title: Tuberculosis: evidence review for newly arriving immigrants and refugees.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Infectious Diseases and Clinical Epidemiology and Community Services Unit, SMBD Jewish General Hospital, McGill University, Montréal, Que. ca.greenaway@mcgill.ca
authors.forename: Christina
authors.initials: C
authors.lastname: Greenaway
authors.forename: Amelia
authors.initials: A
authors.lastname: Sandoe
authors.forename: Bilkis
authors.initials: B
authors.lastname: Vissandjee
authors.forename: Ian
authors.initials: I
authors.lastname: Kitai
authors.forename: Doug
authors.initials: D
authors.lastname: Gruner
authors.forename: Wendy
authors.initials: W
authors.lastname: Wobeser
authors.forename: Kevin
authors.initials: K
authors.lastname: Pottie
authors.forename: Erin
authors.initials: E
authors.lastname: Ueffing
authors.forename: Dick
authors.initials: D
authors.lastname: Menzies
authors.forename: Kevin
authors.initials: K
authors.lastname: Schwartzman
mesh_terms: D002170:Canada / Q000453:epidemiology; D054242:Emigrants and Immigrants; D019317:Evidence-Based Medicine; D006801:Humans; D008403:Mass Screening; D017410:Practice Guidelines as Topic; D012036:Refugees; D014376:Tuberculosis / Q000453:epidemiology* / Q000208:ethnology / Q000517:prevention & control*