Evidence-based clinical guidelines for immigrants and refugees

Infectious diseases

Many immigrants are susceptible to vaccine-preventable diseases upon arrival in Canada. For example, 30%–50% of new immigrants are susceptible to tetanus,37 32%–54% are susceptible to either measles, mumps or rubella,38 and immigrants from tropical countries are 5–10 times more susceptible to varicella,39 which has serious implications for adult immigrants.

A large proportion (20%–80%) of the immigrants who come from countries where chronic hepatitis B virus infection is prevalent are not immune and have not been immunized. In addition, immigrants are more likely to be exposed to hepatitis B virus40 in their households and during travel to countries where hepatitis B is prevalent. Immigrants from countries where chronic hepatitis B virus infection is prevalent (affecting 2% or more of the population) can benefit from screening and treatment to prevent hepatitis and hepatocellular carcinoma.

Foreign-born people account for 65% of all active tuberculosis in Canada,41 and screening and treatment for latent tuberculosis remain priorities for immigrants from countries in sub-Saharan Africa, Asia, and Central and South America.42 To promote patients’ safety and adherence to therapy, patients must be informed of the risks and benefits of treatment in a culturally and linguistically appropriate manner.43^,44 Refugees may already be aware of their HIV-positive status but may have limited knowledge of effective screening and treatment options. HIV-related stigma and discrimination45 put immigrants and refugees at risk for delayed diagnosis and unequal treatment rates for HIV infection. Immigrants are an unrecognized risk group for chronic hepatitis C virus infection and would benefit from early detection and appropriately timed treatment.46

Subclinical strongyloidiasis and schistosomiasis can persist for decades after immigration and, if left untreated, can lead to serious morbidity or death through disseminated disease.47 Serologic tests for these intestinal parasites, rather than traditional stool testing, are recommended.48 Malaria is one of the leading causes of death worldwide,49 and delay in diagnosis and treatment of Plasmodium falciparum may lead to severe disease and even death. Migrant children are especially at risk for malaria and its complications.50

Recommendations for infectious diseases are summarized in Box 1B.

Mental health and physical and emotional maltreatment

Mental health care of immigrants has emerged as one of the most challenging areas for clinicians.15 Among refugees, depression commonly co-occurs with post-traumatic stress disorder and other anxiety disorders,51 which can complicate its detection and treatment.28 Conducting a systematic clinical assessment, or using a validated questionnaire in a language in which the patient is fluent,52 is recommended if the clinician practises in an integrated system that links patients with suspected depression to treatment programs with a stepped-care approach. Effective detection and treatment may also require the use of professional interpreters or trained culture brokers (not children or other family members) to identify patients’ concerns, explain illness beliefs, monitor progress, ensure adherence, and address the social causes and the consequences of depression.28 The majority of those who experience traumatic events will heal spontaneously after reaching safety.53^,54 Empathy, reassurance and advocacy are key clinical elements of the recovery process. Pushing for disclosure of traumatic events could cause more harm than good.

The children of ethnic minorities, including some recently settled immigrants and/or refugees, are disproportionately over-screened (up to 8.75 times more likely) and over-reported as positive (up to four times more likely) for child maltreatment.55 False-positive reports could result in harm, leading to psychological distress, inappropriate family separation, impaired clinician–patient rapport and legal ramifications associated with the involvement of child protection services.56 Routine screening is not recommended; rather, clinicians should remain alert for maltreatment, either intimate partner violence or child maltreatment.

Recommendations related to mental health and maltreatment, both physical and emotional, are summarized in Box 1C.

Chronic and noncommunicable diseases

People of certain ethnic backgrounds (specifically Latin Americans, Africans and South Asians) face a twofold to fourfold higher prevalence of type 2 diabetes mellitus than white people,57 with earlier onset and poorer outcomes. People with hypertension have the most to gain from treatment of obesity, high cholesterol, hypertension and hyperglycemia. Culturally appropriate diabetes education and lifestyle interventions are effective in preventing the disease or improving disease management.58 Iron deficiency is the most common nutritional deficiency in the world,59 and immigrant women60 and children can benefit from screening and supplementation.

Dental disease is often challenging for medical practitioners, but screening and treating pain with nonsteroidal anti-inflammatory drugs can lead to better outcomes and more effective referrals for oral health care.61 In addition, there is value in recommending twice-daily tooth-brushing with fluoridated toothpaste, as some immigrants may not be familiar with this approach to oral health.62 Loss of vision is the final common pathway for all eye diseases,63 and all immigrants can benefit from having their visual acuity assessed soon after arrival in Canada.

Recommendations for chronic and noncommunicable diseases are summarized in Box 1D.

Women’s health

To prevent unintended pregnancy, screening for unmet contraceptive needs should begin soon after a woman’s arrival in Canada. Giving women their contraceptive method of choice (the intrauterine device being the most common contraceptive worldwide, although personal preferences vary), providing the contraceptive method on site and having a good interpersonal relationship all improve contraceptive-related outcomes.64

School vaccination programs vary by province, and immigrant girls and women may miss school programs for human papillomavirus vaccination, depending on their age at the time of arrival. Subgroups of immigrants, most notably South Asian and Southeast Asian women, have substantially lower rates of cervical cytology screening than Canadian-born women.65 Women who have never undergone cervical screening and those who have not had cervical screening in the previous five years account for 60%–90% of invasive cervical cancers. Providing information to patients, building rapport and offering access to female practitioners can improve acceptance of Papanicolau (Pap) testing.66

Finally, newly arrived pregnant women are at increased risk for maternal morbidity.67 We identified social isolation, risks of unprotected or unregulated work environments, and sexual abuse (specifically in forced migrants) as priority areas for research.

Recommendations related to women’s health are summarized in Box 1E.

Relative benefits and harms of vaccination

In the prevaccination era, diseases such as measles, mumps, rubella, diphtheria, pertussis, tetanus, smallpox and polio were very frequent and were a major cause of morbidity and mortality. These diseases also had enormous societal and economic costs, including time off school and work, physician visits and admissions to hospital. Childhood vaccination programs have decreased the morbidity from these diseases by more than 92%–99% and mortality by more than 99%.97 Childhood vaccination programs have repeatedly been found to be one of the most cost-effective medical interventions.96

Measles, mumps and rubella

Measle–mumps–rubella vaccine is highly effective against measles and rubella. Almost 100% of individuals are protected against measles after two doses, and more than 95% are protected against rubella after a single dose, with antibodies persisting for at least 15 years.95^,111 The effectiveness of mumps vaccine is lower and depends on the vaccine strain used, the time since vaccination and possibly the genotype of the wild type.112 In the recent US outbreaks, the effectiveness of mumps vaccine was estimated to be as low as 64% after one dose and 79% after two doses (Jeryl Lynn strain).112 Measle–mumps–rubella vaccine has been associated with fever (about 5%), febrile convulsions (0.3%), benign thrombocytopenia purpura (< 0.01%), parotitis (rarely) and arthritis (up to 25% in postpubertal women), usually within two weeks of vaccination.111^,113^,114 The frequency of adverse reactions in seronegative women, however, is higher among those who have never been vaccinated than among revaccinated seronegative women.111 In 1998 Wakefield and colleagues115 published a case series of 12 children with development disorders and chronic gastrointestinal inflammation, which sparked widespread concern that measles–mumps–rubella vaccine was associated with autism. In 2010, The Lancet fully retracted this paper from the published record, after it became clear that several elements of the paper were incorrect. In addition, several subsequent studies have shown no association between measles–mumps–rubella vaccine and autism, including a population-based study of all Danish children born from 1991 to 1998 (> 500 000 individuals) (relative risk 0.92, 95% confidence interval 0.68–1.24).116

Diphtheria, acellular pertussis, tetanus and polio

Diphtheria and tetanus vaccines are highly effective, with protective levels of antibody developing in more than 95% of individuals after a primary series. Antibodies to diphtheria, which persist for up to 10 years, wane more rapidly than those for tetanus, which persist for up to 25 years.95^,111 There is no immunologic correlate of protection for pertussis, but the clinical protective efficacy of the diphtheria, tetanus and acellular pertussis vaccine for children is about 85%.111 In over 99% of those vaccinated, protective levels of antibodies to all three serotypes of polio vaccine develop after three doses, and a one-time booster in adulthood is required to maintain immunity. For those who have received a primary series of tetanus and diphtheria vaccine, booster doses for tetanus–diphtheria vaccine (adult) are recommended every 10 years to maintain immunity.111 Individuals older than seven years of age who have not received a primary series should be given three doses of tetanus–diphtheria vaccine (adult), the first being tetanus–diphtheria–acellular pertussis, to provide protection against pertussis. In addition, during management of any wound other than clean or minor wounds, these individuals should receive a primary series of vaccine and also tetanus immune globulin.111 Given that infants constitute the group at highest risk for development of severe pertussis, that adults are the main reservoir for pertussis and that antibodies wane over time (5–10 years after a primary series), all adults should be given a one-time booster of tetanus–diphtheria–acellular pertussis.111

Local pain, swelling and erythema are common after administration of the pediatric tetanus–diphtheria–acellular pertussis vaccine and are reported in up to 40% of those vaccinated; the corresponding rates are 75% after adult tetanus–diphtheria–acellular pertussis vaccine and 60%–70% after tetanus–diphtheria vaccine. Fever occurs in less than 5% during a primary series; however, the pediatric and adult tetanus–diphtheria–acellular pertussis vaccines have not been associated with an increased risk of serious adverse events.95^,111^,117

Diagnostic tests to screen for varicella antibodies

The most widely available tests to detect antibodies to varicella zoster virus are enzyme immunoassays. These tests are less sensitive than the fluorescent antibody to membrane antibody test, but they have good specificity (> 95%). Enzyme immunoassays are sufficiently sensitive to detect protective antibodies after natural infection with varicella zoster virus (60%–92%) but are inadequately sensitive to detect protective antibodies resulting from vaccination.142 Given that the majority of adult immigrants at risk for varicella in Canada originate from countries without routine childhood vaccination programs, enzyme immunoassay is an acceptable method of screening for immunity to varicella in this population.

History of prior varicella to determine varicella immune status

The majority of adults (> 95%) who report a history of varicella are immune to the virus.143 However, a positive history of varicella may less reliably predict protective varicella antibodies in immigrant populations where varicella seroprevalence is lower than expected for age.39^,144 In adult immigrant populations, it may be more prudent to perform serologic testing on all individuals before vaccination or to vaccinate empirically (if serologic testing is not available), to avoid the potential poor outcomes associated with varicella.

Efficacy of varicella vaccination

A single dose of varicella vaccine is 80% to 85% effective in preventing disease of any severity and is more than 95% effective in preventing severe varicella.145 Vaccine efficacy for adults has been estimated at about 80%. Because of plateauing rates of varicella between 2003 and 2006 and ongoing outbreaks, despite a one-dose vaccination schedule, the United States recommended a universal two-dose childhood varicella vaccination program (first dose at 12–15 months, second dose at four to six years) in 2006.146 The National Advisory Committee on Immunization of Canada has also recently recommended that two doses of varicella vaccine be given to all children under 13 years of age.147 Adverse events associated with the vaccine include pain and redness at the injection site (22%–35%), rash (which is sometimes varicella-like; 1%–5%) and fever (4%–7%). Secondary transmission has been documented from five vaccine recipients.148 Varicella vaccine is a live attenuated vaccine that should be avoided in immunosuppressed individuals. It can be given to HIV-infected individuals with mild to moderate symptoms and a CD4 count above 200 × 10⁶/L or less than 15%.149

Effectiveness of varicella vaccination to decrease morbidity and mortality

Varicella was a common childhood illness before implementation of widespread universal childhood vaccination programs in Canada (2005) and the United States (1995). These programs have resulted in a significant decrease in the number of cases and in the number of varicella-associated hospital admissions and deaths (> 75%) in all age groups, including adults (Table 5A).135^,136^,150 A recent study of the effect of varicella vaccine in Ontario showed decreases in varicella-associated hospital admissions (by 53%, 95% confidence interval [CI] 48%–58%), emergency department visits (by 43%, 95% CI 41%–44%) and physician visits (by 45%, 95% CI 44%–45%) relative to the prevaccination period (1992–1998).150

Cost-effectiveness of varicella vaccination

Cost-effectiveness analyses of routine varicella vaccination of preschool-age children have demonstrated that the vaccine (one or two doses) is cost-saving from a societal point of view.151^,152 Most cost-effectiveness studies support serologic testing before the vaccine is given to adolescents and adults. A recent cost-effectiveness analysis of strategies to prevent varicella in adult immigrants and refugees found that various vaccination strategies were cost-saving, relative to no intervention, at the following seroprevalence thresholds: vaccinate all without prior serologic testing (threshold 84%; would include immigrant children under 13 years of age, many adolescents and some adults); provide serologic testing for all, and vaccinate those found to be susceptible (threshold 85%–92%; would include some adolescents and most adults); provide serologic testing only for those with a negative or unknown history of varicella (threshold 93%–95%) and vaccinate those found to be susceptible; and no intervention (threshold > 95%).128

What are the potential implementation issues?

We found no data specific to newly arrived immigrants or refugees. General factors associated with low uptake of varicella vaccine were similar to those for other vaccines (e.g., low socioeconomic status, low parental education, younger maternal age, lack of knowledge about the disease and vaccination, negative beliefs about and attitudes toward immunization, fear of adverse effects, lack of transport, inconvenient clinic hours), and cost was the most important barrier.122^,153 Adolescents and adults face additional barriers to vaccination relative to children, including lack of awareness of the need for vaccination, lack of routine well-adolescent or well-adult visits and lack of coordinated vaccination programs for these populations.124^,154 The two most important barriers to vaccination for adult immigrants are likely to be cost of the vaccine and lack of awareness among health care providers that adult immigrants are at increased risk for severe varicella. In certain settings, serologic testing may result in extra costs or may present a barrier to completion of the vaccination series, in which case vaccination without prior serologic testing should be offered.

The most effective interventions to improve uptake of vaccination in the general population were instituting reminder or recall systems, educating target populations and vaccine providers, and reducing out-of-pocket costs.155^,156 The most effective interventions to improve vaccination coverage among adults are standing orders and expanding access to vaccination in nontraditional settings (e.g., schools, work-places and social gathering places such as churches and sports clubs).154^,156

Screening tests

Serologic tests to detect hepatitis B virus are inexpensive, and commercially available tests are sensitive and specific.166 Antigens and antibodies associated with hepatitis B virus infection include hepatitis B surface antigen and its corresponding antibody, antibody to hepatitis B core antigen, and hepatitis B e antigen and its corresponding antibody. The most frequently used serologic markers to differentiate acute, resolving and chronic infection are heptatitis B surface antigen, the antibody to hepatitis B core antigen (immunoglobulin M for acute, immunoglobulin G for chronic or resolved) and the antibody to hepatitis B surface antigen; they should be used for initial screening for hepatitis B virus infection.167 The antibody to hepatitis B core antigen is a useful marker in the diagnosis of hepatitis B virus infection, as it appears during the course of acute infection and usually persists for life in the presence of either chronic infection (in which case the person is also positive for heptatitis B surface antigen) or resolved infection, with or without the presence of concomitant antibody to hepatitis B surface antigen.

Relative benefits and harms of treatment

Several antiviral agents that suppress chronic hepatitis B virus infection have become available over the past 10 years. Although follow-up with the newer antiviral agents has not been long enough to show improved clinical outcomes, these agents have uniformly been shown to decrease surrogate markers of chronic liver disease (normalization of alanine aminotransferase, decrease in hepatitis B DNA, loss of hepatitis B e antigen and even loss of hepatitis B surface antigen).168^–170 However, in a landmark randomized controlled trial of lamividuine versus placebo in patients with advanced liver disease and high-level viral replication, the risk of progressive liver failure (hazard ratio 0.45, p = 0.02) and of hepatocellular carcinoma (hazard ratio 0.49, p = 0.047) were both lower in the lamivudine arm than the placebo arm after a mean of 32 months of treatment (Table 6B).168 Lamivudine is well tolerated, but with prolonged use as a single agent, resistance develops progressively. Since publication of that trial, several other antiviral agents (adefovir, entecavir, telbivudine and tenofovir) have become available, all of which are relatively well tolerated and more potent than lamivudine.169^,171^–173 Treatment of chronic hepatitis B virus infection is rapidly evolving and complex; the decision of who should be treated, when to initiate therapy and which medication to use should be made by professionals with expertise in this area.171

Effectiveness of surveillance for hepatocellular carcinoma

Certain people with chronic hepatitis B virus infection (i.e., those with cirrhosis, Asian men > 40 years of age, Asian women > 50 years of age, Africans > 20 years of age and people with a family history of hepatocellular carcinoma) should be screened for hepatocellular carcinoma with ultrasonography and α-fetoprotein serologic testing every six months.172^,174 This screening will detect cancer at an earlier stage, when it may be amenable to therapeutic intervention resulting in improved survival (five-year disease-free survival of about 50% v. 0%–10%).162^,173 In a randomized controlled trial of screening every six months with ultrasonography and α-fetoprotein testing versus no screening in more than 18 000 Chinese people with positive results for hepatitis B markers, those in the screening arm had a 37% reduction in hepatocellular carcinoma–related mortality after a mean follow-up of five years. This was despite suboptimal adherence rates (< 60%) by the end of the study and represents the minimum benefit that can be expected from surveillance.175

Effectiveness of screening programs for chronic infection with hepatitis B virus (pregnant women)

Screening for chronic infection with hepatitis B is routinely recommended for pregnant women in Canada and the United States.111^,176^,177 There is good evidence that screening and giving immunoprophylaxis to infants born to mothers with chronic hepatitis B virus infection markedly decreases transmission to the newborn. In a recent meta-analysis, the risk of transmission of hepatitis B virus was 92% lower (95% confidence interval [CI] 83%–97%) among infants born to mothers with chronic hepatitis B virus infection who received hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth relative to those whose mothers received placebo.178

Effectiveness of hepatitis B vaccination to decrease morbidity and mortality

Prevaccination screening for prior immunity

From 50% to 80% of adults from countries where hepatitis B is highly endemic (prevalence of hepatitis B surface antigen ≥ 8%) and 20% to 30% of adults from countries where hepatitis B is moderately endemic (prevalence of hepatitis B surface antigen 2%–7%) will have serologic evidence of prior infection with and thus immunity to hepatitis B virus (Table 6B). Cost-effectiveness studies have shown that the “breakpoint seroprevalence” of prior hepatitis B infection, above which prevaccination screening for prior immunity is worth doing, ranges from 17% to 35%.186^,187 Therefore, it would likely be cost-effective to do prevaccination screening for prior infection among adult immigrants originating from countries that are moderately to highly endemic for hepatitis B.188 In two studies of refugee children with mean ages of 7 and 10 years, respectively, from several different world regions (Africa, former Soviet Union and Yugoslavia, Asia), the seroprevalence of hepatitis B surface antigen was 6.5% and 4%, respectively, and the prevalence of prior infection was 30% and 21%, respectively.189^,190 Although these data might not be representative of all immigrant children, they suggest that it would also be cost-effective to do serologic testing for prior infection before vaccinating children.

What are the potential implementation issues?

Studies in immigrant populations have shown that they have relatively little knowledge (40%–60%) of the importance of hepatitis B virus infection and its long-term consequences. Low proportions (< 50%) of at-risk immigrants have been screened for hepatitis B.191^,192 Similarly, low proportions of immigrants are vaccinated (24%–76%) against hepatitis B, and vaccination rates are lower among adults than among children.191^–193 Vaccination rates can be enhanced by reducing language and cultural barriers, educating immigrant and refugee populations and improving social supports for using reminder and recall interventions (these being most effective but also most costly).155^,193^,194 These barriers and limitations need to be considered to improve uptake of screening and vaccination programs among immigrants. In general, when provided with the proper education and access, immigrants and refugees seem to accept vaccines with very little “anti-vaccination” sentiment.193^–195 No data on how acceptance and compliance rates differ between cultures are available for hepatitis B treatment. Cultural and language barriers might need to be overcome to optimize the clinical impact of antiviral therapy and to minimize drug-resistant hepatitis B mutants.

Region of origin

Rates of tuberculosis are highest in immigrant populations that originate from world regions with the highest rates of tuberculosis, such as sub-Saharan Africa and Asia. Immigrants from these regions (which have rates of smear-positive pulmonary tuberculosis of 200 to 300 per 100 000 population) are more likely to be heavily exposed to tuberculosis, to have positive results on tuberculin skin testing and to have been recently exposed to tuberculosis.199^,202^–204

Immigration category

The risk of active tuberculosis in refugee populations is about double that in other immigrant populations.207^–210 This difference is probably due to both a higher prevalence of latent tuberculosis infection and to having lived in crowded conditions that increase the likelihood of recent exposure to tuberculosis.211

Presence of underlying comorbidity

Underlying medical illnesses, especially any conditions that decrease local or systemic immunity, increase the rate of active tuberculosis to varying degrees (Table 7A), with HIV being the strongest risk factor.198 The issue of HIV screening for new immigrants and refugees is discussed in section 8 of this article, below.

Time since arrival

Rates of tuberculosis in immigrant and refugee populations, from all world regions, are highest within the first five years after arrival in a low-incidence region but decrease dramatically after the first year after arrival. Rates of active tuberculosis in the immigrant population, relative to five years after arrival, are 5 to 10 times greater in the first year and twofold greater one to four years after arrival.202^–204 These higher rates are most likely caused by the effect of recent exposure to tuberculosis before arrival. A practical Web-based tool can be used to help calculate the lifetime risk of active tuberculosis on the basis of these factors (www.tstin3d.com/index.html).212

Screening tests

The tuberculin skin test and interferon gamma release assays are available for diagnosing latent tuberculosis infection. The sensitivity of these tests is estimated to be 70%–90%, and the specificity for all tests is above 95%, except for the tuberculin skin test in patients vaccinated with bacille Calmette-Guérin (specificity 60%, because of cross-reactivity).213 With tuberculin skin tests, the likelihood of a false-positive result caused by bacille Calmette-Guérin decreases with time since vaccination, but it also depends on the age when the person was vaccinated. In the first 10 years after vaccination, up to 42% of patients vaccinated after two years of age will have positive results on tuberculin skin testing (the rate being lower among those vaccinated as neonates), but data on the rate of decline are conflicting.214^–218 Among those receiving a tuberculin skin test more than 10 years after vaccination as a neonate, only 1%–2% of results will be positive, compared with 21% for those vaccinated after two years of age. Interpreting the results of a tuberculin skin test is therefore particularly difficult for children under 10 years of age. All HIV-positive patients should be screened for latent tuberculosis infection with a tuberculin skin test.198

Because there is no gold standard test for the diagnosis of latent tuberculosis infection, assessing and comparing the performance of these tests is challenging, especially when there are discrepancies. The major advantage of the tuberculin skin test is that the risk of active disease for different sizes of induration is well described, whereas very few prospective data exist for interferon gamma release assays. The most recent Canadian guidelines recommend using the tuberculin skin test as the primary screening tool for both adults and children and using interferon gamma release assays sequentially, after tuberculin skin testing, in people with a high likelihood of a false-positive result on the tuberculin skin test (i.e., low risk of tuberculosis infection).219 This recommendation is supported by a recent cost-effectiveness analysis.220 The major limitation of these tests is their inability to distinguish the 10% of people with latent tuberculosis infection in whom active tuberculosis will develop from the 90% in whom the disease will not develop.

All patients for whom the results of a tuberculin skin test are positive should undergo chest radiography to rule out active tuberculosis; they should also be questioned for symptoms of active tuberculosis (chronic cough, weight loss, fever, night sweats). If there is any suspicion of active tuberculosis, three samples of sputum or specimens from other sites (e.g., lymph node, cerebrospinal fluid) should be gathered for smear and culture before treatment for latent tuberculosis infection is started.

Relative benefits and harms of treatment

The efficacy of isoniazid relative to that of placebo in decreasing the likelihood that active tuberculosis will develop in people with latent tuberculosis infection has been established in a Cochrane review of 11 randomized controlled trials (relative risk 0.40, 95% confidence interval 0.31–0.52) (Tables 7B and 7C).221^–224 The overall efficacy of isoniazid is 62% after 12 months of treatment, but efficacy increases to 93% among those who adhere to treatment (i.e., take > 80% of their doses).223 Although the efficacy of treatment for 9 versus 12 months has not been directly compared, a recent reanalysis showed that the maximal benefit of isoniazid was achieved at 9 months (Tables 7D).225 A study on the effect of resistance to isoniazid on the efficacy of isoniazid chemopro-phylaxis showed that, at a mean prevalence of 7%–10% isoniazid resistance (the level in the immigrant population), isoniazid was the drug of choice and that only at very high rates of isoniazid resistance (> 15%–20%) were other regimens preferred.226^,227

Hepatotoxicity is a limitation of isoniazid therapy. It most commonly manifests as a transient, asymptomatic increase in liver function (10%–20%), rarely causes clinical hepatitis (0.5%) (which resolves when treatment with isoniazid is stopped224^,228^,229) and very rarely causes fulminant hepatitis and liver failure leading to death or liver transplantation (< 0.01%).230^,231 Initial higher overall rates of hepatotoxicity (1%) were reported among adults in the 1970s, but these data were likely confounded by unrecognized underlying cirrhosis. Hepatotoxicity among patients taking isoniazid is greater among those with pre-existing liver disease, alcoholism, concomitant use of hepatotoxic drugs and older age. Although clinical and fulminant hepatitis are rare, they can occur at any age. This possibility underscores the importance of monthly monitoring for all patients and of teaching them to recognize the symptoms of hepatitis (nausea, vomiting, abdominal pain, jaundice) and to stop medication as soon as worrisome symptoms occur.230^,231 Adequate time must be taken, through interpreters if necessary, to ensure that all patients are appropriately informed and understand the risks and benefits of isoniazid, and they must be given a clear description of what to do if symptoms arise.

What should be considered in screening and treatment?

What are the potential implementation issues?

Barriers to the uptake of screening and completion of treatment for latent tuberculosis infection include a combination of patient, provider and institutional factors. Patient-related barriers include the stigma of tuberculosis and its association with HIV, linguistic barriers and difficulties getting to appointments because of inconvenient clinic locations or limited clinic hours.233^–236 Provider-related barriers to offering screening to migrants are related to inadequate knowledge of which migrants should be screened and how they should be followed.237 Low adherence to treatment for latent tuberculosis infection is associated with barriers similar to those for screening for latent tuberculosis. These barriers include linguistic barriers, cultural taboos and stigmatization, low education level, perceived low risk of progression from latent tuberculosis infection to active disease, belief that positive results from tuberculin skin tests are due to bacille Calmette-Guérin, not wanting to undergo venipuncture and economic factors (costs of travel, lack of insurance, delays in obtaining insurance, missed days at work).234^,235^,238

Increased adherence to tuberculin skin test screening has been achieved with reminders to patients (e.g., letters, phone calls), education of patients and physicians, and novel strategies, such as drive-by tuberculin skin test readings for taxi drivers.237^,239 In one study, educating primary care providers about how and whom to screen for tuberculosis not only increased screening and identification of people with latent tuberculosis, but also increased identification of those with active tuberculosis. In this randomized clinical trial, screening rates were 0.4% in the nonintervention group and 57% in the intervention groups, and identification of both those with latent tuberculosis infection (9% to 19%) and those with active tuberculosis (34% v. 47%) was higher in the intervention group.237 Strategies that have increased adherence to treatment for latent tuberculosis infection in immigrant and refugee populations include patient reminders (calendar stickers for self-monitoring, phone calls, letters and directly observed therapy), adherence coaches who speak the same language as the patient, ongoing education of patients and providers, and cultural case management.43 Goldberg and colleagues240 found that when case managers were matched to the ethnic and linguistic background of patients and provided treatment for latent tuberculosis and monitoring during monthly home visits, adherence with treatment improved substantially over standard clinic-based management before the intervention (82% v. 37%).

Screening tests

Most laboratories in Canada use a two-step testing strategy for HIV. Enzyme-linked immunosorbent assays are sensitive (≥ 99%) and specific (≥ 99%) for both HIV-1 and HIV-2 after about three weeks of infection. Risk-reduction counselling (e.g., regarding condom use) has been shown to be most effective when targeted to HIV-positive or high-risk women and men.249

Relative benefits and harms of treatment

In a meta-analysis of 27 studies on behaviour change in HIV-positive women and men, Weinhardt and associates249 found decreases in high-risk sexual behaviour (including unprotected intercourse) with provision of counselling and screening (Table 8B). We were unable to find quantitative data on anxiety or depression, changes in relationships with sexual partners or discrimination associated with false-positive results.

A meta-analysis by Enanoria and colleagues256 comparing three-drug and two-drug antiretroviral treatment showed a significant decrease in mortality (risk ratio 0.62, 95% confidence interval 0.45–0.86) (Table 8C). In another meta-analysis, Siegfried and coauthors247 reported a relative risk of 1.3 for adverse events associated with antiretroviral treatment. However, most adverse events, including metabolic disturbances associated with cardiovascular events, can be ameliorated by changes in regimen or appropriate treatment.248 Evidence for a greater than 80% reduction in HIV transmission among HIV-discordant couples receiving antiretroviral treatment has been obtained from Spain, Thailand and Uganda.268 Combination antiretroviral therapy is associated with dramatic decreases in mortality, regardless of sex, race, age and risk factors for transmission.260 Recent studies have reported that voluntary counselling and testing for HIV are cost-effective in populations with HIV prevalence above 0.1%.269

What are the potential implementation issues?

Refugees and refugee claimants may delay testing and/or treatment because they fear failing to obtain legal immigration status if HIV-positive.45 Immigrants suffering from post- traumatic stress or depression could require additional social support and reassurance on many fronts before finding the treatment for HIV infection acceptable. Many HIV-positive immigrants adopt codes of silence, which precludes providing sex education to their children.45^,270 This highlights a crucial role for primary care practitioners in providing education about sex and HIV to youth.

Limited education, lower health literacy, linguistic barriers, traditional and religious beliefs,45 psychological issues that stem from HIV-related stigma, practitioners’ reluctance to offer screening tests and perceptions of low risk among women and men suffering from HIV have all been identified as factors impeding HIV testing.271 HIV-related stigma is magnified by structural inequities, sex roles, negative attitudes and discrimination by health care providers, and social attitudes in general.272 Strategies to improve access to care include sensitivity to emotional and trauma issues, provision of comprehensive and holistic care, presence of HIV-positive peer educators and integration of HIV information within settlement services.270 Qualitative studies273 have shown that most immigrant women support HIV screening procedures as part of routine medical care.

Screening tests

Widely available third-generation serologic enzyme immunoassays to detect anti–hepatitis C virus antibodies are highly sensitive (97%) and specific (99%). False-positive results occur in populations where the prevalence of hepatitis C is low, and false-negative results may occur in the setting of severe immunosuppression, such as in patients with HIV, hypogam-maglobulinemia or agammaglobulinemia; those who have undergone solid organ transplantation; or those receiving hemodialysis.278 If the result is positive, a nucleic acid test to detect hepatitis C RNA (qualitative or quantitative) should be performed to confirm the presence of circulating virus.

Relative benefits and harms of treatment

The current standard for treatment is combination therapy with pegylated interferon and ribavirin, which achieves an overall sustained virologic response of about 50% in all patients278^,287^–290 (Table 9A).290^,291 Sustained virologic response has been associated with improved clinical outcomes in patients with cirrhosis due to chronic hepatitis C virus infection. In this population, those who did not achieve a sustained virologic response had higher rates of hepatocellular carcinoma (hazard ratio [HR] 2.59, 95% confidence interval [CI] 1.13–5.97) and liver-related mortality (HR 6.97, CI 1.71–28.42) than those who achieved sustained virologic response.292^–294 The response rate, dosage of the medications and duration of treatment (ranging from 24 to 48 months) are determined by the viral genotype. For infection with genotype 1 virus, treatment response ranges from 42% to 46% and requires 48 weeks of treatment. The response is better for those with genotype 2 (74%) and genotype 3 (69%), and therapy for these genotypes is of shorter duration (usually 24 weeks).278^,288^–290^,295^,296 For other genotypes (4, 5, 6, 7, 8), the results are less well defined: they appear to be better than for genotype 1 but not as good as for genotypes 2 and 3.297^,298 The treatment is associated with numerous adverse effects, and 10% to 14% of patients discontinue therapy because of an adverse event, most commonly psychiatric symptoms or severe anemia.278^,299 Persons with advanced cirrhosis are less likely to have a response to treatment, which highlights the importance of initiating treatment before advanced liver disease develops.300^,301 Recent results for combination regimens with protease inhibitors and standard therapy have shown substantially improved efficacy (70% v. 50%) for those with genotype 1, as well as shorter treatment durations.279^,302 These new treatment options will likely change the standard of therapy in the near future, making screening and appropriately timed treatment an important strategy for controlling the burden of chronic hepatitis C virus infection. Management during therapy often requires a multidisciplinary approach, and all patients found to be positive should be referred to a health care professional with expertise in managing hepatitis C virus infection.

In most studies, screening has been found to be cost-effective only when the prevalence of hepatitis C is high (> 10%) because of the relatively poor efficacy of treatment (overall 50%), the high adverse-effect profile and the high proportion of persons ineligible for treatment because of underlying comorbidities such as substance abuse, psychiatric illness or medical diseases (37%).303 Plunkett and Grobman304 found that screening pregnant women was not cost-effective. They assumed a 1% seroprevalence of hepatitis C virus and 48 weeks of treatment with pegylated interferon and ribavirin, but they calculated only direct costs. Singer and Younossi305 also found that screening for hepatitis C virus in the general US population was not cost-effective. They assumed that the seroprevalence was 3%, that only 20% of individuals found to be positive would be given treatment (because of underlying comorbidities), that the response rate (to interferon and ribavirin) in patients with genotype 1 would be 37% and that 72% of all patients would have genotype 1. In a sensitivity analysis, however, they found that if 50% of individuals positive for hepatitis C virus started treatment, then screening would be cost-effective at a seroprevalence of 3%.304^,305 Certain ethnic groups, such as Southeast Asians, have a better response to therapy than other ethnic groups.46

In summary, we recommend routine screening for immigrant populations in whom the estimated prevalence of chronic hepatitis C virus infection is 3% or higher, given their increased risk of death from viral hepatitis and hepatocellular carcinoma, the more favourable response to treatment before development of cirrhosis (which favours early detection), the likelihood that immigrants are more likely to be eligible for treatment and the likelihood that certain immigrant groups can be expected to respond more favourably to treatment than the general Canadian population.

What are the potential implementation issues?

Few studies have evaluated immigrant populations’ knowledge of the importance of hepatitis C, its consequences and the risk factors for transmission. The data suggest that knowledge of hepatitis C is generally low and that it is significantly lower for immigrants than for nonimmigrants.306^,307 Predictors of better knowledge are higher levels of education, employment and being highly accultured.307 We found no data on the proportion of immigrants who accept screening for hepatitis C virus or their compliance with treatment of infection. In addition to potential patient barriers to the uptake of screening, there are likely important barriers that prevent primary care practitioners from recommending screening. More than half of primary care physicians have little experience in treating patients who test positive for infection, have a poor understanding of the natural history of the disease and incorrectly identify risk factors for infection.308 A large proportion (60%) of primary care physicians do not routinely ask patients about risk factors for hepatitis C on an initial visit.309^,310 Of those who did identify higher-risk patients, only 50% to 75% ordered the appropriate diagnostic tests and correctly interpreted the results.311

Screening tests

Stool microscopy for ova and parasites is the only definitive way to confirm the presence of intestinal infection with either Strongyloides or Schistosoma, but this diagnostic modality has suboptimal sensitivity. Although overall sensitivity can be improved by increasing the number of stool specimens examined, the costs associated with this approach can be substantial, and many patients are reluctant to provide multiple specimens. The sensitivity of a single stool examination to detect Strongyloides is estimated at just 30%, but this increases to over 90% when seven specimens are examined.339

By contrast, serologic testing is the most sensitive diagnostic modality to detect Strongyloides and Schistosoma, making such tests ideal screening tools. Although these tests are also quite specific, serologic positivity cannot definitively distinguish current from remote infection. The National Reference Centre for Parasitology in Montréal, which performs serologic testing for both parasites in Canada, estimates that its enzyme immunoassays have 100% sensitivity and 88% specificity for Strongyloides stercoralis and 96% sensitivity and 82% specificity for Schistosoma mansoni. Several studies have reported levels of antibodies to Strongyloides declining after treatment,48^,340^–343 which suggests that serologic positivity is indicative of current infection; however, this has not been a universal finding.315 Levels of antibodies to Schistosoma do not appear to decline after treatment.317 Nonetheless, given the potential for these infections to persist for decades and to cause potentially life-threatening disease, it is generally presumed that a positive result on serologic testing for either parasite in high-risk newly arriving refugees (without a history of recent effective treatment) represents current infection.

Relative benefits and harms of treatment

The detection and subsequent treatment of strongyloidiasis and schistosomiasis can prevent future morbidity and potentially life-threatening complications. A two-day course of ivermectin (200 μg/kg orally once daily) is the preferred treatment for strongyloidiasis (Table 10A); however, among refugees from areas of the world where Loa loa is endemic, a seven-day course of albendazole (400 mg orally twice daily) should be used. This is because cases of encephalopathy have been reported with use of ivermectin during large-scale treatment campaigns in West and Central Africa, where Loa loa is endemic (see the guidelines of the US Centers for Disease Control and Prevention321 for a table of countries where Loa loa is endemic). This rare but potentially serious event may occur in persons who have a high load of Loa loa microfilaria, which are rapidly killed by ivermectin. Alternatively, because ivermectin is the most effective treatment option available for strongyloidiasis, practitioners may screen refugees at risk for Loa loa infection with a daytime-collected, thin blood smear for microfilaria and treat with ivermectin if high-level microfilaremia is not identified. For Schistosoma species found in Africa, a one-day course of praziquantel (40 mg/kg divided in two doses) is the preferred treatment strategy (Table 10B).

Treatment with ivermectin or praziquantel in patients with underlying neurocysticercosis may lead to an acute inflammatory reaction and could precipitate seizure activity. Therefore, these drugs should not be used in persons with known neurocysticercosis or an unexplained seizure disorder. Otherwise, ivermectin, albendazole and praziquantel each have a generally favourable side-effect profile.344

Screening tests

Microscopic diagnosis with Giemsa-stained thick and thin blood smears has traditionally been the gold standard for diagnosing malaria and determining the level of parasitemia. These tests are inexpensive and ubiquitous,369 but time-consuming, and they rely on substantial expertise that is not readily available in laboratories outside of malaria-endemic areas. Rapid diagnostic tests detect antigens from lysed parasite-infected red blood cells, providing results within 5–20 minutes. These tests have the advantage of portability and ease of use. The usual lower limit of detection is 100 parasites/μL, with sensitivity declining at lower levels of parasitemia.369 A nonsystematic review concluded that the sensitivity of rapid diagnostic tests for P. falciparum was 95.3% (95% confidence interval [CI] 93%–97%); this dropped to 89.2% (95% CI 75%–97%) for 100–500 parasites/μL. The specificity for P. falciparum was 94.2% (95% CI 93%–95%). However, the ability to detect P. vivax malaria was not as robust, with a sensitivity of 68.9% (95% CI 66%–72%) and specificity 99.8% (95% CI 99%–100%).370 There is some uncertainty about the performance of rapid diagnostic tests in asymptomatic individuals. Polymerase chain reaction–based assays are also used to diagnose malaria and have lower detection limits.358^,371^,372 However, this significant improvement in detection levels is offset by the cost, institutional support, accessibility and time required for test results.371

In Canada, there are many regions where laboratories are unaccustomed to diagnosing malaria by microscopy. The technology, convenience and affordability make rapid diagnostic tests a suitable alternative for Canadian health laboratories.

Relative benefits and harms of treatment

Data from predeparture treatment protocols for asymptomatic African refugees to Australia and the United States indicate that there has been a reduction in malaria cases among migrants.366^,367^,373 Of concern, however, are reports of treatment failures, often thought to be due to problems with completion of therapy or delays in departure following therapy.374^,375 The efficacy of treating symptomatic malaria is well documented.348^,350 The World Health Organization recommends artemisinin combination therapy as first-line treatment for P. falciparum malaria.348 However, these drugs are not licensed or available in Canada, where atovaquone and proguanil or quinine plus doxycycline (clindamycin in pregnancy or under the age of eight years) are recommended. Diagnosis and management for symptomatic individuals should follow the Canadian malaria guidelines.350

In summary, although detecting and treating asymptomatic parasitemia may decrease morbidity and mortality from malaria, there is currently a paucity of clinical trials demonstrating the benefits and harms of routine screening and insufficient data to establish the true risk in migrants to Canada.

Screening tools

Many screening instruments for depression have been validated in primary care settings, and little evidence suggests that any particular instrument performs better than other instruments, although brief tools tend to be less specific.398 Both brief screening tools (two or three items) and longer ones tend to have relatively high false-positive rates (60%–70%) when the prevalence of depression is 10%.399 Therefore, positive results on screening must be confirmed by a full diagnostic interview. Most screening instruments have not been validated for many of the immigrant groups commonly seen in primary care in Canada, although the patient health questionnaire has been validated with Chinese, South Asian and other populations.

Relative benefits and harms of treatment

In a systematic review of screening for depression conducted in 2002, the US Preventive Services Task Force found that clinical trials of integrated programs have demonstrated modest improvements in patient outcomes, but benefits have not been observed when screening results are simply reported to physicians without coordinated treatment and follow-up.400 Subsequent reviews have confirmed this finding.401 Adverse effects among immigrants have not been systematically studied, but they may include impaired rapport and less use of general medical services if patients believe they are being labelled and stigmatized or are being treated improperly, the cost and inconvenience of additional follow-up assessments, and possible adverse effects or costs associated with treating patients with an incorrect diagnosis.

In a recent meta-analysis, Gilbody and associates398 found no benefit for screening alone, although there was some benefit in high-risk populations. However, a cumulative meta-analysis showed modest benefit when an integrated system of collaborative care was in place for follow-up (Table 12A).402 In a low-quality longitudinal study conducted in the United States, Wells and colleagues403 examined the effect of screening for depression within an integrated system of care, with follow-up by nurses and with other quality-associated improvements. The greatest improvement was seen for minority groups, specifically African Americans and Latinos.404

Screening

Screening should be conducted in a language in which the patient is fluent, either with translated instruments or through a trained interpreter. Cultural variations in presentation of symptoms, ways of coping and the stigma attached to mental health problems may complicate detection and treatment.405 The presence of prominent somatic symptoms and patients’ tendency to attribute their depressed mood to somatic distress can also reduce primary care physicians’ recognition of depression.406

Among refugee patients with depression, more than half also have post-traumatic stress disorder, and this comorbidity can complicate the recognition of depression.51 Many cultures strongly stigmatize mental health problems, which may limit disclosure of behavioural or emotional difficulties.405 Depression can be distinguished from other forms of mental health problems and can be explained as a state of “energy depletion” and demoralization, which may provide a rationale for psychosocial assessment and treatment.

Child-bearing women

Guidelines from obstetrical groups have proposed that women be screened for depressive symptoms in each trimester of pregnancy, at 1–2 weeks postpartum, and possibly at 2, 4, and 6 months postpartum.407^–409 The Edinburgh Postnatal Depression Scale or nine-item patient health questionnaire have been used with immigrant women. Immigrant women’s multiple roles in the home and the workplace may impede access to health services.395^,396 Availability of child care facilities, transportation and support from family members and spouses can facilitate their seeking help. Group meetings can be an effective way to provide social support and health-promotion information.

What are the potential implementation issues?

Linguistic and cultural differences may constitute substantial barriers to recognition of depression and subsequent treatment negotiation and delivery.413^,414 Medical interpreters, “culture brokers,” bilingual and bicultural mental health practitioners, clinician training in cultural competence and cultural consultation may mitigate these potential barriers.52^,415^–417 Screening for depression produces benefits only when it is linked to an integrated system of care. An integrated system involves the following elements: systematic patient education, availability of allied health professionals to support continuity of care, frequent follow-up, a caseload registry to track patients, caseload supervision by a psychiatrist if indicated, stepped care and a plan for preventing relapse.418 Stepped care involves a progression of levels from patient education and self-management to medication or psychotherapy and, for complex cases, referral to a mental health practitioner.419

The clinical relationship is central to detection and treatment of mental health problems in primary care. Screening with structured questionnaires cannot replace clinical sensitivity, systematic inquiry and relationship-building. Given the great diversity of immigrant and refugee patients, no single approach is likely to be sufficient for optimal recognition and appropriate treatment of depression.

Screening

Several short screening instruments practical for primary care settings have been developed.435 The four-item primary care post-traumatic stress disorder screening scale436 and the Breslau seven-item screening scale (available at http://ajp.psychiatryonline.org/cgi/content/full/156/6/908#T2) are two simple means of identifying symptoms in primary care patients. In both cases, their cultural validity is unknown. Very few screening instruments have been tested for diagnostic accuracy among immigrants, refugees and asylum seekers. However, it may be reasonable to use questionnaires to assist in identifying symptoms, as part of a clinical assessment when addressing functional impairment.

Relative benefits and harms of psychological treatment (adults and children)

The systematic review and meta-analysis commissioned by the National Institute for Clinical Excellence422 provided evidence that psychological treatments, including trauma-focused cognitive–behavioural therapy and eye movement desensitization and processing, reduce the symptoms of post-traumatic stress disorder. We rated the quality of this evidence as low because of study limitations and inconsistency of results. Two Cochrane reviews425^,426 provided similar evidence of effectiveness. A recent systematic review428 showed that psychological treatments (cognitive–behavioural therapy and narrative exposure therapy) can reduce symptoms of post-traumatic stress disorder among refugees, but we rated this evidence as very low quality. Other authors have reported that patients may experience adverse effects with therapy, such as re-experiencing traumatic events, and rates of withdrawal from active therapy may approach 30%.437

What are the potential implementation issues?

Primary care practitioners need to be aware that immigrants and refugees may have been exposed to traumatic events. If a patient discloses a traumatic experience, it may be helpful to acknowledge the pain and suffering associated with the experience, to explain that a reaction is common for anyone who has undergone trauma and to offer empathetic reassurance that the situation is likely to get better. Several Canadian cities have centres and experts available to help care for survivors of trauma and torture.

Exploration of trauma and its consequences is not recommended in the first meeting with a patient unless it is the patient’s primary complaint. However, certain symptom presentations should alert clinicians to the need for assessment for post-traumatic stress disorder, including unexplained physical complaints, sleep disorders,422 depression, panic disorder and somatoform disorder.51 Other presentations, such as severe dissociation mimicking brief reactive psychosis, dissociative disorders (amnesia and conversion) and psychotic depression, although less frequent, may also be related to post-traumatic stress disorder. Key elements of the assessment include level of psychological distress, the impairment associated with the symptoms in the patient and his or her family, substance abuse and suicidality.

Familiarity with the cultural background of the patient is recommended, and assessment should involve a professional interpreter if the patient’s language ability is inadequate to express psychological distress and narrate the experience.422 Disclosing traumatic experience through relatives, family members or, particularly, children can be traumatic.438

Although not supported by clinical trials, the National Institute for Clinical Excellence422 recommends a phased intervention model, reflecting a pragmatic approach for refugees and asylum seekers who face the possibility of being returned to a traumatic environment. Phase I is defined as the period in which safety has not yet been established and during which intervention should focus on practical, family and social support. Phases II and III should focus on the patient’s priorities, which may include social integration and/or treatment of symptoms. Unemployment, isolation and discrimination may overshadow the efficacy of mental health treatment in many patients,430 which suggests that multifaceted interventions that include primary care, community organizations and other social institutions may be effective.432

Screening tools

Most screening methods consist of self-administered questionnaires generally completed by the mother, interviews or checklists completed by the professional who collects information directly from the child or clinical judgments by nurse or professional teams.443^,445 All screening methods attempt to predict child maltreatment on the basis of either parents’ potential for maltreatment or the presence or level of risk factors associated with maltreatment, rather than on the occurrence of actual maltreatment. Three systematic reviews have reported that these instruments tend to have high sensitivity but poor specificity and false-positive rates too high for use in clinical settings.443^–445 Sensitivity ranged between 25% and 100%, specificity between 16.5% and 94.3%, and positive predictive value (when available) between 1.7% and 28.2%.

Relative benefits and harms from screening

False-positive ratings, which are the most common result in low-risk populations, can lead to a number of negative consequences, such as inappropriate labelling and punitive attitudes, psychological distress,56 inappropriate separation of children from family support systems, destruction of family supports, loss of resources and loss of autonomy for those falsely accused.456 This may leave parents wary of any subsequent assistance that may be offered,56 thus reducing their access to care. A systematic review of the performance of screening tests concluded that adding a screening protocol to the clinical encounter yielded additional false-positives that exceeded additional abused children detected.457

Compared with the general population, immigrant and refugee families may be more likely to suffer from the direct and indirect harms related to screening. Screening instruments have not been culturally validated and are less likely to be accurate because of factors such as language barriers, different cultural norms of behaviours and different attitudes toward institutional authority.458 Given the limited state of knowledge in immigrant populations, potential harms from routine screening for child maltreatment outweigh benefits, which have not yet been clearly established.

Relative benefits and harms of preventing child maltreatment

Home visitation programs by nurses aim to prevent child maltreatment by assessing and supporting families. To date, the 15-year longitudinal study by Olds and associates459 has provided the best evidence for the effectiveness of a nurse–family partnership program in reducing actual child maltreatment. The effectiveness of this program is particularly evident for first-time mothers who are younger than 19 years of age, single or economically disadvantaged (Table 14A).444^,446^,460^,461 Another prevention program (the Early Start Program) has also shown efficacy in reducing hospital admissions for child injuries at 36 months (17.5% v. 26.3% for control group).463

Relative benefits and harms of treatment for child maltreatment

Several specific forms of intervention have been devised to reduce the consequences of child maltreatment. Trauma-focused cognitive–behavioural therapy reduces sexually abused children’s symptoms of anxiety, depression and sexual behaviour problems464 in both general population and ethnic minority children. Table 14B presents the outcomes of cognitive behavioural interventions.447 Parent–child interaction therapy465 showed a reduction in repeated reports of physical abuse in treatment relative to control groups (standard psychoeducational program) (19% v. 49%). In most other studies, the outcomes were not statistically significant but there was a consistent tendency in favour of treatment programs. The lack of evidence of efficacy for immigrant or refugee children precludes extrapolation of the findings to these groups.

What are the potential implementation issues?

Some forms of child discipline may be unusual or outside Canadian social norms but are not pathological466 or dangerous for the child. Immigrant or refugee families may resort to other disciplinary behaviours (e.g., hitting a child with an object) that are condoned in their cultural context but that contravene child protection laws in Canada. Some cultural practices (e.g., scarification as part of life cycle rituals among some African children or cupping, a common traditional healing method in some Asian cultures that leaves circular ecchymoses) may be misinterpreted as signs of child abuse. Other culture-specific practices (e.g., female genital cutting) contravene child protection and civil laws in Canada. In situations where child maltreatment is suspected, observed or disclosed, the practitioner must take action in accordance with the child protection law in his or her region.

Language barriers, fear of separation from the child, fear of punitive institutional power and fear of deportation may constitute major barriers to disclosure of child maltreatment. Failure to investigate family dynamics and inter-generational conflicts, after disclosure of maltreatment by an immigrant child, may further disempower the parents and attribute greater power to the child, consequently aggravating his or her problem. Immigrant and refugee children placed in foster care may suffer from loss of connection with language of origin and religious, familial and cultural traditions. As a preventive strategy, clinicians may want to provide families with sources of information about their province’s child protection law, their legal rights and their obligations regarding children, in addition to addressing other risk factors for child maltreatment. Recent research is showing that the SEEK (Safe Environment for Every Kid) model is promising.467

Screening tools

Screening for intimate partner violence differs from traditional screening for medical disorders because the target of clinical concern is a behavioural event, which women usually recognize as a problem but which they may not view as appropriate for medical attention.485^,486 Four short self-report questionnaires have received the most study. The “Hurt, Insulted, Threatened, or Screamed at” questionnaire (four items) yields sensitivity ranging from 30% to 100% and specificity from 86% to 99%.476 The Partner Violence Screen (three items) provides sensitivity from 35% to 71% and specificity from 80% to 94%.477 The Women Abuse Screening Tool (eight items) yields 47% sensitivity and 96% specificity.479 The Abuse Assessment Screen (five items) yields sensitivity ranging from 32% to 94% and specificity from 55% to 99%.487

A Canadian randomized controlled trial found women preferred self-completed approaches.483 However, other studies comparing administration methods of screening instruments (e.g., face-to-face interviews, computer screening, written screening) have shown inconsistent results.484^,488^,489 Furthermore, it is unknown whether these results apply to immigrant and refugee women.

Relative benefits and harms of screening

A Canadian trial on the effect of screening found no statistically significant differences between women screened or not screened at 6, 12 or 18 months follow-up for recurrence of intimate partner violence (Table 15A).478 More than half of the women who disclosed being victims of intimate partner violence on screening did not discuss the violence with their practitioner during the health care visit. An important study limitation was that no specific intervention was provided to women who disclosed or screened positive.478

Other studies have found screening benefits such as decreasing isolation, increasing support, relief, breaking the silence and validating women’s feelings.485^,490 However, these same studies identified several harms, including feeling that the practitioner is too busy or not interested, feeling judged and being disappointed by the practitioner’s response, increased anxiety, concerns about privacy,484 breaches of confidentiality and legal repercussions, fear of being reported to child protective services,485 and concern about or actual increased risk of retaliation or further harm from the partner.485

Relative benefits and harms of treatment

The strongest evidence for treatment has come from studies of the Experimental Social Innovation and Dissemination program,491^,492 which reported decreased physical and emotional abuse at 12–24 months follow-up and improvement of women’s quality of life at 12 months follow-up. Ramsay and coworkers472 reported that, while promising, the results were inconclusive. In Table 15B, we report the efficacy of the Experimental Social Innovation and Dissemination advocacy and counselling intervention program in decreasing the incidence of intimate partner violence475 in an ethnically diverse sample of women who had spent at least one night in a shelter.

What are potential implementation issues?

Signs and symptoms of intimate partner violence differ significantly among women. They may be absent in some women or be of a psychological (depression, anxiety, suicidal ideation, alcohol or drug abuse), social (social isolation) and/or physical (injuries, bruises and aches) nature in other women. Patient–physician rapport thus remains a key element in the detection of intimate partner violence.

Recently settled immigrant women in Canada are more likely to report intimate partner violence to the police than women in the general population but are less likely to use social services.494 Barriers to help-seeking included fear of deportation or not accessing Canadian citizenship, lack of knowledge of services or language-specific services, experiences of racism or discrimination.494 Culturally specific perceptions of spousal relationships, gender roles, negative experiences with authorities, aggression and abuse may affect reporting and disclosure.485 Involvement with police or criminal proceedings may put immigrant women at risk of losing their sponsorship agreements.485^,494

Intimate partner violence is now considered a form of child maltreatment. Women may delay disclosure of violence because of fear of losing custody of their children (child protection services often cite the mother’s failure to protect her children).485^,494 In addition, some women feel coerced into staying in a shelter to keep custody of their children. Although this may protect them from further intimate partner violence, it may also isolate them from extended family and community networks that might otherwise be integrated effectively into the intervention plan.458

Services that can defuse conflict situations and reduce family stress include social welfare, reliable childcare, safe housing, language classes, and other educational and vocational training opportunities. Community grassroots organizations can provide information and support groups in appropriate languages and in a culturally competent manner.495^–498 Research is beginning to show benefits when screening and interventions target women with specific conditions, for example pregnancy, mental illness and substance abuse, but this work has yet to consider the immigrant context.

Screening tests

Fasting blood glucose is considered the most appropriate screening test for diabetes because of its feasibility and specificity.510 A fasting blood glucose level of 7.0 mmol/L has a moderate sensitivity (40%–87%), but good specificity (96%–99%), to predict a blood glucose level of 11.1 mmol/L in a two-hour oral glucose tolerance test. A recent systematic review also concluded that hemoglobin A_1C and fasting blood glucose are equally effective screening tools, but hemoglobin A_1C is more costly than fasting blood glucose.520

Relative benefits and harms of treatment

The 2008 meta-analysis of the US Preventive Services Task Force on lifestyle interventions for prediabetes501 showed a significant decrease in onset of diabetes with minimum harms. We rated the quality of this evidence as high but noted the need to study the long-term effects of delaying diabetes onset (Table 16B).521 Additionally, we identified a Cochrane systematic review58 showing that culturally appropriate health education was effective in reducing blood glucose and increasing diabetes knowledge in ethnic minority groups. None of these trials reported significant adverse effects from lifestyle interventions. The evidence was insufficient to comment on the negative theoretical impact of labelling.

Blood pressure control in diabetes reduces cardiovascular morbidity and mortality.510^,521 Trials reported minor adverse drug reactions such as cough with some antihypertensives and no harms related to the socioeconomic implications of diagnosis and treatment (Table 16C).522 A recent meta-analysis511 of five prospective randomized controlled trials evaluating the effect of intensive glucose control showed a small but significant decrease in myocardial infarctions in the treatment group, which had a hemoglobin A_1C level 0.9% lower than the control group, but no effect on events of stroke or mortality. Very intensive glucose control (hemoglobin A_1C < 6.5%) has not been shown to decrease mortality and has been associated with hypoglycemia. Populations and individuals who would benefit the most from screening have undiagnosed, longstanding disease, and intensive lifestyle and/or hypertension interventions would have the greatest absolute effect.

What are the potential implementation issues?

A Cochrane review523 found that diet and lifestyle interventions reduced weight and the incidence of diabetes, but these measures were more effective in younger populations. Others have found that diabetes education is less effective in situations of low socioeconomic status and cultural factors. Language barriers, migration stress and cultural diversity (diets, lifestyles, perceptions of weight, fasting at Ramadan) may complicate diabetes care and education.

Ethnic groups prefer culturally appropriate dietary and exercise advice.58 A Cochrane review58 on culturally appropriate health education showed improved glycemic control and diabetic knowledge scores compared with standard diabetic education approaches at 12 months. Other outcomes, such as lipid levels and blood pressure, showed no significant difference from control groups. Another review,524 looking at diabetic care in socially disadvantaged populations, identified interventions that may improve outcomes, including culturally tailored care, a focus on individuals in assessment and feedback, and incorporation of treatment algorithms.

Screening

The positive predictive value of hemoglobin concentration below 110 g/L alone for iron deficiency in children (12–35 months) is 29% (95% confidence interval [CI] 20%–38%), and the sensitivity is 30% (95% confidence interval [CI] 20%–40%).531 Diagnostic measures used to confirm iron-deficiency anemia include serum ferritin and hemoglobin or hematocrit response to administration of iron.

Relative benefits and harms of treatment

Iron deficiency can be addressed through primary prevention by ensuring adequate iron intake527^,537^–539 or through secondary prevention by detecting the condition and treating it with iron supplements or diet education.540

Cognitive development in children

Sachdev and colleagues528 evaluated changes in weight-for-height between placebo and iron-treatment groups in children and found no statistically significant difference. Sachdev and colleagues529 also conducted a meta-analysis combining 17 trials (10 of which were conducted in developing countries) of iron supplementation in infants or in children up to 12 years of age and found increased mental development scores in the treatment group (Table 17B). In the subgroup analyses, improvement in mental development scores was attributed mainly to five trials in children seven years of age or older, and the effect was only intermediate for children between two and five years of age. Common adverse effects associated with iron supplements include dose-related reversible gastrointestinal symptoms531^,533 and unintentional overdose.

Work productivity in women of reproductive age

We identified three randomized controlled trials studying the effect of iron supplements on work productivity.530^,541^,542 These trials, conducted in China, Indonesia and Sri Lanka, all reported increases in work productivity with iron supplements. Table 17C presents the study from China, which we chose as the best-quality study for women of child-bearing age who are not pregnant.530 Because of the complexity of measuring work productivity and the significance for only one of the two primary measures, we rated the quality of this evidence as low.

What are the potential implementation issues?

Accessibility issues include language barriers, lower levels of education, low levels of ongoing support and follow-up, and access to supplements.544 Gastrointestinal side effects, changes in stool colour and three times daily dosing have been shown to reduce adherence rates.531

Screening

The mouth should be examined using a tongue depressor to determine swelling, bleeding gums, loose teeth, broken teeth or holes in teeth, odour, mouth ulcers and sores. A systematic review and randomized controlled trial provide evidence that physicians can screen preschool children for dental caries with a high degree of accuracy.62 The evidence supports the effectiveness of prevention through application of sealants in children (Table 18A).557

Relative benefits and harms of treatment

The management of underlying causes of dental pain by dentists is effective for prevention and management of dental disease.548 Potential harms include the cost to patients to access dental care and adverse reactions to treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) manage oral pain effectively (Table 18B).548 Antibiotics should be prescribed only in the presence of concomitant systemic symptoms, such as lymphadenopathy, fever, and associated cellulitis.561 Single-dose studies showed no difference in short-term adverse effects between oral ibuprofen and placebo.562 In patients given NSAIDs over longer periods, adverse reactions included abdominal pain, diarrhea, edema, dry mouth, rash, dizziness, headache and fatigue. These are generally considered to be mild to moderately severe.563

What are potential implementation issues?

Lower income and immigrant status are both associated with fewer visits for preventive dental care.564 Language barriers reduce access to services and quality of care.565 Experiential influences (fear of dentists, history of inadequate care, embarrassment about oral condition) are likely hindrances for individuals who require professional dental care. Financial barriers decrease access to dental care. When nondentists refer on the basis of an oral health screening, people are twice as likely to go to the dentist.62 However, active referral (e.g., specific clinics identified, a patient information notice) is warranted.566

Financial coverage of dental care

During the settlement period, Convention Refugees, refugee claimants and other protected people are eligible to apply for Interim Federal Health Program coverage for dental care. Details of services covered, the application process and a handbook for health care providers are available through the Citizenship and Immigration Canada website (www.cic.gc.ca). In addition to the provincial public dental programs, there are low-cost or no-cost clinics in several of the larger cities. Information on many of these programs and clinics is available from the website of the Federal, Provincial and Territorial Dental Working Group (www.fptdwg.ca) and the Canadian Association of Public Health Dentistry (www.caphd.ca). In the absence of comprehensive dental services for marginalized populations, physicians’ involvement in oral health care is increasing,567 and the application of fluoride varnish by primary care practitioners shows great promise.568

Screening

Measuring visual acuity is a simple manoeuvre that can be carried out accurately (sensitivity of 94% and specificity of 89%)590 in a primary care setting. When measuring vision in immigrants and refugees, a standardized chart with the tumbling E or the Landholt C optotypes could be helpful, because familiarity with an alphabet or numbers is not required. In some cases, a cut-out “E” or “C” for the reader to orient to the chart will simplify communication. The ETDRS-type of visual acuity chart is the preferred chart layout and has several advantages, including five optotypes on each line.591 However, an inexpensive Snellen chart, which uses ambient room lighting, is adequate for screening purposes. A pinhole viewing device can be added as a simple adjunct to determine whether the visual impairment is due to refractive error (sensitivity 79%, specificity 98%).592

Relative benefits and harms of treatment

We did not find direct evidence that routinely screening and treating immigrant children in primary care for visual impairment results in improved visual acuity. However, a randomized clinical trial has shown that intensive screening procedures, compared with usual vision surveillance, leads to improved visual acuity.593 Amblyopia and its leading causes (strabismus, astigmatism and anisometropia) are reversible if diagnosed and treated early after onset within the first seven or eight years of life, after which reversibility is minimal.

For adults, we focused our effectiveness synthesis on the prevalence of vision loss from uncorrected refractive error, which is amenable to simple correction with eyeglasses.589 We were unable to identify any evidence to estimate the effect of adherence to recommendations for an eye examination on whether subsequent prescriptions for eyeglasses are filled. Using the GRADE rating system, we rated the quality of this evidence as very low. Our evidence review found no data on harm to the patient for measuring vision (Table 19A).

What are the potential implementation issues?

Comprehensive ophthalmic examination is not covered for those aged 18 to 64 in any Canadian province.594 However, specific nonrefractive indications for performing an evaluation — such as being at increased risk for glaucoma, screening for diabetic retinopathy or excluding clinically evident cataract as a cause of vision loss — are typically covered by provincial health plans. Convention refugees, covered under the Interim Federal Health Program, receive coverage for correction with eyeglasses and other urgent care for up to one year after arrival.

Beyond issues of financial access, age and sex can be influential. Age can influence the decision to seek care or to treat, a decision that is sometimes beyond the control of elderly patients with vision loss. Female patients appear to face greater barriers to assessment and treatment, and sex discrimination is more influential in low- and middle-income countries than in high-income countries.595 Finally, stigma associated with wearing glasses can also influence eye care for refugees and immigrants to Canada. The desire to conform with societal norms and beauty standards is often stronger than the desire for treatment.596

Screening tests for visual impairment in children

The Canadian Task Force on the Periodic Health Examination597^,598 (now the Canadian Task Force on Preventive Health Care) and the US Preventive Services Task Force recommend screening tests for visual impairment and strabismus for children younger than five years. Additional manoeuvres recommended for children include assessing for a red reflex and inspecting the external eye beginning with newborns.599

Screening tests for visual impairment in adults

For adults, both the Canadian Task Force on Preventive Health Care600 and the US Preventive Services Task Force601 recommend screening tests for visual impairment by primary care practitioners but suggest limiting these tests to people older than 65 years of age. Since these influential guidelines were published more than a decade ago, experts have recognized that the epidemiology of “best corrected” visual acuity on which they are based does not address uncorrected refractive error,602 now recognized as the leading cause of vision loss worldwide.576

Other conditions

In the case of glaucoma and diabetic retinopathy, patients do not typically present with vision impairment until damage has become irreversible. The Canadian Task Force on Preventive Health Care and the US Preventive Services Task Force have presented compelling evidence supporting recommendations for referral of asymptomatic adults at high risk (those older than 65 years, blacks older than 40 years, those with a first-degree relative who has glaucoma and myopia exceeding −6 diopters) for glaucoma testing.600^,603 Similarly, the Canadian Diabetes Association clinical practice guidelines make a compelling case for periodic screening tests for diabetic retinopathy in people with diabetes.604

Which women might need special consideration for contraceptive counselling?

With migration to a more stable environment, fertility rates of refugee women sometimes increase as they choose to rebuild families. Refugee women who have been in their country of resettlement for less than three months appear to have the highest levels of fertility of all resettled populations, although whether these pregnancies are intended or unintended is unknown.627 Alternatively, a desire to prevent pregnancy could increase if women perceive uncertainty and instability with migration.627^,628 Contraceptive needs can fluctuate because of family reunification and an ability to visit partners in their home countries. Pregnancy intention, contraceptive options and emergency contraception should therefore be discussed early in resettlement and should be reassessed as circumstances change.

Unmarried women could be vulnerable to unintended pregnancy if cultural proscriptions on premarital sex prevent them from identifying and seeking support for their contraceptive needs. The most common reason for not using contraception among sexually active, unmarried women surveyed across all developing regions was a low perceived risk of pregnancy because of infrequent sexual activity.608

Adolescent risk-taking and experimentation with sexuality put teenagers at risk for unintended pregnancy. Most young people become sexually active between 15 and 19 years of age. In Canada, teenagers who are recent immigrants have lower rates of sexual activity and pregnancy than Canadian-born teenagers. However, other countries of resettlement show the opposite pattern. Like North American–born teenagers, those from the developing world are interested in discussing sexual health concerns with health care providers, although needing to raise the topic, confidentiality concerns and parental presence often discourage this discussion. Adolescent newcomers sometimes experience conflict between their families’ attitudes toward teenagers’ sexuality and attitudes in their country of resettlement.

What social and cultural factors influence contraceptive counselling?

Women arriving from developing countries might have insufficient knowledge about reproduction and contraception to make an informed decision about family planning.608^,620 Increased education and knowledge about reproduction correlate with more positive attitudes and increased use of and adherence to contraception.609 Women of all cultures use social networks for much of their sexual health information, which might be inaccurate or incomplete.620

Cultural attitudes toward pregnancy and family planning vary. Providential (“children are God’s will”) or pronatalist cultures discourage pregnancy prevention. In some cultures, women who bear many children are highly esteemed.628 Religious beliefs about the acceptability of contraceptive practices also influence some women. Contraception used to space births is acceptable in most religions. Among women of any particular faith, attitudes toward contraception vary widely. Health care providers should avoid assumptions and should assess each woman or couple individually.608 Longer residence in the host country, educational and professional attainment, and youth favour positive attitudes toward modern contraception.

A woman might not perceive herself to be the decision-maker for contraception, but she could be strongly influenced by her spouse, mother-in-law, sex role and religious beliefs. Worldwide, 11%–12% of married women do not use contraception because of opposition from one or more influential parties. In sub-Saharan Africa, this figure is 23%.608 Recognition of the partner’s influence and his involvement, where appropriate, are important in counselling and supporting women’s choices. Some men consider contraception to be their spouse’s responsibility, but often this responsibility is shared, and involvement in counselling may be welcomed. In a population-based study of six African countries,629 women with supportive male partners were more likely to use modern contraceptives. In some traditional cultures, fathering many children is a sign of masculinity; however, perceived economic advantages of smaller families and better future opportunities for children can encourage men’s support for contraception.

What are the medical considerations?

Condom use should be encouraged for women at risk for sexually transmitted infections, irrespective of additional contraceptive use. More common in immigrant and refugee women, HIV infection and sickle cell anemia bear special consideration. Guidelines suggest that hormonal methods can be safely used by HIV-positive women. Although serum levels of contraceptive hormones can be reduced by some antiretroviral medications, the clinical implications are unknown.625 Intrauterine devices are considered safe for women with HIV who are immunocompetent.625 Pregnancy is risky for women with sickle cell anemia. Although combination hormonal contraceptives are considered reasonably safe for women with sickle cell anemia,625 progestin-only contraceptives such as medroxyprogesterone have the added benefit of reducing sickle cell crises.633^,634

What are the potential implementation issues?

Language barriers and lack of familiarity with the Canadian health care system can limit immigrant and refugee women’s access to contraceptive care. In some communities of origin, the husband’s accompaniment or written consent is required to obtain contraception.635 In others, hormonal contraception is available in pharmacies without a prescription.

The caregiver’s sex is important for women in many cultures, particularly for refugee women, many of whom have a history of sexual assault and abuse. The advantages of ethnic and sex matching must be weighed against research suggesting a preference for “Canadian” professionals by immigrant and refugee women.636 Unnecessary medical barriers, such as examinations, blood tests and Papanicolaou smears, and a lack of culturally appropriate teaching aids are additional obstacles to contraceptive use.610

The Interim Federal Health Program covers the cost of contraceptives for Convention refugees, refugee claimants and protected people. Newcomers without health insurance can be guided to publicly funded sexual health clinics that provide services and low-cost contraceptives, regardless of health insurance status. The Society of Obstetricians and Gynaecologists of Canada also has a Compassionate Contraceptive Assistance Program that assists women in financial need (www.sogc.org/compassionate/pdf/compassionnate_form_e.pdf).

Relative benefits and harms of vaccination

A systematic review of vaccination against HPV showed reduction of high-grade cervical cancer lesions with no serious adverse events647 (Table 21A). We downgraded the quality of this evidence to moderate because of indirectness, since high-grade cervical lesions are considered surrogate outcomes for cervical cancer mortality. There were fewer than 15 anaphylactic events in a longitudinal study of more than one million doses of HPV vaccination among women in Australia.656 This adverse reaction occurred within 15 minutes of vaccination and was amenable to treatment.

Screening tests

Cervical cytology testing (liquid-based or conventional) is 60%–80% sensitive for high-grade lesions and 98% specific.645 Identifying cervical cancer using testing for HPV DNA is more sensitive but less specific than cervical cytology.661 Ninety-two per cent of women will survive five years when cervical cancer is localized, but only 13% will survive distant disease.644

Relative benefits and harms of screening and treatment programs

For cervical cancer screening programs, we found two large-scale observational studies653^,654 and two systematic reviews.644^,645 The screening programs used invitation and reminder letters and practitioner incentives to increase screening rates from 61% to 83% of the population. Data from Rieck and coworkers654 showed a reduction in cervical cancer (relative risk 0.48, 95% CI 0.23–0.98) (Table 21B). Adverse effects resulting from referral for colposcopy include anxiety about pain and discomfort.662 However, no data quantifying these adverse effects were found. Perinatal mortality and adverse pregnancy outcomes have also emerged as rare though important potential harms in treatment of cervical intraepithelial neoplasm relevant for young women; however, the quality of this evidence remains very low651 (Table 21B).

Introduction of screening programs to populations naive to screening reduces cervical cancer rates by 60%–90% within three years of implementation.663 Key factors that improve the effectiveness of programs include high participation rate, quality control in smear interpretation, reliable follow-up for abnormal results and facilities for adequate treatment.664

What are the potential implementation issues?

Immigrant women often have little knowledge and many misconceptions about the benefits of screening for cervical cancer. Many cultures are very private regarding sexuality, leaving women reluctant to ask for cervical screening, and some women feel uncomfortable undressing in front of a stranger.668 Patients, especially female Muslim patients, may prefer female practitioners,668 and some also prefer a care-giver from the same culture. Immigrant community health workers and other community interventions that provide information and offer transport, female physicians and interpreters in informal clinic settings may improve uptake of screening.65

Social isolation

One Canadian report showed that, after giving birth, 14.7% of asylum seekers and 7.7% of refugee women live alone, whereas 2.7% of Canadian-born women live alone.67 Perceived lack of social support was reported among 15.4% of immigrants versus 7.2% of Canadian-born women.678 Lack of psychosocial resources for nonmigrants has been found to lead to small-for-gestational-age infants.679

Sexual abuse

Sexual abuse is common in armed conflict and internal strife. Abuse is sometimes used to dominate, sexual torture can be used as a method of interrogation, and refugee camp guards and male refugees sometimes regard unaccompanied women and girls as common sexual property. Violence and rape among refugee women in camps ranges from 24.4% to 40.0%.680 Many refugee women (23%–50%) also report violence at the hands of their husbands.680 Pregnancy-related effects include unwanted pregnancies, sexually transmitted infections, chronic pelvic infection, reproductive tract trauma, psychological trauma, social rejection, and mistreatment or abandonment of resulting infants.676

Hemoglobinopathy

Hemoglobinopathy (predominantly thalassemia and sickle-cell anemia) is more common among newly arrived women from certain regions of the world.681^–683 Hemoglobinopathy can lead to serious maternal complications, severe anemia in infants and painful vaso-occlusive crises.682

Exposure to hazards in the workplace

Newly arrived women are often exposed to unprotected and unregulated work environments, where the risk of adverse pregnancy outcomes is great. Their lack of knowledge of employee rights exaggerates these exposures.

Female genital mutilation

The prevalence of female genital mutilation ranges from 5% to 97% among women in countries where it is practised.684 There are four types of female genital mutilation: type I, excision of the prepuce, with or without excision of all or part of the clitoris; type II, excision of the clitoris with partial or total removal of the labia minora; type III, excision of part or all of the external genitalia and stitching or narrowing of the vaginal opening, also called “infibulation”; and type IV, “unclassified,” which can include pricking, piercing, incising, stretching, cauterizing, scraping, cutting, introducing corrosive substances or other methods. Type III causes a mechanical barrier to delivery; however, types I, II and IV can produce severe vulval and vaginal scarring that may also obstruct delivery.685 Types II and III are associated with greater risks of cesarean section, postpartum hemorrhage, extended hospital stay, infant resuscitation, and stillbirth or early neonatal death.686 An estimated 15% of all circumcised women have undergone type III mutilation.687 Most cases of female genital mutilation in Djibouti, Somalia and Sudan (80%–90%) are type III.687 Practitioners attending Somalian births in Canada have been found to lack knowledge of female genital mutilation and to manifest unprofessional attitudes toward these women.688

Female genital mutilation

Recommendations from the World Health Organization are available,685 as is a review of clinical practice.698 Guidelines for care in cases of female genital mutilation were published by Health Canada,699 although no evidence of the effectiveness of suggested interventions was provided. An article entitled “What Somali women say about giving birth in Canada”688 provides suggestions for providing more respectful and less interventionist care, as well as greater sensitivity for cross-cultural practices.

Sexual abuse

Health Canada’s guidelines on family-centred maternity and newborn care (published in 2000)699 recommend using the ALPHA form700 to assess current and past abuse (including sexual abuse), although sensitivity and specificity (and other measures) are not provided for this tool.701 No recommendations are available specific to the screening and care of sexual abuse victims during pregnancy, a time during which bodily changes and vaginal examinations can elicit untoward memories of sexual abuses.

Hemoglobinopathy

The guidelines of the Society of Obstetricians and Gynaecologists of Canada682 recommend that those who originate from countries outside northern Europe should be considered at high risk for hemoglobinopathy. As well “the definitive test for carriers of hemoglobin S, C, or D is hemoglobin electrophoresis, which should be offered to all couples of African or Caribbean descent.”682 The guidelines of the American College of Obstetricians and Gynecologists’ (based on level A scientific evidence, i.e., good and consistent)702 note that “Individuals of African, Southeast Asian, and Mediterranean descent are at increased risk for being carriers of hemoglobinopathies and should be offered carrier screening and, if both parents are determined to be carriers, genetic counselling.”