Christina Greenaway

Evidence-based clinical guidelines for immigrants and refugees

(see Appendix 2, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.090313/-/DC1][1] for summary of recommendations and clinical considerations) There are more than 200 million international migrants worldwide,[1][2] and this movement of people has implications for individual and

Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network.

Vaccine preventable diseases (VPDs) threaten international travelers, but little is known about their epidemiology in this group. We analyzed records of 37,542 ill returned travelers entered into the GeoSentinel Surveillance Network database. Among 580 (1.5%) with VPDs, common diagnoses included enteric fever (n=276), acute viral hepatitis (n=148), and influenza (n=70). Factors associated with S. typhi included VFR travel (p<0.016) to South Central Asia (p<0.001). Business travel was associated with influenza (p<0.001), and longer travel with hepatitis A virus (p=0.02). 29% of those with VPDs had pre-travel consultations. At least 55% of those with VPDs were managed as inpatients, compared to 9.5% of those with non-VPDs. Three deaths occurred; one each due to pneumococcal meningitis, S. typhi, and rabies. VPDs are significant contributors to morbidity and potential mortality in travelers. High rates of hospitalization make them an attractive target for pre-travel intervention.

The impact of migration on tuberculosis epidemiology and control in high-income countries: a review.

Tuberculosis (TB) causes significant morbidity and mortality in high-income countries with foreign-born individuals bearing a disproportionate burden of the overall TB case burden in these countries. In this review of tuberculosis and migration we discuss the impact of migration on the epidemiology of TB in low burden countries, describe the various screening strategies to address this issue, review the yield and cost-effectiveness of these programs and describe the gaps in knowledge as well as possible future solutions.The reasons for the TB burden in the migrant population are likely to be the reactivation of remotely-acquired latent tuberculosis infection (LTBI) following migration from low/intermediate-income high TB burden settings to high-income, low TB burden countries.TB control in high-income countries has historically focused on the early identification and treatment of active TB with accompanying contact-tracing. In the face of the TB case-load in migrant populations, however, there is ongoing discussion about how best to identify TB in migrant populations. In general, countries have generally focused on two methods: identification of active TB (either at/post-arrival or increasingly pre-arrival in countries of origin) and secondly, conditionally supported by WHO guidance, through identifying LTBI in migrants from high TB burden countries. Although health-economic analyses have shown that TB control in high income settings would benefit from providing targeted LTBI screening and treatment to certain migrants from high TB burden countries, implementation issues and barriers such as sub-optimal treatment completion will need to be addressed to ensure program efficacy.

Tuberculosis: evidence review for newly arriving immigrants and refugees

Background: The foreign-born population bears a disproportionate health burden from tuberculosis, with a rate of active tuberculosis 20 times that of the non-Aboriginal Canadian-born population, and could therefore benefit from tuberculosis screening programs. We reviewed evidence to determine the burden of tuberculosis in immigrant populations, to assess the effectiveness of screening and treatment programs for latent tuberculosis infection, and to identify potential interventions to improve effectiveness. Methods: We performed a systematic search for evidence of the burden of tuberculosis in immigrant populations and the benefits and harms, applicability, clinical considerations, and implementation issues of screening and treatment programs for latent tuberculosis infection in the general and immigrant populations. The quality of this evidence was assessed and ranked using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). Results: Chemoprophylaxis with isoniazid is highly efficacious in decreasing the development of active tuberculosis in people with latent tuberculosis infection who adhere to treatment. Monitoring for hepatotoxicity is required at all ages, but close monitoring is required in those 50 years of age and older. Adherence to screening and treatment for latent tuberculosis infection is poor, but it can be increased if care is delivered in a culturally sensitive manner. Interpretation: Immigrant populations have high rates of active tuberculosis that could be decreased by screening for and treating latent tuberculosis infection. Several patient, provider and infrastructure barriers, poor diagnostic tests, and the long treatment course, however, limit effectiveness of current programs. Novel approaches that educate and engage patients, their communities and primary care practitioners might improve the effectiveness of these programs.

Spectrum of Illness in International Migrants Seen at GeoSentinel Clinics in 1997–2009, Part 2: Migrants Resettled Internationally and Evaluated for Specific Health Concerns

BACKGROUND Increasing international migration may challenge healthcare providers unfamiliar with acute and long latency infections and diseases common in this population. This study defines health conditions encountered in a large heterogenous group of migrants. METHODS Migrants seen at GeoSentinel clinics for any reason, other than those seen at clinics only providing comprehensive protocol-based health screening soon after arrival, were included. Proportionate morbidity for syndromes and diagnoses by country or region of origin were determined and compared. RESULTS A total of 7629 migrants from 153 countries were seen at 41 GeoSentinel clinics in 19 countries. Most (59%) were adults aged 19-39 years; 11% were children. Most (58%) were seen >1 year after arrival; 27% were seen after >5 years. The most common diagnoses were latent tuberculosis (22%), viral hepatitis (17%), active tuberculosis (10%), human immunodeficiency virus (HIV)/AIDS (7%), malaria (7%), schistosomiasis (6%), and strongyloidiasis (5%); 5% were reported healthy. Twenty percent were hospitalized (24% for active tuberculosis and 21% for febrile illness [83% due to malaria]), and 13 died. Tuberculosis diagnoses and HIV/AIDS were reported from all regions, strongyloidiasis from most regions, and chronic hepatitis B virus (HBV) particularly in Asian immigrants. Regional diagnoses included schistosomiasis (Africa) and Chagas disease (Americas). CONCLUSIONS Eliciting a migration history is important at every encounter; migrant patients may have acute illness or chronic conditions related to exposure in their country of origin. Early detection and treatment, particularly for diagnoses related to tuberculosis, HBV, Strongyloides, and schistosomiasis, may improve outcomes. Policy makers should consider expansion of refugee screening programs to include all migrants.

Susceptibility to Measles, Mumps, and Rubella in Newly Arrived Adult Immigrants and Refugees

Context Immigrants from developing countries are likely to be undervaccinated for childhood infectious diseases, such as measles, mumps, and rubella. Contributions The investigators measured antibodies against measles, mumps, and rubella in 1480 adult immigrants in Montreal, Quebec, Canada. They found that 36% were susceptible to at least 1 of the infections. Cautions Participants were selected by convenience. The findings may not be applicable to countries that mandate updated vaccinations before arrival, such as the United States. Implications Many immigrants to Canada are susceptible to measles, mumps, or rubella and may benefit from targeted catch-up vaccination programs. The Editors Effective vaccination programs have almost eliminated measles, mumps, rubella and congenital rubella in the United States and Canada (1, 2). Sporadic outbreaks of measles and rubella, however, continue to occur among undervaccinated populations, such as those who have declined vaccination or foreign-born individuals (36). Many foreign-born adult immigrants are likely to be nonimmune to measles, mumps, and rubella because childhood vaccination programs were not introduced in most developing countries until the late 1970s, because rubella and mumps vaccines are not routinely given in many countries because they are not part of the World Health Organization (WHO) Extended Program on Immunization, and because global vaccination coverage ranges from 50% to 90% (7, 8). Rubella outbreaks in the United States in the mid-1990s, where 80% of involved individuals were unvaccinated Hispanic immigrants (911), highlight the potential vaccination gaps among adult immigrants. Immigrants have also accounted for some of the imported cases of measles in the United States over the past decade (6). Mumps seroprevalence is not well-defined in the immigrant population. The number of immigrants living in the United States and Canada is growing rapidly (12). In 2000, 11.4% (31 million persons) of the U.S. population were foreign-born, and in 2001, 18.5% (5.8 million persons) of the Canadian population were foreign-born. More than 70% of immigrants who have arrived in the United States and Canada since 1990 originated from countries where vaccination may be suboptimal (13, 14). To maintain control of measles, mumps, and rubella in the United States and Canada, identifying nonimmune individuals is essential. To determine the level of susceptibility in the immigrant and refugee populations, we conducted a seroprevalence study among newly arrived adult immigrants and refugees in Montreal, Quebec, Canada. Methods Patient Sample We recruited adult immigrants and refugees 18 years of age or older who were living in Canada for 5 years or less from 2 hospitals and 3 clinics in the Cte-des-Neiges and Notre-Dame-de-Grce borough of Montreal, Quebec, from October 2002 to December 2004. Hospital or clinic staff identified the individuals, and we recruited them consecutively in a convenience sample to ensure sufficient numbers from each of 6 regions of the world (see the Appendix for country classifications within regions of origin). We excluded individuals who had received the measles-mumps-rubella (MMR) vaccine or who had developed 1 of these diseases after arriving in Canada. Setting Montreal is a cosmopolitan city in Quebec, Canada, with a population of 1.81 million persons (in 2001); 28% of whom are foreign-born. The Cte-des-Neiges and Notre-Dame-de-Grce borough of Montreal had a population of 159765 persons in 2001; 45% of whom were immigrants from all regions of the world and 30% of whom had recently arrived in Canada (between 1996 and 2001) (15). We recruited study participants from 4 clinics (tuberculosis, infectious diseases, obstetrics and gynecology, and family medicine clinics) and the postpartum ward at the Jewish General Hospital (a 637-bed, tertiary care hospital), the tuberculosis and prenatal clinics at Saint Justine Hospital (a 450-bed pediatric and obstetric hospital), and 3 primary care clinics: the Cte-des-Neiges local community health center; Clinique Diamant; and La Clinique Mdicale VMS, [Vaccination Medicine Spcialiser]. All sites were situated within 10 city blocks of each other. Questionnaire A study nurse administered a questionnaire to gather demographic data, including age, sex, country of origin, immigration class, socioeconomic status (self-reported income tertile in country of origin), years of formal education, and current and previous occupations of the study participant and his or her parents. Serologic Testing We obtained blood samples for serologic testing from all participants. We tested the initial 300 (20%) serum samples for measles immunoglobin G (IgG) antibodies with the Dade Behring (Deerfield, Illinois) measles IgG assay (with kits that had passed company quality control). Because of a manufacturing problem that arose with these kits, we performed the remaining tests with the Zeus Scientific measles IgG enzyme-linked immunosorbent assay (ELISA) kit (Raritan, New Jersey). We detected mumps antibodies with the Dade Behring ELISA kit for mumps IgG and rubella antibodies with the Abbott rubella IgG ELISA kit (Abbott Park, Illinois). We considered patients with measles or mumps IgG antibodies (defined as per package insert) to be seropositive and immune. We considered patients without measles or mumps IgG antibodies and those with measles or mumps IgG antibodies detected at equivocal levels to be seronegative, susceptible, or nonimmune. We considered patients with rubella antibodies of 10 IU/mL or greater to be seropositive and immune and those with rubella antibodies less than 10 IU/mL to be seronegative, susceptible, or nonimmune. Statistical Analysis We generated seroprevalence estimates for measles, mumps, and rubella separately for the whole study sample, and we stratified estimates by region of origin, age, and immigration class (variables that we felt might influence seroprevalence). We used 3 separate multivariable models to test associations between demographic characteristics and susceptibility to measles, mumps, or rubella, with adjustment for potentially confounding demographic and socioeconomic variables. We conducted all analyses with SAS, version 8.2 (SAS Institute, Cary, North Carolina). Role of the Funding Sources The Fonds de la Recherche en Sant du Qubec and GlaxoSmithKline funded the study. Drs. Greenaway and Schwartzman are recipients of research career awards from the Fonds de la Recherche en Sant du Qubec. The funding sources had no role in the design, analysis, or reporting of the study or in the decision to submit the manuscript for publication. Results We invited 1619 individuals to participate in the study, and 139 (9.2%) of these individuals declined to participate. We had no information on the immigration status or origin of those who declined, but they more often came from the postpartum ward than from other care settings. Serologic testing results for measles, mumps, and rubella were available for the remaining 1480 immigrants. Table 1 presents the sociodemographic characteristics. Almost half the participants were refugees, but only 0.8% had lived in a refugee camp and most refugees had applied for asylum after first arriving in Canada. Participants were well-educated (mean years of education, 13.9 years [SD, 4]; 47% had a university education) and were of relatively high socioeconomic class (94% described their families of origin as middle or upper income). Table 1. Demographic Characteristics Overall, 36% (95% CI, 33% to 38%) of participants were susceptible to at least 1 of the 3 conditions. Susceptibility differed by age, sex, and geographic region of origin (Table 2) but not by immigration class. Table 2. Susceptibility to Measles, Mumps, and Rubella In a multivariable analysis adjusted for demographic and socioeconomic covariates, women were more likely than men to be susceptible to measles (odds ratio, 2.1 [CI, 1.2 to 3.8]) and rubella (odds ratio, 1.7 [CI, 1.2 to 2.6]) but not to mumps (odds ratio, 1.1 [CI, 0.8 to 1.5]). Discussion In a community-based seroprevalence study among new adult immigrants and refugees, 36% of participants were susceptible to at least 1 of the 3 conditions, with prevalence ranging from 22% to 54% in subgroups depending on age, sex, and region of origin. Immigrant women were especially likely to be susceptible. In light of recent rubella and mumps outbreaks, our findings highlight the need to keep MMR vaccinations up to date in foreign-born individuals to protect potentially susceptible persons and to prevent outbreaks (911, 16). Susceptible immigrants may import these diseases after trips to endemic countries to visit friends and relatives (6). Since 1996, all new immigrants to the United States are required to have updated vaccinations as part of the mandatory medical screening before arrival. Gaps in vaccination coverage remain, however, because some groups (asylum seekers, refugees, and adoptees) are excluded and because no systematic mechanism verifies vaccine doses (17). Vaccinations are not updated or verified for adult immigrants after arrival in the United States or Canada. We believe that our study is the first to estimate seroprevalence for measles, mumps, and rubella in a large adult immigrant and refugee population from all major regions of the world. Numbers of immigrants and refugees were similar, with enough participants from each world region to permit useful comparisons between subgroups. Barnett and colleagues study (18) found that 18% of refugee children (age, 0 to 20 years) from 6 regions of the world were susceptible to measles and 18% were susceptible to rubella. Their results are not comparable to our results because they studied children who may have had greater access to childhood vaccines in their countries of origin (18). The major limitation of our study is that we assembled a convenience sample of immigrants and refugees who were s

The Seroprevalence of Hepatitis C Antibodies in Immigrants and Refugees from Intermediate and High Endemic Countries: A Systematic Review and Meta-Analysis

Background & Aims Hepatitis C virus (HCV) infection is a significant global health issue that leads to 350,000 preventable deaths annually due to associated cirrhosis and hepatocellular carcinoma (HCC). Immigrants and refugees (migrants) originating from intermediate/high HCV endemic countries are likely at increased risk for HCV infection due to HCV exposure in their countries of origin. The aim of this study was to estimate the HCV seroprevalence of the migrant population living in low HCV prevalence countries. Methods Four electronic databases were searched from database inception until June 17, 2014 for studies reporting the prevalence of HCV antibodies among migrants. Seroprevalence estimates were pooled with a random-effect model and were stratified by age group, region of origin and migration status and a meta-regression was modeled to explore heterogeneity. Results Data from 50 studies representing 38,635 migrants from all world regions were included. The overall anti-HCV prevalence (representing previous and current infections) was 1.9% (95% CI, 1.4–2.7%, I2 96.1). Older age and region of origin, particularly Sub-Saharan Africa, Asia, and Eastern Europe were the strongest predictors of HCV seroprevalence. The estimated HCV seroprevalence of migrants from these regions was >2% and is higher than that reported for most host populations. Conclusion Adult migrants originating from Asia, Sub-Saharan Africa and Eastern Europe are at increased risk for HCV and may benefit from targeted HCV screening.

Comparison of LED and Conventional Fluorescence Microscopy for Detection of Acid Fast Bacilli in a Low-Incidence Setting

Introduction Light emitting diode fluorescence microscopes have many practical advantages over conventional mercury vapour fluorescence microscopes, which would make them the preferred choice for laboratories in both low- and high-resource settings, provided performance is equivalent. Methods In a nested case-control study, we compared diagnostic accuracy and time required to read slides with the Zeiss PrimoStar iLED, LW Scientific Lumin, and a conventional fluorescence microscope (Leica DMLS). Mycobacterial culture was used as the reference standard, and subgroup analysis by specimen source and organism isolated were performed. Results There was no difference in sensitivity or specificity between the three microscopes, and agreement was high for all comparisons and subgroups. The Lumin and the conventional fluorescence microscope were equivalent with respect to time required to read smears, but the Zeiss iLED was significantly time saving compared to both. Conclusions Light emitting diode microscopy should be considered by all tuberculosis diagnostic laboratories, including those in high income countries, as a replacement for conventional fluorescence microscopes. Our findings provide support to the recent World Health Organization policy recommending that conventional fluorescence microscopy be replaced by light emitting diode microscopy using auramine staining in all settings where fluorescence microscopy is currently used.

Strategies to prevent varicella among newly arrived adult immigrants and refugees: a cost-effectiveness analysis.

In temperate, industrialized countries, such as Canada, varicella is a common disease in childhood [1]. In tropical countries, for reasons that are not entirely clear, varicella occurs among young adults. Seroprevalence data from tropical regions suggest that up to 30% of individuals are susceptible to varicella at 20 years of age, and 5%-10% remain susceptible at 30 years of age [2, 3]. There have been many reported outbreaks of varicella in immigrant populations in industrialized countries, suggesting that foreign-born adults are disproportionately susceptible [4-6]. Recent immigrants also have a high risk of exposure, because many are the parents of young children, who have a high annual incidence of varicella unless they are vaccinated. Varicella is more severe in adults than in children

Lack of transmission of vancomycin-resistant enterococci in three long-term-care facilities.

Three patients colonized with vancomycin-resistant Enterococcus were admitted to one or more of three long-term-care facilities. Six point-prevalence surveys revealed no transmission of vancomycin-resistant Enterococcus after a total of 234 days of exposure during which moderately strict infection control measures were implemented. Four of 116 environmental cultures were positive.