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ReviewCMAJ
CMAJ© 2010 Canadian Medical Association or its licensors
1
There are more than 200 million international migrantsworldwide,1 and this movement of people has implica-tions for individual and population health.2 The 2009
United National Development Report3 suggests migration ben-efits people who move through increased economic and educa-tion opportunities, but migrants frequently face barriers to localservices. In Canada, international migrants are a growing andeconomically important segment of the population (Table 1).
Immigrants to Canada are a very heterogeneous group.Upon arrival, new immigrants are healthier than the Canadian-born population because of immigrant selection processes andpolicies, and socio-cultural aspects of diet and health behav-iours. However, there is a decline in this “healthy immigranteffect” after arrival. Refugees are at risk for a rapid decline inhealth after arrival (odds ratio [OR] 2.31, 95% confidenceinterval [CI] 1.1–4.9) as are low-income immigrants (OR 1.5,95% CI 1.3–1.7).4–9 There is an increased risk of reporting poorhealth among immigrants with limited English- or French-lan-guage proficiency (OR 2.0; 95% CI 1.5–2.7), those with cost-related barriers to health care (OR 2.8; 95% CI 1.7–4.5),10 low-income immigrants7 and non-European immigrants (OR 2.3,95% CI 1.6–3.3).5 Compared with the Canadian-born popula-tion, subgroups of immigrants are at increased risk of disease-specific mortality: southeast Asians from stroke (OR 1.46;95% CI 1.00–1.91),11 Caribbeans from diabetes (OR 1.67;95% CI 1.03–2.32) and infectious diseases (e.g., Caribbeansfrom AIDS: OR 4.23; 95% CI 2.72–5.74), and men from livercancer (OR 4.89; 95% CI 3.29–6.49).12
The health needs of newly arriving immigrants and refugeesoften differ from Canadian-born men, women and children.Prevalence of diseases can differ on the basis of disease expo-sure, migration trajectories (Figure 1), living conditions andgenetic predispositions. Language and cultural differencesalong with lack of familiarity with preventive care and theCanadian health care system can impair access to appropriatehealth care services,13 and patients might present with condi-tions or concerns that are unfamiliar to local practitioners.4,12
Many low-and middle-income countries have yet todevelop their primary health care systems,3 and this underde-
velopment is a source of health inequities.14 We refer to thesecountries in the guidelines as “developing.”
Why are immigrant guidelines needed?
Canadian immigration legislation requires that all permanentresidents, including refugees, refugee claimants and some tem-porary residents, have an immigration medical examination.Screening is undertaken to assess potential burden of illnessand a limited number of public health risks. The examinationis not designed to provide clinical preventive scre ening, as is
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Canadian Guidelines for Immigrant Health
Summary of clinical preventive care recommendations fornewly arriving immigrants and refugees to Canada
Kevin Pottie MD MClSc, Peter Tugwell MD MSc, J. Feightner MD MSc, Vivian Welch MSc PhD,Christina Greenaway MD MSc, Helena Swinkels MD MHSc, Meb Rashid MD, Lavanya NarasiahMD MSc, Laurence J. Kirmayer MD, Erin Ueffing BHSc MHSc, Noni E. MacDonald MD MSc; for theCanadian Collaboration for Immigrant and Refugee Health
From the Departments of Family Medicine and Community Medicine (Pot-tie), Department of Internal Medicine (Tugwell), Institute of PopulationHealth (Ueffing), University of Ottawa, Ottawa, Ont.; Department of FamilyMedicine (Feightner), University of Western Ontario, London, Ont.; Instituteof Population Health (Welch), University of Ottawa, Ottawa, Ont.; Divisionof Infectious Diseases and Clinical Epidemiology and Community ServicesUnit (Greenaway), SMBD Jewish General Hospital, McGill University, Mon-tréal, Que.; Department of Family Practice, University of British Columbia,Vancouver, BC, and Medical Health Officer, Fraser Health Authority, Fraser,BC (Swinkels); Department of Family and Community Medicine (Rashid),University of Toronto, Toronto, Ont.; PRAIDA Clinic site Côtes-des-Neiges,Que., and CSSS de la Montagne (Narasiah); Department of Psychiatry (Kir-mayer), McGill University, Montréal, Que., and Department of Pediatrics(MacDonald), Dalhousie University, Halifax, NS
CMAJ 2010. DOI:10.1503/cmaj.090313
Key points
• Although most migrants arrive in good health, certainsubgroups face health risks because of differing diseaseexposures, genetic predispositions, social and culturaldeterminants, and impaired access to appropriatepreventive and curative health services.
• Preventive health care topics that focused on inequities inhealth and clinical care gaps were chosen for study, andrecommendations were formulated using systematicevidence reviews linked to GRADE guideline development.
• Clinical preventive recommendations covering cervicalcancer, depression, contraception, hepatitis B, HIV, iron-deficiency anemia, oral health, pregnancy, tuberculosisand vision health are presented in this article.
Early release, published at www.cmaj.ca on July 26, 2010. Subject to revision.
Review
routinely performed in Canadian primary care practice, and islinked to ongoing surveillance or clinical actions only fortuberculosis, syphilis and HIV.4
The United States Preventive Services Task Force and theCanadian Task Force on Preventive Health Care have pro-duced many high-quality clinical preventive recommenda-tions, but these statements have not explicitly considered theunique preventive needs and implementation issues for spe-cial populations such as immigrants and refugees. Evidence-based recommendations can improve the uptake and healthoutcomes related to preventive services, even more so whenthey are tailored for specific populations.15 Immigrant-spe-cific, evidence-based clinical guidelines have been scarce,16
and these guidelines are designed to address this gap.In recent years, there has been an increase in development
of practice guidelines for international migrants.17 Notablepublications include Cultural Competency and Health,18
Immigrant Medicine19 and guidelines for refugees from theAustralasian Society for Infectious Diseases.20 Many havebeen designed to address diseases and conditions of publichealth importance,20–22 and some have begun to highlight theimportance of psychosocial problems and mental illness,issues of women’s health and chronic noninfectious dis-eases.18,23 These guidelines have emerged from a descriptivesynthesis of the literature by an expert (or experts) in the fieldand often in response to particular refugee or migratorymovements.17 Other practice guidelines have grouped domes-tic minority, ethnic and immigrant populations, developingstrategies to improve communication (e.g., interpreters),responsiveness to sociocultural background (e.g., culturalcompetence), empowerment (e.g., health literacy), monitoring(e.g., health and access disparities) and strategies for compre-hensive care delivery.18 Use of evidence-based methods hasyet to affect the field of migration medicine substantially.
CMAJ2
Table 1: Classification of international migration to Canada (2007)4*
Immigration category
Annual migration†
(no.)
Permanent residents
Economic class (business and economic migrants)
131 000
Family class (family reunification) 66 000
Humanitarian class (refugees resettled from abroad or selected in Canada from refugee claimants)
28 000
Others 11 000
Total 237 000
Temporary residents
Migrant workers 165 000
International students 74 000
Refugee claimants (those arriving in Canada and claiming to be refugees)
28 000
Other temporary residents 89 000
Total 357 000
Other migrants
Total irregular migrants,‡ not annual migration
~ 200 000
Visitors ~ 30 100 000
*Numbers rounded to nearest 1000. †Unless otherwise indicated. ‡No official migration status; this population includes those who have entered Canada as visitors or temporary residents and remained to live or work without official status. It also includes those who may have entered the country illegally and not registered with authorities or applied for residence.
Permanent (immigrants) • Economic class • Business class • Family class
Voluntary, permanent,
transient
Forced migration
Transient • Migrant workers • International
students • Visitors
Refugee claimants (asylum seekers)
Convention refugees (accepted)
Migration
Figure 1: Categories of international migration to Canada.4
Review
How are CCIRH guidelines different?
The Canadian Collaboration for Immigrant and RefugeeHealth (CCIRH) explicitly aims to improve patients’ healthusing an evidence-based clinical preventive approach to com-plement existing public health approaches. Public health con-cerns and predeparture migrant screening and treatment pro-tocols were considered, but these were not the driving forcefor the recommendations. Primary care practitioners selectedtopics that considered not just burden of illness but also healthinequities and gaps in current knowledge.24 We also imple-mented evidence-based methods, which included searches forimmigrant preferences and values and the use of the GRADEapproach (Grading of Recommendations Assessment, Devel-opment and Evaluation), to formulate clinical preventive rec-ommendations.25 Evidence reviews and recommendationsfrom CCIRH focused on immigrants, refugees and refugeeclaimants, with special attention to refugees and women andthe challenges of integrating recommendations into primarycare. Migrants living without official status are particularlyvulnerable, but specific evidence on this population is lim-ited.26 The “health settlement period” for this project refers tothe first five years of residence in Canada for an immigrant orrefugee, the time in which the loss of the healthy immigranteffect begins to surface.
Development
We followed the internationally recognized Appraisal ofGuidelines for Research and Evaluation (www.agreecollabo-ration.org) as a guide for our development process. We
selected guideline topics using a literature review, stakeholderengagement and the Delphi process using equity-oriented cri-teria.24 In May 2007, we held a consensus meeting of expertsin immigrant and refugee health to develop a systematicprocess for transparent, reproducible, evidence-basedreviews. The guideline committee selected review leadersfrom across Canada based on clinical and evaluation expertiseand a willingness to sign on to a rigorous process of evidenceevaluation and guideline development (Appendix 1, availableat www.cmaj.ca/cgi/content/full/cmaj.090313/DC1).
CMAJ 3
B
Patients’ perspective
4
2
Screening
3
Adverse effects of screening
Adverse effects of treatment
A
People at risk
Early detection or
target condition
Prevention and treatment
strategies 1
Reduced morbidity or
mortality
5
Association
Intermediate outcome
6 7
Figure 2: Logic model for evidence review. *Clear rectangles designate the population targeted for screening and their related prefer-ences; shaded rectangles designate interventions and related outcomes, and circles and numbers provide points in the evidence chainthat were used to develop the search questions. Adapted from United States Preventive Services Task Force.27
Box 1: CCIRH’s 14-step process for evidence reviews25
1.Develop clinician summary table
2.Develop logic model and logic model key questions
3.Set the stage for admissible evidence (search strategy)
4.Assess eligibility of systematic reviews
5.Search for immigrant- and refugee-specific data
6.Refocus on key clinical preventive actions and logic modelkey questions
7.Assess quality of systematic reviews
8.Update systematic reviews used as references
9.Assess eligibility of new studies
10. Integrate data from search for updates
11.Synthesize final evidence bank, including drafting two keyclinical actions
12.Develop summary of findings table
13. Identify gaps in evidence and directions for future research
14.Develop clinical preventive recommendations using GRADE
Review
The 14-step evidence review process (Box 1 and Figure 2)27
used validated tools to appraise the quality of existing system-atic reviews, guidelines, randomized trials and other studydesigns. We identified patient-important outcomes and used theGRADE approach to assess the magnitude of effect on benefitsand harms and on quality of evidence. We assessed whetherbenefits outweighed harms, the quality of evidence, and valuesand preferences to minimize the potentially negative effects oflabelling on patients, families and communities (Table 2).25
Stakeholder engagementPrimary care practitioners selected topics in need of guidelines.Each review team included a topic expert; a primary health carepractitioner with expertise in immigrant and refugee health; andpediatricians, gynecologists, nurses, dietitians or communityhealth promoters as needed. A methodologist and medicallibrarian supported each review team. We sought feedback onour recommendations from selected primary care practitionersand community immigrant health brokers (Edmonton Multicul-tural Health Brokers Cooperative, representing 16 ethnic com-munities). Finally, several practitioners pilot-tested the recom-mendations in primary care practices.
Recommendations
Each of the CCIRH evidence reviews provide detailed methodsand results concerning the burden of illness for the immigrantsand refugees compared with Canadian-born populations, effec-tiveness of screening and interventions, and discussion of clini-cal considerations, basis of recommendations and gaps inresearch. Table 328-38 (found at the end of this article) summa-rizes our initial 15 CCIRH recommendations with specificcomments on how the number needed to screen and treat fornet benefits would differ for immigrant populations.
Clinical considerationsHealth risk among immigrants varies greatly with differingexposures (e.g., mosquitoes and other disease vectors, trauma
from war, poor living conditions, including water and sanita-tion), differing susceptibilities (e.g., ethnicity, comorbidityand migration stress), differing social stratifications (e.g.,race, sex, income, education and occupation), differing accessto preventive services (e.g., limited predeparture access to pri-mary care, immunizations and screening, impaired access toCanadian services associated with shortage of family physi-cians, and access issues related to linguistic and cultural barri-ers).
Soliciting migration health histories will help practitionersestimate health risks and determine appropriateness of recom-mendations. Working with interpreters, patients’ families31
and community support networks can also improve effective-ness of care. Ongoing research is needed to improve the qual-ity of population-specific evidence of many conditions.
Evidence reviews and recommendations for other topics inimmigrant health are forthcoming.
Conclusion and research needs
Immigrant populations are a very heterogeneous group.Although most migrants arrive in good health, some sub-groups are at increased risk of rapidly declining health. Thesesubgroups include refugees, women and immigrants withlow-income and language barriers. Some immigrant popula-tions have an increased prevalence of some preventable andtreatable diseases, diseases that might not be addressedbecause practitioners are unaware of these health risks andbecause immigrants are less likely to seek preventive healthservices. Guidelines were developed by CCIRH using rigor-ous evidence-based methods. Data remain limited in certainareas, and more work must be done to improve access tohealth services, but we hope this evidence-based initiativewill provide a foundation for improved preventive health carefor immigrant populations.
This article has been peer reviewed.
Competing interests: Lavanya Narasiah has received speaker fees for travelhealth presentations to GlaxoSmithKline. John Feightner has worked for thePublic Health Agency of Canada to revitalize the Canadian Task Force onPreventive Health Care. CMAJ has received payment from the Public HealthAgency of Canada for the publication of this guideline series. The series hasbeen peer reviewed by CMAJ. Peter Tugwell, Chair of the CMA JournalOversight Committee, and Noni MacDonald, Section Editor, Population andPublic Health, CMAJ, are coauthors of this article. They were not involved inthe vetting of this article before publication.
Contributors: Each of the authors was a member of the CCIRH GuidelineCommittee and played an active role in overseeing the guideline develop-ment process and in formulating the GRADE recommendations.
Acknowledgements: The authors acknowledge the expert support of AmyNolen, Leanne Idzerda, Andrea Chambers, Erika Espinoza, Britta Laslo,Maria Benkhalti and Liz Lacasse, Patty Thille, Govinda Dahal, BelindaSmith and Glenda Dare. The authors thank Community Stakeholder PartnersYvonne Chiu and Lucenia Ortiz who provided feedback on behalf of theEdmonton Multicultural Health Brokers Cooperative. The authors thankLynn Dunikowski and Jessie McGowan for their expert medical librariansupport. The authors also thank Holger Schünemann, Nancy Santesso, AndyOxman and Gordon Guyatt for their help with GRADE methods and presen-tation of findings.
Funding: The Canadian Collaboration for Immigrant and Refugee Healthacknowledges the funding support of the Public Health Agency of Canada,
CMAJ4
Table 2: Basis of recommendations (adapted from GRADE)25
Issue Process considerations
Balance between desirable and undesirable effects
Those with net benefits or trade-offs between benefits and harms were eligible for a positive recommendation
Quality of evidence Quality of evidence was classified as “high,” “moderate,” “low” or “very low” based on methodologic characteristics of available evidence for a specific clinical action
Values and preferences Values and preferences refer to the worth or importance of health state or consequences relative to following a particular clinical action
GRADE = Grading of Recommendations Assessment, Development and Evaluation.
Review
the Canadian Institutes of Health Research (Institute of Health Services andPolicy Research), the Champlain Local Health Integrated Network and theCalgary Refugee Program. The views expressed in this report are the viewsof the authors and do not necessarily reflect those of the funders. Travel andaccommodations for the Ottawa Expert Panel Conference were funded by thePublic Health Agency of Canada. The Public Health Agency of Canadafunded background papers in chronic diseases and mental illness. The Cal-gary Refugee Program, Champlain Local Integrated Network and CanadianInstitutes of Health Research (Canadian Institute of Health Services and Pol-icy Research) contributed to dissemination of the guidelines.
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4. Gushulak BD, Pottie K, Hatcher Roberts J, et al. Migration and health in Canada:health in the global village. CMAJ. In press.
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12. DesMeules M, Gold J, McDermott S, et al. Disparities in mortality patterns amongCanadian immigrants and refugees, 1980–1998: results of a national cohort study.J Immigr Health 2005;7:221-32.
13. Steele LS, Lemieux C, Clark J, et al. The impact of policy changes on the health ofrecent immigrants and refugees in the inner city. Can J Public Health 2002;93:118-22.
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15. Beach MC, Gary T, Price E, et al. Improving health care quality for racial/ethnicminorities: a systematic review of the best evidence regarding provider and organi-zation interventions. BMC Public Health 2006;6:104.
16. Pottie K, Torres S. Systematic review for guidelines for immigrants and refugees:policy report for the Public Health Agency of Canada. Ottawa (ON): CanadianCollaboration for Immigrant and Refugee Health; 2005. Available: www.ccirh.uot-tawa.ca/eng/index.html (accessed 2010 May 31).
17. Gushulak BD, MacPherson DW. Migration medicine and health: principles andpractice. Hamilton (ON): BC Decker; 2006.
18. National Health and Research Council AG. Cultural competency in health: a guidefor policy, partnerships and participation. Canberra (Australia): The Council; 2005.
19. Walker PF, Barnett ED, Stauffer WM, editors. Immigrant medicine. Philadelphia
(PA): Saunders Elsevier; 2007.20. Australasian Society for Infectious Diseases. Draft guidelines for diagnosis, man-
agement and prevention of infection in recently arrived refugees. Sydney (Aus-tralia): The Society; 2007.
21. Barnett ED. Infectious disease screening for refugees resettled in the United States.Clin Infect Dis 2004;39:833-41.
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24. Swinkels H, Pottie K, Tugwell P, et al. Selecting preventable and treatable condi-tions for guideline development for recently arrived immigrants and refugees toCanada: Delphi Consensus. CMAJ. In press.
25. Tugwell P, Pottie K, Welch V, et al. Evaluation of evidence based literature andformulation of recommendations for Clinical Preventative Guidelines for Immi-grants and Refugees in Canada. CMAJ In press.
26. San Martin C, Ross N. Experiencing difficulties accessing first-contact health ser-vices in Canada. Healthc Policy 2006;1:103-19.
27. Agency for Healthcare Research and Quality. Procedure manual. Publication No.08-05118-EF. Washington (DC): US Department of Health and Human Services;2008. Available: www.ahrq.gov/clinic/uspstf08/methods/procmanual.htm(accessed 2010 May 26).
28. Greenaway C, Narasiah L, Plourde P, et al. Hepatitis B: evidence review for newlyarriving immigrants and refugees. CMAJ. In press.
29. Pottie K, Vissandjee B, Grant J, et al. Human immunodeficiency virus: evidencereview for newly arriving immigrants and refugees. CMAJ. In press.
30. Greenaway C, Sandoe A, Vissandjee B, et al. Tuberculosis: evidence review fornewly arriving immigrants and refugees. CMAJ. In press.
31. Kirmayer LJ, Narasiah L, Ryder A, et al. Depression: evidence review for newlyarriving immigrants and refugees. CMAJ. In press.
32. Pottie K, Chambers A, Brockest B, et al. Iron-deficiency anemia: evidence reviewfor newly arriving immigrants and refugees. CMAJ. In press.
33. McNally M, Matthews D, Pottie K, et al. Common oral conditions (dental cariesand periodontal disease): evidence review for newly arriving immigrants andrefugees. CMAJ. In press.
34. Buhrman R, Toren A, Hodge W, et al. Vision health: evidence review for newlyarriving immigrants and refugees to Canada. CMAJ. In press.
35. Dunn S, Janakiram P, Blake J. Contraception: evidence review and clinical guidefor care of newly arrived immigrants and refugees. CMAJ. In press.
36. Pottie K, Nolen A, Topp P, et al. Cervical cancer: evidence review for newly arriv-ing immigrants and refugees. CMAJ. In press.
37. Gagnon A, Rousseau H, Welt M, et al. Screening during pregnancy: evidencereview for newly arriving immigrants and refugees. CMAJ. In press.
38. McAlister FA. The “number needed to treat” turns 20 — and continues to be usedand misused. CMAJ 2008;179:549.
Correspondence to: Dr. Kevin Pottie, Department of FamilyMedicine, University of Ottawa, 75 Bruyere St., Ottawa ONK1N 5C8; [email protected]
CMAJ 5
Clinical preventive guidelines for newly arrived immigrantsand refugees to Canada
This article is part of a series of guidelines for primary carepractitioners who work with immigrants and refugees. Theseries was developed by the Canadian Collaboration forImmigrant and Refugee Health.
Table 3 appears on next page.
Review
CMAJ6
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
1 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
Infe
ctio
us
dis
eas
es
Hep
atit
is B
28
Scre
en a
du
lts
and
ch
ildre
n
fro
m c
ou
ntr
ies
wh
ere
hep
atit
is B
is p
reva
len
t (≥
2%
h
epat
itis
BsA
g p
osi
tive
) fo
r ch
ron
ic in
fect
ion
wit
h
hep
atit
is B
(H
BsA
g)
to b
oth
d
ecre
ase
dis
ease
sev
erit
y an
d
inci
den
ce o
f h
epat
oce
llula
r ca
rcin
om
a, a
nd
to
dec
reas
e tr
ansm
issi
on
of
hep
atit
is B
in
fect
ion
. In
th
ose
fo
un
d t
o h
ave
chro
nic
hep
atit
is B
infe
ctio
n,
refe
r fo
r ev
alu
atio
n a
nd
as
sess
men
t fo
r th
e n
eed
fo
r tr
eatm
ent
and
scr
een
ris
k g
rou
ps
for
hep
ato
cellu
lar
carc
ino
ma.
Lif
e lo
ng
m
on
ito
rin
g is
req
uir
ed.
Scre
enin
g a
nd
th
en t
reat
ing
ad
van
ced
ch
ron
ic h
epat
itis
B
infe
ctio
n r
edu
ces
the
dev
elo
pm
ent
of
pro
gre
ssiv
e liv
er f
ailu
re N
NT
19 (
con
fid
ence
in
terv
al [
CI]
15–
44).
Scr
eeni
ng
fo
r h
epat
oce
llula
r ca
rcin
om
a (s
ix m
on
thly
ult
raso
un
ds
± αF
P se
rolo
gic
tes
tin
g)
in c
erta
in r
isk
gro
up
s w
ith
ch
ron
ic h
epat
itis
B
infe
ctio
n d
ecre
ases
th
e ri
sk o
f m
ort
alit
y fr
om
hep
atoc
ellu
lar
carc
ino
ma
(NN
S 20
58; C
I 146
2–
4412
).
Ther
e is
a h
igh
er p
reva
len
ce
of
chro
nic
hep
atit
is B
fo
r im
mig
ran
ts a
nd
ref
ug
ees,
ra
ng
ing
fro
m 1
%–1
0%
com
par
ed w
ith
< 0
.5%
fo
r N
ort
h A
mer
ican
s.
Toxi
city
var
ies
by
trea
tmen
t re
gim
en, b
ut
mo
st t
her
apie
s ar
e w
ell t
ole
rate
d.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
pre
ven
tin
g d
eath
du
e to
h
epat
oce
llula
r ca
rcin
om
a an
d le
ss v
alu
e o
n t
he
bu
rden
o
f sc
reen
ing
an
d t
reat
men
t si
de
effe
cts.
Reg
ion
s w
her
e ch
ron
ic h
epat
itis
B is
p
reva
len
t (>
2%
) ar
e fo
un
d in
Afr
ica,
Asi
a,
East
ern
Eu
rop
e, S
ou
th A
mer
ica
and
th
e M
idd
le E
ast.
Tr
eatm
ent
of
chro
nic
hep
atit
is B
in
fect
ion
is c
om
ple
x an
d r
apid
ly e
volv
ing
; th
us,
pat
ien
ts w
ith
po
siti
ve r
esu
lts
sho
uld
b
e re
ferr
ed t
o a
n e
xper
t in
tre
atin
g
hep
atit
is B
infe
ctio
n.
Cer
tain
peo
ple
wit
h c
hro
nic
hep
atit
is B
ar
e at
incr
ease
d r
isk
of
hep
ato
cellu
lar
carc
ino
ma
(th
ose
wit
h c
irrh
osi
s, A
sian
men
>
40
year
s o
f ag
e, A
sian
wo
men
> 5
0 ye
ars
of
age,
Afr
ican
s >
20 y
ears
of
age
and
th
ose
wit
h a
fam
ily h
isto
ry o
f h
epat
oce
llula
r ca
rcin
om
a), a
nd
th
ese
peo
ple
will
ben
efit
fro
m u
ltra
son
og
rap
hy
and
αFP
ser
olo
gic
tes
tin
g e
very
six
mo
nth
s.
This
may
det
ect
hep
ato
cellu
lar
carc
ino
ma
at a
n e
arlie
r st
age
wh
en it
is m
ore
am
enab
le t
o t
her
apeu
tic
inte
rven
tio
n.
Hep
atit
is B
va
ccin
atio
n28
Scre
en a
du
lts
and
ch
ildre
n
fro
m c
ou
ntr
ies
wh
ere
hep
atit
is B
is p
reva
len
t (≥
2%
),
hep
atit
is B
sAg
po
siti
ve)
for
pri
or
imm
un
ity
to h
epat
itis
B
(an
ti-H
Bc,
an
ti-H
Bs)
an
d
vacc
inat
e th
ose
fo
un
d t
o b
e su
scep
tib
le (
neg
ativ
e fo
r al
l th
ree
mar
kers
of
HB
sAg
, an
ti-
HB
c an
d a
nti
-HB
s) t
o d
ecre
ase
mo
rbid
ity
and
mo
rtal
ity
and
tr
ansm
issi
on
of
hep
atit
is B
.
Un
iver
sal p
erin
atal
an
d
child
ho
od
vac
cin
atio
n in
h
epat
itis
-B-e
nd
emic
co
un
trie
s h
as r
esul
ted
in d
ram
atic
re
du
ctio
ns
in c
hro
nic
hep
atit
is
B in
fect
ion
(N
NV
12;
CI 1
1–12
) as
wel
l as
dec
reas
ed m
ort
alit
y d
ue
to h
epat
oce
llula
r ca
rcin
om
a (N
NV
217
391
; CI
174
825–
340
599)
aft
er 1
5 ye
ars
of
inst
itu
tio
n.
In
cou
ntr
ies
wit
h lo
wer
p
reva
len
ce o
f h
epat
itis
B,
vacc
inat
ion
of
adu
lts
dec
reas
es
dev
elo
pm
ent
of
acu
te h
epat
itis
B
infe
ctio
n.
Sid
e ef
fect
s o
f va
ccin
atio
n a
re m
ino
r an
d
self
-lim
ited
.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
red
uci
ng
dis
par
ity
of
chro
nic
h
epat
itis
B in
fect
ion
, a
pre
ven
tab
le a
nd
hig
h-
bu
rden
dis
ease
, an
d m
ore
va
lue
on
pro
tect
ing
fam
ily
and
fri
end
s th
an o
n t
he
bu
rden
of
scre
enin
g a
nd
va
ccin
atio
n.
A la
rge
pro
po
rtio
n (
20%
–80%
) o
f im
mig
ran
ts f
rom
co
un
trie
s w
her
e ch
ron
ic
hep
atit
is B
is p
reva
len
t is
no
nim
mu
ne
and
th
us
at r
isk
for
hep
atit
is B
infe
ctio
n if
ex
po
sed
. Im
mig
ran
ts a
re m
ore
like
ly t
o b
e ex
po
sed
to
hep
atit
is B
vir
us
in t
hei
r h
ou
seh
old
s an
d d
uri
ng
tra
vel t
o c
ou
ntr
ies
wh
ere
hep
atit
is B
is p
reva
len
t an
d w
ou
ld
ther
efo
re b
enef
it f
rom
vac
cin
atio
n.
7
Review
CMAJ 7
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
2 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
HIV
29
Scre
en f
or
HIV
, wit
h in
form
ed
con
sen
t, a
ll ad
ole
scen
ts a
nd
ad
ult
s fr
om
co
un
trie
s w
her
e H
IV is
pre
vale
nt
(> 1
%)
to
red
uce
mo
rbid
ity
and
m
ort
alit
y. L
ink
HIV
-po
siti
ve
peo
ple
to
HIV
tre
atm
ent
pro
gra
ms
in a
sso
ciat
ion
wit
h
po
st-t
est
cou
nse
llin
g.
The
dec
isio
n t
o s
cree
n m
en a
nd
w
om
en f
or
HIV
is b
ased
on
a
dra
mat
ic r
edu
ctio
n in
mo
rtal
ity
wit
h t
reat
men
t w
ith
a
com
bin
atio
n o
f 3
v. 2
an
tire
tro
vira
ls (
NN
T =
132;
CI
91–3
57)
and
red
uct
ion
of
hig
h-
risk
beh
avio
urs
(N
NT
5; C
I 4–7
).
Ther
e is
a h
igh
er p
reva
len
ce
of
HIV
infe
ctio
n in
imm
igra
nts
fr
om
co
un
trie
s w
her
e H
IV i
s p
reva
len
t (>
1%
) co
mp
ared
w
ith
Can
adia
ns
(< 0
.6%
).
Har
ms
incl
ud
ed a
dve
rse
dru
g
reac
tio
ns,
req
uir
ing
ch
ang
e in
re
gim
en.
Dat
a o
n h
arm
s re
late
d t
o
anxi
ety
and
po
ssib
le
dis
crim
inat
ion
rel
ated
to
HIV
st
atu
s ar
e n
ot
avai
lab
le.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
iden
tify
ing
HIV
-po
siti
ve
wo
men
an
d m
en f
or
app
rop
riat
e tr
eatm
ent,
su
pp
ort
an
d p
reve
nti
on
, les
s va
lue
on
un
cert
ain
risk
of
cou
ple
dis
cord
an
d r
isk
of
dis
crim
inat
ion
, an
d le
ss
con
cern
fo
r b
urd
en o
f te
stin
g w
ith
info
rmed
co
nse
nt
pro
cess
.
Co
un
trie
s w
her
e H
IV is
pre
vale
nt
(> 1
%)
incl
ud
e th
ose
in S
ub
-Sah
ara
Afr
ica,
C
arib
bea
n a
nd
Th
aila
nd
. See
Wo
rld
p
reva
len
ce m
ap: h
ttp
://g
amap
serv
er.w
ho
.in
t/m
apLi
bra
ry/F
iles/
Map
s/G
lob
al_
HIV
pre
vale
nce
_200
7.p
ng
. Im
mig
ran
ts a
nd
ref
ug
ees
may
alr
ead
y b
e aw
are
of
thei
r H
IV-p
osi
tive
sta
tus
bu
t m
ay h
ave
limit
ed k
no
wle
dg
e o
f ef
fect
ive
scre
enin
g a
nd
tre
atm
ent
op
tio
ns.
H
IV-r
elat
ed s
tig
ma
and
dis
crim
inat
ion
p
uts
imm
igra
nts
an
d r
efu
gee
s at
ris
k fo
r d
elay
ed d
iag
no
sis
and
un
equ
al t
reat
men
t ra
tes
for
HIV
. Pr
ovi
din
g in
form
atio
n o
n t
he
pro
cess
o
f te
stin
g a
nd
th
e ef
fect
iven
ess
of
trea
tmen
ts c
an im
pro
ve li
kelih
oo
d o
f te
stin
g a
nd
acc
epta
nce
of
trea
tmen
t.
Som
e p
eop
le m
ay b
e in
tere
sted
in
ano
nym
ous
or
no
n-n
omin
al t
esti
ng
.
TB30
C
hild
ren
Sc
reen
chi
ldre
n an
d ad
oles
cent
s ≤
20 y
ears
of
age
from
cou
ntri
es
wit
h hi
gh in
cide
nce
of
tube
rcul
osis
(sm
ear
posi
tive
pu
lmon
ary
TB ≥
15/
100
000
popu
lati
on) a
s so
on a
s po
ssib
le
afte
r th
eir
arri
val i
n Ca
nad
a w
ith
a tu
berc
ulin
ski
n te
st;
reco
mm
end
trea
tmen
t fo
r la
tent
TB
infe
ctio
n if
fou
nd t
o be
pos
itiv
e, a
fter
rul
ing
out
acti
ve T
B.
Ad
ult
s Sc
reen
all
refu
gee
s fr
om
co
un
trie
s w
ith
a h
igh
in
cid
ence
of
TB b
etw
een
th
e ag
es o
f 21
an
d 5
0 ye
ars
as
soo
n a
s p
oss
ible
aft
er t
hei
r ar
riva
l in
Can
ada
wit
h a
tu
ber
culin
ski
n t
est.
Scr
een
all
oth
er a
du
lt im
mig
ran
ts if
th
ey
The
deci
sion
of
who
m t
o sc
reen
an
d of
fer
trea
tmen
t fo
r la
tent
TB
is b
ased
on
the
bala
nce
betw
een
the
pote
nti
al b
enef
it o
f tr
eatm
ent
(the
life
-tim
e ris
k of
in
fect
ion,
infl
uenc
ed b
y ag
e, t
he
pres
ence
of
med
ical
con
diti
ons
that
incr
ease
the
ris
k of
de
velo
pmen
t of
act
ive
TB a
nd
imm
igra
tion
cat
egor
y), v
ersu
s th
e po
tent
ial h
arm
s of
hep
atot
oxic
ity
(tha
t in
crea
ses
wit
h ag
e) a
nd t
he
poor
eff
ecti
vene
ss o
f IN
H in
m
any
sett
ings
du
e to
sub
opti
mal
up
take
of
scre
enin
g an
d tr
eatm
ent.
The
gro
up
s in
wh
om
sc
reen
ing
fo
r la
ten
t TB
sh
ou
ld
be
rou
tin
ely
per
form
ed a
nd
th
ose
fo
un
d p
osi
tive
sh
ou
ld b
e o
ffer
ed t
reat
men
t ar
e ch
ildre
n
fro
m c
ou
ntr
ies
wit
h a
hig
h
inci
den
ce o
f TB
(†N
NT
20–2
6;
Hig
h
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
scre
enin
g a
nd
tre
atin
g
late
nt
tub
ercu
losi
s in
fect
ion
to
pre
ven
t ac
tive
dis
ease
in
ind
ivid
ual
s an
d t
o p
reve
nt
tran
smis
sio
n o
f ac
tive
d
isea
se a
nd
less
val
ue t
o t
he
pra
ctit
ion
er b
urd
en o
f sc
reen
ing
an
d c
ou
nse
llin
g.
Co
un
trie
s w
ith
a h
igh
inci
den
ce o
f TB
in
clu
de
tho
se in
Su
b-S
ahar
a A
fric
a, A
sia,
C
entr
al a
nd
Sou
th A
mer
ica
and
so
me
in
East
ern
Eu
rop
e.
In p
eop
le f
ou
nd
to
hav
e a
po
siti
ve
tub
ercu
lin s
kin
tes
t ch
est
rad
iog
rap
hy
sho
uld
be
per
form
ed t
o r
ule
ou
t ac
tive
TB
. Sy
mp
tom
s (f
ever
, wei
ght
loss
, fat
igu
e an
d n
igh
t sw
eats
) an
d s
ign
s (f
ever
, w
asti
ng
, lym
ph
aden
opat
hy, a
bn
orm
al
ches
t so
un
ds)
of
acti
ve T
B s
ho
uld
be
sou
gh
t. If
act
ive
TB is
su
spec
ted
, ap
pro
pri
ate
inve
stig
atio
ns
sho
uld
be
per
form
ed.
Spec
ial a
tten
tion
sho
uld
be g
iven
to
scre
enin
g in
fant
s an
d yo
ung
child
ren
(< 5
ye
ars)
for
late
nt T
B be
caus
e, if
infe
cted
, the
y ar
e at
hig
h ri
sk o
f ac
tive
TB,
whi
ch is
mor
e di
ffic
ult
to d
iagn
ose
in t
his
popu
lati
on.
Med
ical
co
nd
itio
ns
that
incr
ease
ris
k fo
r TB
incl
ud
e H
IV, o
rgan
tra
nsp
lan
tati
on
, re
cen
t co
nta
ct w
ith
a p
atie
nt
wit
h a
ctiv
e
Review
CMAJ8
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
3 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
TB30 (
con
tin
ued
) h
ave
fact
ors
th
at in
crea
se
the
risk
of
acti
ve T
B w
ith
a
tub
ercu
lin s
kin
tes
t an
d
reco
mm
end
tre
atm
ent
for
late
nt
TB in
fect
ion
in t
ho
se
fou
nd
to
be
po
siti
ve, a
fter
ru
ling
ou
t ac
tive
TB.
†NN
H 1
34–2
68),
adu
lts
wit
h ri
sk
fact
ors
for
acti
ve T
B (†
NN
T 3–
20;
†NN
H v
aria
ble)
and
ref
uge
es <
50
year
s of
age
(†N
NT
14–2
6; †
NN
H 5
4).
Scre
enin
g fo
r la
tent
TB
and
offe
ring
tre
atm
ent
coul
d al
so b
e co
nsid
ered
for
adu
lt r
efug
ees
50–
65 y
ears
of
age
(†N
NT
26–5
3; †
NN
H
9–18
) and
oth
er a
dult
s w
itho
ut
unde
rlyi
ng m
edic
al c
ondi
tion
s <
65
year
s of
age
if t
reat
men
t ad
here
nce
coul
d be
ens
ured
and
he
pato
toxi
city
car
eful
ly m
onit
ored
to
min
imiz
e ha
rms.
A
dec
isio
n t
o s
cree
n is
a
dec
isio
n t
o o
ffer
tre
atm
ent
and
to
en
sure
tre
atm
ent
adh
eren
ce w
ith
ap
pro
pri
ate
cou
nse
llin
g a
nd
m
on
ito
rin
g.
TB, h
emat
olo
gic
mal
ign
ancy
, fib
ron
od
ula
r sc
arri
ng
on
ch
est
rad
iog
rap
h, c
hro
nic
g
luco
cort
ico
id t
reat
men
t, d
iab
etes
an
d c
hro
nic
re
nal
fai
lure
. To
pro
mo
te p
atie
nts
' saf
ety
and
ad
her
ence
, p
atie
nts
mu
st b
e in
form
ed o
f th
e ri
sks
and
b
enef
its
of
trea
tmen
t in
a c
ult
ura
lly a
nd
lin
gu
isti
cally
ap
pro
pri
ate
man
ner
.
Men
tal
healt
h a
nd
no
nco
mm
un
ica
ble
ch
ron
ic d
isea
ses
Dep
ress
ion
31
If li
nke
d t
o a
n in
teg
rate
d tr
eatm
ent
pro
gra
m, s
cree
n
adu
lts
for
dep
ress
ion
wit
h a
sy
stem
atic
clin
ical
en
qu
iry
or
valid
ated
qu
esti
on
nai
re
(PH
Q-9
or
equ
ival
ent)
to
d
ecre
ase
rate
of
dep
ress
ion
. Li
nk
pat
ien
ts w
ith
su
spec
ted
d
epre
ssio
n w
ith
an
in
teg
rate
d tr
eatm
ent
pro
gra
m a
nd
cas
e m
anag
emen
t o
r m
enta
l h
ealt
h c
are.
The
NN
T to
pre
ven
t o
ne
per
son
w
ith
per
sist
ent
dep
ress
ion
was
18
(95
% C
I 10
–91)
in s
tud
ies
of
1–12
mo
nth
s’ d
ura
tio
n.
Dep
ress
ion
tre
atm
ent
in
enh
ance
d d
epre
ssio
n-c
are
mo
del
s ac
cou
nts
fo
r an
ad
dit
ion
al 1
%–2
% r
edu
ctio
n in
d
epre
ssiv
e sy
mp
tom
s co
mp
ared
w
ith
usu
al c
are.
Th
ere
is a
sim
ilar
pre
vale
nce
o
f d
epre
ssio
n in
Can
adia
ns
and
im
mig
ran
ts a
nd
ref
ug
ees
(10.
7%),
bu
t ac
cess
to
car
e m
ay
be
an is
sue
for
imm
igra
nt
po
pu
lati
on
s.
Ther
e w
ere
no
dat
a re
po
rted
o
n h
arm
s, w
hic
h in
clu
de
pat
ien
t o
ut-
of-
po
cket
co
sts.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
scre
enin
g a
nd
tre
atin
g
dep
ress
ion
to
imp
rove
q
ual
ity
of
life
and
less
val
ue
to c
on
cern
s fo
r im
pai
ring
ra
pp
ort
in t
her
apeu
tic
rela
tio
nsh
ip a
nd
cu
ltu
ral
acce
pta
bilit
y, t
he
cost
an
d
inco
nve
nie
nce
of
add
itio
nal
fo
llow
-up
ass
essm
ents
, an
d
po
ssib
le a
dve
rse
effe
cts
or
cost
s as
soci
ated
wit
h
trea
tin
g p
atie
nts
wit
h
inco
rrec
t d
iag
no
sis.
If p
eopl
e ar
e no
t no
t ro
utin
ely
scre
ened
as
part
of
an in
tegr
ated
sys
tem
of
care
, pra
ctit
ione
rs s
houl
d re
mai
n vi
gila
nt f
or s
igns
of
depr
essi
on. T
he
maj
orit
y of
peo
ple
wit
h m
ajor
dep
ress
ion
pres
ent
prim
arily
wit
h so
mat
ic s
ympt
oms,
mos
t fr
equ
entl
y pa
in, f
atig
ue o
r ot
her
nons
peci
fic
sym
ptom
s.
Am
on
g r
efu
gee
s, d
epre
ssio
n c
omm
on
ly c
o-
occ
urs
wit
h p
ost
-tra
um
atic
str
ess
dis
ord
er a
nd
o
ther
an
xiet
y d
iso
rder
s, w
hic
h c
om
plic
ates
th
e d
etec
tion
an
d t
reat
men
t o
f d
epre
ssio
n.
Cond
uct
syst
emat
ic c
linic
al e
nqui
ry o
r va
lidat
ed q
uest
ionn
aire
in a
lang
uag
e in
whi
ch
the
pati
ent
is f
luen
t. L
ink
pati
ents
wit
h su
spec
ted
depr
essi
on t
o in
tegr
ated
tre
atm
ent
prog
ram
s an
d fo
llow
-up
wit
h a
step
ped
care
ap
pro
ach.
Ef
fect
ive
det
ecti
on a
nd
tre
atm
ent
of
dep
ress
ion
am
on
g im
mig
ran
ts a
nd
ref
ug
ees
may
als
o r
equ
ire
the
use
of
inte
rpre
ters
or
cult
ure
-bro
kers
to
iden
tify
pat
ien
t co
nce
rns,
n
ego
tiat
e ill
nes
s m
ean
ing
s, m
on
ito
r p
rog
ress
, en
sure
ad
her
ence
, an
d a
dd
ress
so
cial
cau
ses
and
co
nse
qu
ence
s o
f d
epre
ssio
n.
Review
CMAJ 9
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
4 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
Iro
n d
efic
ien
cy
anem
ia32
C
hild
ren
Sc
reen
fo
r ir
on
def
icie
ncy
in
child
ren
ag
ed 1
–4 y
ears
(w
ith
h
emo
glo
bin
) to
imp
rove
co
gn
itiv
e d
evel
op
men
t. If
ir
on
def
icie
nt,
rec
om
men
d
iro
n su
pp
lem
enta
tio
n.
Trea
tin
g c
hild
ren
wit
h i
ron
d
efic
ien
cy a
nem
ia im
pro
ves
cog
nit
ive
dev
elo
pm
ent,
wit
h
stan
dar
diz
ed m
ean
dif
fere
nce
of
0.30
: eq
uiv
alen
t to
mo
des
t
effe
ct o
f 1.
5–2.
0 in
telli
gen
ce
qu
oti
ent
po
ints
(N
NT
7;
CI 5
–14)
. Th
ere
is a
hig
her
pre
vale
nce
o
f ir
on
def
icie
ncy
an
emia
in
imm
igra
nt
and
ref
ug
ee
child
ren
(>
20%
) co
mp
ared
w
ith
Can
adia
n c
hild
ren
(<
20%
).
Sid
e ef
fect
s fr
om
iro
n tr
eatm
ent
wer
e m
inim
al.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
ensu
rin
g o
pti
mal
o
pp
ort
un
itie
s fo
r im
mig
ran
t ch
ildre
n a
nd
po
ten
tial
re
du
ctio
n o
f ed
uca
tio
n/li
tera
cy/
wag
e d
isp
arit
ies
bet
wee
n
imm
igra
nts
an
d C
anad
ian
s an
d le
ss v
alu
e to
dis
com
fort
o
f te
stin
g a
nd
ris
k o
f d
iarr
hea
fro
m t
reat
men
t.
Gro
win
g c
hild
ren
are
at
risk
fo
r ir
on
d
efic
ien
cy a
nd
rel
ated
mo
rbid
ity.
Iro
n
def
icie
ncy
in c
hild
ren
is o
ften
cau
sed
by
a co
mb
inat
ion
of
inad
equ
ate
die
t, lo
w ir
on
sto
res
at b
irth
an
d f
req
uen
t in
fect
ion
s,
lead
ing
to
an
ore
xia
and
po
or
foo
d in
take
. In
vest
igat
e ab
no
rmal
hae
mo
glo
bin
le
vels
; ver
ify
iro
n s
tore
s (f
erri
tin
) an
d
inve
stig
ate
oth
er c
ause
s o
f an
emia
if
clin
ical
ly in
dic
ated
(b
loo
d s
mea
r,
hem
og
lob
in e
lect
rop
ho
resi
s; g
luco
se 6
p
ho
sph
ate
def
icie
ncy
tes
t, c
hro
nic
infe
ctio
ns
and
oth
er n
utr
itio
nal
def
icie
nci
es).
R
ech
eck
hem
og
lob
in le
vels
fo
r re
spo
nse
to
iro
n a
fter
on
e m
on
th.
Ora
l hea
lth
33
Scre
en f
or d
enta
l pai
n (a
skin
g,
“Do
you
have
any
pro
blem
s or
pa
in w
ith
your
mou
th, t
eeth
or
den
ture
s?”)
to
red
uce
pain
. Tr
eat
dent
al p
ain
wit
h
nons
tero
idal
ant
i-in
flam
mat
ory
drug
s an
d re
fer
the
pati
ent
to a
den
tist
. Sc
reen
fo
r o
bvi
ou
s d
enta
l ca
ries
an
d o
ral d
isea
se in
ch
ildre
n a
nd
ad
ult
s (m
ou
th
exam
wit
h p
enlig
ht
and
to
ng
ue
dep
ress
or)
to
red
uce
o
ral-
rela
ted
mo
rbid
ity.
R
efer
ob
vio
us
den
tal
dis
ease
to
den
tist
or
ora
l h
ealt
h s
pec
ialis
t.
Scre
enin
g a
nd
tre
atin
g d
enta
l p
ain
lead
s to
a s
ign
ific
ant
dec
reas
e in
pai
n a
nd
sw
ellin
g
(NN
T 34
; CI n
ot
esti
mab
le).
Sc
reen
ing
an
d r
efer
rin
g f
or
trea
tmen
t fo
r d
enta
l dis
ease
led
to
a s
ign
ific
ant
dec
reas
e in
d
enta
l car
ies
(NN
T 2.
9;
CI 2
.1–3
.4).
Th
ere
is a
hig
her
pre
vale
nce
o
f d
enta
l car
ies
in n
ew
imm
igra
nt
ado
lesc
ents
(23
.0%
v.
3.5%
in C
anad
ian
s); h
ow
ever
, th
ere
are
po
ten
tial
iss
ues
re
late
d t
o a
cces
s to
den
tal
care
. Har
ms
for
pai
n c
on
tro
l
wer
e m
inim
al a
nd
incl
ud
ed
sho
rt-t
erm
ad
vers
e ev
ents
fr
om
no
nst
ero
idal
an
ti-
infl
amm
ato
ry d
rug
s. H
arm
s fo
r re
ferr
al in
clu
ded
pat
ien
t-
bo
rne
cost
s an
d
dis
com
fort
/an
xiet
y.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
red
uci
ng
den
tal p
ain
and
le
ss v
alu
e to
sm
all r
isk
of
gas
tro
inte
stin
al s
ide
effe
cts
wit
h n
on
ster
oid
al a
nti
-in
flam
mat
ory
dru
g t
her
apy.
Fo
r re
ferr
als,
th
e G
uid
elin
e C
om
mit
tee
attr
ibu
ted
mo
re v
alu
e to
re
du
cin
g o
ral h
ealt
h d
isp
arit
ies
in im
mig
ran
t co
mm
un
itie
s an
d le
ss v
alue
o
n b
urd
en o
f sc
reen
ing
an
d
po
ten
tial
co
sts
of
den
tal
care
fo
r th
e p
erso
n.
Review
CMAJ10
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
5 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
Vis
ion
hea
lth
34
Ag
e-ap
pro
pri
ate
scre
enin
g
for
visu
al im
pai
rmen
t an
d
corr
ecti
on
wit
h s
pec
tacl
es t
o
red
uce
ass
oci
ated
fu
nct
ion
al
limit
atio
n a
nd
mo
rbid
ity.
If
pre
sen
tin
g v
isio
n <
6/1
2 (w
ith
hab
itu
al c
orr
ecti
on
in
pla
ce)
refe
r th
e p
atie
nt
to a
n
op
tom
etri
st o
r o
ph
thal
mo
log
ist
for
com
pre
hen
sive
op
hth
alm
ic
eval
uat
ion
.
Un
corr
ecte
d r
efra
ctiv
e er
rors
, th
e m
ost
co
mm
on
cau
se o
f vi
sual
im
pai
rmen
t, a
re a
men
able
to
corr
ecti
on
wit
h s
pec
tacl
es
(NN
S to
fin
d o
ne
per
son
wit
h vi
sio
n w
ors
e th
an 6
/15
or
20/5
0 d
ue
to u
nco
rrec
ted
ref
ract
ive
erro
r =
19)
. Th
ere
is a
hig
her
pre
vale
nce
o
f u
nco
rrec
ted
ref
ract
ive
erro
rs
in im
mig
ran
t p
op
ula
tio
ns;
h
ow
ever
, eco
no
mic
an
d c
ult
ura
l b
arri
ers
cou
ld d
imin
ish
up
take
of
refe
rral
an
d t
he
nee
d f
or
spec
tacl
es.
Har
ms
are
min
imal
an
d
may
incl
ud
e o
ut-
of-
poc
ket
co
sts.
Ver
y lo
w
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to t
he
imp
ort
ance
of
ensu
rin
g
adeq
uat
e vi
sual
acu
ity
for
dai
ly f
un
ctio
nin
g a
nd
em
plo
ymen
t an
d d
etec
tin
g
seri
ou
s u
nd
erly
ing
ocu
lar
dis
ease
, an
d le
ss v
alu
e to
th
e b
urd
en o
f sc
reen
ing
an
d t
he
cost
of
spec
tacl
es.
Even
mo
des
t vi
sual
imp
airm
ent
(vis
ual
ac
uit
y <
6/12
) is
ass
oci
ated
wit
h s
ign
ific
ant
mo
rbid
ity.
Sp
ecia
l co
nsi
der
atio
ns
exis
t fo
r d
oin
g
visi
on
scr
een
ing
of
child
ren
< 8
yea
rs o
f ag
e. Ref
erra
l fo
r as
sess
men
t is
als
o
war
ran
ted
fo
r o
ther
ris
k fa
cto
rs f
or
blin
din
g e
ye d
isea
se, i
ncl
ud
ing
dia
bet
es,
age
> 6
5 ye
ars,
bla
cks
> 40
yea
rs, g
lau
com
a in
a f
irst
-deg
ree
rela
tive
an
d m
yop
ia
exce
edin
g –
6 d
iop
ters
.
Wo
men
’s h
ea
lth
Co
ntr
acep
tion
35
Scre
en w
om
en o
f re
pro
duc
tive
ag
e fo
r u
nm
et
con
trac
epti
ve n
eed
s an
d
pro
vid
e cu
ltu
rally
sen
siti
ve,
pat
ien
t-ce
ntr
ed
con
trac
epti
ve c
ou
nse
llin
g t
o
dec
reas
e u
nin
ten
ded
p
reg
nan
cy a
nd
pro
mo
te
pat
ien
t sa
tisf
acti
on
.
Co
ntr
acep
tive
co
un
selli
ng
led
to
im
pro
ved
pat
ien
t sa
tisf
acti
on
(NN
T 3;
CI 2
–5)
and
co
nti
nu
atio
n
rate
s (N
NT
4; C
I 3–7
). E
vid
ence
th
at in
-dep
th c
ou
nse
llin
g
red
uce
s u
nin
ten
ded
pre
gn
ancy
ra
tes
sho
ws
som
e u
nce
rtai
nty
(R
R 0
.47;
CI
0.16
–1.3
4); h
ow
ever
, th
e G
uid
elin
e C
om
mit
tee
jud
ged
th
at c
on
trac
epti
ve
con
tin
uat
ion
rat
es a
re a
n
acce
pta
ble
su
rro
gat
e fo
r u
nin
ten
ded
pre
gn
ancy
rat
es.
Ther
e is
a h
igh
pre
vale
nce
of
un
met
nee
d f
or
con
trac
epti
on
in
imm
igra
nt
and
ref
ug
ee w
omen
(7
%–3
7%).
M
inim
al h
arm
s w
ere
rep
ort
ed. T
her
e w
ere
no
dat
a av
aila
ble
on
co
up
le o
r fa
mily
d
isco
rd.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
sup
po
rtin
g in
form
ed c
ho
ice
to m
eet
futu
re f
amily
nee
ds
and
per
son
al n
eed
s o
f th
e w
om
an (
emp
ow
erm
ent)
an
d
less
val
ue
on
co
nce
rns
abo
ut
cau
sing
co
upl
e an
d f
amily
d
isco
rd.
Scre
enin
g s
ho
uld
beg
in s
oo
n a
fter
a
wo
man
’s a
rriv
al in
Can
ada.
An
un
met
n
eed
fo
r co
ntr
acep
tio
n is
hig
hly
pre
vale
nt
wo
rld
wid
e. W
om
en f
rom
dev
elo
pin
g
cou
ntr
ies
are
oft
en u
naw
are
of
emer
gen
cy
con
trac
epti
on.
Acc
epta
bili
ty o
f co
ntr
acep
tio
n a
nd
m
eth
od
pre
fere
nce
s va
ry a
cro
ss w
orl
d
reg
ion
s an
d s
ho
uld
be
con
sid
ered
in
cou
nse
llin
g (
e.g
., in
trau
teri
ne
dev
ices
are
p
red
om
inan
t in
Lat
in A
mer
ican
an
d
Car
ibb
ean
). In
so
me
com
mu
nit
ies,
co
nd
om
s m
ay h
ave
con
no
tati
on
s o
f in
fid
elit
y, p
rom
iscu
ity
or
sexu
ally
tr
ansm
itte
d i
nfe
ctio
n, o
r ar
e u
sed
on
ly
wit
h n
on
mar
ital
par
tner
s.
Giv
ing
wom
en t
hei
r m
eth
od
of
cho
ice,
p
rovi
din
g t
he
con
trac
epti
ve m
eth
od
on
si
te, a
nd
hav
ing
a g
oo
d in
terp
erso
nal
re
lati
ons
hip
imp
rove
co
ntr
acep
tive
-rel
ated
o
utc
om
es.
Review
CMAJ 11
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
6 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
Cer
vica
l ca
nce
r36
Vac
cin
atio
n a
gai
nst
HPV
: re
com
men
d v
acci
nat
ion
ag
ain
st H
PB t
o 9
–26-
year
-o
ld f
emal
es t
o r
edu
ce
inva
sive
ch
ang
es r
elat
ed
to c
ervi
cal c
ance
r.
HPV
vac
cin
atio
n p
reve
nte
d in
vasi
ve
chan
ges
rel
ated
to
cer
vica
l can
cer
(NN
V 1
39; C
I 117
–180
) in
stu
die
s w
ith
a 1
5- t
o 4
8-m
on
th d
ura
tio
n.
Ther
e is
imp
aire
d a
cces
sib
ility
to
cy
tolo
gy
scre
enin
g in
imm
igra
nt
wo
men
an
d a
hig
her
pre
vale
nce
of
HPV
infe
ctio
n in
dev
elo
pin
g
cou
ntr
ies.
Har
ms
incl
ud
ed t
reat
able
an
aph
ylax
is in
less
th
an 1
in
100
000
do
ses.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
pre
ven
tin
g c
ervi
cal c
ance
r an
d le
ss v
alu
e to
cu
rren
t ab
sen
ce o
f lo
ng
-ter
m d
ata
on
mo
rtal
ity.
HPV
infe
ctio
n is
str
ongl
y as
soci
ated
wit
h
cerv
ical
can
cer.
HPV
is c
omm
on (6
6% li
fe-t
ime
prev
alen
ce o
f on
coge
nic
stra
in o
f H
PV) a
nd c
an
be a
cqui
red
even
if it
is t
he f
irst
rel
atio
nshi
p in
volv
ing
sexu
al in
terc
ours
e fo
r bo
th p
eopl
e.
Sch
oo
l im
mu
niz
atio
n p
rog
ram
s va
ry b
y p
rovi
nce
; im
mig
ran
t g
irls
an
d w
om
en m
ay
mis
s sc
ho
ol v
acci
nat
ion
pro
gra
ms
dep
endi
ng
o
n t
hei
r ag
e at
th
e ti
me
of
arri
val.
As
wit
h al
l inj
ecta
ble
vacc
ines
, app
ropr
iate
m
edic
al t
reat
men
t sh
ould
be
read
ily a
vaila
ble
for
unco
mm
on a
naph
ylac
tic
reac
tion
s.
Cer
vica
l cy
tolo
gy36
Sc
reen
sex
ual
ly a
ctiv
e w
om
en f
or
cerv
ical
ab
no
rmal
itie
s (P
ap t
est)
to
d
etec
t an
d t
reat
inva
sive
ch
ang
es t
o r
edu
ce
mo
rbid
ity
and
mo
rtal
ity.
Iden
tify
ing
an
d t
reat
ing
ear
ly
cerv
ical
can
cer
red
uce
s m
ort
alit
y.
The
NN
S to
pre
ven
t o
ne
dea
th
fro
m c
ervi
cal c
ance
r is
349
7 (C
I 236
1 –90
909
).
Ther
e is
a s
ign
ific
antl
y lo
wer
ra
te o
f cy
tolo
gy
scre
enin
g in
im
mig
ran
t w
omen
(40
%–6
0%)
com
par
ed w
ith
Can
adia
n w
om
en
(60%
–80%
).
Har
ms
are
min
imal
an
d d
epen
d
on
th
e co
urs
e o
f th
erap
y.
Low
Th
e G
uid
elin
e C
om
mit
tee
attr
ibu
ted
mo
re v
alu
e to
p
reve
nti
ng
cer
vica
l can
cer
and
less
val
ue
to u
nce
rtai
nty
o
f si
ze o
f ef
fect
an
d b
urd
en
of
scre
enin
g o
n h
ealt
h
serv
ices
.
Sub
gro
up
s o
f im
mig
ran
t an
d r
efu
gee
w
om
en h
ave
low
er r
ates
of
cerv
ical
cyt
olo
gy
scre
enin
g. W
omen
wh
o h
ave
nev
er h
ad
cerv
ical
scr
een
ing
or
hav
e n
ot
had
cer
vica
l sc
reen
ing
in t
he
pre
vio
us
five
yea
rs a
cco
un
t fo
r 60
%–9
0% o
f in
vasi
ve c
ervi
cal c
ance
rs.
Pro
vid
ing
info
rmat
ion
to
pat
ien
ts,
bu
ildin
g r
app
ort
an
d o
ffer
ing
acc
ess
to
fem
ale
pra
ctit
ion
ers
can
imp
rove
acc
epta
nce
o
f Pa
p t
esti
ng
. Lac
k o
f p
rofi
cien
cy w
ith
th
e o
ffic
ial l
ang
uag
e as
wel
l as
dif
ficu
ltie
s w
ith
ch
ild c
are
and
tra
nsp
ort
atio
n a
re a
sso
ciat
ed
wit
h lo
wer
scr
een
ing
rat
es.
Org
aniz
ed s
cree
nin
g s
yste
ms,
incl
ud
ing
ca
ll/re
call,
imp
rove
scr
een
ing
rat
es a
nd
may
b
e p
oss
ible
to
imp
lem
ent
at t
he
clin
ic o
r p
rovi
nci
al le
vel.
Iro
n d
efic
ien
cy
anem
ia32
Wo
men
Sc
reen
fo
r ir
on
def
icie
ncy
an
emia
(w
ith
hem
og
lob
in)
in im
mig
ran
t an
d r
efu
gee
w
om
en o
f re
pro
du
ctiv
e ag
e to
imp
rove
h
emo
glo
bin
leve
ls a
nd
w
ork
pro
du
ctiv
ity.
If
th
e w
om
an is
iro
n
def
icie
nt,
rec
om
men
d ir
on
su
pp
lem
enta
tio
n.
Trea
tin
g ir
on
def
icie
ncy
an
emia
p
rovi
des
an
ave
rag
e n
et c
han
ge
in
hem
og
lob
in le
vel o
f 15
g/L
(N
NT
2;
CI 2
–3),
an
incr
ease
in f
un
ctio
n a
nd
a
net
ch
ang
e in
th
e p
rod
uct
ivit
y ra
tio
(N
NT
4; C
I 3–8
).
The
pre
vale
nce
of
iro
n
def
icie
ncy
is h
igh
er in
imm
igra
nt
wo
men
(>
15%
) co
mp
ared
wit
h
Can
adia
n w
om
en (
< 1
5%).
H
arm
s w
ere
min
imal
an
d
incl
ud
e d
iarr
hea
an
d p
erso
nal
co
sts
of
iro
n su
pp
lem
ents
.
Mo
der
ate
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
imp
rovi
ng
hea
lth
of
wom
en
of
child
-bea
ring
ag
e an
d le
ss
valu
e to
th
e u
nce
rtai
nty
ab
ou
t w
het
her
as
ymp
tom
atic
imm
igra
nt
and
ref
ug
ee w
om
en v
alu
e th
e tr
eatm
ent
ou
tco
mes
.
Imm
igra
nt
and
ref
ug
ee w
omen
are
at
hig
her
ris
k fo
r ir
on
def
icie
ncy
an
emia
p
rim
arily
bec
ause
of
hig
h p
arit
y, s
om
e lo
w-
iro
n d
iets
an
d p
aras
itic
infe
ctio
ns.
In
vest
igat
e ab
no
rmal
hae
mo
glo
bin
leve
ls;
veri
fy ir
on
sto
res
(fer
riti
n)
and
inve
stig
ate
oth
er c
ause
s o
f an
emia
if c
linic
ally
ind
icat
ed
(blo
od
sm
ear,
hem
og
lob
in e
lect
rop
ho
resi
s;
G6P
D t
est,
ch
ron
ic in
fect
ion
s an
d o
ther
n
utr
itio
nal
def
icie
nci
es).
R
ech
eck
hem
og
lob
in le
vels
fo
r re
spo
nse
to
iro
n s
up
ple
men
ts a
fter
on
e m
on
th.
Review
CMAJ12
Tab
le 3
: Can
adia
n C
olla
bo
rati
on
fo
r Im
mig
ran
t an
d R
efu
gee
Hea
lth
: Ph
ase
I rec
om
men
dat
ion
s (p
art
7 o
f 7)
Bas
is o
f re
com
men
dat
ion
Cat
ego
ry
Rec
omm
end
atio
n
Bal
ance
of
ben
efit
s an
d h
arm
s Q
ual
ity
of
evid
ence
V
alu
es a
nd
pre
fere
nce
s C
linic
al c
on
sid
erat
ion
s
Preg
nan
cy37
R
esea
rch
rec
om
men
dat
ion
to
d
evel
op
and
stu
dy
inte
rven
tio
ns
for
soci
al
iso
lati
on
fo
r p
reg
nan
t im
mig
ran
ts a
nd
ref
ug
ees
giv
en t
he
risk
fo
r m
ater
nal
m
orb
idit
y an
d in
fan
ts s
mal
l fo
r th
eir
ges
tati
on
al a
ge.
Preg
nan
t im
mig
ran
t an
d
refu
gee
wo
men
fac
e h
igh
er r
isks
o
f so
cial
iso
lati
on
(15
%)
than
C
anad
ian
wo
men
(7.
5%),
wh
ich
is
ass
oci
ated
wit
h m
ater
nal
m
orb
idit
y an
d in
fan
ts s
mal
l fo
r th
eir
ges
tati
on
al a
ge.
H
ow
ever
, no
inte
rven
tio
n
evid
ence
was
ava
ilab
le, a
nd
th
ere
is a
ris
k o
f ca
usi
ng h
arm
w
ith
so
cial
inte
rven
tio
ns
wh
en
no
evi
den
ce e
xist
s to
sh
ow
it
wo
rks.
Th
eref
ore,
the
Gui
del
ine
Com
mit
tee
supp
orts
a r
esea
rch
reco
mm
enda
tion
to
dev
elop
and
st
udy
inte
rven
tio
ns f
or p
regn
ant
wom
en a
nd s
ocia
l iso
lati
on.
Low
, no
in
terv
enti
on
ev
iden
ce
avai
lab
le.
The
Gu
idel
ine
Co
mm
itte
e at
trib
ute
d m
ore
val
ue
to
pre
ven
tin
g u
nce
rtai
n h
arm
s th
an t
o p
rovi
din
g u
nce
rtai
n
ben
efit
s in
un
stu
die
d
inte
rven
tio
ns.
Rep
ort
s su
gg
est
that
so
me
new
ly a
rriv
ed
pre
gn
ant
wo
men
are
at
incr
ease
d r
isk
for
mat
ern
al m
ort
alit
y.
Alt
ho
ug
h n
o c
linic
al a
ctio
n
reco
mm
end
atio
n is
mad
e to
ad
dre
ss s
oci
al
iso
lati
on
, pre
gn
ant
wo
men
may
ben
efit
fr
om
an
ten
atal
scr
een
ing
fo
r d
iab
etes
, d
epre
ssio
n, H
IV, h
epat
itis
B, h
epat
itis
C,
syp
hili
s, ir
on
def
icie
ncy
, hem
og
lob
in-
op
ath
ies,
ru
bel
la a
nd
var
icel
la
susc
epti
bili
ty.
Rem
ain
ing
ale
rt f
or
risk
s o
f u
np
rote
cted
/ un
reg
ula
ted
wo
rk
envi
ron
men
ts a
nd
sex
ual
ab
use
(s
pec
ific
ally
in f
orc
ed m
igra
nts
) m
ay a
lso
b
e b
enef
icia
l.
No
te: α
FP =
alp
ha-
feto
pro
tein
, CI =
co
nfi
den
ce in
terv
al, H
IV =
hu
man
imm
un
od
efic
ien
cy v
iru
s, H
PV =
hu
man
pap
illo
ma
viru
s, IN
H =
iso
nia
zid
, NN
H =
nu
mb
er n
eed
ed t
o h
arm
, NN
S =
nu
mb
er n
eed
ed t
o s
cree
n, N
NT
=
nu
mb
er n
eed
ed t
o t
reat
, NN
V =
nu
mb
er n
eed
ed t
o v
acci
nat
e, R
R =
rel
ativ
e ri
sk, T
B =
tu
ber
culo
sis.
*R
eco
mm
end
atio
ns
for
scre
enin
g w
ere
dev
elo
ped
wh
en t
her
e w
as a
rel
iab
le s
cree
nin
g t
oo
l or
if t
he
scre
enin
g m
eth
od
was
co
nsi
der
ed c
linic
ally
fea
sib
le (
e.g
., id
enti
fyin
g d
enta
l pai
n o
r u
nm
et c
on
tra c
epti
on
nee
ds)
. A
bso
lute
eff
ects
(e.
g.,
NN
T) a
re a
co
mp
aris
on
of
even
t ra
tes
bet
wee
n t
wo
tre
atm
ent
op
tio
ns
that
can
als
o b
e in
flu
ence
d b
y b
asel
ine
risk
, tim
e fr
ame
and
ou
tco
mes
.28 C
linic
al c
on
sid
erat
ion
s h
igh
ligh
t re
leva
nt
med
ical
an
d im
ple
men
tati
on
issu
es.
†Est
imat
ed N
NT
and
NN
H a
re b
ased
on
th
e fo
llow
ing
ass
um
pti
on
s: s
even
yea
rs a
fter
arr
ival
th
e an
nu
al r
isk
of
dev
elo
pin
g a
ctiv
e TB
is 0
.1%
, th
e re
lati
ve r
isk
of
infe
ctio
n in
th
e fi
rst
six
year
s af
ter
arri
val i
s h
igh
er b
ut
dec
reas
es (
RR
5.1
–1.4
), t
he
per
son
will
live
to
ag
e 80
yea
rs, t
he
effi
cacy
of
INH
is 9
0% (
in t
ho
se t
akin
g >
80%
of
do
ses)
an
d c
om
plia
nce
is 7
0%.
