Tuberculosis (TB) and Immigrants/Refugees:

Implications for Toronto Public Health's TB Control Program

The Board of Health recommends the adoption of the report dated September 21, 1999, from the Medical Officer of Health.

The Board of Health reports, for the information of Council, having requested the Chair of the Board of Health, Councillor Joan King and the Medical Officer of Health to meet with the Federal Minister of Citizenship and Immigration to convey the Board's request for federal funding to address Tuberculosis among immigrants and refugees, with particular reference to recent influxes of refugee claimants from TB endemic countries, and to report back to the Board thereon.

The Board of Health submits the following report (September 21, 1999) from the Medical Officer of Health:

Purpose:

To inform the Board of Health about the TB control issues regarding immigrants and refugees in Toronto, with particular reference to the recent influx of Tibetan refugee claimants.

Financial Implications:

The 1998 base budget for the TB Control Program was $2,100,000.00. In March 1999, City Council approved a budget increase in order to harmonize the program throughout the City. The annualized increase will be $1,163,700.00 which will bring the total TB Control budget to $3,263,700.00 for 2000 and beyond.

TB Control is a mandatory public health program, cost-shared between the provincial and municipal governments in Ontario.

The high prevalence of TB among a recently arrived refugee group requires an intensive public health response. The TB Control Program cannot institute adequate control measures within the currently approved budget. Federal funding in the amount of $200,740.00 per year (for two years) to fund an additional four FTEs should be pursued to address the current refugee influx.

Recommendations:

It is recommending that:

(1)the City of Toronto immediately pursue federal funding for Toronto Public Health to expand the capacity of the TB Control Program to provide outreach and post-landing medical surveillance for refugee influxes from TB endemic countries;

(2)the City of Toronto urge Citizenship and Immigration Canada (CIC) to strengthen its post-landing surveillance mechanism to identify TB and other health issues (as appropriate) in refugee/immigrant groups, in consultation with Toronto Public Health and other key stakeholders. Specifically, the 60-day interval for medical examination of refugees must be shortened, and compliance monitored and enforced;

(3)the City of Toronto request Citizenship and Immigration Canada and Health Canada to expand current research to determine the optimal process for the medical follow-up of immigrants and refugees from TB-endemic areas and recommend and fund a national program to accomplish this, in consultation with Toronto Public Health and other key stakeholders;

(4)the City of Toronto urge the Province of Ontario to fully cost-share the harmonized base budget of Toronto Public Health's TB Control Program; and

(5)this report be forwarded for information to the Community Services Committee and the Toronto Advisory Committee on Immigrant and Refugee Issues.

Background:

Recent media coverage has highlighted TB among Tibetan refugee claimants in Toronto. The arrival of this high-risk group has prompted Toronto Public Health (TPH) to examine the broader issues of TB epidemiology among refugee communities in Toronto, including immigration health screening policy, post-landing medical surveillance and funding for public health TB services to immigrants and refugees (particularly where there is a rapid influx such as the Tibetan and Kosovar communities).

The prevention and control of TB requires coordinated action by all levels of government. The federal government (Citizenship and Immigration Canada) sets immigration health screening policy and funds medical services for incoming refugee claimants. The provincial government funds TB care, including provision of free TB drugs and cost-sharing of public health services. At the local level, Public Health Units ensure that people with active TB get the treatment they need, people in contact with active cases receive medical follow-up and transmission to others is prevented.

Toronto City Council approved an expansion of the TB Control Program to address the minimum provincial Mandatory Guidelines across the city as of September 1999. This expansion is currently being implemented.

Comments:

The City of Toronto is the key destination for immigrants and refugees coming to Canada. At the 1996 census, approximately 48 percent of Toronto's population was made up of immigrants and refugees. Over 49 percent of refugee claimants in 1998 entered Canada through the Toronto Region (about 10,000 people). It is therefore the municipality most affected by immigration and settlement policy and funding, which is primarily the responsibility of the federal government. Immigration patterns have changed considerably. In the early 1960's and 70's, newcomers to Canada came primarily from Western Europe, while today immigrants and refugees come to Canada primarily from Asia, Africa and Latin America, many of which are TB-endemic areas.

TB in the Tibetan Refugee Group:

Between December 1998 and July 1999, about 150 Tibetan refugee claimants arrived in Toronto from the United States. In August 1999, approximately another 180 arrived. Most of these new arrivals were born in the Tibetan refugee camps of northern India and Nepal - countries with high TB incidence rates.

There have been eight cases of TB reported among Tibetan refugees in Toronto since January 1999. Five of these were cases of multi-drug resistant TB (MDR-TB). Recognizing that this is based on limited data, it is clear that this group is experiencing a very high incidence of TB, (estimated to be 3,000 per 100,000 as compared to the Toronto rate of 20 per 100,000, and the Canadian rate of seven per 100,000).

TB is a Global Issue:

TB is a global health issue. The World Health Organization estimates that one third of the world's population is infected with latent (inactive) TB. In 1997, eight million new cases of TB disease developed. The Far East and Southeast Asia, the Indian Subcontinent, Sub-Saharan Africa, Eastern Europe, the former Soviet Union, the Caribbean, Central America and much of South America are all considered TB endemic areas. TB disease is also associated with poor socioeconomic conditions, poverty, crowding, lack of public health infrastructure, malnutrition and stress.

TB in Toronto:

There are 450-500 new cases of TB reported in Toronto each year, which is 25 percent of the TB in all of Canada. Ninety percent of these cases occur in people who were born in countries where TB is endemic. While immigrants and refugees are most at risk of developing active TB within the first five years of arrival, many cases have been in Canada for much longer. Individuals generally experience rates of TB which reflect those in their country of origin; their children have intermediate rates of TB, possibly due to household transmission (i.e. higher than other Canadian-born individuals). Other groups at high risk for TB locally include the homeless/under housed, the immuno- compromised and Aboriginal Canadians.

Based on laboratory testing, 15-20 percent of TB cases in Toronto are resistant to at least one antibiotic, compared to 11.8 percent of Canadian isolates in 1998. Approximately three percent of cases are MDR-TB, i.e. resistant to both Isoniazid and Rifampin, the major drugs used to treat TB. This is almost triple the rate of Canadian MDR-TB (1.2 percent in 1998). Drug resistant TB is much more difficult to treat. The antibiotics which are required are not as effective and therefore treatment is prolonged (18-24 months) as compared to 6 months for fully drug sensitive TB; also side-effects are more common and the cost of the medication is significantly higher. In addition, contacts of resistant cases must be followed intensively (directly observed prophylaxis is recommended) to ensure that future cases are prevented and outbreaks are avoided. These measures have huge resource implications for public health.

Immigration Medical Screening:

Immigration medical screening has two purposes: to protect the public health of Canadians by excluding individuals with an immediate contagious disease risk at the time of entry to Canada, and to exclude people with a medical condition which would impose an undue burden on Canada's medical or social system. Refugees do not have to meet the undue burden requirement. Visitors intending to stay in Canada for less than six months are not required to have a medical examination of any kind.

People who apply for immigration to Canada are required to undergo a medical examination in their country of origin within the year prior to arrival. For everyone over 11 years of age this includes a chest x-ray. Those found to have active TB are not permitted to enter Canada until they have been fully treated. Those with a history of treated TB, or signs of inactive TB, are allowed to enter the country provided they agree to medical surveillance.

Refugees who apply from outside Canada follow similar procedures but can complete treatment within Canada. Those who apply for refugee status within Canada or at the border, must file their claim within 30 days of arrival and are required to have their immigration medical within 60 days of submitting their claim. However, in practice this is often longer since there are currently no enforcement mechanisms or penalties for delay. Thus, individuals who have active TB may be in Canada for a considerable length of time before diagnosis. Given the transient and overcrowded settings in which newcomers must often live, this presents a significant risk of transmission to others in the community.

Health Canada began a reassessment of immigration health screening policy several years ago; however it has yet to produce its report and recommendations. Experience elsewhere may provide policy alternatives to the current Canadian situation.

Post-Landing Surveillance for TB:

Those individuals who are identified at increased risk of developing active TB based on their immigration medical are placed under medical surveillance. Immigration officials inform the Ontario Ministry of Health of such individuals and the Ministry then notifies the local health unit. However, a recent analysis found that post-landing surveillance detected only 10 percent of cases. This is because the current procedures for follow-up are unclear and inconsistently applied and there are issues regarding data-sharing between jurisdictions. In general, the health unit sends a letter to the individual's last known address reminding them to see a physician. Approximately 50 percent of referrals to Toronto Public Health for this purpose are locatable.

An in-depth study is currently being planned to determine how effective the current criteria for post-landing surveillance are in predicting future disease; results are not expected for several years.

TB Control Initiatives re Tibetan Refugees:

Toronto Public Health identified an unusually high rate of TB and MDR-TB among Tibetan refugee claimants in June 1999. At that time, staff notified provincial and federal authorities and began to work on strengthening prevention and early detection activities. All reported cases of TB in Tibetan refugee claimants have received priority for public health investigation and follow-up. Referral links have been established with respirologists familiar with drug-resistant TB and directly observed therapy (DOT) has been put in place for these individuals. To date, there have been no concerns whatsoever about compliance with treatment and Toronto Public Health is working in close collaboration with the Tibetan community.

As an interim measure to assist in early detection of TB, starting in August, 1999, Toronto Public Health provided TB screening for over 60 individuals; 18 percent have a history of active TB and 92 percent of those tested were skin-test positive and have been referred for further assessment. Notably, 100 percent of those screened have returned for follow-up.

Public Health worked in collaboration with the Tibetan community to identify issues and develop strategies for education and outreach. The Tibetan community has assisted with translation of resources and outreach. Community members also identified access to affordable housing and settlement services as urgent issues. Staff from the City's Shelter, Housing and Support Division, and Access and Equity Centre are also working with the community.

In late August, a system to fast-track TB assessments for incoming Tibetan refugees was developed in collaboration with Health Canada, Citizenship and Immigration Canada (CIC), the Ontario Ministry of Health (Public Health Branch), the Niagara Public Health Department and three local hospitals (St. Michael's Hospital, The University Health Network and West Park Hospital). Immediate medical screening of Tibetan refugees at the border was implemented on September 7, 1999. In addition, CIC is in the process of requesting recent Tibetan refugee claimants who have not yet had their immigration medical, to do so immediately.

TB and Immigrants/Refugees:

The recent Tibetan refugee claimants are only one example of newcomers with high rates of TB. Immigration patterns show that Toronto will continue to be a major destination for immigrants/refugees entering Canada, and that the majority will originate from TB-endemic countries.

The success of local TB control efforts is thus largely dependent on effective and timely surveillance, as well as follow-up mechanisms to identify new groups and cases and local capacity for community outreach. This requires staff who can speak the relevant languages and understand the cultural issues pertaining to that community. Strong linkages with other health and social services are also critical. TB care must be integrated with access to medical care as well as adequate housing, food, education and other basic determinants of health.

Federal policies regarding immigration in general and immigrant health screening in particular, have a considerable and disproportionate impact on Toronto's TB control program. Medical services for refugees are covered for a period of two years under the Interim Federal Health (IFH) program; health coverage is provided for refugee claimants once their claim is registered (up to six weeks). However, there is currently no designated federal funding for TB outreach, treatment or follow-up of immigrants and refugees by public health units.

The current cost of Toronto's TB Control Program is $3.2 million. It is estimated that the cost of providing TB service for immigrants and refugees ranges from $1.6 million to $2.9 million annually. An infected adult has a 10 percent chance of developing TB disease throughout their lifetime; thus, the public health efforts required for TB control will continue for many decades.

A number of intensified public health activities are required over the next decade to mitigate the increased risk of developing TB, in particular MDR-TB. These should include outreach and education, promotion of prophylaxis, provision of directly observed therapy and prophylactic therapy and close coordination with the rest of the health care system to ensure intensive medical follow-up. The resources to adequately address the public health concerns arising from communities, at very high risk of TB and MDR-TB, are currently not available. This would require at a minimum, four FTE's for two years: 1.5 Public Health Nurse, 1.5 Registered Practical Nurses and one Community Outreach Worker.

TB cases arising from the influx of such refugees will require close monitoring through directly observed therapy (DOT) for a minimum of six months. Those with MDR-TB will require DOT for 18-24 months; three times longer than a drug-sensitive case. Contacts of MDR-TB patients who develop TB infection may require directly observed prophylactic therapy (DOPT) to prevent their infection from progressing to active disease. This is particularly important for children and individuals who are immuno-compromised who are more likely to develop severe disease very rapidly. In addition, an infection rate of over 90 percent requires rigorous post-landing surveillance at two-three interventions per person. The resources to carry out the above measures were not anticipated at the time the harmonization request was put forward.

As more refugees from this or other high risk groups come to Toronto, it is essential that Toronto Public Health's TB control program be adequately resourced to protect our community. Preventing even one outbreak of MDR-TB will more than pay for the additional resources requested at this time.

At this point Toronto Public Health receives no federal funding for TB. Other jurisdictions do receive direct financial support from the federal level of government. For example, the TB program in New York City receives 60 percent of its funding from the federal government. In part this reflects the different organization of health and social services in the United States. However, it recognizes both the national interest in TB services, particularly related to immigration, and the unique situation of New York City. Like Toronto, New York is a major destination for immigrants and refugees, and has the largest TB caseload in the country. New York's TB problem became extremely severe, with outbreaks of MDR-TB, before the infusion of federal funds. Toronto needs this kind of federal support now in order to prevent a similar resurgence of TB and outbreaks of MDR-TB here.

Municipal Services to Immigrants and Refugees:

In a February 1999 report, "The Need for Federal Funding Assistance for Municipal Services to Immigrants and Refugees", the Commissioner of Community and Neighbourhood Services estimated that the City of Toronto provides social assistance, emergency shelter and public health services for immigrants and refugees at an approximate net cost of $30 million per year. As a key destination for newcomers to Canada, it is critical that the City of Toronto continue to provide supports and services to this population. The issue is not whether these services should be provided, but which level of government has access to adequate resources to appropriately fund these services to best meet newcomer needs and those of the host communities.

The City of Toronto has endorsed the recommendations pertaining to municipalities of the Legislative Review Advisory Group established in 1996 by the federal government to review legislation relating to immigration and the protection of refugees. Of particular interest is the recommendation that the federal government reimburse municipalities for the costs associated with providing social assistance, emergency shelter and other services. The Association of Municipalities of Ontario is also in support of the City of Toronto's request for Federal support for Toronto Public Health's TB Control Program (see attached). Unfortunately, no progress has been made on this issue to date.

Conclusions:

Toronto prides itself on being an international city. As such, however, we experience three times the national rate of TB. The World Health Organization has declared TB a global health emergency. The recent influx of Tibetan refugee claimants who have a high rate of TB and MDR-TB serves to highlight the need for a strong infrastructure to prevent and control TB. This requires changes to the federal policies regarding immigrant and refugee health screening.

In addition, despite expansion of Toronto's TB Control Program to meet the minimum provincial mandatory requirements, Toronto Public Health does not have adequate resources to prevent and control TB in the city's high-risk groups particularly for intensive influxes of refugees from TB-endemic areas. Federal funding for TB work related to all high-risk immigrants and refugees is critical.

Contact Name:

Dr. Barbara Yaffe

Director, Communicable Disease Control and Associate Medical Officer of Health

Tel.: 392-7405/Fax: 392-0713

(Communication dated August 5, 1999, from Mr. Michael Power,

President, Association of Municipalities of Ontario to

The Honourable Allan Rock, Minister of Health, referred to

in the foregoing report.)

I am writing to support the City of Toronto's request for the urgent need to devote more resources to combat the rate of Tuberculosis disease in Toronto.

The City of Toronto faces approximately 500 cases per year which result in about 20 preventable deaths. Toronto's Tuberculosis threat is augmented by the increasing number of immigrants moving to Toronto which could be carrying the disease.

AMO supports the City of Toronto's request that the federal government play a larger role in addressing Tuberculosis disease.

--------

Dr. Barbara Yaffe, Director, Communicable Disease Control and Associate Medical Officer of Health, gave a presentation to the Board of Health in connection with the foregoing matter.