Webinar: Supporting immigrant and refugee TB clients

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Jessica Helwig: Hello everyone and thank you for joining the Communicable Disease and Infection Control webinar series. We are pleased to have you join us for today's webinar which is being presented in partnership between the Public Health Agency of Canada and the National Collaborating Center for Infectious Diseases otherwise known as NCCID. My name is Jessica Helwig and I'm a senior policy analyst with the agency. 

I will be the co-moderator for today's webinar alongside Signy Baragar who is the KT project manager at NCCID. As we gather virtually today, I want to start off by acknowledging the different lands that we each find ourselves from coast to coast to coast. These lands have long been home to many Inuit, Metis, and First Nation peoples, and we have recognized their enduring presence. 

I, myself, am currently located on the unceded, unsurrendered territory of the Anishinaabe Algonquin Nation. I also want to acknowledge, as we gather to discuss tuberculosis, the significant and disproportionate impact it has had and continues to have among many Indigenous communities. And that if we are to eliminate TB, we must recognize and address the historical and ongoing impacts of colonialism, systemic racism, and social exclusion that have contributed to these health disparities. 

Signy Baragar: I would like to acknowledge that NCCID is hosted by the University of Manitoba. Both the University of Manitoba and I are situated on Treaty 1 Territory, the original lands of the Anishinaabe, Cree, Oji-Cree, Dakota, and Dene peoples, and homeland of the Métis Nation. As a European settler, I am thankful for these lands that I am able to live and work upon and I recognize the responsibilities that I have inherited for their protection. 

As an organization, NCCID recognizes the systemic inequities and treaties that have been implemented as part of the process of colonization intended to benefit some while harming others. We are committed to working with our partners towards reconciliation. 

Jessica: Thanks Signy. A short disclaimer about today's presentation. It includes speakers external to the agency which may not reflect the views of the agency or NCCID. This webinar will be conducted in English. 

Simultaneous interpretation in French can be accessed through selecting the interpretation button in the menu at the bottom of your screen. Following today's webinar, a feedback form will also be sent to you. A few more technical notes. 

Your audio has been muted to reduce noise, and your video has been disabled for this webinar. If you are having technical problems and need help, you can reach us through the chat function or send us an email. Please feel free to communicate in either English or French. 

If you have a question for the speakers, please submit your questions using the Q&A function and we will have a look to answer them at the end of the webinar during the Q&A section. Note you may check send anonymously if you do not want your name attached to your question. Our goal with today's webinar is to present key information on supporting immigrant and refugee TB clients. 

To start us off, we are fortunate to hear from Ridhdhi Tokia who has graciously agreed to share her own experience with TB disease and immigration to Canada. While she could not make it for today's webinar, she has recorded her thoughts in advance.  

[Text on screen: Please tell us a bit about your experience] 

Ridhdhi Tokia: So let me introduce myself first. 

My name is Ridhdhi Tokia and I'm 34 years old and I come from India. So I came first to Canada in 2022 and after that actually I visited twice India once when my mother left and the second in the 2022 December and in 23 December when my father died. So like as you can understand that during this two one or two years were usually stressful for me. 

So I was just doing everything with the as a newcomer do as an immigration do that's work and everything that's like that. So I was very got excited when I finally got my PR invitation in September 2024. So actually in my PR invitation when I supposed to submit my medical exam during that time I was diagnosed with first time that I may have the TB symptoms through which they found out in my chest X-ray. 

So my immigration doctors asked me to go for the further examination like sputum test and all those stuff. So I get that done and to my surprise those test result come positive and to be very honest I wasn't prepared for this because it was very surprise for me because I thought in my like all time coughing you know you have the constant some certain symptoms you have that physically overall I didn't have those symptoms but as internally it was actually was in a very bad stage that I was diagnosed. So it was the very good time when I got diagnosed. 

I got good support from the health care system. I was immediately got the medication right away it got started and then I also got the very good support from healthcare group my nurse and everything like that. I didn't know how to apply for EI all those stuff was very new and very alien concept for me. 

So of course for all those procedures, how to do it, what should what are my rights, what can I have get help from the healthcare system or from the government. All those stuff they made me aware of it.  

[Text on screen: What was it like interacting with the healthcare system?] 

For like really emotional and mental support was really good given by my nurse Linda she was really helpful throughout this process. She used to call me, we used to meet initially we used to meet every day, then every two weeks we used to call and of course on phone she's always available for me. So yeah she would be great help and support for me from her side that because sometimes this guy got really numb when I just started missing my parents and everything I don't have anyone to talk, she was always there. Even I'm crying she was just sit there and you know she was always really sit there patiently and you we got this we are here for you everything. So, in that way she really helped me. 

One other thing I really want to mention that where I was living like when initially I got diagnosed I was living in somewhere else as a paying guest. They were not that much supportive of this thing although they don't know anything about it but still and Linda kind of know this thing so she really helped me to okay you know what we'll keep it a secret and you don't have to explain anything to anyone and she was really supportive at that time.  

[Text on screen: How did you diagnosis impact you?] 

So, health-wise, I did have some concern because I thought it whether it would always stay  within my body like you know kind of like diabetes or something like that. It always, you kind of have to live with it. 

So I in my mind is it like that those concern I always had that what if something happens with me here because I don't have that much kind of you know insurance or something like that so what if this my health gets deteriorate and it's something worse versus what would be the worst case scenario and like that. So immigration wise it is really tough even till now so because I personally find feel this like the patients like me kind of they're treating like in a bias like you know because I got the express entry draw when I got the PR invitation so by the law they have to give the decision in the 6 months it's been over 6 month and because of my this medical condition they haven't given me any kind of a decision so now problem is right now that because my status got expired now I'm not able to work. I'm not eligible to apply even EI second time and now I'm literally sitting at home. So this is very like you know frustrating at the same time it feels like it's made me feel like that it's my fault that it's because I'm diagnosed with this such disease and that's why I'm facing all these troubles. 

I was diagnosed with this TB, doctor told me that it's you I have very old infection this probably you know 20 or 15 to 20 year old infection but it come resurfaced because of the mental stress probably that I went through because I lost my parents, of course for this immigration process and the everything. And this is because of the excess amount of stress this infection came to the surface. Now this thing actually add upon this because is it like right now in this stage I have to be very physically and mentally have to be really you know stress free and everything I should be focus on my health and everything but I can't like you know this is very stressful situation because I don't know what would be the next should I wait should I leave because if I leave then I have to start back from the zero so what should I do like should I wait if I wait then until when is there any time limit I don't have any answer. So this is where I really think that you know there are room for improvement there are room for better treatment you know that's I really hopeful that it should get better from the others who are coming in the in this immigration program. 

[Text on screen: What do you want health professionals to know?] 

The healthcare system can make aware the immigration system that this is the stage this is how people go through and it's not their fault if they came with this disease or infection or whatever you say but they are not threatened to the people of the Canada like you know, we are not the threat like, we are not someone like we are here for threatening the people or the healthcare system or we are trying to burden on the healthcare system of course we all want to live a happy healthy life so of course we are all going to support them. But if they do this kind of a discrimination in the immigration, there is probably high chance that the people who came in immigration and if they have slightly knowledge of the they have something in bad happening in their body or in medical wise they most likely to actually hide it rather than it coming to face it because they know that the what kind of the repercussion can become like the story they might be have be heard from like people like me. Oh, if what if I also diagnosed with like something like that, you know, they better try to avoid this medic medical examination or something like that. 

Jessica: I'd like to take a moment to express how grateful we are for Ridhdhi in sharing her story. While not all immigrant and refugees with TB have the same experience navigating the health care system, her story provides us with a great example of the many ways primary care providers can create a positive experience for their patients. As we move into our panel discussion, let us keep in mind her journey and the lived reality faced by all immigrants and refugees and the complexities of navigating TB care as a newcomer. 

With that, I will pass it on to Signy to kick us off with our panel discussion and introduce today's speakers.  

Signy: Great. Thanks, Jessica. 

I'm excited to welcome our panelists for today's webinar. I'll ask them to turn on their videos now if they haven't done so already. so first off 

Dr Nancy Bedingfield is a post-doctoral scholar with strong interests in qualitative methods, patient education, health equity, and implementation science. Nancy has over a decade of experience working as a nurse, a clinical trials project manager and a knowledge translation project manager, all in the field of TB. She is working on international patient-centred research projects with the McGill International TB Research Centre, the Dahdaleh School of Global Health, and the Desmond Tutu Health Foundation. 

Dr. James Johnston is the Evaluation Lead at Provincial TB Services and Clinical Professor of Medicine at The University of British Columbia. He is also President of The Union Against Tuberculosis and Lung Disease North American region. His research interests include mycobacterial epidemiology, treatment outcomes, drug resistance and genomics. 

Amanda Koyama is the Director of Strategic Engagement with the Calgary Catholic Immigration Society, a large Settlement organization that provides a wide range of services to immigrants and refugees in Calgary and Southern Alberta. Amanda has spent the majority of her professional career in the public sector with a focus on access and engagement, including identifying barriers to health care access for Newcomers to Canada. 

Dr. Jill Quinton is a family physician and the acting director of the Ottawa Regional Medical Office at Immigration, Refugees, and Citizenship Canada, otherwise known as IRCC. This unit is responsible for the adjudication and delivery of the immigration medical examination for the Americas. 

Welcome to all of our panelists and thank you for joining us today.  

So our first question is going to be to Jill. So Jill, can you provide us with an overview of the immigration medical exam or IME and IRCC's TB medical surveillance process for newcomers. 

Jill Quinton: Hi, thanks so much for having me. there will be some slides accompanying what my answers to these questions. So here they are. 

Hopefully everybody can see them. Okay. so thanks so much for the introduction. 

So, I'm Jill and like Signy said, I'm from the Ottawa Regional Medical Office. I'm here with my colleague Julie from the public health liaison unit also of IRCC and we're here to discuss the immigration medical exam and TB medical surveillance.  

Next slide, please. 

So the immigration medical exam or the IME is an exam, a screening medical exam, to determine medical inadmissibility to Canada. So this exam is mandated by existing legislation and is based on three screening pillars. The first being danger to public health and the condition of concern for this pillar is active pulmonary tuberculosis. 

The rationale being it's a global infectious disease has significant morbidity and mortality as we're all aware and can be challenging to detect and treat. The second pillar for the IME is danger to public safety and examples of this would be clients with conditions that where they have unpredictable or violent behavior that may put other Canadians at risk. And the third piece of the IME screening objectives is what we term excessive demand on health and social services. 

So these are medical conditions that may result in strain on Canada's public health care system. And the formal definition is when a health condition or conditions would foreseeably exceed three times the Canadian average Canadian health care cost per capita or would impact weight lists for Canadians for certain procedures. So the current threshold for 2025 is $27,162 per year or an average of $135,810 over 5 years and this amount is updated annually. 

So important to note there is no medical condition that automatically leads to inadmissibility based on excessive demand. And please also note that refugees are exempt from excessive demand considerations. So the conditions that most commonly result in excessive demand are conditions such as renal dialysis, the need for a solid organ transplant, and some conditions where the cost of medications are very high such as some cancer treatments, immunologics, some multiple sclerosis medications, things of that nature. 

Next slide, please.  

So in terms of who requires an IME, it's those who are applying for permanent residency as we heard on the video. That also includes refugees and asylum claimants. 

it also includes those who are going to be working with vulnerable populations, so children or in the healthcare field and it also includes those who have been residing in a high TB rate country for at least 6 months in the past year. Now a high TB rate country is defined by IRCC as it's based on the WHO TB incidence statistics. So rates those countries with rates of more than 30 per 100,000 and a few other factors result in the determination. 

Next slide please.  

So the IME itself consists of a medical history and physical examination. All clients aged 11 and older also undergo a chest X-ray. 

And clients 15 and older are also required to have serology for HIV, syphilis, and creatinine. The IME is submitted electronically and it's reviewed at one of the four regional medical offices around the world and additional investigations may be requested by our medical adjudicators. The IME is a private pay exam. 

However, asylum claimants and refugees have coverage under the interim federal health care program that covers the cost of one IME and some healthcare services. The IME is conducted by designated physicians who we term panel physicians or PPs. We're not currently looking to add to our Canadian physician network in the foreseeable future with the exception of some rural and remote locations. 

Now, it's important to note that not all findings of medical significance are relevant for the IME. So, during an IME, if a medical condition is uncovered, panel physicians are instructed to direct applicants to correct to appropriate medical intervention, whether that be primary care provider or the emergency department to follow up on their condition. And panel physicians are also instructed that they must follow any local public health guidance for the jurisdiction in which they practice. 

Next slide please.  

So as previously mentioned one of the main aims of the IME is to detect active pulmonary tuberculosis and ideally to detect it and have it treated before clients arrive in Canada. Now as some of you may be aware global health TB rates are going up and especially in many of Canada's traditional top source countries for immigration. 

So the immigration medical exam will not be finalized until active TB is ruled out and should active TB be diagnosed the treatment must be completed to Canadian standards before the IMEU will be assessed. When active TB is suspected for because of either symptoms or concerning radiologic findings, we require u clients to have sputum testing and be referred urgently to a TB expert. 

Or when there is evidence of previous TB on a chest X-ray but the findings are less concerning they will be what we term furthered for further investigation to rule out active TB in terms of latent tuberculosis this is clients are screened though we only screen certain clients so they clients who have conditions in one of five high-risk groups who are felt to have the highest risk of reactivating to active pulmonary TB will be screened via the IGRA blood test. If they're positive, they will go undergo investigation to rule out active TB and then they're encouraged to undergo TB preventative therapy. However, this cannot be mandated. 

The five conditions that triggers this screening are clients who have been in close contact with an active TB case in the last 5 years, clients who are HIV positive, clients with a history of head and neck cancer in the last 5 years, that excludes thyroid cancer, and clients with advanced chronic kidney failure or end stage kidney disease with an eGFR of less than 30. And lastly, clients with a solid organ or bone marrow transplant on immunosuppressants.  

Next slide, please. 

So now moving on to TB medical surveillance. So this is a client this would be a client who has undergone their IME and has a condition of medical surveillance attached to their application. and then they are referred to public health authorities in the province or territory of their destination. 

So who gets referred? These would be clients who have had active TB ruled out but who have chest X-ray findings suggestive of inactive TB. clients who were diagnosed with active TB at the time of the IME and were treated, clients who have a history of TB in the last five years, and those who have a condition of one of the five high-risk groups with a positive IGRA test. 

And the goal of TB medical surveillance is to mitigate the risk of TB reactivation after arrival in Canada.  

Next slide, please.  

So TB medical surveillance is only initiated as I said after a client arrives in Canada. 

A client will receive instructions when they arrive from either border services or via the public health liaison unit. And it's important for those of you that are primary care providers to note that you may have patients who have received notification that they must undergo this process and that sometimes these appointments with local public health may take weeks or months to occur. So, it's the client's responsibility to ensure IRCC has their correct updated contact information at all times. 

Next slide, please.  

And you can see on this graphic how information is shared with provinces and territories. Once a client completes their first medical appointment with local public health and that includes any tests required by the province or territory to evaluate the risk for reactivation or rule out active TB, a client may be placed in compliance by the province or territory. 

So each public health authority in each province and territory runs their own program. and this is not run by IRCC. However, IRCC does engage in yearly engagement with provinces and territories to provide opportunities to discuss best practices, pain points, and review any program improvements. 

Next slide, please.  

So, important to note that non-compliance with TB medical surveillance does not impact a client's approved and valid status in Canada. However, non-compliance with TB medical surveillance may result in delays at the border and or in visa and permit applications and extensions. 

It is within a migration officer's authority to re to refuse an application due to TB medical surveillance non-compliance and this does happen on occasion. Also important to note, however, that non-compliance with TB medical surveillance is different than non-compliance with treatment for active tuberculosis disease. So should a client be in Canada with no open application but develops active TB and is non-compliant that becomes an enforcement issue and would involve the public health authority and Canadian border services. 

So thanks very much for the opportunity to speak on these two issues and I'd like to pass it back to Jessica and Signy.  

Thank you. 

Signy: Thanks so much Jill for sharing that. 

To build on this presentation, I now have a question for Amanda.  

So, what are some common challenges or concerns faced by immigrant and refugee clients when trying to navigate or access the health care system? And what opportunities are there for primary care providers to offer support? 

Amanda Koyama: Thanks, Signy, and thanks so much for the invitation to the panel to most likely share opinions that are not representative of the agency.  

So I, yeah, I feel like I have to kind of focus here. I just learned a lot about the IME. 

So, the first thing I want to say, and I feel like I'll probably say it several times, is we're probably going to hear about a lot of things that exist, but I want to emphasize that availability does not equal accessibility. And so, that's what we see over and over again. The system is not necessarily designed for the individual. 

And so, this is where we get lost. Our clients get lost in the cracks. And so I would say migration barriers is a big one. 

Migration itself is considered a social determinant of health which I think is not kind of relevant enough in lots of conversations. I'm glad that Ridhdhi had a positive experience. But I also want to point out that she speaks English. 

So that automatically makes it more accessible to her to navigate all of these things. Although she also did mention the bias in the system and the eligibility problems for other available services. I think when migration's not considered and looking at client well for you I guess patient services the systems in Canada tend to treat newcomers as if they their lives began upon arrival disregarding sort of the migration and their settlement journey which is actually could cause harm produce harm in terms of outcomes even down to the point of what immigration categories they exist in terms of refugee, immigrant, was express entry there's very little conversation about temporary residence refugee claimants, temporary foreign workers, international students who end up in health systems. 

But it complicates everything. And so because of this, there's of course fragmentation of health records, which you know is why I think people start as if they just arrived. And I learned, and I'm sure someone correct me, the IME that we were just learning about, from my understanding, that doesn't get to the primary care physician of a newcomer once they're like settled in their community. 

So, I find that kind of interesting. There are very legitimate system barriers in terms of national provincial health care. Which I don't think anyone's going to be shocked to hear me say. 

We have very clear examples of how the system barriers cause harm. I would say especially in terms of I'll speak to funding because there's the federal government seems to be responsible for public health which is fantastic and then provincial governments have their own jurisdiction. There seems to be disconnect there and then even down here. 

So there's two things that I can give an example. We used to have here in Calgary a refugee health clinic under our PCN our primary care network who last year decided they were no longer going to focus on refugee health. So if I'm not sure how that decision came to be or how that happened but it happened. 

So if there's no focus and refugee health doesn't get its own population profile, I don't know what the expectations are among that. And then for some of you, I'm sure know N4 was an IRCC funded national organization that intersected with health and immigration who lost their funding this year. And all the evidence they built over six or seven years was no one really cared. 

We, the community, came to the table to try and kind of keep it. So if the systems and the funders don't prioritize the intersection of culture and health, I'm not sure why we expect the client to advocate for themselves in a system that doesn't count them. 

And also there's barriers within that system in terms of cultural safety, first language, the inclusion of faith in terms of health practices and then just lack of like cultural responsiveness within primary care providers, which I'm not going to say as an individual fault. Of course, I'm always curious more around the backing it up a bit for education in terms of what's being taught, what's being learned for health professionals and more importantly research. We do a lot of research in the newcomer space and the amount of medical research that comes to us with an attempt to engage has a wild lack of cultural safety in it and often is only engaging people that have no reduced barriers. 

So, when they want to do research and they want to only focus group people who speak English, that's a bit of a that's a not an equity question. 

I wasn't watching my time, so I just want to make sure I'm okay. 

Signy: We'll move on to the next question now, Amanda, and then we'll come back to you later for another question. 

So, this next one is for Dr. James Johnson.  

So the BCCDC TB services provides TB consultation for health care providers across BC and has its TB clinics or the regional health authority arrange the TB medical surveillance for newcomers in BC. 

So James as an evaluation lead for the BCCDC's TB services, can you provide us with kind of a general overview of the TB screening process for healthcare providers and for example kind of knowing when and who to screen or risk factors to look out for example?  

James Johnston: Yeah. 

So thanks for having me.  

This is a very complicated question and I'm coming from a centralized TB program where we do a lot of the screening and we do the care from a specialized clinic rather than primary care providers doing the care in terms of giving TB preventative therapy and TB active TB therapy which I think is important. TB screening I mean there's multiple ways you could look at it. 

You could talk about TB screening for active disease or TB disease as it's now known. I will not talk about that right now. I also won't talk about the IME which really I think you know was well explained and really describes how this is not a system that screens for TB infection but rather is just looking for people with active disease with a small proportion about in our province about 3% of people who are screened for TB infection also known as latent TB so I won't talk about as well. What I'll talk about is screening for TB infection or also known as latent disease we're trying to move away from calling it latent disease and moving into calling TB infection because that latent kind of is we don't call it latent hepatitis C for example, we call it hepatitis C infection. 

So when we're screening for TB infection, it really is a multifactorial assessment.  

There's no clean answer to say this person should be screened and this person should not be screened. I would direct everybody from a national level to look at chapter four of the Canadian TB standards and chapter 13 of the Canadian TB standards. 

Chapter 4 describes the TB infection screening process. And really this is a multifactorial assessment where we look at the person's exposure history. Where were they born? 

What is their refugee status which actually in and of itself doubles risk of TB disease? What social networks do they reside in? Obviously if they've had a contact with TB. 

So knowing somebody's exposure history is very important. Knowing their risk of disease once exposed. So if somebody's living with HIV or has significant immune suppression, that's actually quite important to know. 

And then what are the risk of side effects of preventative therapy if we were to offer that person preventive therapy? If they're 85, I'm going to be very reluctant to screen them because downstream I'm going to be very reluctant to give them preventative therapy. And so it really is that multifactorial assessment. 

So there are risk calculators that can help you with this process which include country of origin as one of the variables and I would encourage everyone to look at tstin3d.com. I can put that in the chat later. You can also look at a risk calculator looking at tbmigrate.com which looks at TB risk and migrants before screening. 

So that being said, there are some groups you should screen every time, right? And I think that's probably what people are looking for in terms of answers right now. Who should I screen every time? 

The people you should screen every time are in the TB standards chapter 4. You can look at the people who are considered high risk and that is people living with HIV, people who've had contact with TB obviously people on TNF inhibitors or on chronic immune suppression, people with dialysis bone marrow transplant. So really immune suppressed people regardless should be screened. 

And so that makes that multi-factorial assessment easy. The other part is much more difficult and is sort of province to province specific and is provider to provider specific. So that's when I would encourage you to turn to these evidence-based risk calculators like tst-in-3d or periscope is another one or the risk score tbmigrate.com and I'll put those in the chat so people can look at them. 

I'm done now.  

Signy: Perfect. Thanks so much James. 

We actually have a follow-up question for you. In your experience, so what are some kind of key challenges that primary care providers have faced when trying to support their newcomer clients?  

James: So, I have to say I feel a bit awkward answering this question, not being a primary care provider. 

I live in the privileged position of being a specialist who sits in a specialist clinic who actually sees people who have mostly been diagnosed with TB or have been highly suspected as having TB. And so the things that I see from my perspective are probably very different from primary care. So that's my disclaimer. 

So I don't want to speak on behalf of primary care providers. But I think obviously you know as been alluded to competing priorities of people when they migrate, people have difficulty navigating the system. People have very great difficulty navigating access to health care and we are seeing this actually recently with students having a heck of a time trying to find health care. Mobility, so people, you know, may land in one province and move to another province and these interprovincial barriers are a major problem. So from that perspective, it's very hard for a primary care provider to help that person because there are so many system barriers impacting that person. But I also think it's hard for primary care providers to understand who to screen, which I've tried to describe here briefly. 

And also understanding when to screen somebody for active TB. You know, asymptomatic TB is quite common, minimally symptomatic TB is quite common. and it can mimic other diseases. 

You know, if we were to screen people across the board, we would find a heck of a lot more TB than we are actually finding right now. And so what I would encourage people to do is lower your threshold to look for TB. Don't wait for those night sweats and hemoptysis. 

If they have a chronic cough, pursue it. I see on my side way too late delay diagnosis because, oh, it's just a cough. It's not a big deal. 

And that person ends up with having advanced TB. So really put it high in your mind and lower your threshold for active TB screening because I think it's a lot more common than we even expected to. 

The other thing I'd put a plug for as a person who researches this area is once that TB is treated and so-called cured, that person has a higher rate of death, a person higher rate of cardiovascular disease, an extremely high rate of pulmonary disease. Post TB is a major health issue and one in 50 people around the world live with it and we estimate over 100,000 people in Canada are living with the effects of post-tuberculosis. So please treat that person, screen them for lung cardiovascular disease, depression if they've been treated for TB in another country or in our own country because we don't provide good post TB care. 

We often just say, "Oh, you're cured. Have a great day. Have a great life." and that person is left with all of these substantial problems from post TB. 

And I'm done that.  

Signy: Thank you so much. Our next question is going to be for Nancy. 

So according to the latest TB standards, only a majority of active TB cases among newcomer populations are identified during the postlanding surveillance programs and many newcomers are lost follow up along the care pathway for TB infection. So there's systemic barriers in our health and social systems as we've discussed today that can make it really challenging for newcomers to access care but also for health professionals to deliver the care that the clients need. So can you speak to the gaps or barriers in the health care system that need to be addressed for services to be improved? 

Nancy Bedingfield: Absolutely.  

Thanks Signy and thanks to everyone. Thanks for the invitation to speak to everyone today. 

For this question, I'm just going to focus on the TB infection care pathway. So, we know that the TB infection care pathway is long. It has many steps and there's lots of opportunities to lose people along the way. 

And there's lots of good systematic review, lots of research evidence that people are lost in large numbers along that care pathway and that people who are migrants and are affected by language barriers are lost more often along that care pathway. And there's also lots of good research on what kinds of interventions are helpful in keeping people in that care pathway. So things like increasing accessibility. 

We've already talked a lot about health insurance and managing better with language barriers. But other things like extending clinic hours because you know people as James said competing priorities people need to work. So extending clinic hours, allocating services and using incentives and enablers. 

They're all shown to be effective interventions. including education for patients and healthcare providers as well. But I'm really conscious and I'm sure it's coming into your heads too that it's not within the power of any individual healthcare provider to suddenly start providing some of these interventions. 

You just can't all of a sudden start practicing in a new place because it's more convenient for your patients or start even start using something simpler like start using enablers or incentives. This gets really hard and takes a lot of policy change and system change. Our system has a lot of barriers as we know but some barriers are really specific to TB in this population. 

So you know TB is very stigmatized in many cultures and latent TB or excuse me TB infection is really unheard of you know almost in every population and so patients are really need in need of a lot of education but the adherence culture both that's really strong adherence culture is really strong in TB care and sometimes that pushes out the need for patient centered education you know just take your treatment do the next step. Don't ask why. That kind of culture unfortunately is strong. 

and embedding this care pathway within an immigration process is really difficult. If anyone has time, there's a really great PhD thesis that was done at the University of Toronto showing how difficult it is to provide for providers to provide patient centered care within an immigration process when people have a lot of fear about deportation and also people who are born outside of Canada sometimes don't come from cultures where patient-centered decision making and really active patient education is the norm. 

and deference to healthcare providers is a little bit more common. So, you know, people really need a lot of education, but there's a lot of barriers up to providing that education. and so to provide that sort of education, you really need a lot of time and appointments. 

You need training to provide that sort of education. You need resources. But  you know you likely don't have a lot of those resources at your disposal if anyone is a care provider in the call. 

so to implement a lot of these interventions we really need well-coordinated public health primary care and newcomer settlement organizations but we don't have those at the moment. All those all those systems operate on shoestring budgets and they're not well connected. So, so there's things that you can do as an individual provider, but it's limited. 

And it's just really important that we keep advocating for better services for people experiencing TB and people born outside of Canada. So, system advocacy system change is really important in this area.  

Signy: Thanks, Nancy. 

And so as a follow-up question to that, we know that receiving a TB diagnosis can be really stressful for patients. So what are some strategies that primary care providers should employ when counseling their patients about TB?  

Nancy: Sure. 

So here I'll focus a little bit more on active TB, but it all it everything applies to TB infection as well. So just running through some of the research that shows that TB being, I think Ridhdhi did a really great job of explaining to us why being diagnosed with TB is so stressful but just to bring the research element into it. There's a lot of quality of life research in tuberculosis treatment active tuberculosis treatment and it's quality of life can be very low when people are first diagnosed with TB. 

Some studies in the international setting show that quality of life can be as low as 30% of the national average or 10% of the maxim score for the tool and that impairments go across physical, social, emotional. again, Ridhdhi did a better job of explaining that than I could. And because TB is a slow growing infection, quality of life doesn't improve for months and as James rightly pointed out, it doesn't often doesn't go back to population norms when treatment is finished. 

So there's less evidence about quality of life in late in TB infection but we know that mental like emotional psychological scores of people taking TB preventative treatment can be lower likely related to self-stigma and there's a lot of research about catastrophic costs associated with people taking TB treatment for TB disease that as many as half of households that affected by active TB. This is from the international setting, but still very true in settings in high income settings can experience losses greater than 20% of their household income. And depression and anxiety are really closely related to TB disease. 

There's lots of different pathways where that can happen. Some are biological related to the disease, related to the medication, related to self stigma and isolation. So we there's have no doubt that TB diagnosis is very stressful. 

So I think you know keeping in mind what we've just said about all the system barriers what you can do is again just do the best you can in the system that we're operating in right now. And I think the most important thing you can do is just to open up the door to some of those non-biomedical conversations so that people know that it's a safe place to talk about some of those concerns that are very real. so you know just even sentences like we know that people with TB experience depression, legal problems, huge financial problems or you know sometimes people think that TB is incurable things like you know just open up the door to some of those biomedical conversations and if you can refer like primary care providers and other generalist care providers are hopefully pretty good at referring to other places for services for financial or legal assistance or mental health counseling and also you can you know delivering education is crucial. 

It's crucial in this area because people have so many misconceptions or knowledge gaps. but delivering verbal education only is always the least people retain that verbal information the least. So if you can provide an additional source of information that's great and both BCCDC where Dr. Johnson works and Toronto Public Health, they have freely available TB resources that are translated, which is huge. So, if you can try and improve the resources at your clinic, that's great. and again, just try and position, just speaking about, TB infection or TB preventative treatment specifically, just trying to position that as a personal choice. 

Yes, there's people that are in high-risk groups where treatment is really important. but coming at it sometimes coming at it from an adherence perspective rather than a I'd like to inform you about your personal risk or and allowing people to make that choice and engaging in some good shared decision-making can build trust in the health care system which is crucially important for people for the rest of their lives. So those are some of the interventions that might be helpful to ease the stress of a TB diagnosis. 

Signy: Thanks Nancy. and we also know that social service providers, especially in the settlement sector, play a really important role in supporting newcomers, including with this education and resources for them.  

So, I'm now going to move it on to Amanda. 

Can you speak to how your organization supports clients in accessing the care and services they need and kind of what opportunities there are for a coordinated service pathway between public health, primary care, and social service providers?  

Amanda: I can I do want to give the disclaimer that we don't we haven't done any work in the TB space. So, I think I might say things that are maybe not super possible with the TB things we're talking about today, but we have done work in the RCV. 

We currently have an active HPV self-sample pilot going and we're doing starting to do work in the HEP area. So, this is sort of how it's related to the topic. so many things. 

So, with I would say HPV in particular because a it's where it's piloted under AHS. So, it's really good and resourced properly. And so the thing I'll say again over and over because I appreciate Nancy’s mentioning we need a well-coordinated system which requires money which people don't say out loud but requires proper funding amongst all players. 

I don't personally feel like settlement organizations are given the credit they should be given on the care pathway. They're kind of come at kind of like even researchers also last minute sort of can you help us? Can you talk to your clients? 

Can we come into your already existing overwhelming work and just kind of do can you do this for us? And so I feel like we're shifting on the settlement side to say like no actually we're overwhelmed as it is and under resourced. So if you want to do extra you need to come in and sort of look at that differently. 

And so I want to give credit to AHS for doing that properly. But we do we work closely with two nonprofit health organizations. Praxus is one here in Calgary and for those in Ontario we work with Health Commons who I think are amazing and have a real good handle on the need for community health ambassadors. 

So we have this community health ambassador model. We also have health navigators for the refugee services and this seems to be very effective in terms of having basically having a an advocate for you within the healthcare system who can translate knowledge for you and navigate the system. It's not like a super novel idea, but it's not resourced properly. 

And so this could solve a lot of problems. and so I think that is one way and it's been really effective for us. I think the other point Nancy made about the TB process being embedded in the immigration process is so important because the to tie that with fear of possible deportation I think is very damaging. 

And so I think that should definitely be considered in terms of the education patient education. settlement organizations have access to so many newcomers and at all categories refugee, immigrant, foreign worker. And we in generally we can other systems can trade on the trust of settlement orgs if there's trust between the org and the system. 

And so patient education, we've done translation, not of just resources because we weren't allowed to translate certain ones anyhow, but not just language translation, but cultural translation to really bring it down to plain language because translating clinical language is not helpful for clients either because it's still clinical and it's still unfamiliar. So we did we co-designed content that would be more relevant for newcomers based on their cultural norms, their language. That was specifically around our RCVs. 

Lots of the health navigation has to be done in person. I know a lot of health systems have like phone or like internet based language interpretation services but we really advocate for cultural interpretation and not just language interpretation but I know that's again a hard thing for the systems to do and we also spend a lot of time in the research space as mentioned. So kind of advocating for research equity and data equity even in terms of the data questions as health systems are asking newcomers to inform their care pathways including and I saw in the questions there's lots of questions around temporary residents and care pathways and there's an assumption made that anyone you see is going to be here for a long time however often they may not be here long enough to go through the full care pathway so stuff like that.  

And one thing I want to add because I think it's important going back to the not well-coordinated funded system because it's not well funded within these systems we have two projects that are through a through another party being funded by pharmaceutical companies which I don't know if that's the best idea for public health but I can tell you that from at the bottom end of that we are they are spending the time to figure out how to best engage newcomer populations, how they need to shift, what that looks like, what the demographics are per region and I know I mean I don't know enough to say anything I have social you know opinions about pharmaceutical companies but the fact that they are the ones spending the times and our public health systems can't dedicate the resources I think is probably a bit problematic and so I think that's worth mentioning but I'm happy that I guess someone cares enough that to know that newcomers need like not a standardized approach towards health engagement 

Signy: Thank you so much, Amanda, for that informative response. 

We're now going to open it up to the audience for some questions for our panelists. And we've already received many questions, so I'll start right away. So one of the questions is about those with a visitor status who have TB or migrants on work permits. 

So, for example, the question says, you know, is it possible for Canadian migrants on work permits that are TB positive to have TB treated while in Canada or are they usually treated before arriving to Canada?  

So, I'm not sure who would like to start on this question. 

James: I mean I'm happy to answer from a BC perspective, and I think this probably represents a few provinces and territories, but yeah, at least in British Columbia, all TB screening and treatment should be free. There are some occupational health screening that people pay for. 

You know, if you're going to start nursing school, you may have to have a skin test done, but TB screening at the BCCDC and treatment, all drugs should be free and they are free here. And I suspect that many places across this country that exists. 

You may need to link with the TB clinic to make sure that they get that screening and that they get the free treatment. We also can hospitalize people who are of, you know, public health importance. and often we kind of you know change that around a bit if we need to if they have some medical issues that need to be cared for. 

So from within British Columbia and I don't want to speak for all of Canada but for I think many places in Canada that exists. I can't speak to prior to migration though.  

Signy: Thanks. Jill. 

Jill: Yeah thanks so much.  

So I can mention and perhaps that I should have been more clear in my presentation. So most people ideally are screened before they come to Canada. 

So they're having their immigration medical exam in their country of origin. And so then the goal is that they're screened and treated before they arrive. We do many in Canada and that's the situation where you know somebody is an asylum claimant so they're just making opening an application when they arrive in the country or they've changed the type of visa category they're applying for. 

So, they've come on a visitor visa, for instance, but now they've decided they want to stay for longer. So, they didn't require an IME before they came, but now they want to stay longer. So, now they do need one. 

So I will admit, you know, one of the struggles we have is that the IME is currently a one-size fits-all process. And I think arguably, you know, the process in Canada maybe needs to look a little different as from what it happens outside of Canada. and so things really especially during COVID have shifted in terms of the number of IMEs that are being done when people have already arrived. 

I can speak to the piece where you know when you apply you are expected to have coverage, medical coverage, you're expected to source private medical coverage before you arrive in Canada. now again that can be very problematic because often people do not necessarily obtain coverage do not necessarily understand the coverage that they're covered for. There can be many exclusions as this group of physicians will know. 

So it's definitely problematic. and I can say from the IME perspective treatment is covered in most places in Canada. However, investigations aren't always. 

So we often will require that a client undergo investigations and often time that is a huge barrier because some provinces you know they will say well this person does not have provincial healthcare coverage. So you know we're swamped as it is we you know we can't accommodate the investigations necessarily. So there is very much patchwork and then we are aware of that definitely affects access and diagnosis. 

I'll stop there. Thanks.  

Signy: Thanks. And Nancy.  

Nancy: yeah, I'll just add in my practice in my nursing practice, we've run into lots of people that are on visitor visas, or temporary residents that have had huge financial problems associated with having TB. while the drugs are free, if people don't have private medical insurance, they don't have public health insurance, and they wind up being admitted to the hospital, those bills are thousands of dollars sometimes. and you know, if someone decides to take TB infection treatment, all of the screening tests that go along with that, the drugs are free, but sometimes the drugs are the smallest part of the cost. 

There's lots of testing that's involved. That's all out of pocket. so there there's there can there's huge for people who don't have private medical insurance and are here in Canada on a temporary status, it can be a huge problem. 

It's different, you know, of course, from province to province. a good change that it's good to know about is that be until very recently refugees that refugees could not apply going to hope I have this right refugees could not apply for unemployment insurance which is really important you know when you have TB if for if you're infectious and need to and can't work if you have no source of income that's terrifying and awful for anyone. but I think for people experiencing TB that are refugees, there's been a recent change where they can apply, but it's a very, you know, small exception that you need to know about. 

But anyway, it can be a huge problem. It was one of the main reasons that we got a social worker at the Calgary TB clinic to navigate some of these problems because it's tough for sure.  

Signy: Thanks, Nancy. 

So, we have another question here. could one of you share your insight on how primary care providers review and adjust TB records from immigrants and refugees when they differ from Canadian standards to ensure safe and effective care? More than one of you can answer this, but is there anyone that wants to start? 

James: Can you repeat that question or put it in the chat? It seems complicated.  

Signy: Yeah, I'll put it in the chat. 

And the but the question is could you share your insight on how primary care providers review and adjust TB records from immigrants and refugees when these records differ from the Canadian standards. I'll put it in the chat here.  

James: I don't understand the question. 

Sorry. Maybe someone else could take a shot. 

Jill: I'm wondering if they're asking if somebody's had treatment abroad but it doesn't meet Canadian standards what happens next in terms of, so I can speak from the IME perspective. 

I mean, we ask for treatment if it's happened recently and if it hasn't been followed to TB, Canadian TB standards, we'll ask for more information often if there's any extenuating circumstances, etc. and then we often will use the TB medical surveillance to ask our provincial and territorial colleagues to determine whether somebody needs to be retreated or extended treatment, etc. So, I'm guessing that's what the question is getting at. 

James: Yeah. And from a post-landings perspective, when that person referred to us, we have at least in British Columbia and again it's different across we review that a physician reviews their prior treatment. 

Generally speaking, most people because TB therapy is so standardized, generally most people receive a standard six-month regimen, which would be the international and Canadian standard. Sometimes they're not treated for 9 months when we would treat for 9 months. But we very rarely would redo care in people who have been treated for TB. 

Sometimes we may monitor them for a year or two if we're really, you know, concerned about what the care was. But generally speaking, the, you know, care in most countries is up to the WHO standard. In the distant past, people sometimes, you know, they were treated in the 70s or 60s or 50s and then they migrate now. 

And we certainly don't even know what they were treated with. And usually that just involves monitoring. But it's pretty rare to retreat somebody unless we have very clear of you know they had drug resistant tuberculosis and they were treated with a drug susceptible regimen which is very rare. 

Signy: So another question is what are your thoughts on newcomers who don't necessarily meet the high-risk criteria for screening? So, for example, there's nothing that's been discovered that needs to be flagged in their overseas immigration medical. And so, they don't meet the criteria for TBMS yet. 

But it seems for this person, they say, "It seems that most of our active TB clients don't meet the high-risk criteria yet." So, any thoughts on how this group of people can be identified prior to activating?  

James: So this is a very area an active area of research for me. This is kind of what I do. 

So I have opinions that are very different from my health authority, from my province, from the federal government, from you know so my opinions are reflected in chapter 13 of the TB standards which say that basically people who have more than 1% risk should we should consider for screening. But that actually is trying to achieve TB elimination. That is a mindset of we need to reduce TB and we are trying to find a threshold where people would individually benefit from therapy and prevention even if marginally. 

And that's where that threshold is and that's a and that's where chapter 13 of the TB standards recommendations come from. And so in those recommendations it says if you're from a country greater than 200 per 100,000 and I think it's age less than 50 you should be screened. I can tell you that there's no province or territory that does that because of it is a huge resource strain. 

Right now we just can't afford to do that even though there may be benefits to individuals along the way. It would be marginal benefits in a huge population of people and provinces haven't stepped up to say we want to do that. I think if we want to achieve TB elimination, we have to consider that. 

But keep in mind that is a very marginal benefit to that individual person and it is serving a public health goal. And so we need to always keep in mind that individual person when we're discussing it with them and the screening that it may not be a huge benefit to them and there's a lot of toxicity of these drugs. And so although I feel like that should be our approach, that is not on a day-to-day clinical basis what I do. 

I do not screen that group of people. And so, I tend to screen people who are at higher risk only because our systems can't afford that. And, you know, it's a very marginal benefit to people. 

To be honest, I think we could spend our money elsewhere in migrant health probably more effectively to be honest.  

All personal opinion. 

Signy: Interesting. 

And another question is how can we encourage LTBI or latent tuberculosis infection screening and testing and what are the ideal opportunities to engage? So this question is more so focusing on when health care providers should be testing.  

James: Somebody else want to take that? 

I've been talking a lot. I think we can do a better job. I honestly I think we need to you know TB is the number one infectious disease killer and I don't even think a lot of people know that. 

And our TB rates in Canada are going up. I don't think people know that. I think we need to do a better job as a TB community letting primary care providers, obviously the people on this call know, right, and they're on the call, but we need to let primary care providers that this is an issue and that we really need to be very active about talking to people about TB and screening them and get the affected populations involved in this. 

So get migrant organizations, people affected by TB more involved in the cause of limiting TB in this population because I right now I think it's we're really siloed from a we're very sort of in our little medical research bubble and not engaging communities like HIV for example. And I think we do a much better job in engaging affected communities and getting the word out, getting people to activate it, to talk about it, and demand that we have better screening programs, demand we have more funding for TB. Right now, we're just not there. 

And I feel like we should not put this on the primary care provider alone. It should be on the TB community to help activate all of the affected communities. And those affected communities would really help our voices. 

Signy: Thanks.  

And Nancy, did you have anything to add to that?  

Nancy: Well, just it it's not relevant to the person's question, but I think you know that whole community outreach is really important. 

Like I think that's a hu we could engage affected communities by saying, "Hey, this is something that I because I don't think it like just the awareness is all so low and it's such a huge problem like this is a health problem that affects you. Let's work together to try and advocate for better services." I think that could be a huge window of opportunity, but it's not something that's really done, you know, just because there's other health problems that are always more important, but this is a huge it's a huge problem and like Dr. Johnson said, the rates are going up and I just think the community outreach is something that's really neglected and engaging communities and advocating for better services would be huge and something I would love to do more of provided there was funding. 

Signy: So another question is kind of about that coordinated pathway with settlement organizations and healthcare and primary care. So, this person asks, "Is there a way for IRCC to directly notify the associated settlement agencies who house the GARS or GARS who need to report to the local public health unit for follow-up on suspected TB?" So, they say sometimes the NAAT will indicate follow up, but it may not indicate the need to report to local public health units. And then it becomes dependent on the client to notify us that they received a notice for surveillance and they might not understand what the paper is for or they might not disclose that with us. 

So this question may be better I don't know if Amanda or Jill if you have any thoughts on this. 

Jill: I was actually going to ask my colleague Julie Lafleche okay who's just unmuted herself. She might be best positioned. 

Julie Lafleche: Okay. Thank you, Signy. I just answered this question, but I think a new one came in. 

So, in terms of the form itself, when they receive the form, that form is not does not provide a lot of information for the client. Really going on the IRCC client website for medical surveillance is the best way to explain the process. But generally clients are advised that they have to make sure that their address is updated with the public health surveillance unit and it gives the website. 

And then what happens is that we send them a communication letting them know that we've already submitted their file to the province and that they need to wait for someone to contact them for an appointment. And sometimes that's difficult because the timelines are long. So they might feel that the information wasn't received or what's going on. 

Sometimes they contact us and lets us know that they haven't gotten an appointment yet. And if they reside in Ontario, the communication that we send them is a specific link that they have to click on and depending on their health unit, they will receive a variety of instructions on how to get in contact or get an appointment. So it's not the same across the board. 

Signy: Thank you so much for that.  

Another question is so talking about what can we do if it takes up to 3 months before a patient or client is able to see a specialist in the public health system? And so this is not for active TB, but how could primary care providers support their clients with this delay while they wait to see a specialist? 

Yeah, Nancy.  

Nancy: Well, being that I'm going to let others weigh in on this and I unmuted too quickly, but I think you know it really providing that education is huge because if active disease is not a concern, then you're talking about TB preventative treatment which is prevention. So, you know, firstly, making sure that people really, it doesn't matter how many times you say it, you have to, if you're talking about TB, people think they're infectious. 

And so, people are terrified that they a that they're not in compliance with the with the immigration requests, and then b that they're infectious, that they're sick. So, you know, if as long as you can tell people that just by reporting, Jill can correct me if I'm saying something that's incorrect here, but by initiating the process and you know and reporting for screening, you've you're in compliance with the regulations and you're not sick and you're not infectious. So, there's no urgency. 

Like, you have to spend a lot of time reassuring people. And so, I just I think that's huge. That's what primary care providers can do. 

Like, a you're in compliance with what's been asked of you. B, you're not sick. C, you're not infectious. 

So, it's okay that it takes three months. It's not ideal for sure. It's not ideal that it takes three months. 

So again, advocating for system change is some another thing that primary provide providers can do, but just really taking the time, you know, taking the time to provide that education to the best of your ability or even, you know, if you don't have time yourself, maybe, you know, engage some of the allied healthcare providers in your area because education can be provided by lots of people. It doesn't have to be the primary care physician.  

[overlapping talking] 

James: Oh, sorry. 

Julie: I'm sorry. I did want to add to Nancy's point that in terms of surveillance, it really is that initial appointment, initial set that they needed to be in compliance with their medical surveillance requirements. if there are additional things that are needed like an appointment with a specialist or a follow-up six or eight months down the road. 

you don't need to wait before saying that the client has been in compliance with their medical surveillance. Of course, we live we give some leeway. If you're very concerned about this client, you're not sure that they're going to do the test. 

and the public health authorities know that if they have concerns, they can always come back to us and say, "Oh, actually this client was not in compliance." But that very rarely happens. and just reassuring the client that they're in compliance, but also communicating that information back so that it can be changed in the portal for by the public health authorities.  

James: Yeah. 

I just want to reinforce that every meeting I have with people post like in the post landing referral, the first thing I say is you have completed what you need to do. This is all for your health from here on in. So hopefully that would alleviate any concerns about immigration status although it probably doesn't to be honest. 

And then the second thing is recognizing that surveillance although from a big picture point of view people are high risk we're talking about people referred for postlanding surveillance have between 1 and 2% risk in multiple cohort studies. So from an individual perspective they still have a 98% or more chance of not having TB. And so you know just to say this is for your health. 

We're being preventative, but you know, we're not it's not likely that you're going to end up developing TB. That said, we can do things to prevent it. And so, just reassuring people about those two issues for me. 

Amanda: Can I can I jump in with just a couple comments?  

And this I I'm not I just want to be kind of it's just facts, not fiction or not feelings here. But like Julie, thanks for explaining the system for GARS, which are government assisted refugees. 

In terms of like you have to send them they have to give you their contact information and then you follow up with them. but the reality is in several of areas around Canada that housing problem is an issue and so the address of the GARS is my office for like two months. and so that's the reality of it. 

And then when they move, if it's all the onus is all on the individual to update the public health agency while they're doing all the other things we're supposed to be doing, employment, language classes, registering the registering their kids for school, all of that. That is how also it gets overwhelming and people get lost in the follow-up care pathway. So again, even though that system is available, it's not necessarily accessible. 

So I just want to say that. and the other thing about I lost my other thoughts so that's okay. But that's the one sort of fact that I wanted to share about the real life experience of GARS and settlement organizations in that role. 

Signy: I'm going to jump in here and just because we are at time and I want to give a chance for Jessica to wrap up here but I'll move it on to you Jessica for some final closing remarks.  

Jessica: Great. thank you Signy for moderating such a great discussion. 

I also want to extend special thanks to our amazing panelists for sharing their incredible insight. and once again thank Ridhdhi  for sharing her personal experiences at the start. There was a lot of great information shared today and we hope you'll leave this webinar with a deepened understanding of TB detection and diagnosis. 

But we also know that you are probably looking for more. So, please note that in the next few days, you will be receiving an email that contains a recording of today's presentation along with additional resources that our panelists recommend. As a reminder, you will also receive a feedback form when this webinar ends and we kindly ask that you share your thoughts with us. 

We hope you enjoyed today's webinar and are wishing you a great rest of the day. Thank you everyone.