeted medical history and basic laboratory investigations in immigrants. A retrospective cohort of 391 foreign-born adults referred to the Edmonton Tuberculosis Clinic (Edmonton, AB, Canada) was studied using multiple logistic regression analysis to predict PTB. Seven characteristics of disease were used as explanatory variables. Cross-validation assessed performance. Each predictor was tested on two outcomes: “culture-positive” and “smear-positive”. Receiver operating characteristic (ROC) curves were generated and the area under the ROC curve (AUC) was quantified. Symptoms, subacute duration of symptoms, risk factors for reactivation of latent TB infection and anaemia were all associated with a positive culture (adjusted OR 1.79, 2.24, 1.72 and 2.28, respectively; p<0.05). Symptoms, inappropriate prescription of broad-spectrum antibiotics and a “typical” chest radiograph were associated with smear-positive PTB (adjusted OR 2.91, 1.55 and 12.34, respectively; p<0.05). ROC curve analysis was used to test each model, yielding AUC=0.91 for the outcome “culture-positive” disease and AUC=0.94 for the outcome “smear-positive” disease. PTB among the foreign-born can be predicted from a targeted medical history and basic laboratory investigations, raising the threshold of suspicion in settings where the disease is relatively rare. In high-income, low tuberculosis incidence countries, certain clinical characteristics should raise the threshold of suspicion to confirm a timely diagnosishttp://ow.ly/bRDZ30iPurz
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Affiliation(s)
- Courtney Heffernan
- Tuberculosis Program Evaluation and Research Unit, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexander Doroshenko
- Tuberculosis Program Evaluation and Research Unit, Dept of Medicine, University of Alberta, Edmonton, AB, Canada.,Division of Preventive Medicine, Dept of Medicine, University of Alberta, Edmonton, AB, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Mary Lou Egedahl
- Tuberculosis Program Evaluation and Research Unit, Dept of Medicine, University of Alberta, Edmonton, AB, Canada
| | - James Barrie
- Dept of Radiology, University of Alberta, Edmonton, AB, Canada
| | | | - Richard Long
- Tuberculosis Program Evaluation and Research Unit, Dept of Medicine, University of Alberta, Edmonton, AB, Canada.,School of Public Health, University of Alberta, Edmonton, AB, Canada
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5
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Factors Affecting Outcome of Tuberculosis in Children in Italy: An Ecological Study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017. [PMID: 27677276 DOI: 10.1007/5584_2016_94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
INTRODUCTION Tuberculosis is a major problem in children depending on their families for management and a re-emerging disease in low incidence countries, where foreign-born cases account for a large proportion of cases. METHODS We investigated socioeconomic features of families and their impact on management and outcome of children with tuberculosis disease seen at a tertiary care centre for paediatric infectious diseases in Italy. RESULTS Forty-nine Italian and 30 foreign-origin children were included. Children from foreign families had more complicated diseases (20 % vs 0 %; P = 0.002), harbored more drug resistant strains (20 % vs 2 %; P = 0.011), showed longer hospital stay (12 ± 13.1 vs 5.1 ± 6.5 days; P = 0.012) and higher proportion of missed medical visits (15.7 ± 16 vs 8.6 ± 9.6; P ≤ 0.042) than those from Italian families. Harboring drug resistant strains was an independent risk factor for complicated disease course (OR: 72.98; 95 %CI: 1.54-3468.58; P = 0.029), and this risk is higher in children from Eastern Europe (OR: 10.16; 95 %CI: 1.7-61.9; P = 0.012). CONCLUSIONS Children from immigrant families showed an increased risk of complicated course of tuberculosis due to a higher rate of resistant strains and raise problems in clinical management. Specific protocols are needed to support these populations ensuring easy access to health services and monitoring.
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Ronald LA, Campbell JR, Balshaw RF, Roth DZ, Romanowski K, Marra F, Cook VJ, Johnston JC. Predicting tuberculosis risk in the foreign-born population of British Columbia, Canada: study protocol for a retrospective population-based cohort study. BMJ Open 2016; 6:e013488. [PMID: 27888179 PMCID: PMC5168543 DOI: 10.1136/bmjopen-2016-013488] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Improved understanding of risk factors for developing active tuberculosis (TB) will better inform decisions about diagnostic testing and treatment for latent TB infection (LTBI) in migrant populations in low-incidence regions. We aim to examine TB risk factors among the foreign-born population in British Columbia (BC), Canada, and to create and validate a clinically relevant multivariate risk score to predict active TB. METHODS AND ANALYSIS This retrospective population-based cohort study will include all foreign-born individuals who acquired permanent resident status in Canada between 1 January 1985 and 31 December 2013 and acquired healthcare coverage in BC at any point during this period. Multiple administrative databases and disease registries will be linked, including a National Immigration Database, BC Provincial Health Insurance Registration, physician billings, hospitalisations, drugs dispensed from community pharmacies, vital statistics, HIV testing and notifications, cancer, chronic kidney disease and dialysis treatment, and all TB and LTBI testing and treatment data in BC. Extended proportional hazards regression will be used to estimate risk factors for TB and to create a prognostic TB risk score. ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the University of British Columbia Clinical Ethics Review Board. Once completed, study findings will be presented at conferences and published in peer-reviewed journals. An online TB risk score calculator will also be created.
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Affiliation(s)
- Lisa A Ronald
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jonathon R Campbell
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert F Balshaw
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - David Z Roth
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria J Cook
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - James C Johnston
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
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Ronald LA, FitzGerald JM, Benedetti A, Boivin JF, Schwartzman K, Bartlett-Esquilant G, Menzies D. Predictors of hospitalization of tuberculosis patients in Montreal, Canada: a retrospective cohort study. BMC Infect Dis 2016; 16:679. [PMID: 27846812 PMCID: PMC5111232 DOI: 10.1186/s12879-016-1997-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hospitalization is the most costly health system component of tuberculosis (TB) control programs. Our objectives were to identify how frequently patients are hospitalized, and the factors associated with hospitalizations and length-of-stay (LOS) of TB patients in a large Canadian city. METHODS We extracted data from the Montreal TB Resource database, a retrospective cohort of all active TB cases reported to the Montreal Public Health Department between January 1996 and May 2007. Data included patient demographics, clinical characteristics, and dates of treatment and hospitalization. Predictors of hospitalization and LOS were estimated using logistic regression and Cox proportional hazards regression, respectively. RESULTS There were 1852 active TB patients. Of these, 51% were hospitalized initially during the period of diagnosis and/or treatment initiation (median LOS 17.5 days), and 9.0% hospitalized later during treatment (median LOS 13 days). In adjusted models, patients were more likely to be hospitalized initially if they were children, had co-morbidities, smear-positive symptomatic pulmonary TB, cavitary or miliary TB, and multi- or poly-TB drug resistance. Factors predictive of longer initial LOS included having HIV, renal disease, symptomatic pulmonary smear-positive TB, multi- or poly-TB drug resistance, and being in a teaching hospital. CONCLUSIONS We found a high hospitalization rate during diagnosis and treatment of patients with TB. Diagnostic delay due to low index of suspicion may result in patients presenting with more severe disease at the time of diagnosis. Earlier identification and treatment, through interventions to increase TB awareness and more targeted prevention programs, might reduce costly TB-related hospital use.
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Affiliation(s)
- Lisa A Ronald
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - J Mark FitzGerald
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Institute for Heart and Lung Health, University of British Columbia, Vancouver, Canada
| | - Andrea Benedetti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit (RECRU)/ Montreal Chest Institute, McGill University Health Centre, Room 419, 2155 Guy St, Montreal, QC, H3H 2R9, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada
| | - Jean-François Boivin
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Kevin Schwartzman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Respiratory Epidemiology and Clinical Research Unit (RECRU)/ Montreal Chest Institute, McGill University Health Centre, Room 419, 2155 Guy St, Montreal, QC, H3H 2R9, Canada
| | | | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. .,Respiratory Epidemiology and Clinical Research Unit (RECRU)/ Montreal Chest Institute, McGill University Health Centre, Room 419, 2155 Guy St, Montreal, QC, H3H 2R9, Canada.
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Roth D, Otterstatter M, Wong J, Cook V, Johnston J, Mak S. Identification of spatial and cohort clustering of tuberculosis using surveillance data from British Columbia, Canada, 1990-2013. Soc Sci Med 2016; 168:214-222. [PMID: 27389850 DOI: 10.1016/j.socscimed.2016.06.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/27/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
Abstract
Since 2000, the global incidence of tuberculosis (TB) has decreased by 1.5% per year, becoming increasingly clustered in key subpopulations in low incidence settings. TB clustering can manifest spatially from recent transmission, or in non-spatial cohort clusters resulting from reactivation of latent infection in populations with shared risk factors. Identifying and interrupting disease clusters is required to eliminate TB in low incidence countries. Here we demonstrate an analytical approach for detecting both spatial and cohort clustering of TB among population subgroups, and describe the value in differentiating these forms of clustering. TB cases in British Columbia meeting the Canadian case definition were geocoded and mapped using Geographic Information Systems (GIS). Incidence rates were calculated for three periods (1990-1997, n = 2556; 1998-2005, n = 2488; 2006-2013, n = 2225) among Canadian born (CB) and foreign-born (FB) populations using denominator data from the Canadian Census. Spatial clusters were identified using a scanning window statistic (SaTScan) and overlaid on provincial incidence maps. Country of birth (cohort) clustering in the FB was identified using Lorenz curves and Gini coefficients. TB incidence in the CB population was generally low, but punctuated with few areas of high incidence; the spatial clusters identified in the CB match previously identified clusters. TB incidence in the FB did not show spatially localized clusters. However, Lorenz curves revealed substantial, and increasing, cohort clustering in the FB in semi-urban and rural regions of British Columbia, and less pronounced, and decreasing, clustering in urban regions. In general, the TB incidence in groups defined by country of birth shifted over time to become increasingly uniform across regions. Our approach, based on spatial analysis and the application of Lorenz curves revealed a complex coexistence of spatial and cohort clustering. Spatial and cohort clusters require differing public health responses, and differentiating types of clustering can inform TB prevention programs.
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Affiliation(s)
- David Roth
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada
| | - Michael Otterstatter
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Victoria Cook
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - James Johnston
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Sunny Mak
- British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V5Z 4R4, Canada.
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Long R, Heffernan C, Gao Z, Egedahl ML, Talbot J. Do "Virtual" and "Outpatient" Public Health Tuberculosis Clinics Perform Equally Well? A Program-Wide Evaluation in Alberta, Canada. PLoS One 2015; 10:e0144784. [PMID: 26700163 PMCID: PMC4689372 DOI: 10.1371/journal.pone.0144784] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Meeting the challenge of tuberculosis (TB) elimination will require adopting new models of delivering patient-centered care customized to diverse settings and contexts. In areas of low incidence with cases spread out across jurisdictions and large geographic areas, a "virtual" model is attractive. However, whether "virtual" clinics and telemedicine deliver the same outcomes as face-to-face encounters in general and within the sphere of public health in particular, is unknown. This evidence is generated here by analyzing outcomes between the "virtual" and "outpatient" public health TB clinics in Alberta, a province of Western Canada with a large geographic area and relatively small population. METHODS In response to the challenge of delivering equitable TB services over long distances and to hard to reach communities, Alberta established three public health clinics for the delivery of its program: two outpatient serving major metropolitan areas, and one virtual serving mainly rural areas. The virtual clinic receives paper-based or electronic referrals and generates directives which are acted upon by local providers. Clinics are staffed by dedicated public health nurses and university-based TB physicians. Performance of the two types of clinics is compared between the years 2008 and 2012 using 16 case management and treatment outcome indicators and 12 contact management indicators. FINDINGS In the outpatient and virtual clinics, respectively, 691 and 150 cases and their contacts were managed. Individually and together both types of clinics met most performance targets. Compared to outpatient clinics, virtual clinic performance was comparable, superior and inferior in 22, 3, and 3 indicators, respectively. CONCLUSIONS Outpatient and virtual public health TB clinics perform equally well. In low incidence settings a combination of the two clinic types has the potential to address issues around equitable service delivery and declining expertise.
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Affiliation(s)
- Richard Long
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Courtney Heffernan
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Zhiwei Gao
- Clinical Epidemiology Unit, Department of Medicine, Memorial University, St. John’s, Newfoundland, Canada
| | - Mary Lou Egedahl
- Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - James Talbot
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- Alberta Health Province of Alberta, Edmonton, Alberta, Canada
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Abstract
Making a timely diagnosis of adult-type pulmonary tuberculosis (TB) is critical to interrupting transmission and optimizing treatment outcomes. A hypothesis based on clinical experience is that a timely diagnosis may be made by addressing seven clinical rubrics: six related to history, one to the laboratory. Responses may be considered to be part of a clinical heuristic for making a timely diagnosis of pulmonary TB. The larger the number of affirmative responses, the more likely the diagnosis, although it is probable some questions carry more weight than others. The radiograph is key and may almost be considered to be confirmatory of the history. Collectively, the responses should prompt suspicion of pulmonary TB - submission of sputum for acid-fast bacilli smear and culture, and respiratory isolation.
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Khan K, Hirji MM, Miniota J, Hu W, Wang J, Gardam M, Rawal S, Ellis E, Chan A, Creatore MI, Rea E. Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada. CMAJ 2015; 187:E473-E481. [PMID: 26416993 DOI: 10.1503/cmaj.150011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 08/05/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND All Canadian immigrants undergo screening for tuberculosis (TB) before immigration, and selected immigrants must undergo postimmigration surveillance for the disease. We sought to quantify the domestic health impact of screening for TB in all new immigrants and to identify mechanisms to enhance effectiveness and efficiency of this screening. METHODS We linked preimmigration medical examination records from 944,375 immigrants who settled in Ontario between 2002 and 2011 to active TB reporting data in Ontario between 2002 and 2011. Using a retrospective cohort study design, we measured birth country-specific rates of active TB detected through preimmigration screening and postimmigration surveillance. We then quantified the proportion of active TB cases among residents of Ontario born abroad that were detected through postimmigration surveillance. Using Cox regression, we identified independent predictors of active TB postimmigration. RESULTS Immigrants from 6 countries accounted for 87.3% of active TB cases detected through preimmigration screening, and 10 countries accounted for 80.4% of cases detected through postimmigration surveillance. Immigrants from countries with a TB (all-sites) incidence rate of less than 30 cases per 100 000 persons resulted in pre- and postimmigration detection of 2.4 and 0.9 cases per 100 000 immigrants, respectively. Postimmigration surveillance detected 2.6% of active TB cases in Ontario residents born abroad, and TB was detected a median of 18 days earlier in those undergoing surveillance than in those who were not referred to surveillance or who did not comply. Predictors of active TB postimmigration included radiographic markers of old TB, birth country, immigration category, location of application for residency, immune status and age. INTERPRETATION Universal screening for TB in new immigrants has a modest impact on the domestic burden of active TB and is highly inefficient. Focusing preimmigration screening in countries with high incidence rates and revising criteria for postimmigration surveillance could increase the effectiveness and efficiency of screening.
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Affiliation(s)
- Kamran Khan
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont.
| | - M Mustafa Hirji
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Jennifer Miniota
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Wei Hu
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Jun Wang
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Michael Gardam
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Sameer Rawal
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Edward Ellis
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Angie Chan
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Maria I Creatore
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
| | - Elizabeth Rea
- Department of Medicine (Khan, Gardam), Division of Infectious Diseases, University of Toronto; Centre for Research on Inner City Health (Khan, Miniota, Creatore, Chan, Hu, Wang), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.; Public Health and Preventive Medicine Residency Program (Hirji), Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Infection Prevention and Control (Gardam), University Health Network; Faculty of Medicine (Rawal), University of Toronto, Toronto, Ont.; Faculty of Medicine (Ellis), University of Ottawa, Ottawa, Ont.; Toronto Public Health and Dalla Lana School of Public Health (Rea), University of Toronto, Toronto, Ont
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Brode SK, Varadi R, McNamee J, Malek N, Stewart S, Jamieson FB, Avendano M. Multidrug-resistant tuberculosis: Treatment and outcomes of 93 patients. Can Respir J 2015; 22:97-102. [PMID: 25493698 PMCID: PMC4390019 DOI: 10.1155/2015/359301] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a leading cause of death worldwide and the emergence of multidrug-resistant TB (MDR TB) poses a threat to its control. There is scanty evidence regarding optimal management of MDR TB. The majority of Canadian cases of MDR TB are diagnosed in Ontario; most are managed by the Tuberculosis Service at West Park Healthcare Centre in Toronto. The authors reviewed 93 cases of MDR TB admitted from January 1, 2000 to December 31, 2011. RESULTS Eighty-nine patients were foreign born. Fifty-six percent had a previous diagnosis of TB and most (70%) had only pulmonary involvement. Symptoms included productive cough, weight loss, fever and malaise. The average length of inpatient stay was 126 days. All patients had a peripherally inserted central catheter for the intensive treatment phase because medications were given intravenously. Treatment lasted for 24 months after bacteriologic conversion, and included a mean (± SD) of 5 ± 1 drugs. A successful outcome at the end of treatment was observed in 84% of patients. Bacteriological conversion was achieved in 98% of patients with initial positive sputum cultures; conversion occurred by four months in 91%. CONCLUSIONS MDR TB can be controlled with the available anti-TB drugs.
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Affiliation(s)
- Sarah K Brode
- West Park Healthcare Centre, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | - Robert Varadi
- West Park Healthcare Centre, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | | | - Nina Malek
- West Park Healthcare Centre, Toronto, Ontario
| | | | | | - Monica Avendano
- West Park Healthcare Centre, Toronto, Ontario
- University of Toronto, Toronto, Ontario
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13
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Ingrosso L, Vescio F, Giuliani M, Migliori GB, Fattorini L, Severoni S, Rezza G. Risk factors for tuberculosis in foreign-born people (FBP) in Italy: a systematic review and meta-analysis. PLoS One 2014; 9:e94728. [PMID: 24733156 PMCID: PMC3986251 DOI: 10.1371/journal.pone.0094728] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/19/2014] [Indexed: 11/30/2022] Open
Abstract
In Italy, TB notifications in foreign-born people (FBP) are steadily increasing. To investigate this issue we did a meta-analysis on risk factors for FBP people. A systematic search was performed in PubMed and EMBASE from Jan-1980 to Jan-2013. We analysed HIV status, previous TB-treatment, intravenous drug use and alcohol abuse, and multidrug resistant TB. Odd ratio was used as a measure of effect. One and two-stages approaches were used. In the main analysis we used a 2-stages approach to include studies with only aggregate estimates. Among 1996 references, 18 fulfilled inclusion criteria. In TB-affected FBP people positive HIV-status was about 3 times higher than among Italians, after 1996 when combined antiretroviral therapy for HIV was introduced (OR: 2.91; 95%CI: 1.37; 6.17). No association was found between FBP and intravenous drug users in adults; after 1-stage meta-analysis foreign born people from highly endemic countries had a 4 times higher risk to be multidrug resistant TB than Italian people. Finally, TB-affected FBP were less likely than Italians to be alcoholics (OR: 0.10 95%CI: 0.01; 0.84) or of having received previous TB-treatment (OR: 0.55; 95%CI: 0.43; 0.71). An association of multidrug resistant TB with immigrant status as well as an association of Tuberculosis with HIV-positive status in foreign-born people are major findings of this analysis. Drugs and alcohol abuse do not appear to be risk factors for TB in FBP, however they cannot be discharged since may depend on cultural traditions and their role may change in the future along with the migratory waves. An effective control of TB risk factors among migrants is crucial to obtain the goal of TB eradication.
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Affiliation(s)
- Loredana Ingrosso
- Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - Fenicia Vescio
- Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - Massimo Giuliani
- Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Lanfranco Fattorini
- Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Roma, Italy
| | - Santino Severoni
- Migration and Health, WHO European office for investment for health and development, Castello, Venice, Italy
| | - Giovanni Rezza
- Department of Infectious, Parasitic and Immune-mediated Diseases, Istituto Superiore di Sanità, Roma, Italy
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14
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Baussano I, Mercadante S, Pareek M, Lalvani A, Bugiani M. High rates of Mycobacterium tuberculosis among socially marginalized immigrants in low-incidence area, 1991-2010, Italy. Emerg Infect Dis 2014; 19:1437-45. [PMID: 23965807 PMCID: PMC3810899 DOI: 10.3201/eid1909.120200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Migration from low- and middle-income countries to high-income countries increasingly determines the severity of tuberculosis (TB) cases in the adopted country. Socially marginalized groups, about whom little is known, may account for a reservoir of TB among the immigrant populations. We investigated the rates of and risk factors for Mycobacterium tuberculosis transmission, infection, and disease in a cohort of 27,358 socially marginalized immigrants who were systematically screened (1991-2010) in an area of Italy with low TB incidence. Overall TB and latent TB infection prevalence and annual tuberculin skin testing conversion rates (i.e., incidence of new infection) were 2.7%, 34.6%, and 1.7%, respectively. Prevalence of both TB and latent TB infection and incidence of infection increased as a function of the estimated TB incidence in the immigrants' countries of origin. Annual infection incidence decreased with time elapsed since immigration. These findings have implications for control policy and immigrant screening in countries with a low prevalence of TB.
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15
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Campbell J, Marra F, Cook V, Johnston J. Screening immigrants for latent tuberculosis: do we have the resources? CMAJ 2014; 186:246-7. [PMID: 24468691 DOI: 10.1503/cmaj.131025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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16
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Langlois-Klassen D, Senthilselvan A, Chui L, Kunimoto D, Saunders LD, Menzies D, Long R. Transmission of Mycobacterium tuberculosis Beijing Strains, Alberta, Canada, 1991-2007. Emerg Infect Dis 2013; 19:701-11. [PMID: 23648234 PMCID: PMC3649004 DOI: 10.3201/eid1905.121578] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Transmission of Beijing strains posed no more of a public health threat than did non-Beijing strains.
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Mor Z, Leventhal A, Diacon AH, Finger R, Schoch OD. Tuberculosis screening in immigrants from high-prevalence countries: interview first or chest radiograph first? A pro/con debate. Respirology 2013; 18:432-8. [PMID: 23336500 DOI: 10.1111/resp.12054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 01/14/2013] [Indexed: 11/28/2022]
Abstract
Immigration from high tuberculosis (TB) prevalence countries has a substantial impact on the epidemiology of TB in receiving countries with low TB incidence. Cross-border migration offers an ideal opportunity for active case finding that will result in a lower caseload in the host country and a reduced spread of disease to both the indigenous and migrant populations. Screening strategies can start 'offshore', thereby indirectly assisting and empowering public health systems in the source countries, or be performed at ports of entry with or without long-term engagement of 'onshore' facilities and systems to provide either preventive therapy or surveillance for reactivation of latent TB. The chest radiograph seems to be playing a key role in this process, but questions remain regarding when, where and in whom radiographs are best done for optimal yield and cost-effectiveness, and with what other tests they might best be combined to further increase the usefulness of transborder TB control.
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Affiliation(s)
- Zohar Mor
- Ramla Department of Public Health, Ministry of Health, Ramla, Israel
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Long R, Langlois-Klassen D. Increase in multidrug-resistant tuberculosis (MDR-TB) in Alberta among foreign-born persons: implications for tuberculosis management. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2013; 104:e22-e27. [PMID: 23618116 PMCID: PMC6973612 DOI: 10.1007/bf03405649] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 01/09/2013] [Accepted: 12/08/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Globally, the prevalence of anti-tuberculosis drug resistance has been increasing. This study sought to identify trends in multidrug-resistant tuberculosis (MDR-TB) among foreign-born persons in Alberta, a major immigrant-receiving province of Canada. METHODS A retrospective cohort study design was used to investigate the prevalence of MDR-TB in foreign-born culture-positive TB cases between 1982 and 2011. Relevant demographic, clinical and laboratory data were abstracted from the TB Registry, individual medical records and the Provincial Laboratory for Public Health. RESULTS Of the 2,234 foreign-born culture-positive TB cases in Alberta in 1982-2011, 27 (1.2%) had MDR-TB. Overall, MDR was associated with age <65 years (p=0.025), TB relapse/retreatment, and diagnosis and arrival in the last decade (2002-2011). The prevalence of MDR-TB in 2002-2011 was 2.1%, a significant increase from 0.65% in 1982-1991 (p=0.022) and 0.56% in 1992-2001 (p=0.009). Only immigrants from the Philippines and Vietnam showed a significant increase in the prevalence of MDR-TB between the first two decades and the last. Compared to MDR-TB cases reported in the first two decades, those reported in the last decade were more frequently younger than 35 years of age, new active versus relapse/retreatment cases and diagnosed with non-respiratory versus respiratory TB. In 1992-2011, MDR-TB strains had unique DNA fingerprints. CONCLUSIONS Recent trends in the prevalence and clinical characteristics of foreign-born MDR-TB cases have important implications for TB case management in Canada. Early diagnosis of MDR-TB, using genotypic drug susceptibility testing, is suggested in foreign-born TB cases at increased risk of being MDR.
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Affiliation(s)
- Richard Long
- Tuberculosis Program Evaluation and Research Unit, Department of Medicine, University of Alberta, Edmonton, AB.
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Langlois-Klassen D, Kunimoto D, Saunders LD, Chui L, Boffa J, Menzies D, Long R. A population-based cohort study of Mycobacterium tuberculosis Beijing strains: an emerging public health threat in an immigrant-receiving country? PLoS One 2012; 7:e38431. [PMID: 22679504 PMCID: PMC3367965 DOI: 10.1371/journal.pone.0038431] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 05/09/2012] [Indexed: 11/24/2022] Open
Abstract
Introduction Mycobacterium tuberculosis Beijing strains are frequently associated with tuberculosis outbreaks and drug resistance. However, contradictory evidence and limited study generalizability make it difficult to foresee if the emergence of Beijing strains in high-income immigrant-receiving countries poses an increased public health threat. The purpose of this study was to determine if Beijing strains are associated with high risk disease presentations relative to other strains within Canada. Methods This was a retrospective population-based study of culture-confirmed active TB cases in a major immigrant-receiving province of Canada in 1991 through 2007. Of 1,852 eligible cases, 1,826 (99%) were successfully genotyped. Demographic, clinical, and mycobacteriologic surveillance data were combined with molecular diagnostic data. The main outcome measures were site of disease, lung cavitation, sputum smear positivity, bacillary load, and first-line antituberculosis drug resistance. Results A total of 350 (19%) patients had Beijing strains; 298 (85%) of these were born in the Western Pacific. Compared to non-Beijing strains, Beijing strains were significantly more likely to be associated with polyresistance (aOR 1.8; 95% CI 1.0–3.3; p = 0.046) and multidrug-resistance (aOR 3.4; 1.0–11.3; p = 0.049). Conversely, Beijing strains were no more likely than non-Beijing strains to be associated with respiratory disease (aOR 1.3; 1.0–1.8; p = 0.053), high bacillary load (aOR 1.2; 0.6–2.7), lung cavitation (aOR 1.0; 0.7–1.5), immediately life-threatening forms of tuberculosis (aOR 0.8; 0.5–1.6), and monoresistance (aOR 0.9; 0.6–1.3). In subgroup analyses, Beijing strains only had a significant association with multidrug-resistant tuberculosis (aOR 6.1; 1.2–30.4), and an association of borderline significance with polyresistant tuberculosis (aOR 1.8; 1.0–3.5; p = 0.062), among individuals born in the Western Pacific. Conclusion Other than an increased risk of polyresistant or multidrug-resistant tuberculosis, Beijing strains appear to pose no more of a public health threat than non-Beijing strains within a high-income immigrant-receiving country.
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Tuberculosis Trends in the Kingdom of Saudi Arabia, 2005 to 2009. Ann Epidemiol 2012; 22:264-9. [DOI: 10.1016/j.annepidem.2012.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 01/18/2012] [Accepted: 01/30/2012] [Indexed: 11/17/2022]
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Ricks PM, Cain KP, Oeltmann JE, Kammerer JS, Moonan PK. Estimating the burden of tuberculosis among foreign-born persons acquired prior to entering the U.S., 2005-2009. PLoS One 2011; 6:e27405. [PMID: 22140439 PMCID: PMC3226620 DOI: 10.1371/journal.pone.0027405] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 10/16/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The true burden of reactivation of remote latent tuberculosis infection (reactivation TB) among foreign-born persons with tuberculosis (TB) within the United States is not known. Our study objectives were to estimate the proportion of foreign-born persons with TB due reactivation TB and to describe characteristics of foreign-born persons with reactivation TB. METHODS We conducted a cross-sectional study of patients with an M. tuberculosis isolate genotyped by the U.S. National TB Genotyping Service, 2005-2009. TB cases were attributed to reactivation TB if they were not a member of a localized cluster of cases. Localized clusters were determined by a spatial scan statistic of cases with isolates with matching TB genotype results. Crude odds ratios and 95% confidence intervals were used to assess relations between reactivation TB and select factors among foreign-born persons. MAIN RESULTS Among the 36,860 cases with genotyping and surveillance data reported, 22,151 (60%) were foreign-born. Among foreign-born persons with TB, 18,540 (83.7%) were attributed to reactivation TB. Reactivation TB among foreign-born persons was associated with increasing age at arrival, incidence of TB in the country of origin, and decreased time in the U.S. at the time of TB diagnosis. CONCLUSIONS Four out of five TB cases among foreign-born persons can be attributed to reactivation TB and present the largest challenge to TB elimination in the U.S. TB control strategies among foreign-born persons should focus on finding and treating latent tuberculosis infection prior to or shortly after arrival to the United States and on reducing the burden of LTBI through improvements in global TB control.
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Affiliation(s)
- Philip M. Ricks
- Division of Tuberculosis Elimination, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Kevin P. Cain
- Division of Tuberculosis Elimination, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - John E. Oeltmann
- Division of Tuberculosis Elimination, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - J. Steve Kammerer
- Division of Tuberculosis Elimination, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Patrick K. Moonan
- Division of Tuberculosis Elimination, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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