Once thought a “romantic disease” (1) and long since forgotten in popular culture, tuberculosis (TB) continues to be the world’s leading infectious cause of death that killed 1.4 million people in 2021 (2). With its latest general population incidence rate being 5.3 active TB cases per 100,000 in 2021, Canada is considered a low-incidence country and has been since the 1980s (3, 4). While incidence numbers are indeed relatively low within the general Canadian population, they do not reflect the deep inequities in the distribution of the TB burden (5). The vast majority of new TB infection diagnoses each year are among newcomers to Canada and Indigenous people, outlining how tuberculosis remains a disease of poverty, targeting marginalized populations disproportionally (5–7).

In 2001, Canada adopted the Stop TB Partnership goal of eliminating TB as a public health threat by 2030 (8), and in 2014, the country signed the World Health Organization (WHO)‘s Action Framework for Low-Incidence Countries for the pre-elimination goal of less than 1 TB case per 100,000 by 2035 (2, 9). Part of the path outlined by the WHO to reduce tuberculosis impact and eventually reach TB elimination in low-incidence countries such as Canada includes the detection and management of latent tuberculosis infection (LTBI) among higher-risk groups (10–13). Indeed, in low-incidence countries, most new active TB cases are due to the reactivation of LTBI. This makes people living with LTBI, while non-contagious, a reservoir for future active TB cases and possible subsequent transmission (13). For reference, a summary of the major differences between LTBI and active TB is outlined in Table 1.

Between 2013 and 2020, 70–72% of TB cases diagnosed in Canada were among individuals born outside of the country, and 42% of those cases occurred within 5 years of arrival (4, 5). For a variety of reasons, including a higher likelihood of being born in an area of high incidence and migrating through precarious conditions, refugees are at increased risk of tuberculosis infection compared to other newcomer categories (such as certain skilled workers or international students) (14). The most recent 2022 Canadian tuberculosis guidelines recommend targeted LTBI screening for refugees aged up to 65 years (15). In the absence of a formal national immigration LTBI screening and management program in Canada, the management of LTBI among refugees varies by province and is left to the discretion of healthcare providers (14, 16).

In Saskatchewan (SK), TB management (including LTBI) has been centralized through the provincial Tuberculosis Prevention and Control (TBPC) program since the 1980s (17). Until the establishment of the Refugee Engagement and Community Health (REACH) clinic in 2017, all TB regimen prescriptions were done exclusively by TBPC’s TB consultants, and no specific TB program for refugees existed. The REACH clinic is housed within the Saskatoon Community Clinic, which, since its inception in 1962, has been instrumental in the development of Medicare in Canada and in providing access to care to marginalized populations (18). REACH’s mandate is to provide all refugees resettling in Saskatoon with primary and pediatric healthcare through multidisciplinary teams (including interpreters, settlement agencies, and other community partners) for a duration of 12–18 months post-arrival to Canada. The clinic is staffed by providers with additional training in refugee health, trauma-informed care, and infectious diseases. With a population of 266,141 in 2021 (19), Saskatoon is Saskatchewan’s largest city and receives an average of 250–500 refugees per year, depending on world events and the Canadian federal government’s commitment to refugee resettlement.

The REACH clinic is thus well positioned to perform LTBI screening and management for refugees in Saskatoon. Since its creation in 2017, it has worked collaboratively with the province’s TBPC program to design an LTBI program dedicated to this population. REACH’s physicians screen patients as per the Canadian TB standards (15) and manage identified LTBI cases within the clinic, allowing for community-based LTBI treatment and follow-up. Later, REACH patients are followed for LTBI at their primary care home and by their own physician, with TB medications dispensed by the REACH clinic’s partner pharmacy located in the same building. In accordance with national and provincial guidelines (20), TB treatment and support are provided free of charge regardless of the patients’ insured status or immigration documentation (21).

In this study, the primary purpose was to assess the outcomes of the REACH clinic’s LTBI community treatment program in terms of treatment acceptance and completion.

Ethical approval for this project was received from the University of Saskatchewan Biomedical Ethics Board (Bio-REB ID number 2616).

Of the 78 patients who were tested for LTBI, those who had a positive test result, those who did not receive TB treatment prior to resettlement, and those who were not transferred to TBPC, n = 12 (15.3%) were not included in the final chart review due to missing information on treatment acceptance and outcome. Missing information was due to moving out of the province prior to discussing management options, deferring treatment due to breastfeeding or pill burden due to other conditions and not knowing if treatment was accepted later on, awaiting further investigation prior to offering LTBI treatment, or unknown reasons.

Of the remaining 66 patients offered LTBI treatment, n = 56 (84.9%) accepted LTBI treatment, and n = 10 (15.1%) declined treatment to opt for medical surveillance. Reasons for declining treatment included concerns regarding side effects related to pregnancy or non-specified. All patients who declined treatment were adults (age > 18 years old), leading to a statistically significant difference (p = 0.02) between adults and children (age < 18 years old) when it came to treatment acceptance. Treatment acceptance did not vary significantly in association with gender, categories of refugees, WHO region of origin, or year of arrival to Canada (p >0.05).

Of those 56 patients who chose and initiated treatment, n = 3 (5.3%) moved out of the province before treatment completion and were transferred to other provincial TB programs, n = 2 (3.5%) had accepted the treatment but not started prior to study completion, and n = 6 (10.7%) had ongoing treatment at the time of analysis. The final number of 45 remaining patients was used to examine LTBI treatment outcomes (completion vs. non-completion).

Of those 45 patients, n = 42 (93.3%) completed their respective LTBI treatment. Reasons for non-completion included being lost to follow-up (n = 2 or 4.4%) and treatment discontinued before completion with reasons not documented in the chart (n = 1 or 2.2%).

Treatment completion outcome did not significantly vary by age, gender, categories of refugees, WHO region of origin, or year of arrival to Canada (p >0.05). Outcomes were also analyzed for different LTBI treatment regimens (3HP, 3HR, 4R, and 9H), and no statistically significant difference was found between these four groups (p > 0.05).

Table 3 outlines the outcomes by demographic data for treatment acceptance and completion and treatment completion by each LTBI treatment regimen with their associated respective value of ps.

As outlined in the previous section, LTBI screening test positivity was 23.9% (n = 125 positive tests out of n = 523 patients screened). Screening test positivity for IGRA and TSTs specifically were 22.3% (n = 117) and 24.2% (n = 8), respectively.

This study sought to evaluate LTBI screening and treatment in our local refugee population, with care delivered by a specialized refugee clinic and additional community support. The Canadian TB standards indicate the minimal acceptable LTBI treatment delivery outcomes as follows: 80% of those eligible for LTBI prophylaxis accept treatment, and of those who accept treatment, at least 80% complete treatment (30). In our population, treatment acceptance was 84.8%, and treatment completion was greater than 90%, regardless of the regimen chosen. These rates compare favorably to other previous estimates in Canada. A study conducted in Edmonton in a refugee clinic implementing systematic LTBI screening of GARs found that 96% accepted treatment and 73% completed therapy with no difference noted between 9H and 4R regimens (31). Of the 45 eligible patients at BridgeCare Clinic in Winnipeg, 75% accepted therapy for LTBI and 79% completed 9H (32).

Recently, with shorter TB treatment regimens being preferred, LTBI treatment completion rates have generally improved. Another study done at BridgeCare examined their TB program outcomes with 4R and 3HP LTBI treatment regimens (33). Their reported treatment acceptance and completion rates were both 90%, a notable improvement compared to the previous study. LTBI treatment completion rates at REACH showed a trend of shorter treatment regimens having higher completion rates (despite no statistical difference between regimens with value of ps >0.05); though the numbers were small, treatment with 9H was still associated with a completion rate of >90%.

Interestingly, treatment acceptance was statistically different between adults and children (p = 0.02). Although underlying explanations for this difference were not explored, children are generally at higher risk of developing active TB (23) compared to adults, and this would have been discussed with caregivers, perhaps leading them to favor treatment initiation. Other Canadian studies mentioned above did not include pediatric-specific data.

Integrated patient-centered refugee care is another factor that has been acknowledged as being important in optimizing LTBI treatment success (34). At the REACH clinic, the medical team has adopted a multidisciplinary approach by working closely with nursing, in-house pharmacy, laboratory medicine, and medical imaging to create a medical home for the patients. The primary care team at REACH is responsible for TB screening and treatment, which allows patients to have sustained contact with their primary care providers and continuity of care as it relates to integrating LTBI management with ongoing medical care. The use of trained interpreters at every visit and medical staff espousing principles of culturally sensitive care are other aspects of patient-centered care at REACH. Finally, a vital asset has been the partnership with local settlement agencies and their case workers, who help coordinate care and remove barriers for patients, including language, transportation, medication funding, health literacy, and lack of familiarity with the healthcare system. The care workers from the settlement agencies act as community health workers (CHWs) and form an essential part of the clinic’s care team. This emphasis on relational care and supporting vulnerable people has been well studied in the treatment of chronic conditions in resource-poor areas (35) and could be a key strategy in reducing TB incidence in North America as well.

Historically, there has been some skepticism regarding the effectiveness of identifying and treating LTBI cases among refugees and immigrants resettling in low-incidence countries (36). However, this study and others (31–33) 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%. In another study of a large community health center caring for over 124,000 patients, of which a large proportion comprised non-US-born immigrants, a number of electronic record and education interventions were implemented in order to reduce barriers to LTBI identification and management (38). These led to increased LTBI screening and treatment over a 10-year period. It offers yet another example of how primary care can help drive TB elimination in low-incidence countries such as Canada and the US.

Having said that, the challenges encountered at REACH over the last several years have been numerous, largely involving the need for more resources. Given the complexity of patient difficulties being discussed, communication through interpreters, and the need to get some sense of the patients’ understanding and experience of health issues, appointment times at REACH tend to be longer and often require multiple visits. All levels of staff at the clinic need to be mindful of the diverse health literacy skills of the patients, which requires continued effort and education. The pharmacy, in particular, has had to refine its communication and problem-solving skills as the potential for medication errors is significant. Given the importance of the CHWs at the settlement agencies and their role in facilitating patient care, communication between them and the clinic physicians must be direct and timely. This level of coordination and teamwork requires regular meetings to discuss successes and, more importantly, to troubleshoot challenges such as missed appointments, increasing in-person interpreters, and coordination of healthcare services.

Our study population’s LTBI test positivity was 23.9% overall. This is lower than previous reports from refugee clinics in Canada, which had prevalence rates ranging from 34 to 53% (31). However, during the study period, at least half of the patients that were seen at the clinic were from the eastern Mediterranean, a region described by the WHO as having a TB incidence of 112/100,000 (compared to 226/100,000 in sub-Saharan Africa) (34). A study of Syrian newcomers to Canada showed an LTBI prevalence rate of 9% (39). Significant variability in reported TB prevalence rates is to be expected based on the years of arrival and countries of origin (40).

Screening and treatment of LTBI among refugee patients can be an effective contribution to the goal of TB elimination in low-incidence countries. The REACH clinic espouses a multidisciplinary approach addressing barriers to care and a commitment to patient-centeredness and continuity of care. Given that TB is a disease rooted in social inequity, this emphasis on relational care and community support of vulnerable patients is critical. The shorter duration of LTBI treatment regimens is also contributing to high completion rates and, in combination with specialized refugee care, represents a path forward for LTBI management among this population.

This study has a number of limitations. The retrospective design and chart review methodology bring their usual constraints, including missing or incomplete documentation and a relatively small number of participants, especially in the 3HP treatment group. Our study window was during a time when preferred treatment regimens were shifting, and therefore, we may not have captured differences in treatment completion outcomes among treatment regimens. The study period also occurred during the COVID-19 pandemic, thus reducing new refugee arrivals to Saskatoon. Because of our small sample size, the findings may not be reproducible or generalizable to other settings. Certainly, a qualitative study examining patients’ experience of care at REACH and, more specifically, concerning LTBI management would give us helpful insights into how treatment acceptance and completion could be improved further and offer avenues for future research. Furthermore, exploration of pediatric qualitative data in terms of treatment acceptance and why they contrast among adults would be valuable.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the University of Saskatchewan Biomedical Ethics Board (Bio-REB ID number 2616). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.