A Step toward Tuberculosis Elimination in a Low-Incidence Country: Successful Diagnosis and Treatment of Latent Tuberculosis Infection in a Refugee Clinic

Abstract

Objectives. Approximately 65 percent of tuberculosis (TB) cases in Canada each year occur from reactivation in foreign-born individuals. Refugees are at high risk after immigration. Routine screening of this population for latent TB infection (LTBI) is generally considered infeasible. We evaluated the outcome of LTBI screening and treatment amongst refugees. Methods. Government-sponsored refugees in Edmonton are seen at the New Canadians' Clinic and screened for TB and LTBI. We reviewed records of patients between 2009 and 2011. Completeness of initial assessment, diagnosis of latent infection, and completion of LTBI treatment were evaluated. Treatment for LTBI was offered when patients had a positive Tuberculin Skin Test (TST) and risk factors for progression to TB. An Interferon-Gamma Release Assay (IGRA) was performed on all other TST positives; treatment is only offered if it was positive. Results. 949 refugees were evaluated. 746 TSTs were read, with 265 positive individuals. IGRA testing was performed in 203 TST positive individuals without other TB risk factors; 110 were positive. LTBI treatment was offered to 147 of 151 eligible patients, 141 accepted, and 103 completed a treatment course. Conclusion. We observed high proportions of patient retention, completion of investigations, and treatment. This care model promises to be a component of effective TB prevention in this high-risk population.

Barriers to treatment adherence for individuals with latent tuberculosis infection: A systematic search and narrative synthesis of the literature

“…Assuming a remote LTBI activation rate of 0.15% per year, this could imply a potential TB disease incidence rate from these latent pools of 16.5 (95% uncertainty interval, 14.9‐19.2) per 100 000 per year in 2035, which is above the 10 per 100 000 per year target in the End TB Strategy . Thus, there is a need to prioritize the management of LTBI to meet the goal of TB elimination . This is reflected in the recent statement by the European Centre for Disease Control, which has strongly emphasized the need for greater political commitment to facilitate LTBI control …”

Demographic predictors of active tuberculosis in people migrating to British Columbia, Canada: a retrospective cohort study

“…28 In Canada, refugees who are assisted by the government are placed in a reception house until permanent housing can be located; during this period, refugees receive a medical evaluation, which could provide an opportunity for LTBI screening. 29 High rates of LTBI screening and treatment completion have also been reported in a Canadian refugee clinic. 29 Notably, Canadian guidelines for TB recommend LTBI screening for refugees up to age 50 years and to age 65 years when sufficient monitoring for drug-related adverse events can be ensured.…”

“…29 High rates of LTBI screening and treatment completion have also been reported in a Canadian refugee clinic. 29 Notably, Canadian guidelines for TB recommend LTBI screening for refugees up to age 50 years and to age 65 years when sufficient monitoring for drug-related adverse events can be ensured. 4 We did not investigate adverse events related to LTBI treatment; however, based on TB rates, our results support screening some groups up to the age of 65 years.…”

Is Universal Screening Necessary? Incidence of Tuberculosis among Tibetan Refugees Arriving in Calgary, Alberta

“…Patients who were tested with TST in this cohort were either seen at the Calgary Refugee Clinic first or preferred a TST. Similar to the screening program in other cities, we offer confirmatory IGRA following positive TST [8]. Whether our local practice of using IGRA for LTBI screening is cost-effective remains to be determined.…”

“…Screening for LTBI is not a requirement for entry or resettlement; however there exists multiple primary care guidelines and published screening programs for targeted high-risk populations including refugees [1, 7, 8]. Canadian-based guidelines recommend screening all children and adult refugees under 50 years of age originating from countries with a high incidence of TB (>15 per 100 000) [1].…”