Canadians seek reforms in immigration system
Canadians seek reforms in immigration system
Too much delay in province notification
As American TB experts ponder changing TB screening procedures for overseas immigrants, their Canadian counterparts are calling for repairs to their own system. The problem, critics charge, is that the federal immigration authorities are failing to provide timely notification to the provinces and territories when new arrivals in need of follow-up are headed their way.
"We’ve told Immigration Canada to either fix the system or scrap it," says Dick Menzies, MD, head of the Montreal Chest Clinic. "So far, they’ve done neither."
In Canada, as here, immigrants undergo a chest X-ray as part of the overseas medical exam. The difference is that when an active case is picked up, the immigrant must undergo at least six months of therapy before entering Canada. New arrivals to the United States, by contrast, must simply be treated to the point where they’re no longer infectious.
As in American immigration procedures, Canadian immigrants whose chest X-rays show evidence of old disease are admitted provisionally, with the understanding that they will show up at a public health facility with 30 days of arriving at their new home. Here, apparently, is where the trouble starts.
Getting the word on less than two-thirds
When experts compared records from immigration authorities with records kept at public health offices in the provinces, it was discovered that provinces had been notified of the newcomers headed their way only about 60% of the time.
"It’s conceivable that the provinces didn’t record the notification," says Wendy Wobeser, MD, MSc, FRCPC, assistant professor of medicine in the infectious diseases division of the University of Queens School of Medicine in Kingston, Ontario, and chief of the team that did the analysis. "But I suspect most of the problem is a failure to relay the information from the federal level to the provinces."
In Canada, as here, immigration accounts for an increasing proportion of TB cases. Though the country’s overall number of TB cases is holding steady despite a burgeoning population, the proportion of cases occurring among the foreign-born has grown from 35% in 1985 to 63% at present, according to Neil Heywood, MD, director of Immigration Health Policy for Citizenship and Immigration Canada. Most newcomers come from China, which sends Canada 18,000 immigrants; other countries, including Thailand and the Philippines, aren’t far behind.
Even when notification does take place, it’s too slow, complains Menzies — on average, about three months. That helps account for why so many people, even when the provinces learn about them, still fall through the cracks, he adds.
When he and his colleagues at the Montreal Chest Clinic took a year to study what happened to immigrants once they arrived in Quebec, they found that only a small number of immigrants actually got preventive treatment. Here’s what happened along the way:
• Of the 60% of newcomers notified to the province, about one-third could not be found, Menzies discovered. "That’s because their address is wrong, or it’s missing, or they’ve already moved," he says. More often than not, immigrants have moved on by the time local authorities finally get word.
• Language barriers further complicate the picture, Menzies says. Immigrants sign documents stating they have a condition that may require treatment and that they must show up at the local health department, but because the explanation and instructions are written in English and French only, many immigrants can’t read them.
• Due to failures in the notification process, provinces hear about only 40% of the original group, says Menzies. Of those, only 80% actually show up at the local clinic. Of those, about 70% are judged to have inactive disease, while the rest are "totally normal," Menzies found.
• Of the 70%, some are too old for preventive therapy, and others already have undergone treatment, Menzies says.
The result? "About 20% of those who were referred for treatment of inactive TB are finally found and actually have something done to prevent TB," says Menzies.
The yield may be even lower in other parts of the country because not all provinces and territories pursue immigrants with equal zeal, he adds. "In Quebec and in all the Western provinces, we try to track people down as aggressively as possible," he notes. In decentralized provinces such as Ontario, authority is delegated to local jurisdictions, and in such cases, follow-up may not be as energetic.
A solution: New forms in different languages
Canadian immigration officials concede there’s work to be done. "We must ensure that adequate notification is provided," explains Heywood. "For one thing, when someone is at the port of entry, why not send an e-mail instead of using snail mail?" Notifications could be sent electronically in batches every two to three days, as he envisions.
To further speed up the process, immigration authorities are thinking about notifying all provinces and territories at once, instead of just an immigrant’s declared destination. "That might present some problems with privacy," he adds. As an alternate scenario, Heywood proposes waiting to see whether an immigrant shows up where he says he will, and if he doesn’t, word could be sent out to other provinces.
Heywood also wants to see a revision of the paperwork incoming immigrants sign. "When someone is confronted with a bilingual form, he’ll sign it, but because he wants to go to Canada, not because he necessarily understands it," he says. Also on Heywood’s wish list is additional training for officials in multicultural sensitivity, plus forms that state a newcomer’s condition and obligations plainly and in a variety of languages.
Still, he argues that part of the problem may be immigrants not doing what they’re supposed to do. "Technically, they could be removed. But that doesn’t happen. Canada is a nice country."
Some say skin-testing costs too much
As for adding a skin-testing component to the overseas exam — something the United States is considering because of a recent Institute of Medicine report — it’s not likely that Canada would switch to such a policy, TB experts say.
To Menzies, widespread testing for latent infection is not cost-effective. "When you do a cross-sectional slice of a population, you find that fibrotic scarring occurs much more frequently than latent infection," he says. Of the instances of infection that are found, he adds, "many are false-positive or evidence of old infection that’s unlikely to reactivate."
To Heywood, the notion of skin-testing immigrants overseas is purely impractical. "I was at a meeting not long ago where a fellow stood up and presented [one of my colleagues] with a passport, very professional-looking and complete with photo, signature, and all the necessary demographics," he says. The fake document had been purchased for $3 at a bazaar. "You can get whatever you want for the right price."
In addition, Heywood adds, even under the best of circumstances, the tuberculin skin test is notoriously tricky to implant and read. "Even if a TST were bona fide," he asks, "would it be valid?"
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