Implementing GRADE Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugee - PowerPoint PPT Presentation

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Implementing GRADE Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugee

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Objective: Develop evidence-based clinical preventive guidelines for immigrants ... GRADE meeting to make recommendations. CCIRH 14 Step Methods Process ... – PowerPoint PPT presentation

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Title: Implementing GRADE Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugee


1
Implementing 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
2
Canadian 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.

3
Objective 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)

4
Development 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

5
CCIRH 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)

6
Making 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

7
PICO Question
  • Should Canadian primary care practitioners
    routinely vaccinate female immigrants and
    refugees against human papillomavirus (HPV) to
    reduce morbidity and mortality from cervical
    cancer?

8
GRADE 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)
10
Cervical Cancer Vaccination
  • Recommend vaccination to 9-26 year old females
    against Human Papillomavirus (HPV) to reduce
    invasive changes related to cervical cancer.

11
Basis 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.

12
HEPATITIS 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
13
GRADE 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
  • Thank You

15
Pregnancy 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.

16
Basis 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.

17
Clinical 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.

18
Vision
  • 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

19
Basis 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.

20
Tuberculosis (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.

21
Recommendations 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.

22
Basis 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?
  • Is it important?

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)
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