Title: Implementing GRADE Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugee
1Implementing GRADE Canadian Clinical
Preventive Guidelines for Newly Arriving
Immigrants and Refugees forPrimary Care
Practitioners Dr. Kevin PottieCentre for
Global Health, Institute of Population Health,
University of Ottawa
Website http//www.ccirh.uottawa.ca
2Canadian Collaboration for Immigrant and Refugee
Health (CCIRH)
- 43 Delphi Participants-selected topics
- 23 Interdisciplinary Expert Review Teams
- 10 Panel Members Kevin Pottie (co-chair), Peter
Tugwell (co-chair), John Feightner, Vivian Welch,
Chris Greenaway, Laurence Kirmayer, Helena
Swinkels, Meb Rashid, Lavanya Narasiah, Noni
MacDonald - Collaborating Partners Public Health Agency of
Canada, Citizenship and Immigrant Canada,
Edmonton Multicultural Health Broker, Calgary
Refugee Program, Champlain Regional Health, CIHR.
3Objective Develop evidence-based clinical
preventive guidelines for immigrants and refugees
new to Canada for primary care practitioners.
- Mental Health
- Depression
- Child Maltreatment
- Intimate Partner Violence
- Post Traumatic Stress Disorder
- Other Chronic Disease
- Cancer of the Cervix
- Unmet Contraceptive Needs
- Diabetes
- Dental Caries/Peridontal disease
- Iron Deficiency Anemia
- Pregnancy Care
- Vision Disorders
- Infectious Diseases
- Hepatitis B
- Hepatitis C
- HIV
- Intestinal Parasites
- Malaria
- MMR/DPTP-HIB
- Tuberculosis
- Varicella (Chicken Pox)
4Development Process
- CCIRH Planning Committee (GRADE)
- Delphi consensus to select priority conditions
- Expert Consensus Meeting (May 2006) (GRADE as
part of CCIRH methods) - Systematic Evidence Reviews 6-12 months
- PICO Question refinement and development of GRADE
DNP documents - GRADE meeting to make recommendations
5CCIRH 14 Step Methods Process
- Logic model and key questions approach (U.S. and
Can Task Forces with GRADE-Related Questions
values and preferences, clinically important
outcomes, cost) - Search strategies and summary of findings tables
and equity considerations (Cochrane
Collaboration) - Review appraisals (NICE AGREE, EPOC)
- Quality assessment and recommendation development
(GRADE)
6Making Recommendations (GRADE Approach)
- Determine GRADE PICO Question.
- Determine most important desirable and
undesirable effects (SoF table) - Rate quality of evidence (type of evidence,
quality, directness, consistency, effect size) - Determine recommendation (yes/no) and summarize
basis for recommendation
7PICO Question
- Should Canadian primary care practitioners
routinely vaccinate female immigrants and
refugees against human papillomavirus (HPV) to
reduce morbidity and mortality from cervical
cancer?
8GRADE QUALITY CCIRH SUMMARYHPV vaccination for
prevention of cervical caner
Consistency is downgraded since there was
statistically significant heterogeneity in the
per protocol analysis which disappeared in the
intention to treat analysis. Results are graded
as direct since there are no plausible
biological or cultural reasons why the relative
efficacy of the HPV vaccine for the prevention of
cervical cancer is likely to be different.
Rambout et al. 2007 CMAJ
9(No Transcript)
10Cervical Cancer Vaccination
- Recommend vaccination to 9-26 year old females
against Human Papillomavirus (HPV) to reduce
invasive changes related to cervical cancer.
11Basis of Recommendation
- Balance of benefits and harms Net benefits. For
HPV vaccination, the number needed to vaccinate
(NNT) i.e. vaccinate to prevent invasive
changes is 139 (117 to 180) in studies with a
15-48 month duration (relative risk 0.52, 95 CI
0.43 to 0.63). The expected NNT in immigrant and
refugee women is expected to be more favourable
since there is higher mortality from cervical
cancer in foreign-born women than Canadian-born
(3.4 vs 2.5 per 100,000 women) and higher
prevalence of HPV infection in developing
countries. Anaphylaxis occurs in less than 1 in
100,000 doses. - Quality of evidence moderate
- Values and preferences The Committee attributed
more value to preventing cervical cancer and less
value to current uncertainty of impact on
mortality.
12HEPATITIS B SCREENINGScreen
adults and children from intermediate and high
Hepatitis B endemic countries with HBCore AB and
HBsAg to decrease disease severity and
transmission and mortality from Hepatocarcinoma.
Basis of Recommendation Balance of benefits
and harms Net benefit The number needed to
screen to prevent one death due to hepatocellular
carcinoma (HCC) is 2058 (95 CI 1462 to 4412),
corresponding to a relative risk reduction of 38
(95 CI 17 to 52). The expected NNS in
refugees and immigrants is expected to be more
favourable due to higher prevalence of hepatitis
B for immigrants and refugees, ranging from 1-10
compared to lt0.5 for North Americans. Toxicity
depends on treatment decisions.Quality of
evidence moderateValues and preferences The
Committee attributed more value to preventing
death due to hepatocellular carcinoma and less
value to burden of screening and side effects of
treatment
13GRADE Challenges and Response
- Quality of evidence- focus on effectiveness of
intervention (rare RCT for prevention) - Whose values and preferences? How to evaluate
explicitly? - YES/No vs. Strong/Weak recommendation
- Response CMAJ- positive peer review debate on
how to present basis of recommendation
14 15Pregnancy Womens Health
- Immigrants and refugees have an elevated risk for
social isolation which is associated with
maternal physical and mental morbidity. Research
recommendation to develop and study interventions
for social isolation.
16Basis of Recommendation
- Balance of benefits and harms Risk of causing
harm with a social intervention to reduce social
isolation and no evidence to demonstrate
effectiveness. Perceived lack of social support
is higher amongst immigrant and refugee women
than Canadian-born women (15.4 compared to
7.2). Therefore, we approved a research
recommendation to develop and study interventions
for pregnant women and social isolation. - Quality of evidence very low
- Values and preferences The Committee attributed
more value to the large uncertainty of benefits
without a studied intervention.
17Clinical Considerations
- Immigrant and refugee women account for over half
of the total births in Canada. Reports suggest a
higher risk status in some newly arrived pregnant
women for maternal mortality. - Although no clinical action recommendation made
to address social isolation, pregnant women may
benefit from other established antenatal
screening diabetes, depression, HIV, Hepatitis
B, Hepatitis C, syphilis, iron deficiency,
hemoglobinopathies, rubella and varicella
susceptibility. - Being alert for risks of unprotected/ unregulated
work environments and sexual abuse (specifically
in forced migrants) may also be beneficial.
18Vision
- Screen all adults for visual impairment to reduce
vision loss and related morbidity. Vision lt
6/12, refer to optometrist or ophthalmologist for
comprehensive ophthalmic evaluation
19Basis of Recommendation
- Balance of benefits and harms Net benefits.
Refractory error is correctible with spectacles
for 83 of people, corresponding to a number
needed to treat of 5 people. Effects of
screening are likely to be important for
immigrants and refugees since there is a higher
burden of uncorrected visual impairment in
developing countries (e.g. blindness prevalence
is 1 in Africa compares to 0.3 in the
Americas). Harms are minimal, and may include
out of pocket costs. - Quality of evidence very low
- Values and preferences The Committee attributed
more value to the importance of ensuring adequate
visual acuity for daily functioning and
employment and less value to the concern of
screening and cost of spectacles. - Clinical Considerations
- Even modest visual impairment (visual acuity
lt6/12) is associated with significant morbidity. - Special considerations exist for doing vision
screening kidslt8 years of age. - Referral for assessment is also warranted for
other risk factors for blinding eye disease
including diabetes, agegt65 blacks over 40 and a
family history of glaucoma.
20Tuberculosis (TB) in Adults
- Screen all refugees from high TB incidence
countries, between the ages of 21 and 50 years,
as soon as possible after their arrival in Canada
with a TST. Screen all other adult immigrants
if they have risk factors that increase the risk
of developing active TB with a TST. Treat for
latent TB infection in those found to be
positive, after ruling out active TB.
21Recommendations for Preventing Tuberculosis
(TB) in Immigrants and Refugees
- Children
- Screen children and adolescents 20 years from
high TB incidence countries (smear positive
pulmonary TB 15/100,000 population) as soon as
possible after their arrival in Canada, with a
Tuberculin Skin Test (TST) and treat for latent
TB infection if found to be positive, after
ruling out active TB.
22Basis of Recommendation
- The recommendation is based on the balance
between the potential benefit of treatment
(lifetime risk of infection which is influenced
primarily by age, presence of medical factors
that increase the risk of development of active
TB, immigration class, and to a lesser degree the
effect of time since arrival) versus the
potential harm of hepatotoxicity and the poor
efficacy of INH in many settings due to
sub-optimal uptake of screening and treatment. - Assuming 70 adherence, children from high TB
incidence countries number needed to treat (NNT)
20-26 and number needed to harm (NNH) 134-268
and those with risk factors for development of
active TB were the groups judged most likely to
benefit from chemoprophylaxis (NNT 2-20, NNH-
variable).
23- What are the health problems?
- What are the clinically important outcomes
desirable and undesirable effects?
Diversity of Effectiveness How do immigrants and
refugees differ from the Canadian population?
What actions might be most feasible for primary
care practitioners? -users views-
- Is it useful for practitioners
- Does doing this cost more than that? (societal
values)
- Will immigrants accept it? (values and
preferences)