Migration and health in Canada: health in the global village.

BACKGROUND: Immigration has been and remains an important force shaping Canadian demography and identity. Health characteristics associated with the movement of large numbers of people have current and future implications for migrants, health practitioners and health systems. We aimed to identify demographics and health status data for migrant populations in Canada. METHODS: We systematically searched Ovid MEDLINE (1996-2009) and other relevant web-based databases to examine immigrant selection processes, demographic statistics, health status from population studies and health service implications associated with migration to Canada. Studies and data were selected based on relevance, use of recent data and quality. RESULTS: Currently, immigration represents two-thirds of Canada's population growth, and immigrants make up more than 20% of the nation's population. Both of these metrics are expected to increase. In general, newly arriving immigrants are healthier than the Canadian population, but over time there is a decline in this healthy immigrant effect. Immigrants and children born to new immigrants represent growing cohorts; in some metropolitan regions of Canada, they represent the majority of the patient population. Access to health services and health conditions of some migrant populations differ from patterns among Canadian-born patients, and these disparities have implications for preventive care and provision of health services. INTERPRETATION: Because the health characteristics of some migrant populations vary according to their origin and experience, improved understanding of the scope and nature of the immigration process will help practitioners who will be increasingly involved in the care of immigrant populations, including prevention, early detection of disease and treatment.

A comparative examination of tuberculosis immigration medical screening programs from selected countries with high immigration and low tuberculosis incidence rates.

BACKGROUND: Tuberculosis (TB) in migrants is an ongoing challenge in several low TB incidence countries since a large proportion of TB in these countries occurs in migrants from high incidence countries. To meet these challenges, several countries utilize TB screening programs. The programs attempt to identify and treat those with active and/or infectious stages of the disease. In addition, screening is used to identify and manage those with latent or inactive disease after arrival. Between nations, considerable variation exists in the methods used in migration-associated TB screening. The present study aimed to compare the TB immigration medical examination requirements in selected countries of high immigration and low TB incidence rates. METHODS: Descriptive study of immigration TB screening programs. RESULTS: 16 out of 18 eligible countries responded to the written standardized survey and phone interview. Comparisons in specific areas of TB immigration screening programs included authorities responsible for TB screening, the primary objectives of the TB screening program, the yield of detection of active TB disease, screening details and aspects of follow up for inactive pulmonary TB. No two countries had the same approach to TB screening among migrants. Important differences, common practices, common problems, evidence or lack of evidence for program specifics were noted. CONCLUSIONS: In spite of common goals, there is great diversity in the processes and practices designed to mitigate the impact of migration-associated TB among nations that screen migrants for the disease. The long-term goal in decreasing migration-related introduction of TB from high to low incidence countries remains diminishing the prevalence of the disease in those high incidence locations. In the meantime, existing or planned migration screening programs for TB can be made more efficient and evidenced based. Cooperation among countries doing research in the areas outlined in this study should facilitate the development of improved screening programs.

Population mobility, globalization, and antimicrobial drug resistance.

Population mobility is a main factor in globalization of public health threats and risks, specifically distribution of antimicrobial drug-resistant organisms. Drug resistance is a major risk in healthcare settings and is emerging as a problem in community-acquired infections. Traditional health policy approaches have focused on diseases of global public health significance such as tuberculosis, yellow fever, and cholera; however, new diseases and resistant organisms challenge existing approaches. Clinical implications and health policy challenges associated with movement of persons across barriers permeable to products, pathogens, and toxins (e.g., geopolitical borders, patient care environments) are complex. Outcomes are complicated by high numbers of persons who move across disparate and diverse settings of disease threat and risk. Existing policies and processes lack design and capacity to prevent or mitigate adverse health outcomes. We propose an approach to global public health risk management that integrates population factors with effective and timely application of policies and processes.

Death and international travel--the Canadian experience: 1996 to 2004.

BACKGROUND: Death during international travel concerns several levels of the travel industry. In addition to the immediate effects for the traveler, their family and friends, the nature of travel-related mortality has important implications for pretravel health advisors and providers of medical care services. METHODS: The Consular Affairs Bureau, Foreign Affairs Canada provides information and assistance to Canadian civilians abroad. Beginning in 1995, the Consular Management and Operations System tracked Canadian deaths abroad notifications. The annual data for 1996 to 2004 was extracted for sex, age, and cause of death by location for all reports received. RESULTS: There were 2,410 reported deaths in Canadians abroad; reported sex was 32% female and 68% male, average age of 61.7 and 60.4 years, respectively. Recorded causes of death: natural (1,762), accidental (450), suicide (92), and murder (106). Country of death reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. Average age of natural death (66 years) distinguished it from all other causes of death: accidental (45), suicide (41), and murder (43). CONCLUSION: Natural causes and suicide deaths may be anticipated or planned to occur abroad. The risk of death may be mitigated through personal knowledge and medical assessment and prevention strategies. Deaths due to vaccine-preventable diseases, exotic and infectious diseases were rare in this population. Consular services may be able to provide various types of support. Local laws and customs, as well as international regulations in health and quarantine govern other responsibilities such as funeral services and repatriation of the deceased to Canada.

Arrest and detention in international travellers.

Systematic published reviews of national arrests of travellers abroad are rare. The pattern of arrest during international travel has implications for travellers and those involved in providing traveller services. There are also consequences for travellers who are arrested and detained abroad. The Consular Affairs Bureau, Foreign Affairs Canada assists Canadian civilians who are abroad. Beginning in 1995 the Consular Management and Operations System was used to track notifications of Canadian arrests abroad. This database was designed for the demographics, destinations, and reported causes of Canadians arrested abroad for 1996-2004. In this period, there were 6514 notifications of arrested Canadians abroad; 1024 (16%) females and 5490 (84%) males with an average age of 33.3 and 36.4 years, respectively. Recorded reasons for arrest were for females: drugs: 420 (41% of females arrested), violence: 75 (7%), other criminal acts: 198 (19%), immigration: 169 (17%), other minor causes: 20 (2%); and for males: drugs: 1554 (28% of males arrested), violence: 581 (11%), other criminal acts: 1468 (27%), immigration: 1056 (20%), other minor causes: 105 (1.9%); or the cause was not recorded for 142 women and 747 men. The USA was the most common host country for arrested Canadians. Alleged drug offences, other criminal activities, and immigration reasons were the most common cited reasons for arrest. Country of arrest reflected the pattern of Canadian international travel for recreation, business, and ancestral linkages. There are a wide-range of potential physical and mental health outcomes to arrest and imprisonment abroad that may be different in foreign jurisdictions due to language, culture, judicial processes and penalties imposed. The prison environment may also pose significant health risks.

The basic principles of migration health: population mobility and gaps in disease prevalence.

Currently, migrants and other mobile individuals, such as migrant workers and asylum seekers, are an expanding global population of growing social, demographic and political importance. Disparities often exist between a migrant population's place of origin and its destination, particularly with relation to health determinants. The effects of those disparities can be observed at both individual and population levels. Migration across health and disease disparities influences the epidemiology of certain diseases globally and in nations receiving migrants. While specific disease-based outcomes may vary between migrant group and location, general epidemiological principles may be applied to any situation where numbers of individuals move between differences in disease prevalence. Traditionally, migration health activities have been designed for national application and lack an integrated international perspective. Present and future health challenges related to migration may be more effectively addressed through collaborative global undertakings. This paper reviews the epidemiological relationships resulting from health disparities bridged by migration and describes the growing role of migration and population mobility in global disease epidemiology. The implications for national and international health policy and program planning are presented.

A Review of Research on Health Outcomes for Workers, Home and Host Communities of Population Mobility Associated with Extractive Industries.

With a growing awareness of the association between extractive industries, the nature of work in remote locations, population mobility and health status, there is a need to advance an evidence-based approach to ensuring the health of migrant and mobile populations, and the home and host communities with whom they interact. Through a narrative synthesis of peer-reviewed and grey literature, this review examines what is known, and the nature of research activity concerning the range of health impacts determined by the social conditions inherent with population mobility alongside mining and extractive industries; and the extent to which health outcomes impact on workers, and home and host communities. While much of the literature reviewed in the study considered health in a traditional disease or illness based approach, it is clear that many risk factors for the health of mobile workers in the sector reflect broader social determinants. To support the mitigation of individual and population vulnerability to infectious disease endemics, consideration of both the etiology and the social conditions that give rise to adverse health outcomes is required, including an improvement to workers' living conditions, the expansion of diagnostic and medical services, and an approach that ensures the right to health for mobile populations. To further improve upon the rich body of research, resources are required to implement robust data collection including epidemiological surveillance, outbreak monitoring and investigation, and the long term tracking of standardized health information at both origin locations and destination communities.

Globalization of infectious diseases: the impact of migration.

With up to 2% of the world's population living outside of their country of birth, the potential impact of population mobility on health and on use of health services of migrant host nations is increasing in its importance. The drivers of mobility, the process of the international movement, and the back-and-forth transitioning between differential risk environments has significance for the management of infectious diseases in migrant receiving areas. The management issues are broad, high-level, and cross-cutting, including policy decisions on managing the migration process for skilled-labor requirements, population demographic and biometric characteristics, and family reunification; to program issues encompassing health care professional education, training, and maintenance of competence; communication of global events of public health significance; development of management guidelines, particularly for nonendemic diseases; access to diagnostic and therapeutic interventions for exotic or rare clinical presentations; and monitoring of health service use and health outcomes in both the migrant and local populations.

National immigration health policy: existing policy, changing needs, and future directions.

Canada has a long history of welcoming immigrants and a longstanding immigration policy framework. The historic principles that govern immigration selection and processing also include regulatory policies in the area of health. Based on historical principles that pre-date Confederation, Canadian immigration health policy has remained relatively constant. Policies are based on the identification of specific individuals and the exclusion, if appropriate, of the affected individuals - an approach that continues today. During the past three decades, however, evolutionary changes in the patterns, volume and demography of immigration have created situations that may necessitate changes to existing policy frameworks. This paper reviews current immigration health policies and practices in Canada, describes the nature and impact of existing challenges, and proposes some alternatives for future consideration.

Health of displaced Albanian Kosovars in the former Yugoslav Republic of Macedonia: fitness to travel and health outcomes assessment.

INTRODUCTION: During the 1999 conflict in Kosovo, an estimated 850,000 people were displaced from Kosovo. Many thousands of these people arrived in the Former Yugoslav Republic of Macedonia (FYROM), for whom a humanitarian evacuation programme (HEP) was conducted by the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM). More than 91,000 people were moved to third countries under this programme. METHODS: A health assessment tool was designed, validated, and implemented to document the health status of the refugees prior to departure. The IOM evaluated 41,652 pre-travel "fitness to travel" medical assessments for refugees transported by the Organization. A colour coding system for fitness-to-travel was used to clearly identify refugees to the receiving health authorities according to their health condition at the time of departure. RESULTS: A total of 41,652 fitness-to-travel assessments were performed between 05 April and 25 June 1999, and were entered into a database. There were 21,923 females and 19,566 males. The average age was 25.3 years (women, 26 years; men, 24.3 years). Of these assessments, 4,647 (11.2%) individuals who were deemed fit-to-travel required medical assessment at the host destination, and of those 1,204 required urgent care. The majority of health complaints were acute respiratory tract infections and hypertension. CONCLUSIONS: A rapid and efficient system for fitness-to-travel was created to assist in the management of health issues related to the urgent and mass movement of refugees. The collected health information was of use to health-care planners during the crisis and for those responsible for the health-care of newly arrived refugees. The lessons learned have implications for future similar operations and for the development of research and education programs for both the refugees and the host recipient nations.

Vitamin D insufficiency and bone mineral status in a population of newcomer children in Canada.

BACKGROUND: Low levels of circulating vitamin D are more likely to be found in those with darker skin pigmentation, who live in areas of high latitude, and who wear more clothing. We examined the prevalence of vitamin D deficiency and inadequacy in newcomer immigrant and refugee children. METHODS: We evaluated circulating vitamin D status of immigrant children at the national level. Subsequently, we investigated vitamin D intake, circulating vitamin D status, and total body bone mineral content (TBBMC) in newcomer children living in Saskatchewan. RESULTS: In the sample of newcomer children in Saskatchewan, the prevalence of inadequacy in calcium and vitamin D intakes was 76% and 89.4%, respectively. Vitamin D intake from food/supplement was significantly higher in immigrants compared to refugees, which accords with the significant difference in serum status. Circulating vitamin D status indicated that 29% of participants were deficient and another 44% had inadequate levels of serum 25(OH)D for bone health. Dietary vitamin D intake, sex, region of origin, and length of stay in Canada were significant predictors of serum vitamin D status. RESULTS for TBBMC revealed that 38.6% were found to have low TBBMC compared to estimated values for age, sex, and ethnicity. In the regression model, after controlling for possible confounders, children who were taller and had greater circulating vitamin D also had greater TBBMC. Nationally, immigrant children, particularly girls, have significantly lower plasma 25(OH)D than non-immigrant children. INTERPRETATION: Newcomer immigrant and refugee children are at a high risk of vitamin D deficiency and inadequacy, which may have serious negative consequences for their health.

The history and evolution of immigration medical screening for tuberculosis.

Identifying and managing TB in immigrating populations has been an important aspect of immigration health for over a century, with the primary aim being protecting the host population by preventing the import of communicable diseases carried by the arriving migrants. This review describes the history and development of screening for TB and latent TB infection in the immigration context (describing both screening strategies and diagnostic tests used over the last century), outlining current practices and considering the future impact of new advances in screening. The recent focus of the WHO, regarding their elimination strategy, is further increasing the importance of diagnosing and treating latent TB infection. The last section of this review discusses the latest public health developments in the context of TB screening in immigrant populations.

Online communication as a potential travel medicine research tool: analysis of messages posted on the TravelMed listserv.

BACKGROUND: Access to the Internet and electronic mail has created opportunities for online discussion that can facilitate medical education and clinical problem solving. Research into the use of these information technologies is increasing and the analysis of these tools can support and guide the activities of professional organizations, including educational endeavors. OBJECTIVE: The initial objective was to analyze patterns of information exchange on the International Society of Travel Medicine's (ISTM) travel health electronic mailing list related to a specific area of society interest. Secondary objectives included the analysis of listserv use in relation to subscriber demographics and rates of participation to support travel health educational activities. METHODS: This study examined the use of the ISTM TravelMed listserv over an 8-month period from January 1, 2006, to July 31, 2006. Descriptive data analysis included TravelMed user demographics, the type of posting, the topic and frequency of postings, and the source of information provided. RESULTS: During the study period, 911 (47%) of the eligible ISTM members subscribed to the TravelMed listserv. About 369 of these subscribers posted 1,710 individual messages. About 1,506 (88%) postings were educational; 207 (12%) postings were administrative. A total of 389 (26%) of the educational postings were primary queries and 1,120 (74%) were responses, with a mean string length of 2.9 responses per query (range: 1-51). Twenty participants contributed 40% of the educational postings. The topics with the most frequent postings were vaccines and vaccine-preventable diseases (473/31%) and malaria (258/17%). Postings focused on special populations, including pregnant women or immigrants, comprised a total of 14 postings (<1%). CONCLUSIONS: During the study period, a limited number of ISTM members (19%) authored postings on the listserv. Regular discussion centered on a limited number of recurring topics. The analysis provides several opportunities for the support of educational initiatives, clinical problem solving, and program evaluation.

Syphilis in immigrants and the Canadian immigration medical examination.

BACKGROUND: Immigrants to Canada must undergo screening for syphilis. This study presents the results of syphilis screening from 2000 to 2004 and describes its impact on Canadian syphilis reporting and epidemiology. The study identifies migrant groups at risk of syphilis disease. METHODS: All permanent resident applicants 15 years of age or older; younger individuals who have syphilis risk factors, and long-term temporary resident applicants are required to have non-treponemal syphilis screening done. Reactive results were confirmed. Immigration-related syphilis screening results were analyzed for year, migrant origin, migrant age and classification. RESULTS: A total of 2,209 individuals were found with positive syphilis serology from the screening of 2,001,417 applicants. The sex ratio of positive cases was M:F = 1.4. Rates per 100,000 applicants were: refugees 286, refugee claimants 267, family class 187, temporary residents 85, and economic class 63. Age and geographic distribution reflected sexual transmission, known international prevalence, and the Canadian processes of immigration. CONCLUSIONS: Certain immigration class applicants from syphilis high-prevalence source countries are a significant source of syphilis notifications in Canada. Identifiable populations and the immigration application medical processes represent global public health policy and program opportunities at the national level.