Validation of case-ascertainment algorithms using health administrative data to identify people who inject drugs in Ontario, Canada

OBJECTIVE

Health administrative data can be used to improve the health of people who inject drugs by informing public health surveillance and program planning, monitoring, and evaluation. However, methodological gaps in the use of these data persist due to challenges in accurately identifying injection drug use at the population level. In this study, we validated case-ascertainment algorithms for identifying people who inject drugs using health administrative data in Ontario, Canada.

STUDY DESIGN AND SETTING

Data from cohorts of people with recent (past 12 month) injection drug use, including those participating in community-based research studies or seeking drug treatment were linked to health administrative data in Ontario from 1992-2020. We assessed the validity of algorithms to identify injection drug use over varying lookback periods (i.e., all years of data [1992 onwards] or within the past 1-5 years), including inpatient and outpatient physician billing claims for drug use, emergency department visits or hospitalizations for drug use or injection-related infections, and opioid agonist treatment (OAT).

RESULTS

Algorithms were validated using data from 15,241 people with recent IDU (918 in community cohorts, 14,323 seeking drug treatment). An algorithm consisting of ≥1 physician visit, emergency department visit or hospitalization for drug use, or OAT record could effectively identify IDU history (91.6% sensitivity, 94.2% specificity) and recent IDU (using 3 years lookback: 80.4% sensitivity, 99% specificity) among community cohorts. Algorithms were generally more sensitive among people who inject drugs seeking drug treatment.

CONCLUSION

Validated algorithms using health administrative data performed well in identifying people who inject drugs. Despite high sensitivity and specificity, the positive predictive value of these algorithms will vary depending on the underlying prevalence of injection drug use in the population in which they are applied.

Impact of new direct-acting antiviral therapy on the prevalence and undiagnosed proportion of chronic hepatitis C infection

BACKGROUND

Patients with chronic hepatitis C (CHC) can be cured with the new highly effective interferon-free combination treatments (DAA) that were approved in 2014. However, CHC is a largely silent disease, and many individuals are unaware of their infections until the late stages of the disease. The impact of wider access to effective treatments and improved awareness of the disease on the number of infections and the number of patients who remain undiagnosed is not known in Canada. Such evidence can guide the development of strategies and interventions to reduce the burden of CHC and meet World Health Organization's (WHO) 2030 elimination targets. The purpose of this study is to use a back-calculation framework informed by provincial population-level health administrative data to estimate the prevalence of CHC and the proportion of cases that remain undiagnosed in the three most populated provinces in Canada: British Columbia (BC), Ontario and Quebec.

METHODS

We have conducted a population-based retrospective analysis of health administrative data for the three provinces to generate the annual incidence of newly diagnosed CHC cases, decompensated cirrhosis (DC), hepatocellular carcinoma (HCC) and HCV treatment initiations. For each province, the data were stratified in three birth cohorts: individuals born prior to 1945, individuals born between 1945 and 1965 and individuals born after 1965. We used a back-calculation modelling approach to estimate prevalence and the undiagnosed proportion of CHC. The historical prevalence of CHC was inferred through a calibration process based on a Bayesian Markov chain Monte Carlo (MCMC) algorithm. The algorithm constructs the historical prevalence of CHC for each cohort by comparing the model-generated outcomes of the annual incidence of the CHC-related health events against the data set of observed diagnosed cases generated in the retrospective analysis.

RESULTS

The results show a decreasing trend in both CHC prevalence and undiagnosed proportion in BC, Ontario and Quebec. In 2018, CHC prevalence was estimated to be 1.23% (95% CI: .96%-1.62%), .91% (95% CI: .82%-1.04%) and .57% (95% CI: .51%-.64%) in BC, Ontario and Quebec respectively. The CHC undiagnosed proportion was assessed to be 35.44% (95% CI: 27.07%-45.83%), 34.28% (95% CI: 26.74%-41.62%) and 46.32% (95% CI: 37.85%-52.80%) in BC, Ontario and Quebec, respectively, in 2018. Also, since the introduction of new DAA treatment in 2014, CHC prevalence decreased from 1.39% to 1.23%, .97% to .91% and .65% to .57% in BC, Ontario and Quebec respectively. Similarly, the CHC undiagnosed proportion decreased from 38.78% to 35.44%, 38.70% to 34.28% and 47.54% to 46.32% in BC, Ontario and Quebec, respectively, from 2014 to 2018.

CONCLUSIONS

We estimated that the CHC prevalence and undiagnosed proportion have declined for all three provinces since the new DAA treatment has been approved in 2014. Yet, our findings show that a significant proportion of HCV cases remain undiagnosed across all provinces highlighting the need to increase investment in screening. Our findings provide essential evidence to guide decisions about current and future HCV strategies and help achieve the WHO goal of eliminating hepatitis C in Canada by 2030.

Hepatitis C Attributable Healthcare Costs and Mortality among Immigrants: A Population-Based Matched Cohort Study

Background

Data on the economic burden of chronic hepatitis C (CHC) among immigrants are limited. Our objective was to estimate the CHC-attributable mortality and healthcare costs among immigrants in Ontario, Canada.

Methods

We conducted a population-based matched cohort study among immigrants diagnosed with CHC between May 31, 2003, and December 31, 2018, using linked health administrative data. Immigrants with CHC (exposed) were matched 1 : 1 to immigrants without CHC (unexposed) using a combination of hard (index date, sex, and age) and propensity-score matching. Net costs (2020 Canadian dollars) collected from the healthcare payer perspective were calculated using a phase-of-care approach and used to estimate long-term costs adjusted for survival.

Results

We matched 5,575 exposed individuals with unexposed controls, achieving a balanced match. The mean age was 47 years, and 52% was male. On average, 10.5% of exposed and 3.5% of unexposed individuals died 15 years postindex (relative risk = 2.9; 95% confidence interval (CI): 2.6-3.5). The net 30-day costs per person were $88 (95% CI: 55 to 122) for the prediagnosis, $324 (95% CI: 291 to 356) for the initial phase, $1,016 (95% CI: 900 to 1,132) for the late phase, and $975 (95% CI: -25 to 1,974) for the terminal phase. The mean net healthcare cost adjusted for survival at 15 years was $90,448.

Conclusions

Compared to unexposed immigrants, immigrants infected with CHC have higher mortality rates and greater healthcare costs. These findings will support the planning of HCV elimination efforts among key risk groups in the province.

Impact of Language Barriers on Outcomes and Experience of COVID-19 Patients Hospitalized in Quebec, Canada, During the First Wave of the Pandemic

Language barriers (LB) contribute to coronavirus disease 2019 (COVID-19) health inequities. People with LB were more likely to be SARS-CoV-2 positive despite lower testing and had higher rates of hospitalization. Data on hospital outcomes among immigrants with LB, however, are limited. We aimed to investigate the clinical outcomes of hospitalized COVID-19 cases by LB, immigration status, ethnicity, and access to COVID-19 health information and services prior to admission. Adults with laboratory-confirmed community-acquired COVID-19 hospitalized from March 1 to June 30, 2020, at four tertiary-care hospitals in Montréal, Quebec, Canada were included. Demographics, comorbidities, immigration status, country of birth, ethnicity, presence of LB, and hospital outcomes (ICU admission and death) were obtained through a chart review. Additional socio-economic and access to care questions were obtained through a phone survey. A Fine-Gray competing risk subdistribution hazards model was used to estimate the risk of ICU admission and in-hospital death by immigrant status, region of birth and LB Among 1093 patients, 622 (56.9%) were immigrants and 101 (16.2%) of them had a LB. One third (36%) of immigrants with LB did not have access to an interpreter during hospitalization. Admission to ICU and in-hospital mortality were not significantly different between groups. Prior to admission, one third (14/41) of immigrants with LB had difficulties accessing COVID-19 information in their mother tongue and one third (9/27) of non-white immigrants with a LB had difficulties accessing COVID-19 services. Immigrants with LB were inequitably affected by the first wave of the pandemic in Quebec, Canada. In our study, a large proportion had difficulties accessing information and services related to COVID-19 prior to admission, which may have increased SARS-CoV-2 exposure and hospitalizations. After hospitalization, a large proportion did not have access to interpreters. Providing medical information and care in the language of preference of increasing diverse populations in Canada is important for promoting health equity.

Engagement with the HCV care cascade among high-risk groups: A population-based study

BACKGROUND

HCV elimination requires a thorough understanding of the care cascade. A direct-acting antiviral (DAA)-era description of the care cascade has not been undertaken in Ontario, Canada's most populous jurisdiction. Our primary objective was to describe the current population-level care cascade in the general Ontario population and among key risk groups ─ baby boomers, immigrants, and individuals experiencing residential instability. The secondary objective was to identify predictors of engagement.

METHODS

We conducted a population-based cohort study of Ontario residents undergoing HCV testing between January 1, 1999, and December 31, 2018, and mapped the care cascade [antibody-diagnosed, RNA tested, RNA positive, genotyped, treated, achieved sustained virologic response, reinfected/relapsed] as of December 31, 2018. The cascade was stratified by risk groups. Cause-specific hazard modeling was used to identify demographic, and socioeconomic predictors of engagement with key steps of the cascade.

RESULTS

Among 108,428 Ontario residents living with an HCV antibody diagnosis, 88% received confirmatory RNA testing; of these, 62% tested positive and 94% of positive tests were genotyped. Of those with confirmed viremia, 53% initiated treatment and 76% of treated individuals achieved sustained virologic response, while ~1% experienced reinfection or relapse. Males, older birth cohorts, long-term residents, those with a history of substance use disorder and social marginalization (eg, material deprivation, residential instability), and those initially diagnosed in the pre-DAA era exhibited lower rates of engagement with almost every step of HCV care.

CONCLUSIONS

Despite DAA era improvements, treatment initiation remains a major gap. HCV screening and linkage-to-treatment, particularly for those with a history of substance use disorder and social marginalization, will be needed to equitably close gaps in HCV care in the province.

Strongyloidiasis-related lung involvement: too much of a bad thing

PURPOSE OF REVIEW

Strongyloidiasis is a soil-transmitted helminthiasis, a neglected tropical disease that affects 300-900 million individuals globally. Strongyloides stercoralis is associated with cutaneous, respiratory, and gastrointestinal clinical manifestations. Chronicity is due to an autoinfective cycle, and host immunosuppression can lead to severe and fatal disease. Lung involvement is significant in severe strongyloidiasis, and Strongyloides has a complex association with a number of lung diseases, which will be discussed in this review.

RECENT FINDINGS

The treatment of chronic lung diseases such as asthma and chronic obstructive pulmonary disease with corticosteroids is an important risk factor for Strongyloides hyperinfection syndrome (SHS)/disseminated strongyloidiasis. The use of corticosteroids in the treatment of coronavirus disease 2019 (COVID-19) and potentially COVID-19-induced eosinopenia are risk factors for severe strongyloidiasis. Recent findings have demonstrated a significant immunomodulatory role of Strongyloides in both latent and active pulmonary tuberculosis associated to an impaired immune response and poor outcomes in active pulmonary tuberculosis.

SUMMARY

Strongyloides lung involvement is a common finding in severe infection. Prompt recognition of Strongyloides infection as well as prevention of severe disease by screening or presumptive treatment are important goals in order to improve Strongyloides outcomes in at-risk population.

A population-based study of reported hepatitis C diagnoses from 1998 to 2018 in immigrants and nonimmigrants in Quebec, Canada

Immigrants living in low hepatitis C (HCV) prevalence countries bear a disproportionate HCV burden, but there are limited HCV population-based studies focussed on this population. We estimated rates and trends of reported HCV diagnoses over a 20-year period in Quebec, Canada, to investigate subgroups with the highest rates and changes over time. A population-based cohort of all reported HCV diagnoses in Quebec (1998-2018) linked to health administrative and immigration databases. HCV rates, rate ratios (RR) and trends overall and stratified by immigrant status and country of birth were estimated using Poisson regression. Among 38,348 HCV diagnoses, 14% occurred in immigrants, a median of 7.5 years after arrival. The average annual HCV rate/100,000 decreased for immigrants and nonimmigrants, but the risk (RR) among immigrants increased over the study period [35.7 vs. 34.5 (RR = 1.03) and 18.4 vs. 12.7 (1.45) between 1998-2008 and 2009-2018]. Immigrants from middle-income Europe & Central Asia [55.8 (RR = 4.39)], sub-Saharan Africa [51.7 (RR = 4.06)] and South Asia [32.8 (RR = 2.58)] had the highest rates between 2009 and 2018. Annual HCV rates decreased more slowly among immigrants vs. nonimmigrants (-5.9% vs. -8.9%, p < 0.001), resulting in a 2.5-fold (9%-21%) increase in the proportion of HCV diagnoses among immigrants (1998-2018). The slower decline in HCV rates among immigrants over the study period highlights the need for targeted screening for this population, particularly those from sub-Saharan Africa, Asia and middle-income Europe. These data can inform micro-elimination efforts in Canada and other low-HCV-prevalence countries.

Reducing the burden of TB among migrants to low TB incidence countries

BACKGROUND: International migrants to low TB incidence countries are disproportionately affected by TB compared to the native population: migrants are at increased risk for TB transmission and TB disease due to a variety of personal, environmental and socio-economic determinants experienced during the four phases of migration (pre-departure, transit, arrival and early settlement, return travel).OBJECTIVE: To provide an up-to-date overview of the determinants that drive the TB burden among migrants, as well as effective and feasible interventions to address this for each migration phase.METHODS: We conducted a literature review by searching PubMed and the grey literature for articles and reports on determinants and interventions addressing migrant health and TB.RESULTS: Lowering the risk of TB transmission and TB disease among migrants would be most effective by improving the socio-economic position of migrants pre-, during and after migration, ensuring universal health coverage, and providing tailored and migrant-sensitive care and prevention activities.CONCLUSION: In addition to migrant-sensitive health services and cross-border collaboration between low TB incidence countries, there is a need for international financial and technical support for endemic countries.

Epidemiological and clinical characteristics of patients with monkeypox in the GeoSentinel Network: a cross-sectional study

BACKGROUND

The early epidemiology of the 2022 monkeypox epidemic in non-endemic countries differs substantially from the epidemiology previously reported from endemic countries. We aimed to describe the epidemiological and clinical characteristics among individuals with confirmed cases of monkeypox infection.

METHODS

We descriptively analysed data for patients with confirmed monkeypox who were included in the GeoSentinel global clinical-care-based surveillance system between May 1 and July 1 2022, across 71 clinical sites in 29 countries. Data collected included demographics, travel history including mass gathering attendance, smallpox vaccination history, social history, sexual history, monkeypox exposure history, medical history, clinical presentation, physical examination, testing results, treatment, and outcomes. We did descriptive analyses of epidemiology and subanalyses of patients with and without HIV, patients with CD4 counts of less than 500 cells per mm³ or 500 cells per mm³ and higher, patients with one sexual partner or ten or more sexual partners, and patients with or without a previous smallpox vaccination.

FINDINGS

226 cases were reported at 18 sites in 15 countries. Of 211 men for whom data were available, 208 (99%) were gay, bisexual, or men who have sex with men (MSM) with a median age of 37 years (range 18-68; IQR 32-43). Of 209 patients for whom HIV status was known, 92 (44%) men had HIV infection with a median CD4 count of 713 cells per mm³ (range 36-1659; IQR 500-885). Of 219 patients for whom data were available, 216 (99%) reported sexual or close intimate contact in the 21 days before symptom onset; MSM reported a median of three partners (IQR 1-8). Of 195 patients for whom data were available, 78 (40%) reported close contact with someone who had confirmed monkeypox. Overall, 30 (13%) of 226 patients were admitted to hospital; 16 (53%) of whom had severe illness, defined as hospital admission for clinical care rather than infection control. No deaths were reported. Compared with patients without HIV, patients with HIV were more likely to have diarrhoea (p=0·002), perianal rash or lesions (p=0·03), and a higher rash burden (median rash burden score 9 [IQR 6-21] for patients with HIV vs median rash burden score 6 [IQR 3-14] for patients without HIV; p<0·0001), but no differences were identified in the proportion of men who had severe illness by HIV status.

INTERPRETATION

Clinical manifestations of monkeypox infection differed by HIV status. Recommendations should be expanded to include pre-exposure monkeypox vaccination of groups at high risk of infection who plan to engage in sexual or close intimate contact.

FUNDING

US Centers for Disease Control and Prevention, International Society of Travel Medicine.

Monkeypox in Montréal: Epidemiology, Phylogenomics, and Public Health Response to a Large North American Outbreak

BACKGROUND

Monkeypox, a viral zoonotic disease, is causing a global outbreak outside of endemic areas.

OBJECTIVE

To characterize the outbreak of monkeypox in Montréal, the first large outbreak in North America.

DESIGN

Epidemiologic and laboratory surveillance data and a phylogenomic analysis were used to describe and place the outbreak in a global context.

SETTING

Montréal, Canada.

PATIENTS

Probable or confirmed cases of monkeypox.

MEASUREMENTS

Epidemiologic, clinical, and demographic data were aggregated. Whole-genome sequencing and phylogenetic analysis were performed for a set of outbreak sequences. The public health response and its evolution are described.

RESULTS

Up to 18 October 2022, a total of 402 cases of monkeypox were reported mostly among men who have sex with men (MSM), most of which were suspected to be acquired through sexual contact. All monkeypox genomes nested within the B.1 lineage. Montréal Public Health worked closely with the affected communities to control the outbreak, becoming the first jurisdiction to offer 1 dose of the Modified Vaccinia Ankara-Bavarian Nordic vaccine as preexposure prophylaxis (PrEP) to those at risk in early June 2022. Two peaks of cases were seen in early June and July (43 and 44 cases per week, respectively) followed by a decline toward near resolution of the outbreak in October. Reasons for the biphasic peak are not fully elucidated but may represent the tempo of vaccination and/or several factors related to transmission dynamics and case ascertainment.

LIMITATIONS

Clinical data are self-reported. Limited divergence among sequences limited genomic epidemiologic conclusions.

CONCLUSION

A large outbreak of monkeypox occurred in Montréal, primarily among MSM. Successful control of the outbreak rested on early and sustained engagement with the affected communities and rapid offer of PrEP vaccination to at-risk persons.

PRIMARY FUNDING SOURCE

None.

Improving screening and treatment for infectious diseases in migrant populations

Many migrants living in high-income countries have increased morbidity and mortality due to undetected and untreated infections. Improving and strengthening the care continuum (screening and linkage to care and treatment) and building migrant-friendly health systems that improve access to care will be required to address this health disparity.

Patterns and characteristics of TB among key risk groups in Canada, 1993–2018

BACKGROUND: Canada has a low incidence of TB, although certain groups are disproportionately affected.OBJECTIVE: To describe and compare the epidemiology, trends and characteristics of TB in Quebec, Canada, among all patients reported during 1993–2018.METHODS: Demographics and risk factors were compared for the three groups accounting for most TB diagnoses reported in Quebec (foreign-born, Canadian-born non-Indigenous and Inuit). Average annual incidence and incidence rate ratios (IRRs) were estimated and compared using Poisson regression.RESULTS: Of 6,941 persons with a first episode of TB, 4,077 (59%) were foreign-born, 2,314 (33%) were Canadian-born non-Indigenous and 389 (6%) were Inuit. The average annual incidence for foreign-born, Canadian-born non-Indigenous and Inuit was respectively 17.0, 1.4 and 137.1 per 100,000 population. Compared to Canadian-born non-Indigenous, the IRR for foreign-born and Inuit was respectively 12.3 (95% CI 11.6–12.9) and 98.7 (95% CI 88.6–109.9). There was evidence of community transmission among the Inuit, with more than 80% of patients having a TB contact (2012–2018 data) and 65% (251/389) of diagnoses in those aged <25 years.CONCLUSION: Although TB rates among the Canadian-born non-Indigenous are extremely low, there are persistent and distinct TB epidemics among the foreign-born and Inuit. Tailored approaches to TB prevention and care are needed to address TB among high-risk populations in low TB incidence settings.

Outcomes of hospitalized COVID-19 patients in Canada: impact of ethnicity, migration status and country of birth

BACKGROUND

Ethnoracial groups in high-income countries have a 2-fold higher risk of SARS-CoV-2 infection, associated hospitalizations, and mortality than Whites. Migrants are an ethnoracial subset that may have worse COVID-19 outcomes due to additional barriers accessing care, but there are limited data on in-hospital outcomes. We aimed to disaggregate and compare COVID-19 associated hospital outcomes by ethnicity, immigrant status and region of birth.

METHODS

Adults with community-acquired SARS-CoV-2 infection, hospitalized March 1-June 30, 2020, at four hospitals in Montréal, Quebec, Canada, were included. Age, sex, socioeconomic status, comorbidities, migration status, region of birth, self-identified ethnicity [White, Black, Asian, Latino, Middle East/North African], intensive care unit (ICU) admissions and mortality were collected. Adjusted hazard ratios (aHR) for ICU admission and mortality by immigrant status, ethnicity and region of birth adjusted for age, sex, socioeconomic status and comorbidities were estimated using Fine and Gray competing risk models.

RESULTS

Of 1104 patients (median [IQR] age, 63.0 [51.0-76.0] years; 56% males), 57% were immigrants and 54% were White. Immigrants were slightly younger (62 vs 65 years; p = 0.050), had fewer comorbidities (1.0 vs 1.2; p < 0.001), similar crude ICU admissions rates (33.0% vs 28.2%) and lower mortality (13.3% vs 17.6%; p < 0.001) than Canadian-born. In adjusted models, Blacks (aHR 1.39, 95% confidence interval 1.05-1.83) and Asians (1.64, 1.15-2.34) were at higher risk of ICU admission than Whites, but there was significant heterogeneity within ethnic groups. Asians from Eastern Asia/Pacific (2.15, 1.42-3.24) but not Southern Asia (0.97, 0.49-1.93) and Caribbean Blacks (1.39, 1.02-1.89) but not SSA Blacks (1.37, 0.86-2.18) had a higher risk of ICU admission. Blacks had a higher risk of mortality (aHR 1.56, p = 0.049).

CONCLUSIONS

Data disaggregated by region of birth identified subgroups of immigrants at increased risk of COVID-19 ICU admission, providing more actionable data for health policymakers to address health inequities.

In-hospital outcomes of SARS-CoV-2-infected health care workers in the COVID-19 pandemic first wave, Quebec, Canada

Background

Health care workers (HCW), particularly immigrants and ethnic minorities are at increased risk for SARS-CoV-2 infection. Outcomes during a COVID-19 associated hospitalization are not well described among HCW. We aimed to describe the characteristics of HCW admitted with COVID-19 including immigrant status and ethnicity and the associated risk factors for Intensive Care unit (ICU) admission and death.

Methods

Adults with laboratory-confirmed community-acquired COVID-19 hospitalized from March 1 to June 30, 2020, at four tertiary-care hospitals in Montréal, Canada were included. Demographics, comorbidities, occupation, immigration status, country of birth, ethnicity, workplace exposures, and hospital outcomes (ICU admission and death) were obtained through a chart review and phone survey. A Fine and Gray competing risk proportional hazards model was used to estimate the risk of ICU admission among HCW stratified by immigrant status and region of birth.

Results

Among 1104 included persons, 150 (14%) were HCW, with a phone survey participation rate of 68%. HCWs were younger (50 vs 64 years; p<0.001), more likely to be female (61% vs 41%; p<0.001), migrants (68% vs 55%; p<0.01), non-White (65% vs 41%; p<0.001) and healthier (mean Charlson Comorbidity Index of 0.3 vs 1.2; p<0.001) compared to non-HCW. They were as likely to be admitted to the ICU (28% vs 31%; p = 0.40) but were less likely to die (4% vs. 17%; p<0.001). Immigrant HCW accounted for 68% of all HCW cases and, compared to Canadian HCW, were more likely to be personal support workers (PSW) (54% vs. 33%, p<0.01), to be Black (58% vs 4%) and to work in a Residential Care Facility (RCF) (59% vs 33%; p = 0.05). Most HCW believed that they were exposed at work, 55% did not always have access to personal protective equipment (PPE) and 40% did not receive COVID-19-specific Infection Control (IPAC) training.

Conclusion

Immigrant HCW were particularly exposed to COVID-19 infection in the first wave of the pandemic in Quebec. Despite being young and healthy, one third of all HCW required ICU admission, highlighting the importance of preventing workplace transmission through strong infection prevention and control measures, including high COVID-19 vaccination coverage.

Country-specific approaches to latent tuberculosis screening targeting migrants in EU/EEA* countries: A survey of national experts, September 2019 to February 2020

Background

Migrants in low tuberculosis (TB) incidence countries in the European Union (EU)/European Economic Area (EEA) are an at-risk group for latent tuberculosis infection (LTBI) and are increasingly included in LTBI screening programmes.

Aim

To investigate current approaches and implement LTBI screening in recently arrived migrants in the EU/EEA and Switzerland.

Methods

At least one TB expert working at a national level from the EU/EEA and one TB expert from Switzerland completed an electronic questionnaire. We used descriptive analyses to calculate percentages, and framework analysis to synthesise free-text responses.

Results

Experts from 32 countries were invited to participate (30 countries responded): 15 experts reported an LTBI screening programme targeting migrants in their country; five reported plans to implement one in the near future; and 10 reported having no programme. LTBI screening was predominantly for asylum seekers (n = 12) and refugees (n = 11). Twelve countries use ‘country of origin’ as the main eligibility criteria. The countries took similar approaches to diagnosis and treatment but different approaches to follow-up. Six experts reported that drop-out rates in migrants were higher compared with non-migrant groups. Most of the experts (n = 22) called for a renewed focus on expanding efforts to screen for LTBI in migrants arriving in low-incidence countries.

Conclusion

We found a range of approaches to LTBI screening of migrants in the EU/EEA and Switzerland. Findings suggest a renewed focus is needed to expand and strengthen efforts to meaningfully include migrants in these programmes, in order to meet regional and global elimination targets for TB.

Interventions facilitating access to perinatal care for migrant women without medical insurance: A scoping review protocol

Introduction

Inadequate pregnancy monitoring for pregnant migrant women without medical insurance (PMWMI) exposes them to severe complications during childbirth and consequences for the health of their child (e.g. preterm delivery, low birth weight, etc.). This scoping review aims to identify existing interventions globally to improve access to perinatal care for PMWMI. It will also highlight the strengths, weaknesses as well as the costs of these interventions.

Materials and methods

The methodological framework developed by Arksey & O’Malley (2005) will be used. An electronic search of studies from 2000 to 2021, published in French or English, will be conducted in 12 databases. Publication in Websites of non-governmental organizations working on migrant women without medical insurance issues will be also searched. All articles related to perinatal follow-up and care of PMWMIs, regardless of design, will be included. Editorial comments will be excluded. Outcomes of interest will focus on the impacts, strengths, weaknesses, and cost of interventions. Selection of articles and data extraction will be done by two independent researchers following the Tricco et al. (2018) reporting guide. Finally, a deliberative workshop with experts will allow to identify the most promising and appropriate interventions that can facilitate access to perinatal services by PMWMIs in the Quebec province of Canada.

Strongyloidiasis in immunocompromised migrants to non-endemic countries in the era of COVID-19: what is the role for presumptive ivermectin?

The COVID-19 pandemic has led to widespread use of dexamethasone. Corticosteroid therapy is an important risk factor for Strongyloides hyperinfection. Challenges associated with the performance of Strongyloides tests, and the poor availability of high quality and timely diagnostic testing, makes the use of presumptive ivermectin reasonable in selected situations.

415. A Whole Genome Sequencing Analysis of a Multi-unit Long-term Care Facility COVID-19 Outbreak

Background

The coronavirus disease (COVID-19) pandemic has affected residents in long-term care facilities (LTCF) significantly. Understanding transmission dynamics in this setting is crucial to control the spread of COVID-19 in this population. Using whole genome sequencing (WGS) of SARS-CoV-2, we aimed to delineate the points of introduction and transmission pathways in a large LTCF in Quebec, Canada.

Methods

Between 2020-10-28 and 2021-01-09, COVID-19 cases occurred in 102 residents and 111 HCW at a 387-bed LTCF; cases were distributed in 11 units on 6 floors. As part of outbreak analysis, SARS-CoV-2 isolates underwent WGS using the Oxford Nanopore Minion and the Artic V3 protocol. Lineage attribution and sequence types (ST, within 3 mutations) were assigned based on Pangolin classification and variant analysis. Epidemiologic data including date of positive PCR test, resident room number and HCW work location were collected. Self-reported high-risk exposures were collected by HCW questionnaire via phone interview after consent. Cases and their ST, geo-temporal relations and HCW-reported exposures were examined via network plots and geography-based epidemic curves to infer points of introduction and paths of transmission.

Results

Of 170 isolates available from 100/102 residents and 70/111 HCW, 130 (76.4%) were successfully sequenced. Phylogenetic analysis revealed 7 separate introductions to the LTCF. Grouping of ST by units was observed, with temporal appearance of ST supporting HCW introduction in 7/11 units. Proportion of phone interview completion was low at 35% (26/70). Few HCW recalled specific high-risk exposures. Recalled exposures supported by genetic linkage revealed potential between-unit introductions from HCW-to-HCW transmission at work and outside the workplace (e.g. carpooling). On one unit, a wandering resident was identified as a likely source of transmission to other residents (Figure 1).

Network plot of cases clustered by geographic unit, colour-coded by sequence type. Circles represent residents; addition signs represent healthcare workers. Blue lines represent identified high-risk exposures. Node labels represent floor and unit identifiers; 2 units per floor.

Conclusion

We demonstrate the complex genomic epidemiology of a multi-unit LTCF outbreak, putting into evidence the importance of a multi-faceted approach to limit transmission. This analysis highlights the utility of using WGS to uncover unsuspected transmission routes, such as HCW contact outside work, which can prompt new infection control measures.

Disclosures

All Authors: No reported disclosures

Multidrug-resistant tuberculosis imported into low-incidence countries-a GeoSentinel analysis, 2008-2020

BACKGROUND

Early detection of imported multidrug-resistant tuberculosis (MDR-TB) is crucial, but knowledge gaps remain about migration- and travel-associated MDR-TB epidemiology. The aim was to describe epidemiologic characteristics among international travellers and migrants with MDR-TB.

METHODS

Clinician-determined and microbiologically confirmed MDR-TB diagnoses deemed to be related to travel or migration were extracted from GeoSentinel, a global surveillance network of travel and tropical medicine clinics, from January 2008 through December 2020. MDR-TB was defined as resistance to both isoniazid and rifampicin. Additional resistance to either a fluoroquinolone or a second-line injectable drug was categorized as pre-extensively drug-resistant (pre-XDR) TB, and as extensively drug-resistant (XDR) TB when resistance was detected for both. Sub-analyses were performed based on degree of resistance and country of origin.

RESULTS

Of 201 patients, 136 had MDR-TB (67.7%), 25 had XDR-TB (12.4%), 23 had pre-XDR TB (11.4%) and 17 had unspecified MDR- or XDR-TB (8.5%); 196 (97.5%) were immigrants, of which 92 (45.8%) originated from the former Soviet Union. The median interval from arrival to presentation was 154 days (interquartile range [IQR]: 10-751 days); 34.3% of patients presented within 1 month after immigration, 30.9% between 1 and 12 months and 34.9% after ≥1 year. Pre-XDR- and XDR-TB patients from the former Soviet Union other than Georgia presented earlier than those with MDR-TB (26 days [IQR: 8-522] vs. 369 days [IQR: 84-827]), while patients from Georgia presented very early, irrespective of the level of resistance (8 days [IQR: 2-18] vs. 2 days [IQR: 1-17]).

CONCLUSIONS

MDR-TB is uncommon in traditional travellers. Purposeful medical migration may partly explain differences in time to presentation among different groups. Public health resources are needed to better understand factors contributing to cross-border MDR-TB spread and to develop strategies to optimize care of TB-infected patients in their home countries before migration.

Initiation and completion of treatment for latent tuberculosis infection in migrants globally: a systematic review and meta-analysis

Background

Latent tuberculosis infection (LTBI) is one of the most prevalent infections globally and can lead to the development of active tuberculosis disease. In many low-burden countries, LTBI is concentrated within migrant populations often because of a higher disease burden in the migrant's country of origin. National programmes consequently focus on screening and treating LTBI in migrants to prevent future tuberculosis cases; however, how effective these programmes are is unclear. We aimed to assess LTBI treatment initiation and outcomes among migrants, and the factors that influence both.

Methods

For this systematic review and meta-analysis, we searched Embase, MEDLINE, and Global Health, and manually searched grey literature from Jan 1, 2000, to April 21, 2020. We included primary research articles reporting on LTBI treatment initiation or completion, or both, in migrants and excluded articles in which data were not stratified by migrant status, or in which the data were related to outcomes before 2000. There were no geographical or language restrictions. All included studies were quality appraised using recognised tools depending on their design, and we assessed the heterogeneity of analyses using I². We extracted data on the numbers of migrants initiating and completing treatment. Our primary outcomes were LTBI treatment initiation and completion in migrants (defined as foreign-born). We used random-effects meta-regression to examine the influence of factors related to these outcomes. The study is registered with PROSPERO (CRD42019140338).

Findings

2199 publications were retrieved screened, after which 39 publications from 13 mostly high-income, low-burden countries were included in our analyses, with treatment initiation and completion data reported for 31 598 migrants positive for LTBI, with not all articles reporting the full pathway from initiation to completion. The pooled estimate for the true proportion of migrants testing positive who initiated treatment was 69% (95% CI 51–84; I²= 99·62%; 4409 of 8764). The pooled estimate for the true proportion of migrants on treatment in datasets, who subsequently completed it was 74% (95% CI = 66–81; I²= 99·19%; 15 516 of 25 629). Where data were provided for the entire treatment pathway, the pooled estimate for the true proportion of migrants who initiated and completed treatment after a positive test was only 52% (95% CI 40–64; I²= 98·90%; 3289 of 6652). Meta-regression showed that LTBI programmes are improving, with more recent reported data (2010–20) associated with better rates of treatment initiation and completion, with multiple complex factors affecting treatment outcomes in migrants.

Interpretation

Although our analysis highlights that LTBI treatment initiation and completion in migrants has improved considerably from 2010–20, there is still room for improvement, with drop out reported along the entire treatment pathway. The delivery of these screening and treatment programmes will require further strengthening if the targets to eradicate tuberculosis in low-incidence countries are to be met, with greater focus needed on engaging migrants more effectively in the clinic and understanding the diverse and unique barriers and facilitators to migrants initiating and completing treatment.

Funding

European Society of Clinical Microbiology and Infectious Diseases, the Rosetrees Trust, the National Institute for Health Research, and the Academy of Medical Sciences.

Viral hepatitis C cascade of care: A population-level comparison of immigrant and long-term residents

BACKGROUND & AIMS

Viral hepatitis C represents a major global burden, particularly among immigrant-receiving countries such as Canada, where knowledge of disparities in hepatitis C virus among immigrant groups for micro-elimination efforts is lacking. We quantify the hepatitis C cascades of care among immigrants and long-term residents prior to the introduction of direct-acting antiviral medications.

METHODS

Using laboratory and health administrative records, we described the hepatitis C virus cascades of care in terms of diagnosis, engagement with care, treatment initiation, and clearance in Ontario, Canada (1997-2014). We stratified the cascade by immigrant and long-term resident groups and identify drivers at each stage using multivariable Poisson regression.

RESULTS

We included 940 245 individuals in the study with an estimated hepatitis C prevalence of 167 923 (1.4%) overall, 23 759 (0.7%) among all immigrants, and 6019 (1.1%) among immigrants from hepatitis C endemic countries. Overall there were 104 616 individuals with reactive antibody results, 73 861 tested for viral RNA, 52 388 with viral RNA detected, 50 805 genotyped, 13 159 on treatment and 3919 with evidence of viral clearance. Compared to long-term residents, immigrants showed increased nucleic-acid testing (aRR: 1.09 [95%CI: 1.08, 1.10]), treatment initiation (aRR: 1.46 [95%CI: 1.38, 1.54]), and higher clearance rates (aRR: 1.07 [95%CI: 1.03, 1.11]).

CONCLUSIONS

Hepatitis C virus is more prevalent among long-term residents compared to immigrants overall, however, immigrants from endemic countries are an important subgroup to consider for future screening and linkage to care initiatives. These findings are prior to the introduction of newer medications and provide a population-based benchmark for follow-up studies and evaluation of treatment programs and surveillance activities.

Comparison of hospitalized patients with COVID-19 who did and did not live in residential care facilities in Montréal: a retrospective case series

BACKGROUND

As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs.

METHODS

We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model.

RESULTS

In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39).

INTERPRETATION

During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.

Severe Cystic Echinococcosis-Associated Immune Thrombocytopenic Purpura: A Case Report

We present a case of immune thrombocytopenic purpura (ITP), which leads to the diagnosis of severe cystic echinococcosis. Our patient presented with platelets of 5 × 10⁹/L, and investigations uncovered multiple large echinococcal hepatic cysts, the largest of which measured 19.4 × 15 × 12 cm, and peritoneal implants. While initially refractory to prednisone and immunoglobulins, the ITP responded to dexamethasone. The echinococcosis was treated with albendazole followed by surgical resection of all lesions. Our patient’s disease course has evolved favorable since his initial treatment with an isolated episode of recurrent thrombocytopenia 2 years later, and has remained in remission for the past 2 years. While a causal association between echinococcosis and ITP cannot be confirmed, this case is a reminder of the importance of remaining inquisitive for atypical potential triggers of ITP. We also present a review of the limited literature on the association of parasitic infections and ITP.

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: A systematic review

BACKGROUND

Migrants in high-income countries may be at increased risk of COVID-19 due to their health and social circumstances, yet the extent to which they are affected and their predisposing risk factors are not clearly understood. We did a systematic review to assess clinical outcomes of COVID-19 in migrant populations, indirect health and social impacts, and to determine key risk factors.

METHODS

We did a systematic review following PRISMA guidelines (PROSPERO CRD42020222135). We searched multiple databases to 18/11/2020 for peer-reviewed and grey literature on migrants (foreign-born) and COVID-19 in 82 high-income countries. We used our international networks to source national datasets and grey literature. Data were extracted on primary outcomes (cases, hospitalisations, deaths) and we evaluated secondary outcomes on indirect health and social impacts and risk factors using narrative synthesis.

RESULTS

3016 data sources were screened with 158 from 15 countries included in the analysis (35 data sources for primary outcomes: cases [21], hospitalisations [4]; deaths [15]; 123 for secondary outcomes). We found that migrants are at increased risk of infection and are disproportionately represented among COVID-19 cases. Available datasets suggest a similarly disproportionate representation of migrants in reported COVID-19 deaths, as well as increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected. Migrants experience risk factors including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

CONCLUSIONS

Migrants in high-income countries are at high risk of exposure to, and infection with, COVID-19. These data are of immediate relevance to national public health and policy responses to the pandemic. Robust data on testing uptake and clinical outcomes in migrants, and barriers and facilitators to COVID-19 vaccination, are urgently needed, alongside strengthening engagement with diverse migrant groups.

Risk of latent and active tuberculosis infection in travellers: a systematic review and meta-analysis

INTRODUCTION

Achieving tuberculosis (TB) elimination in low TB incidence countries requires identification and treatment of individuals at risk for latent TB infection (LTBI). Persons travelling to high TB incidence countries are potentially at risk for TB exposure. This systematic review and meta-analysis estimates incident LTBI and active TB among individuals travelling from low to higher TB incidence countries.

METHODS

Five electronic databases were searched from inception to 18 February 2020. We identified incident LTBI and active TB among individuals travelling from low (<10 cases/100 000 population) to intermediate (10-100/100 000) or high (>100/100 000) TB incidence countries. We conducted a meta-analysis and meta-regression using a random effects model of log-transformed proportions (cumulative incidence). Subgroup analyses investigated the impact of travel duration, travel purpose and TB incidence in the destination country.

RESULTS

Our search identified 799 studies, 120 underwent full-text review, and 10 studies were included. These studies included 1 154 673 travellers observed between 1994 and 2013, comprising 443 health care workers (HCW), 1 068 636 military personnel and 85 594 general travellers/volunteers. We did not identify any studies that estimated incidence of LTBI or active TB among people travelling to visit friends and relatives (VFRs). The overall cumulative incidence of LTBI was 2.3%, with considerable heterogeneity. Among individuals travelling for a mean/median of up to 6 months, HCWs had the highest cumulative incidence of LTBI (4.3%), whereas the risk was lower for military (2.5%) and general travellers/volunteers (1.6%). Meta-regression did not identify a difference in incident LTBI based on travel duration and TB incidence in the destination country. Five studies reported cases of active TB, with an overall pooled estimate of 120.7 cases per 100 000 travellers.

CONCLUSIONS

We found that travelling HCWs were at highest risk of developing LTBI. Individual risk activities and travel purpose were most associated with risk of TB infection acquired during travel.

COVID-19: Exposing and addressing health disparities among ethnic minorities and migrants

COVID-19 disproportionately affects vulnerable and marginalized populations such as ethnic minorities and migrant groups. In this perspective we review the complex interaction of the many factors driving these inequities and suggest several possible solutions to mitigate the negative impact of COVID-19 on these populations.

Epidemiology of varicella among immigrants and non-immigrants in Quebec, Canada, before and after the introduction of childhood varicella vaccination: a retrospective cohort study

BACKGROUND

Many immigrants are susceptible to varicella on arrival to Canada because of different transmission dynamics in their countries of origin and scarcity of vaccination. Universal childhood vaccination programmes decrease varicella incidence rates through herd immunity, but the accumulating number of susceptible adult immigrants could remain at risk for severe varicella. Our aim was to describe the epidemiology of varicella among immigrants and non-immigrants before and after childhood varicella vaccination.

METHODS

We did a population-based, retrospective cohort study of all varicella cases in Quebec, Canada, diagnosed between 1996 and 2014 in administrative health databases linked to immigration data. Cases of varicella met diagnostic codes in the International Classification of Diseases, Ninth and Tenth Revision Canadian modifications. Cases with a co-occurring zoster diagnostic code and immigrants from Australia, New Zealand, the USA, and western European countries were excluded. Vaccination periods included pre-vaccination (1996-98), private vaccination (1999-2005), and public vaccination (2006-14). Incidence rate and comparative rate ratios were estimated using census data.

FINDINGS

A total of 231 339 varicella cases diagnosed between Jan 1, 1996, and Dec 31, 2014, were linked to 1 115 696 immigrants who arrived between Jan 1, 1980, and Dec 31, 2014. 1444 herpes zoster cases and 1276 immigrants from Australia, western Europe, New Zealand, and the USA were excluded. Among 228 619 varicella cases, 13 315 (5·8%) occurred in immigrants. In pre-vaccination versus public vaccination periods, varicella incidence declined in immigrants by 87% (95% CI 86·6-87·9; 324·3 cases per 100 000 person-years to 40·9 cases per 100 000 person-years) and in non-immigrants by 93% (92·4-92·7; 484 cases per 100 000 person-years to 36 cases per 100 000 person-years). Mean age at diagnosis increased in both groups (15·1 vs 19·4 years in immigrants and 8·4 vs 12·0 years in non-immigrants). In the public vaccination period, immigrants younger than 50 years had higher varicella rates than non-immigrants, with relative risk ranging from 1·53 (95% CI 1·37-1·72) to 4·64 (3·90-5·53) with the highest risk in adolescents and young adults, and people from Latin America and the Caribbean (age-specific incidence rate ratio [aIRR]_I-NI pre-vaccination 2·19 and post-vaccination aIRR_I-NI6·07) and south Asia (aIRR_I-NI pre-vaccination 3·41 and aIRR_I-NI post-vaccination 4·46) and in childbearing women (15-40 years; IRR_I-NI 2·48).

INTERPRETATION

Immigrant adolescents, young adults, and women of childbearing age had higher age-standardised rates of varicella than non-immigrants, with increasing disparities following vaccine introduction. Immigrants younger than 50 years of age would benefit from targeted vaccination upon arrival to host countries.

FUNDING

The Canadian Institutes of Health Research and The Department of Medicine, Jewish General Hospital, Montreal, QC, Canada.

The Global Prevalence of Strongyloides stercoralis Infection

Strongyloidiasis is a common neglected tropical disease in tropical and sub-tropical climatic zones. At the worldwide level, there is high uncertainty about the strongyloidiasis burden. This uncertainty represents an important knowledge gap since it affects the planning of interventions to reduce the burden of strongyloidiasis in endemic countries. This study aimed to estimate the global strongyloidiasis prevalence. A literature review was performed to obtain prevalence data from endemic countries at a worldwide level from 1990 to 2016. For each study, the true population prevalence was calculated by accounting for the specificity and the sensitivity of testing and age of tested individuals. Prediction of strongyloidiasis prevalence for each country was performed using a spatiotemporal statistical modeling approach. The country prevalence obtained from the model was used to estimate the number of infected people per country. We estimate the global prevalence of strongyloidiasis in 2017 to be 8.1% (95% CI: 4.2-12.4%), corresponding to 613.9 (95% CI: 313.1-910.1) million people infected. The South-East Asia, African, and Western Pacific Regions accounted for 76.1% of the global infections. Our results could be used to identify those countries in which strongyloidiasis prevalence is highest and where mass drug administration (MDA) should be deployed for its prevention and control.

Prevalence of strongyloidiasis and schistosomiasis among migrants: a systematic review and meta-analysis

BACKGROUND

Global migration from regions where strongyloidiasis and schistosomiasis are endemic to non-endemic countries has increased the potential individual and public health effect of these parasitic diseases. We aimed to estimate the prevalence of these infections among migrants to establish which groups are at highest risk and who could benefit from screening.

METHODS

We did a systematic review and meta-analysis of strongyloidiasis and schistosomiasis prevalence among migrants born in endemic countries. Original studies that included data for the prevalence of Strongyloides or Schistosoma antibodies in serum or the prevalence of larvae or eggs in stool or urine samples among migrants originating from countries endemic for these parasites and arriving or living in host countries with low endemicity-specifically the USA, Canada, Australia, New Zealand, Israel, and 23 western European countries-were eligible for inclusion. Pooled estimates of the prevalence of strongyloidiasis and schistosomiasis by stool or urine microscopy for larvae or eggs or serum antibodies were calculated with a random-effects model. Heterogeneity was explored by stratification by age, region of origin, migrant class, period of study, and type of serological antigen used.

FINDINGS

88 studies were included. Pooled strongyloidiasis seroprevalence was 12·2% (95% CI 9·0-15·9%; I² 96%) and stool-based prevalence was 1·8% (1·2-2·6%; 98%). Migrants from east Asia and the Pacific (17·3% [95% CI 4·1-37·0]), sub-Saharan Africa (14·6% [7·1-24·2]), and Latin America and the Caribbean (11·4% [7·8-15·7]) had the highest seroprevalence. Pooled schistosomiasis seroprevalence was 18·4% (95% CI 13·1-24·5; I² 97%) and stool-based prevalence was 0·9% (0·2-1·9; 99%). Sub-Saharan African migrants had the highest seroprevalence (24·1·% [95% CI 16·4-32·7]).

INTERPRETATION

Strongyloidiasis affects migrants from all global regions, whereas schistosomiasis is focused in specific regions and most common among sub-Saharan African migrants. Serological prevalence estimates were several times higher than stool estimates for both parasites. These data can be used to inform screening decisions for migrants and support the use of serological screening, which is more sensitive and easier than stool testing.

FUNDING

None.

Strengthening screening for infectious diseases and vaccination among migrants in Europe: What is needed to close the implementation gaps?

Migration to the European Union (EU)/European Economic Area (EEA) affects the epidemiology of infectious diseases, including tuberculosis (TB), HIV, hepatitis B/C, and parasitic diseases. Some sub-populations of migrants are also considered to be an under-immunised group and thus at risk of vaccine-preventable diseases. Providing high-risk migrants access to timely and efficacious screening and vaccination, and understanding how best to implement more integrated screening and vaccination programmes into European health systems ensuring linkage to care and treatment, is key to improving the health of migrants and their communities, alongside meeting national and regional targets for infection surveillance, control, and elimination. The European Centre for Disease Prevention and Control (ECDC) has responded to calls to action to improve migrant health and strengthen universal health coverage by developing evidence-based guidance for policy makers, public health experts, and front-line healthcare professionals on how to approach screening and vaccination in newly arrived migrants within the EU/EEA. In this Commentary, we provide a perspective towards developing efficacious screening and vaccination of newly arrived migrants, with a focus on defining implementation challenges and evidence gaps in high-migrant receiving EU/EEA countries. There is a need now to leverage the increasing momentum around migrant health to both strengthen the evidence-base and to advocate for universal access to health care for all migrants in the EU/EEA, including undocumented migrants. This should include voluntary, confidential, and non-stigmatising screening and vaccination that should be free of charge and facilitate linkage to appropriate care and treatment.

2301. Increased Risk of Varicella-Associated Hospitalizations Among Adult Immigrants From Temperate and Tropical Countries After the Introduction of a Childhood Varicella Vaccination Program in Quebec, Canada

Background

Varicella zoster virus (VZV) hospitalizations are an uncommon, severe and costly consequence of VZV. Childhood VZV vaccination leads to decreased VZV rates across all age groups through herd immunity but increases the age of VZV acquisition and the potential risk of severe VZV in non-immune adults. A large proportion (~15%) of young adult immigrants from tropical regions are susceptible to VZV due to different transmission dynamics in their countries of origin and lack of vaccination. We aimed to describe the impact of the childhood VZV program introduced in 2006 in Quebec on VZV hospitalizations in immigrants and nonimmigrants.

Methods

A population-based cohort of all medically-attended VZV cases in Quebec, Canada (1996–2014) were identified in administrative health databases and linked to immigration data. VZV-attributable hospitalizations included those with primary or secondary ICD-9 or ICD-10 codes for VZV. Overall age-standardized and age-specific rates of hospitalizations were calculated during pre- (1996–98), private (1999–2005) and public vaccination (2006–14) periods and by immigrant status and pregnancy. Relative risk (RR_I-NI) and 95% CI for immigrants vs. nonimmigrants were estimated.

Results

5873 hospitalizations occurred among 230,052 VZV cases. Hospitalization rates decreased dramatically in the pre to public vaccination period (6.6 to 1.3/100,000 population); however, the proportion of hospitalized varicella cases increased from 1.7% to 3.9% (P < 0.01). Immigrants only accounted for 3.6% of hospitalizations (N = 213) however, the proportion of all hospitalizations among immigrants increased in the pre- vs. public-vaccination periods in those aged 10–19 years (2.9% to 13.7%) and 20–39 years (8.8% to 22.7%). The RR was higher in these age groups in the public vaccination period [RR_I-NI 1.96 and RR_I-NI 1.67] (Table 1). Adults (>20 years) accounted for 52% (CI: 45–59%) and pregnant women 18% (13–25%) of all hospitalizations among immigrants compared with only 14% (13–15%) and 1.6% (1.3–2.0%) in nonimmigrants, respectively.

Conclusion

Young adult and pregnant immigrants bore a disproportionate burden of VZV hospitalizations after the introduction of childhood VZV vaccination. Susceptible immigrant adults would benefit from targeted VZV vaccination.

Disclosures

All authors: No reported disclosures.

The effectiveness and cost-effectiveness of screening for active tuberculosis among migrants in the EU/EEA: a systematic review

: The foreign-born population make up an increasing and large proportion of tuberculosis (TB) cases in European Union/European Economic Area (EU/EEA) low-incidence countries and challenge TB elimination efforts. Methods: We conducted a systematic review to determine effectiveness (yield and performance of chest radiography (CXR) to detect active TB, treatment outcomes and acceptance of screening) and a second systematic review on cost-effectiveness of screening for active TB among migrants living in the EU/EEA. Results: We identified six systematic reviews, one report and three individual studies that addressed our aims. CXR was highly sensitive (98%) but only moderately specific (75%). The yield of detecting active TB with CXR screening among migrants was 350 per 100,000 population overall but ranged widely by host country (110–2,340), migrant type (170–1,192), TB incidence in source country (19–336) and screening setting (220–1,720). The CXR yield was lower (19.6 vs 336/100,000) and the numbers needed to screen were higher (5,076 vs 298) among migrants from source countries with lower TB incidence (≤ 50 compared with ≥ 350/100,000). Cost-effectiveness was highest among migrants originating from high (> 120/100,000) TB incidence countries. The foreign-born had similar or better TB treatment outcomes than those born in the EU/EEA. Acceptance of CXR screening was high (85%) among migrants. Discussion: Screening programmes for active TB are most efficient when targeting migrants from higher TB incidence countries. The limited number of studies identified and the heterogeneous evidence highlight the need for further data to inform screening programmes for migrants in the EU/EEA.

The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review

Migrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

Migration Medicine

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.

Infectious diseases at different stages of migration: an expert review

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.

Spectrum of illness in migrants to Canada: sentinel surveillance through CanTravNet

BACKGROUND

Due to ongoing political instability and conflict in many parts of the world, migrants are increasingly seeking asylum and refuge in Canada.

METHODS

We examined demographic and travel correlates of illnesses among migrants to Canada to establish a detailed epidemiologic framework of this population for Canadian practitioners. Data on ill-returned Canadian travellers presenting to a CanTravNet site between 1 January 2015 and 31 December 2015 were analyzed.

RESULTS

During the study period, 2415 ill travellers and migrants presented to a CanTravNet site, and of those, 519 (21.5%) travelled for the purpose of migration. Sub-Saharan Africa (n = 160, 30.8%), southeast Asia (n = 84, 16.2%) and south central Asia (n = 75, 14.5%) were the most common source regions for migrants, while the top specific source countries, of 98 represented, were the Philippines (n = 45, 8.7%), China (n = 36, 6.9%) and Vietnam (n = 31, 6.0%). Compared with non-migrant travellers, migrants were more likely to have a pre-existing immunocompromising medical condition, such as HIV or diabetes mellitus (P < 0.0001), and to require inpatient management of their illness (P < 0.0001). Diagnoses such as tuberculosis (n = 263, 50.7%), hepatitis B and C (n = 78, 15%) and HIV (n = 11, 2.1%) were over-represented in the migrant population compared with non-migrant travellers (P < 0.0001). Most cases of tuberculosis in the migrant population (n = 263) were latent (82% [n = 216]); only 18% (n = 47) were active.

CONCLUSIONS

Compared with non-migrant travellers, migrants were more likely to present with a communicable infectious disease, such as tuberculosis, potentially complicated by an underlying immunosuppressing condition such as HIV. These differences highlight the divergent healthcare needs in the migrant population, and underscore the importance of surveillance programmes to understand their burden of illness. Intake programming should be adequately resourced to accommodate the medical needs of this vulnerable population of new Canadians.

Effectiveness of Screening and Treatment Approaches for Schistosomiasis and Strongyloidiasis in Newly-Arrived Migrants from Endemic Countries in the EU/EEA: A Systematic Review

We aimed to evaluate the evidence on screening and treatment for two parasitic infections-schistosomiasis and strongyloidiasis-among migrants from endemic countries arriving in the European Union and European Economic Area (EU/EEA). We conducted a systematic search of multiple databases to identify systematic reviews and meta-analyses published between 1 January 1993 and 30 May 2016 presenting evidence on diagnostic and treatment efficacy and cost-effectiveness. We conducted additional systematic search for individual studies published between 2010 and 2017. We assessed the methodological quality of reviews and studies using the AMSTAR, Newcastle⁻Ottawa Scale and QUADAS-II tools. Study synthesis and assessment of the certainty of the evidence was performed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. We included 28 systematic reviews and individual studies in this review. The GRADE certainty of evidence was low for the effectiveness of screening techniques and moderate to high for treatment efficacy. Antibody-detecting serological tests are the most effective screening tests for detection of both schistosomiasis and strongyloidiasis in low-endemicity settings, because they have higher sensitivity than conventional parasitological methods. Short courses of praziquantel and ivermectin were safe and highly effective and cost-effective in treating schistosomiasis and strongyloidiasis, respectively. Economic modelling suggests presumptive single-dose treatment of strongyloidiasis with ivermectin for all migrants is likely cost-effective, but feasibility of this strategy has yet to be demonstrated in clinical studies. The evidence supports screening and treatment for schistosomiasis and strongyloidiasis in migrants from endemic countries, to reduce morbidity and mortality.

Accessibility and Acceptability of Infectious Disease Interventions Among Migrants in the EU/EEA: A CERQual Systematic Review

In the EU/EEA, subgroups of international migrants have an increased prevalence of certain infectious diseases. The objective of this study was to examine migrants' acceptability, value placed on outcomes, and accessibility of infectious disease interventions. We conducted a systematic review of qualitative reviews adhering to the PRISMA reporting guidelines. We searched MEDLINE, EMBASE, CINAHL, DARE, and CDSR, and assessed review quality using AMSTAR. We conducted a framework analysis based on the Health Beliefs Model, which was used to organize our preliminary findings with respect to the beliefs that underlie preventive health behavior, including knowledge of risk factors, perceived susceptibility, severity and barriers, and cues to action. We assessed confidence in findings using an adapted GRADE CERQual tool. We included 11 qualitative systematic reviews from 2111 articles. In these studies, migrants report several facilitators to public health interventions. Acceptability depended on migrants' relationship with healthcare practitioners, knowledge of the disease, and degree of disease-related stigma. Facilitators to public health interventions relevant for migrant populations may provide clues for implementation. Trust, cultural sensitivity, and communication skills also have implications for linkage to care and public health practitioner education. Recommendations from practitioners continue to play a key role in the acceptance of infectious disease interventions.

The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review

Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.

Addressing hepatitis C in the foreign-born population: A key to hepatitis C virus elimination in Canada

Hepatitis C virus (HCV) is the leading cause of death from infectious disease in Canada. Immigrants are an important group who are at increased risk for HCV; they account for a disproportionate number of all HCV cases in Canada (~30%) and have approximately a twofold higher prevalence of HCV (~2%) than those born in Canada. HCV-infected immigrants are more likely to develop cirrhosis and hepatocellular carcinoma and are more likely to have a liver-related death during a hospitalization than HCV-infected non-immigrants. Several factors, including lack of routine HCV screening programs in Canada for immigrants before or after arrival, lack of awareness on the part of health practitioners that immigrants are at increased risk of HCV and could benefit from screening, and several patient- and health system-level barriers that affect access to health care and treatment likely contribute to delayed diagnosis and treatment uptake. HCV screening and engagement in care among immigrants can be improved through reminders in electronic medical records that prompt practitioners to screen for HCV during clinical visits and implementation of decentralized community-based screening strategies that address cultural and language barriers. In conclusion, early screening and linkage to care for immigrants from countries with an intermediate or high prevalence of HCV would not only improve the health of this population but will be key to achieving HCV elimination in Canada. This article describes the unique barriers encountered by the foreign-born population in accessing HCV care and approaches to overcoming these barriers.

Prevention and assessment of infectious diseases among children and adult migrants arriving to the European Union/European Economic Association: a protocol for a suite of systematic reviews for public health and health systems

INTRODUCTION

The European Centre for Disease Prevention and Control is developing evidence-based guidance for voluntary screening, treatment and vaccine prevention of infectious diseases for newly arriving migrants to the European Union/European Economic Area. The objective of this systematic review protocol is to guide the identification, appraisal and synthesis of the best available evidence on prevention and assessment of the following priority infectious diseases: tuberculosis, HIV, hepatitis B, hepatitis C, measles, mumps, rubella, diphtheria, tetanus, pertussis, poliomyelitis (polio), Haemophilus influenza disease, strongyloidiasis and schistosomiasis.

METHODS AND ANALYSIS

The search strategy will identify evidence from existing systematic reviews and then update the effectiveness and cost-effectiveness evidence using prospective trials, economic evaluations and/or recently published systematic reviews. Interdisciplinary teams have designed logic models to help define study inclusion and exclusion criteria, guiding the search strategy and identifying relevant outcomes. We will assess the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

ETHICS AND DISSEMINATION

There are no ethical or safety issues. We anticipate disseminating the findings through open-access publications, conference abstracts and presentations. We plan to publish technical syntheses as GRADEpro evidence summaries and the systematic reviews as part of a special edition open-access publication on refugee health. We are following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols reporting guideline. This protocol is registered in PROSPERO: CRD42016045798.

Encouraging understanding or increasing prejudices: A cross-sectional survey of institutional influence on health personnel attitudes about refugee claimants' access to health care

Background

This paper investigates the personal, professional and institutional predictors of health institution personnel's attitudes regarding access to healthcare for refugee claimants in Canada.

Methods

In Montreal, the staff of five hospitals and two primary care centres (n = 1772) completed an online questionnaire documenting demographics, occupation, exposure to refugee claimant patients, and attitudes regarding healthcare access for refugee claimants. We used structural equations modeling to investigate the associations between professional and institutional factors with latent functions of positive and negative attitudes toward refugee's access to healthcare.

Results

Younger participants, social workers, participants from primary care centres, and from 1st migrant generation had the lowest scores of negative attitudes. Respondents who experienced contact with refugees had lower scores of negative attitudes (B = -14% standard deviation [SD]; 95% CI: -24, -4%). However, direct contact with refugees increased scores of negative attitudes in the institution with the most negative attitudes by 36% SD (95% CI: 1, 71%).

Interpretation

Findings suggest that institutions influence individuals’ attitudes about refugee claimants’ access to health care and that, in an institutional context of negative attitudes, contact with refugees may further confirm negative perceptions about this vulnerable group.

A population-based study of chronic hepatitis C in immigrants and non-immigrants in Quebec, Canada

BACKGROUND

Immigrants originating from intermediate and high HCV prevalence countries may be at increased risk of exposure to hepatitis C infection (HCV) in their countries of origin, however they are not routinely screened after arrival in most low HCV prevalence host countries. We aimed to describe the epidemiology of HCV in immigrants compared to the Canadian born population.

METHODS

Using the reportable infectious disease database linked to the landed immigration database and several provincial administrative databases, we assembled a cohort of all reported cases of HCV in Quebec, Canada (1998-2008). Underlying co-morbidities were identified in the health services databases. Stratum specific rates of reported cases/100,000, rate ratios (RRs) and trends over the study period were estimated.

RESULTS

A total of 20,862 patients with HCV were identified, among whom 1922 (9.2%) were immigrants. Immigrants were older and diagnosed a mean of 9.8 ± 7 years after arrival. The Canadian born population was more likely to have behavior co-morbidities (problematic alcohol or drug use) and HIV co-infection. Immigrants from Sub-Saharan Africa, Asia and Eastern Europe had the highest HCV reported rates with RRs compared to non-immigrants ranging from 1.5 to 1.7. The age and sex adjusted rates decreased by 4.9% per year in non-immigrants but remained unchanged in immigrants. The proportion of HCV occurring in immigrants doubled over the study period from 5 to 11%.

CONCLUSIONS

Immigrants from intermediate and high HCV prevalence countries are at increased risk for HCV and had a mean delay in diagnosis of almost 10 years after arrival suggesting that they may benefit from targeted HCV screening and earlier linkage to care.

Hospitalizations in Immigrants and Nonimmigrants Diagnosed With Chronic Hepatitis C Infection in Québec

BACKGROUND

 Rates of hospitalization due to chronic hepatitis C virus (HCV) are increasing in Canada and the United States. A large proportion of immigrants originate from countries with intermediate to high HCV prevalence but are not screened for HCV post-arrival and may therefore have increased risks of liver-related complications and hospitalization.

METHODS

 We conducted a retrospective cohort study of reported HCV cases in Québec, Canada, from 1998 to 2007 that were linked to administrative health databases. Outcomes included all-cause and liver-related hospitalizations and in-hospital days in immigrants compared with nonimmigrants adjusted for age, sex, and comorbidities.

RESULTS

 We identified 20 139 HCV cases; 9% (N = 1821) were immigrants. At diagnosis, immigrants were older (47.6 vs 43.2 years) and more likely to have hepatocellular carcinoma (HCC; 0.93% vs 0.31%), while nonimmigrants were 2- to 10-fold more likely to have substance use-related comorbidities. Mean time to HCV diagnosis after arrival was 9.8 years. Nonimmigrants had higher rates of all-cause hospitalization (adjusted rate ratio [95% confidence interval], 1.42 [1.35-1.47]), driven by mental illness and injury and/or poisoning. Unadjusted liver-related hospitalization rates were similar between cohorts. After adjustment, immigrant status was associated with lower rates of liver-related hospitalization (0.68 [.53-.88]).

CONCLUSIONS

 Higher burden of all-cause hospitalization in nonimmigrants likely reflects more prevalent behavioral comorbidities. Similar liver-related hospitalization rates appear to be driven by older age in immigrants who were more likely to have HCC at diagnosis possibly reflecting delayed HCV diagnosis. These findings suggest that earlier screening and treatment in immigrants could play an important role in preventing HCV complications in this population.