{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T21:11:39Z","timestamp":1770325899303,"version":"3.49.0"},"reference-count":30,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T00:00:00Z","timestamp":1652918400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>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 \u224814% of them comply with the multiple steps of the \u2018cascade of care\u2019 and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>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\u20132020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010\u201314 (n = 1906) and 2018\u201319 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997\u20132008) and after (2009\u20132020) setting up the clinic were identified. All costs associated with TB or LTBI were measured.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>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\u20132008) to 26.3 per 100,000 person-years (2009\u20132020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0267781","type":"journal-article","created":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T18:01:45Z","timestamp":1652983305000},"page":"e0267781","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1074-3655","authenticated-orcid":true,"given":"Jacques","family":"P\u00e9pin","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"France","family":"Desjardins","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alex","family":"Carignan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michel","family":"Lambert","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isabelle","family":"Vaillancourt","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christiane","family":"Labrie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dominique","family":"Mercier","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rachel","family":"Bourque","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Louiselle","family":"LeBlanc","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2022,5,19]]},"reference":[{"issue":"2\u20133","key":"pone.0267781.ref001","first-page":"67","article-title":"Tuberculosis in Canada: 2017.","volume":"45","author":"M LaFreni\u00e8re","year":"2019","journal-title":"Can Commun Dis Rep."},{"key":"pone.0267781.ref002","unstructured":"Immigration, Refugees and Citizenship Canada. Annual Report to Parliament on Immigration, for the period ending December 31 2019. [Cited 2022 Feb 22]. Available from: https:\/\/www.canada.ca\/en\/immigration-refugees-citizenship\/corporate\/publications-manuals\/annual-report-parliament-immigration-2020.html"},{"key":"pone.0267781.ref003","unstructured":"Immigration, Refugees and Citizenship Canada. Canadian Panel Member Guide to Immigration Medical Examinations. [Cited 2022 Feb 22]. Available from: https:\/\/www.canada.ca\/en\/immigration-refugees-citizenship\/corporate\/publications-manuals\/panel-members-guide.html#sec1.6.5"},{"key":"pone.0267781.ref004","article-title":"Tuberculosis surveillance and screening in selected high-risk populations","author":"C Greenaway","year":"2014","journal-title":"Canadian Tuberculosis Standards"},{"issue":"12","key":"pone.0267781.ref005","doi-asserted-by":"crossref","first-page":"E939","DOI":"10.1503\/cmaj.090302","article-title":"Tuberculosis: evidence review for newly arriving immigrants and refugees","volume":"183","author":"C Greenaway","year":"2011","journal-title":"CMAJ"},{"issue":"11","key":"pone.0267781.ref006","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.1016\/S1473-3099(16)30216-X","article-title":"The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis","volume":"16","author":"H Alsdurf","year":"2016","journal-title":"Lancet Infect Dis"},{"issue":"2","key":"pone.0267781.ref007","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1093\/aje\/kwab150","article-title":"Modelling the cost-effectiveness of latent tuberculosis screening and treatment strategies in recent migrants to a low incidence setting","volume":"191","author":"KD Dale","year":"2021","journal-title":"Am J Epidemiol"},{"key":"pone.0267781.ref008","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1186\/s12879-016-1550-y","article-title":"Initiation and completion rates for latent tuberculosis infection treatment: a systematic review","volume":"16","author":"A Sandgren","year":"2016","journal-title":"BMC Infect Dis"},{"key":"pone.0267781.ref009","unstructured":"Law S, Menzies D, Pai M, Benedetti A. The online TST\/IGRA interpreter. [Cited 2022 Feb 22]. Available from: tstin3d.com"},{"issue":"5","key":"pone.0267781.ref010","first-page":"498","article-title":"Thinking in three dimensions: a web-based algorithm to aid the interpretation of tuberculin skin test results.","volume":"12","author":"D Menzies","year":"2008","journal-title":"Int J Tuberc Lung Dis."},{"key":"pone.0267781.ref011","doi-asserted-by":"crossref","unstructured":"Menzies D, Adjobimey M, Ruslami, Trajman A, Sow O, Kim H, et al. Four months of rifampin or nine months of isoniazide for latent tuberculosis in adults. N Engl J Med. 2018; 379(5): 440\u2013453. https:\/\/doi.org\/10.1056\/NEJMoa1714283 30067931","DOI":"10.1056\/NEJMoa1714283"},{"key":"pone.0267781.ref012","doi-asserted-by":"crossref","unstructured":"Diallo T, Adjobimey M, Ruslami R, Trajman A, Sow O, Obeng Baah J, et al. Safety and side effects of rifampin versus isoniazid in children. N Engl J Med. 2018; 379(5): 454\u2013463. https:\/\/doi.org\/10.1056\/NEJMoa1714284 30067928","DOI":"10.1056\/NEJMoa1714284"},{"key":"pone.0267781.ref013","unstructured":"Canadian Agency for Drugs and Technologies in Health. Guidelines for the economic evaluation of health technologies: Canada. 4th edition. [Cited 2022 Feb 22]. Available from: https:\/\/www.cadth.ca\/guidelines-economic-evaluation-health-technologies-canada-0"},{"issue":"4","key":"pone.0267781.ref014","doi-asserted-by":"crossref","first-page":"895","DOI":"10.1183\/09031936.00196610","article-title":"Piecing the puzzle together: foreign-born tuberculosis in an immigrant-receiving country","volume":"38","author":"D Langlois-Klassen","year":"2011","journal-title":"Eur Respir J"},{"key":"pone.0267781.ref015","unstructured":"World Bank. Incidence of tuberculosis (per 100,000 people). [Cited 2022 Feb 22]. Available from: https:\/\/data.worldbank.org\/indicator\/SH.TBS.INCD"},{"issue":"3","key":"pone.0267781.ref016","doi-asserted-by":"crossref","first-page":"169","DOI":"10.7326\/M19-3741","article-title":"Health systems costs of treating latent tuberculosis infection with 4 months of rifampin versus 9 months of isoniazid in different settings","volume":"173","author":"ML Bastos","year":"2020","journal-title":"Ann Intern Med"},{"key":"pone.0267781.ref017","unstructured":"World Health Organization. Towards tuberculosis elimination: an action framework for low-incidence countries. [Cited 2022 Feb 22]. Available from: https:\/\/www.who.int\/tb\/publications\/elimination_framework\/en\/"},{"issue":"16","key":"pone.0267781.ref018","doi-asserted-by":"crossref","first-page":"E473","DOI":"10.1503\/cmaj.150011","article-title":"Domestic impact of tuberculosis screening among new immigrants to Ontario, Canada.","volume":"187","author":"K Khan","year":"2015","journal-title":"CMAJ"},{"issue":"12","key":"pone.0267781.ref019","doi-asserted-by":"crossref","first-page":"2101","DOI":"10.1093\/cid\/ciz188","article-title":"Estimated impact of World Health Organization latent tuberculosis screening guidelines in a region with a low tuberculosis incidence: retrospective cohort study","volume":"69","author":"LA Ronald","year":"2019","journal-title":"Clin Infect Dis"},{"issue":"5","key":"pone.0267781.ref020","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1007\/BF03405248","article-title":"Costs for tuberculosis care in Canada.","volume":"99","author":"D Menzies","year":"2008","journal-title":"Can J Pub Health"},{"issue":"1","key":"pone.0267781.ref021","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1186\/s12879-016-1997-x","article-title":"Predictors of hospitalization of tuberculosis patients in Montreal, Canada: a retrospective cohort study.","volume":"16","author":"LA Ronald","year":"2016","journal-title":"BMC Infect Dis."},{"issue":"1","key":"pone.0267781.ref022","first-page":"16","article-title":"Interferon-gamma release assays and TB screening in high-income countries: a cost-effectiveness analysis","volume":"11","author":"O Oxlade","year":"2007","journal-title":"Int J Tuberc Lung Dis"},{"issue":"5","key":"pone.0267781.ref023","doi-asserted-by":"crossref","first-page":"842","DOI":"10.1111\/j.1524-4733.2008.00334.x","article-title":"Cost-effectiveness of LTBI treatment for TB contacts in British Columbia.","volume":"11","author":"MC Tan","year":"2008","journal-title":"Value Health"},{"key":"pone.0267781.ref024","article-title":"Diagnosis of latent tuberculosis infection","author":"M Pai","year":"2014","journal-title":"Canadian Tuberculosis Standards"},{"issue":"12","key":"pone.0267781.ref025","doi-asserted-by":"crossref","first-page":"1941","DOI":"10.1038\/s41591-020-1076-0","article-title":"Discovery and validation of a personalized risk predictor for incident tuberculosis in low transmission settings","volume":"26","author":"RK Gupta","year":"2020","journal-title":"Nature Medicine"},{"key":"pone.0267781.ref026","doi-asserted-by":"crossref","first-page":"m549","DOI":"10.1136\/bmj.m549","article-title":"Absolute risk of tuberculosis among untreated populations with a positive tuberculin skin test or interferon-gamma release assay result: systematic review and meta-analysis","volume":"368","author":"JR Campbell","year":"2020","journal-title":"BMJ"},{"issue":"8","key":"pone.0267781.ref027","doi-asserted-by":"crossref","first-page":"E209","DOI":"10.1503\/cmaj.170817","article-title":"Demographic predictors of active tuberculosis in people migrating to British Columbia, Canada: a retrospective cohort study.","volume":"190","author":"LA Ronald","year":"2018","journal-title":"CMAJ"},{"issue":"9","key":"pone.0267781.ref028","doi-asserted-by":"crossref","first-page":"e3486","DOI":"10.1093\/cid\/ciaa780","article-title":"How well does TSTin3D predict risk of active tuberculosis in the Canadian immigrant population? An external validation study","volume":"73","author":"JH Puyat","year":"2021","journal-title":"Clin Infect Dis"},{"key":"pone.0267781.ref029","doi-asserted-by":"crossref","first-page":"57","DOI":"10.3389\/fpubh.2019.00057","article-title":"Integrated care for latent tuberculosis infection (LTBI) at a primary health care facility for refugees in Winnipeg, Canada: a mixed methods evaluation.","volume":"7","author":"D Benjumea-Bedoya","year":"2019","journal-title":"Front Public Health."},{"key":"pone.0267781.ref030","article-title":"A step toward tuberculosis elimination in a low-incidence country: successful diagnosis and treatment of latent tuberculosis infection in a refugee clinic.","author":"E Rennert-May","year":"2016","journal-title":"Can Respir J"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0267781","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T18:02:22Z","timestamp":1652983342000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0267781"}},"subtitle":[],"editor":[{"given":"Gang","family":"Qin","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2022,5,19]]},"references-count":30,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2022,5,19]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0267781","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,5,19]]}}}