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

Abstract

Introduction The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the ‘cascade of care’ and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management. Methods Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009–2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010–14 (n = 1906) and 2018–19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997–2008) and after (2009–2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured. Results Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997–2008) to 26.3 per 100,000 person-years (2009–2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change. Conclusions Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.

Interventions to improve latent and active tuberculosis treatment completion rates in underserved groups in low incidence countries: a scoping review

“…There were 17 single-arm studies (5 as part of a mixed-methods study, online supplemental material 4). These looked at completion rates after 3HP/DOT (in prisoners35 and people experiencing homelessness36); mandatory screening in asylum seekers37; a migrant focused TB screening programme38; medical examination by civil surgeons for people who were adjusting immigration status to permanent residency39; screening at a sexual health clinic for sex workers40; integrated clinics for migrants, refugees or asylum seekers41–46; other strategies tailored to migrants, refugees or asylum seekers (such as engaging community health workers or TB education)47–50 or the effect of the CureTB Programme, a continuity of care programme for patients relocating outside of the USA before completing treatment 51. Completion rates were not directly comparable due to heterogeneity in populations, settings, approaches to screening and treatment, length and methods of follow-up and definition of completion rate, as well as any differences in intervention components.…”

“…health clinic for sex workers 40 ; integrated clinics for migrants, refugees or asylum seekers [41][42][43][44][45][46] ; other strategies tailored to migrants, refugees or asylum seekers (such as engaging community health workers or TB education) [47][48][49][50] or the effect of the CureTB Programme, a continuity of care programme for patients relocating outside of the USA before completing treatment. 51 Completion rates were not directly comparable due to heterogeneity in populations, settings, approaches to screening and treatment, length and methods of follow-up and definition of completion rate, as well as any differences in intervention components.…”

Community treatment of latent tuberculosis in child and adult refugee populations: outcomes and successes

“…However, this study and others (31)(32)(33) illustrate that systematic LTBI screening and treatment of refugees can be done in dedicated clinics with expertise and community support and that Canadian TB standards for acceptance and completion rates can be attained. Furthermore, this model has proven to be cost-beneficial in a refugee clinic in Montreal, with every dollar spent on LTBI treatment saving 2 dollars in averted active TB treatment (37). Most importantly, in the 12 years since opening their clinic, TB incidence among migrants screened at the clinic had decreased by 61%.…”