Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada

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.

Prevalence of antithrombin deficiency in healthy blood donors: a cross-sectional study

The prevalence of antithrombin (AT) deficiency in the general population has been variously estimated to be between 0.05 and 5 per 1,000 in the population; 2,491 blood donors were screened in an attempt to clarify this issue using plasma samples taken from the blood donor units. From this initial population, 122 individuals were identified as having plasma AT levels lower than 2 standard deviations below the normal mean. Twenty-two samples had evidence that thrombin had been generated during blood collection and the remaining cohort of 100 blood donors were asked to return but only 59 complied. The data obtained from these 59 were compared with that from 51 age- and sex-matched control blood donors. Both groups of subjects were assessed for previous evidence, or family history, of thrombotic events, as well as exposure to risk factors associated with the development of deep vein thrombosis (DVT). All had venous blood samples taken from which the supernatant plasma was immediately removed and quick frozen for later assaying. Only 6 of the 59 subjects with initial low AT levels had repeat AT-Xa levels below 0.80 units/ml (normal range 0.94 +/- 0.14). Upon repeating the AT-Xa determinations on new samples from these six individuals, only three were found again to be low. One was found to have a type 3 AT deficiency (an Arg47Cys substitution). The other two with a low AT level had mean functional AT-Xa levels of 0.61 and 0.71 units/ml, respectively, with correspondingly low AT:Ag levels consistent with a type 1 AT deficiency. Two of these three subjects has been in high risk situations without evidence of having developed DVT and none had evidence of venous reflux on Doppler venography. In addition, none had personal or family histories of previous thrombotic events. These present data indicate that the prevalence of AT deficiency in our blood donor population is 2 per 1,000 (95% confidence intervals: 0.7-6/1,000).

Influence of oral antibiotics on resistance and enterotoxigenicity of Escherichia coli

Three groups of five piglets were formed and 1390 Escherichia coli isolates were obtained during the 45-day period of observation. One of the groups received feed without antibiotic whereas the second received feed containing 100 ppm neomycin and the third feed with 100 ppm neomycin plus 100 ppm tetracycline. Rectal swabbings for bacterial isolation were repeated ten times, twice during an adaptation period and eight times during the treatment period. Resistance among the isolates to tetracycline, streptomycin and triple sulfas remained high throughout this experiment whereas resistance to neomycin, chloramphenicol and ampicillin were found to increase significantly under the influence of antibiotic supplemented feed. This increase of antibiotic resistance was associated with an increase of the percentage of isolates harboring an R. factor. When comparing the ability of strains harboring an R factor to receive the plasmid Ent from the E. coli K12 (P155) with isolates not harboring such a plasmid, no significant difference was observed in their ability to receive the Ent plasmid.

A serological survey for Brucella canis in dogs in the Province of Quebec

A serological survey for canine brucellosis has been conducted on 341 dogs from different regions of the province of Quebec. A significant titer was found in six sera (1.6%) with the 2-mercaptoethanol tube agglutination test. Only two dogs presented titers >/= 1:200 which is considered as indicative of active infection.