Immigration and Tuberculosis: What are we doing now?

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• Immigration and Tuberculosis
• What are we doing now ?
• What are our neighbours doing ?
• What should we be doing ?
• Dr Dina Fisher MD, MSC, FRCPC
• Calgary Tuberculosis Clinic

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CIC Statistics 2009
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CIC Statistics 2009
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CDC TB Technical Instructions
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CDC TB Technical Instructions
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WHO 2009 Report
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CIC Statistics 2009
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PHAC TB in Canada 2007 Report
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Yang et al IUATLD 2002
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Canadian Tuberculosis Standards 2007
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Goals of Immigration Screening for Tuberculosis

• Prevent new cases of TB in foreign-born
• diagnose new cases of TB in foreign-born
• protect Canadians from TB

Canadian Guidelines 2001
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Who is screened for TB ?

• All Immigrants and refugees,
• Visitors and students planning on staying in
  Canada at least 6 months
• Occupation with public health implications
  applying from a designated country
• Temporary workers from countries with TB
  incidence gt 15/100,000
• IME medical history, physical exam, CXR if gt 11

Canadian Guidelines 2001
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Assessing Process
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Assessing Process
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Concerns Identified

• High level of anxiety regarding immigration
  requirements, ability to communicate in English
  and the availability of assistance from family
  and/or friends arose as factors that could be
  affecting the time taken to follow-up on
  immigration surveillance requirements.
• Of the 72 people who immigrated from outside of
  Canada, 45 clients required translation to allow
  a medical assessment to be completed and 18
  different languages were identified as the
  language most suitable for communication.
• Clients were asked for comments with regards to
  improvements that could be made with the clinic.
  Location, hours of operation, and wait times for
  chest radiograph assessment were identified as
  areas for improvement
• Clients were also asked for comments in regards
  to improvements that could be made with the
  tuberculosis surveillance process. The need for
  additional information to be provided to the
  client for surveillance was identified as a
  concern. Specific requests for the listing of the
  Calgary TBS number information sheet was
  mentioned by several individuals. In addition, a
  more detailed explanation of inactive
  tuberculosis was requested.

Canadian Guidelines 2001
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Five Year Review

• Care of TB inpatients, ordering of medication
• LTBI treatment
• Always check induced sputum before starting
• Always repeat testing before change in medication
• How did someone immigrate with active
  tuberculosis?

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Assessing Process

• CIC/immigration sub-committee of CTC
• Enhanced surveillance, assessing cases of
  foreign-born tuberculosis occurring in the first
  two years after arrival in Canada (27 of
  foreign-born cases) to identify and examine
  factors associated with development of
  tuberculosis. Also examine the number of cases
  identified through medial surveillance and
  efficiency of process
• Ontario, link data-bases to be able to assess
  medical surveillance assessments of all case of
  foreign-born TB

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Cost-effectivenessof our current system
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Cost-effectiveness of our current system

• Swartzman et al article demonstrated that failure
  to provide LTBI Rx to appropriate candidates
  significantly decreased cost-effectiveness
• Macintyre et al (IUATLD 2000) also showed that
  failure to provide LTBI therapy decreased the
  cost-effectiveness of screening in an Australian
  setting

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Decision analysis examining costs associated with
different investment strategies into tuberculosis
control
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What are other countries doing ?

• Chest x-ray screening
• Port-of-entry
• Post-migration
• Alternate screening method
• tuberculin skin test
• interferon assay for tuberculosis infection
• symptom-based referral

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US process for medical surveillance of
tuberculosis in foreign-born

• Recent assessment of process from 1995-2005
  reported in NEJM
• New screening practice in process of being
  implemented (2007) that includes
• tuberculin skin test
• interferon assay for tuberculosis infection

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CDC TB Technical Instructions
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CDC TB Technical Instructions
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CDC TB Technical Instructions
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CDC TB Technical Instructions
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CDC TB Technical Instructions
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CDC TB Technical Instructions
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Decision analysis examining costs associated with
different investment strategies into tuberculosis
control
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