Integrated Care for Latent Tuberculosis Infection (LTBI) at a Primary Health Care Facility for Refugees in Winnipeg, Canada: A Mixed-Methods Evaluation

Abstract

Although Canada has one of the lowest tuberculosis incidence rates in the world, certain groups are disproportionately affected, including foreign born people from high incidence countries. The Winnipeg Regional Health Authority has initiated a process to decentralize latent tuberculosis infection (LTBI) management at primary care clinics in Winnipeg. One of these clinics is BridgeCare Clinic which provides services to government-assisted refugees. The present study describes the BridgeCare Clinic LTBI program and reviews program outcomes from January 2015 to October 2016. Refugees at BridgeCare Clinic receive comprehensive care, including LTBI screening and treatment. The LTBI program is managed by physicians, nurse practitioners, and primary care nurses under a patient-centered model of care. An accessible interpretation service, education to clients, and laboratory sampling at the clinic with free IGRA testing are important components of the program. Anonymized data on client outcomes were statistically analyzed and qualitative interviews were conducted with senior staff. During the study period, 274 IGRA tests were ordered with 158 negative results (57.7%) and 101 positive results (36.9%). Of 45 clients eligible (from January to December 2015) for LTBI treatment, 11 (24.4%) declined to receive treatment and 34 (75.6%) started treatment. Twenty-seven (79.4%) clients completed treatment, 3 (8.8%) clients moved out of province, and 4 (11.8%) did not complete treatment. The most recent World Health Organization strategy for tuberculosis control calls for integrated, patient-centered care and prevention. Aligned with these WHO recommendations, our experience suggests that LTBI care and treatment can be delivered effectively in a primary care setting using an integrated patient-centered approach.

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

“…The 39 included publications contained data on 31 598 migrants positive for LTBI. Studies were done in 13 countries, across three WHO regions (European region, region of the Americas, and Western Pacific region): Australia (n=4 studies), [31][32][33][34] Canada (n=3), [35][36][37] Germany (n=1), 38 Israel (n=1), 39 Japan (n=1), 40 the Netherlands (n=2), 41,42 Norway (n=2), 43,44 South Korea (n=1), 45 Spain (n=3), [46][47][48] Sweden (n=1), 49 Switzerland (n=1), 50 UK (n=4), [51][52][53][54] and USA (n=15). [55][56][57][58][59][60][61][62][63][64][65][66][67][68][69] In total, 25 studies with outcome data on 8764 migrants were used to calculate the proportion of individuals initiating treatment.…”

“…[55][56][57][58][59][60][61][62][63][64][65][66][67][68][69] In total, 25 studies with outcome data on 8764 migrants were used to calculate the proportion of individuals initiating treatment. [33][34][35][36][37][38][39][41][42][43]48,[50][51][52][53][54][55][56][58][59][60]65,66,68,69 3A). Demographic and patient factors associated with noninitiation of treatment reported in the studies were being of sub-Saharan African origin 55 and being a refugee from sub-Saharan Africa, northern Africa, or the Middle East.…”

“…52 35 studies with outcome data on 25 629 migrants (of whom 15 516 completed treatment) were used to calculate the proportion of individuals completing treatment subsequent to initiation. [32][33][34][35][36][37][38][39][40][41][42]44,45,[47][48][49][50][51][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69] The pooled estimate for the true proportion of LTBI treatment completion among migrants initiating treatment was 74% (95% CI 66- Analysing by treatment regimen, migrants treated with 4 months of rifampicin were significantly more likely to complete treatment (89% [95% CI 67-97]; p=0•020) than migrants prescribed 9 months of isoniazid (ref); no other treatment regimen showed significant differences (table; figure 3B).…”

“…Ailinger et al (2007) 66 Benjumea-Bedoya et al (2019) 35 Bennet et al (2014) 55 Bishara et al (2015) 39 Bodenmann et al ( 2009) 50 Brassard et al ( 2006) 36 Carter et al (2017) 56 Duchen et al (2017) 58 Elliot et al (2018) 33 Gacek et al (2013) 59 Goswami et al (2012) 60 Hargreaves et al (2014) 51 Harstad et al (2010) 43 Lim et al (2016) 37 Loutet et al (2018) 52 Nuzzo et al (2015) 65 OʼShea et al (2014) 53 Sprujit et al (2019) 41 Sprujit et al (2019) 42 Subedi et al (2015) 68 Thee et al (2019) 38 Trauer & Krause 2011 34 Usdin et al (2017) 54 Villa et al (2019) 48 Walters & Sullivan (2016 66 Benjumea-Bedoya et al (2019) 35 Bennet et al (2014) 55 Bishara et al (2015) 39 Bodenmann et al (2009) 50 Brassard et al (2006) 36 Carter et al (2017) 56 Chang et al (2013) 57 Dobler & Marks (2012) 32 Duchen et al (2017) 58 Elliot et al (2018) 33 Gacek et al (2013) 59 Goswami et al (2012) 60 Haley et al (2008) 61 Hargreaves et al (2014) 51 Hirsch-Moverman et al (2010) 62 Jimenez-Fuentes et al (2013) 47 Kawatsu et al (2017)…”

Latent tuberculosis screening and treatment among asylum seekers: a mixed-methods study

“…LTBI treatment initiation and completion proportions were high, which is in contrast to a pilot study among immigrants [15]. Studies performed in other countries and settings also showed that these high proportions can be achieved among persons seeking asylum, provided that personalised LTBI treatment support by trained (TB) care staff, including education throughout the treatment process, is given [16][17][18][19]. Furthermore, the use of professional interpreters and peer educators is crucial to allow informed decision making of clients throughout the LTBI screening and treatment process, and these are important facilitators in LTBI treatment completion [20][21][22][23].…”