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Brinkmann F, Feiterna-Sperling C, Günther A, Breuer C, Hartmann P, Hufnagel M, Priwitzer M, Otto-Knapp R, Witte P, Diel R, Häcker B. [Screening for tuberculosis among refugee children and adolescents from Ukraine - A recommendation of the German Central Committee against Tuberculosis e. V. (DZK) together with the writing group pediatric tuberculosis of the Society of Pediatric Pneumology (GPP)]. Pneumologie 2022; 76:479-484. [PMID: 35609817 DOI: 10.1055/a-1832-2546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Folke Brinkmann
- Universitätskinderklinik der Ruhr-Universität Bochum, Abteilung für pädiatrische Pneumologie/CF-Zentrum
| | - Cornelia Feiterna-Sperling
- Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m. S. Pneumologie, Immunologie und Intensivmedizin
| | - Annette Günther
- Helios Klinik Emil von Behring Berlin, Klinik für Kinder- und Jugendmedizin
| | - Cornelia Breuer
- Landeshauptstadt Dresden, Amt für Gesundheit und Prävention.,Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Pia Hartmann
- Labor Dr. Wisplinghoff Köln, Klinische Infektiologie
| | - Markus Hufnagel
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Abteilung Pädiatrische Infektiologie und Rheumatologie
| | | | - Ralf Otto-Knapp
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
| | - Peter Witte
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin.,Institut für Krankenhaushygiene, Mühlenkreiskliniken, Minden
| | - Roland Diel
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin.,Institut für Epidemiologie, Christian-Albrechts-Universität zu Kiel
| | - Brit Häcker
- Deutsches Zentralkomitee zur Bekämpfung der Tuberkulose e. V. (DZK), Berlin
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Pilot study to identify missed opportunities for prevention of childhood tuberculosis. Eur J Pediatr 2022; 181:3299-3307. [PMID: 35771355 PMCID: PMC9395448 DOI: 10.1007/s00431-022-04537-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 03/03/2022] [Accepted: 06/19/2022] [Indexed: 11/23/2022]
Abstract
UNLABELLED Tuberculosis (TB) in exposed children can be prevented with timely contact tracing and preventive treatment. This study aimed to identify potential barriers and delays in the prevention of childhood TB in a low-incidence country by assessing the management of children subsequently diagnosed with TB. A pilot retrospective cohort study included children (< 15 years) treated for TB between 2009 and 2016 at a tertiary care hospital in Berlin, Germany. Clinical data on cases and source cases, information on time points of the diagnostic work up, and preventive measures were collected and analyzed. Forty-eight children (median age 3 years [range 0.25-14]) were included; 36 had been identified through contact tracing, the majority (26; 72.2%) being < 5 years. TB source cases were mostly family members, often with advanced disease. Thirty children (83.3%) did not receive prophylactic or preventive treatment, as TB was already prevalent when first presented. Three cases developed TB despite preventive or prophylactic treatment; in three cases (all < 5 years), recommendations had not been followed. Once TB was diagnosed in source cases, referral, assessment, TB diagnosis, and treatment were initiated in most children in a timely manner with a median duration of 18 days (interquartile range 6-60, range 0-252) between diagnosis of source case and child contact (information available for 35/36; 97.2%). In some cases, notable delays in follow-up occurred. CONCLUSION Prompt diagnosis of adult source cases appears to be the most important challenge for childhood TB prevention. However, improvement is also needed in the management of exposed children. WHAT IS KNOWN • Following infection with Mycobacterium tuberculosis, young children have a high risk of progression to active and severe forms of tuberculosis (TB). • The risk of infection and disease progression can be minimized by prompt identification of TB-exposed individuals and initiation of prophylactic or preventive treatment. WHAT IS NEW • We could show that there are avoidable time lags in diagnosis in a relevant proportion of children with known TB exposure. • Delayed diagnosis of adult source cases, losses in follow-up examinations, and delay in referral to a specialized TB clinic of TB-exposed children, especially among foreign-born children, appear to be the main issue in this German pediatric study cohort.
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Marx FM, Hauer B, Menzies NA, Haas W, Perumal N. Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis. BMC Public Health 2021; 21:2172. [PMID: 34836526 PMCID: PMC8622109 DOI: 10.1186/s12889-021-12142-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background Enhancing tuberculosis (TB) prevention and care in a post-COVID-19-pandemic phase will be essential to ensure progress towards global TB elimination. In low-burden countries, asylum seekers constitute an important high-risk group. TB frequently arises post-immigration due to the reactivation of latent TB infection (LTBI). Upon-entry screening for LTBI and TB preventive treatment (TPT) are considered worthwhile if targeted to asylum seekers from high-incidence countries who usually present with higher rates of LTBI. However, there is insufficient knowledge about optimal incidence thresholds above which introduction could be cost-effective. We aimed to estimate, among asylum seekers in Germany, the health impact and costs of upon-entry LTBI screening/TPT introduced at different thresholds of country-of-origin TB incidence. Methods We sampled hypothetical cohorts of 30–45 thousand asylum seekers aged 15 to 34 years expected to arrive in Germany in 2022 from cohorts of first-time applicants observed in 2017–2019. We modelled LTBI prevalence as a function of country-of-origin TB incidence fitted to data from observational studies. We then used a probabilistic decision-analytic model to estimate health-system costs and quality-adjusted life years (QALYs) under interferon gamma release assay (IGRA)-based screening for LTBI and rifampicin-based TPT (daily, 4 months). Incremental cost-effectiveness ratios (ICERs) were calculated for scenarios of introducing LTBI screening/TPT at different incidence thresholds. Results We estimated that among 15- to 34-year-old asylum seekers arriving in Germany in 2022, 17.5% (95% uncertainty interval: 14.2–21.6%) will be latently infected. Introducing LTBI screening/TPT above 250 per 100,000 country-of-origin TB incidence would gain 7.3 (2.7–14.8) QALYs at a cost of €51,000 (€18,000–€114,100) per QALY. Lowering the threshold to ≥200 would cost an incremental €53,300 (€19,100–€122,500) per additional QALY gained relative to the ≥250 threshold scenario; ICERs for the ≥150 and ≥ 100 thresholds were €55,900 (€20,200–€128,200) and €62,000 (€23,200–€142,000), respectively, using the next higher threshold as a reference, and considerably higher at thresholds below 100. Conclusions LTBI screening and TPT among 15- to 34-year-old asylum seekers arriving in Germany could produce health benefits at reasonable additional cost (with respect to international benchmarks) if introduced at incidence thresholds ≥100. Empirical trials are needed to investigate the feasibility and effectiveness of this approach.
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Affiliation(s)
- Florian M Marx
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany. .,Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa. .,DSI-NRF South African Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.
| | - Barbara Hauer
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Walter Haas
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany
| | - Nita Perumal
- Department for Infectious Disease Epidemiology, Respiratory Infections Unit, Robert Koch Institute, Berlin, Germany.,Immunization Unit, Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Laukamp A, Prüfer-Krämer L, Fischer F, Krämer A. Health of Syrian unaccompanied asylum seeking adolescents (UASA) at first medical examination in Germany in comparison to UASA from other world regions. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2019; 19:5. [PMID: 30808358 PMCID: PMC6390530 DOI: 10.1186/s12914-019-0192-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 01/18/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The war in Syria has led to the biggest refugee crisis of our time. Unaccompanied asylum seeking adolescents (UASA) are a particularly vulnerable subgroup of refugees. This study aims to describe the weight status, health behaviour and disease spectrum of Syrian UASA in comparison to UASA from other world regions. METHODS The study was conducted as a prospective cross-sectional analysis of health metrics and diagnoses from 346 UASA (78% male; mean age 16 years) between 2011 and 2017. The data was collected in an outpatient clinic for internal and tropical medicine during a systematic medical examination after arrival. Descriptive and bivariate analyses stratified by gender and region/country of origin were performed. RESULTS The general health status of the UASA in most cases was good. Compared to other UASA Syrian UASA had the highest underweight prevalence (16.7%) (p = .013) and the second highest smoking prevalence (37.9%) (p < .001). Diseases at first medical examination mostly were infections and diseases of the digestive system, with significant differences between the regions/countries of origin (p < .001; p < .001, respectively). Syrian UASA had a lower prevalence of infections (28%) and a similar prevalence of mental and behavioural problems (10.3%) than the average of all regions/countries of origin (48.6%; 11%, respectively). CONCLUSION Tailored screening for diseases as well as for health behaviour immediately after arrival in Germany is needed to reduce the individual burden of disease and to offer targeted preventive measures.
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Affiliation(s)
- Annika Laukamp
- School of Public Health, Bielefeld University, PO Box 100131, 33501, Bielefeld, Germany.
| | | | - Florian Fischer
- School of Public Health, Bielefeld University, PO Box 100131, 33501, Bielefeld, Germany
| | - Alexander Krämer
- School of Public Health, Bielefeld University, PO Box 100131, 33501, Bielefeld, Germany
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Fiebig L, Hauer B, Andrés M, Haas W. Tuberculosis screening in asylum seekers in Germany, 2015: characteristics of cases and yield. Eur Respir J 2017; 50:50/4/1602550. [DOI: 10.1183/13993003.02550-2016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 08/02/2017] [Indexed: 11/05/2022]
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[Recommendations for the diagnosis and prevention of infectious diseases in pediatric and adolescent refugees in Germany : Statement of the German Society of Pediatric Infectious Diseases, the Society of Tropical Pediatrics and International Child Health, and the Professional Association of Pediatricians]. Internist (Berl) 2017; 57:416-33. [PMID: 27138489 DOI: 10.1007/s00108-016-0040-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Child and adolescent refugees in Germany represent a particularly vulnerable social group and treating infectious diseases forms a crucial part of providing their medical care. From an infectious diseases perspective, refugees themselves, as a result of their difficult personal circumstances, are the ones at highest risk. Even in crisis situations, medical practitioners are medically and ethically obliged to provide a high standard of care. The guidelines presented here propose recommendations for diagnosing and preventing infectious diseases among refugees under 18 in Germany. The guidelines are intended to assist in optimizing vaccine protection and treatment of diseases while taking into consideration factors such as refugees' challenging living conditions, cultural differences and potential language barriers.Upon refugees' arrival at the first housing sites, it is recommended that a basic clinical screening (and not just a brief visual inspection) be provided in order to identify and initiate treatment for acute medical problems and potentially contagious diseases (including tuberculosis), as well as to close gaps in vaccination coverage. Documentation of the clinical findings is critical, both to avoid redundant investigations and to optimize individual medical care. For this, an effective communication system must be established.Once refugees have been transferred into their destination community, outpatient and inpatient care providers should collaborate to bring refugees up-to-date with all vaccines recommended by STIKO (German Standing Committee on Vaccination). The same high standard of medical care should be delivered to refugees as would be to the general population. Due to the high prevalence of multi-resistant organisms (MRO) in the refugees' countries of origin, MRO screening is recommended for most patients receiving inpatient care.
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[Health examination of asylum seekers: A nationwide analysis of state policies in Germany : § 62 of the asylum law]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 60:108-117. [PMID: 27885404 DOI: 10.1007/s00103-016-2489-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A health examination of newly arrived asylum seekers, aimed at detecting infectious diseases and preventing disease outbreaks in accommodation facilities, is mandated by national law in all German states. Due to the decentralized German federal system, different state policies are in place and lead to substantial variation in the content and implementation of the health examination. OBJECTIVES To compare health examination policies in the 16 German states with a focus on conducted tests, preventive measures and the general procedure. METHODS A comparative content analysis of policy documents addressing the health examination was conducted. Relevant documents were identified through a nationwide search (conducted June-October 2015) through public sources, inquiries at responsible authorities and interviews with representatives of public health services. RESULTS In the study period, relevant policy documents for 13 states were identified, of which eight were administrative decrees of the responsible state ministries. Policies differed strongly with respect to the content of the health examination and the selection of compulsory screening measures. We identified three main groups: (A) states with compulsory screening limited to measures enshrined in federal law, (B) states with extended tuberculosis screening for children and pregnant women, and (C) states with extended mandatory screening measures for further infectious diseases beyond tuberculosis. Considerable differences were also found with regard to the implementation of the examinations, and the purchasing and re-imbursement policies. CONCLUSIONS The stark heterogeneity in health examination policies between the states cannot be rationally explained from a public health perspective. The indication for certain measures remains unclear. A broad discussion of the medical necessity of screening tests, combined with further systematic analyses, is necessary in order to develop nationwide evidence-based recommendations and decision-making tools for the conduct of health examinations of asylum seekers.
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Bozorgmehr K, Razum O, Saure D, Joggerst B, Szecsenyi J, Stock C. Yield of active screening for tuberculosis among asylum seekers in Germany: a systematic review and meta-analysis. Euro Surveill 2017; 22:30491. [PMID: 28367795 PMCID: PMC5388130 DOI: 10.2807/1560-7917.es.2017.22.12.30491] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/03/2016] [Indexed: 12/03/2022] Open
Abstract
All asylum seekers in Germany undergo upon-entry screening for tuberculosis TB, but comprehensive evidence on the yield is lacking. We compared the national estimates with the international literature in a systematic review and meta-analysis of studies reporting the yield of TB, defined as the fraction of active TB cases detected among asylum seekers screened in Germany upon entry. We searched 11 national and international databases for empirical studies and the internet for grey literature published in English or German without restrictions on publication time. Among 1,253 screened articles, we identified six articles reporting the yield of active TB based on German data, ranging from 0.72 (95% confidence interval (CI): 0.45-1.10) to 6.41 (95% CI: 4.19-9.37) per 1,000 asylum seekers. The pooled estimate across all studies was 3.47 (95% CI: 1.78-5.73; I2 = 94.9%; p < 0.0001) per 1,000 asylum seekers. This estimate was in line with international evidence (I2 = 0%; p for heterogeneity 0.55). The meta-analysis of available international estimates resulted in a pooled yield of 3.04 (95% CI: 2.24-3.96) per 1,000. This study provides an estimate across several German federal states for the yield of TB screening in asylum seekers. Further research is needed to develop more targeted screening programmes.
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Affiliation(s)
- Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Daniel Saure
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | | | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
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Esmail M, Weckbecker K, Just J. [Medical care for refugees in Germany]. MMW Fortschr Med 2017; 159:38-44. [PMID: 28357771 DOI: 10.1007/s15006-017-9034-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
| | - Klaus Weckbecker
- Institut für Hausarztmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Johannes Just
- Institut für Hausarztmedizin, Universitätsklinikum Bonn, Bonn, Deutschland
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Weinrich JM, Diel R, Sauer M, Henes FO, Meywald-Walter K, Adam G, Schön G, Bannas P. Yield of chest X-ray tuberculosis screening of immigrants during the European refugee crisis of 2015: a single-centre experience. Eur Radiol 2017; 27:3244-3248. [DOI: 10.1007/s00330-016-4684-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/28/2016] [Accepted: 11/29/2016] [Indexed: 01/15/2023]
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12
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Asylbewerber und ihre Versorgungssituation. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kobbe R, Kitz C, Trapp S, Pfeil J, Hufnagel M. Versorgung von minderjährigen Flüchtlingen. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0180-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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[Infectious diseases in refugees and their minors arriving in Germany--what the GP needs to know]. MMW Fortschr Med 2016; 158:58-62. [PMID: 27119890 DOI: 10.1007/s15006-016-7883-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Empfehlungen zur infektiologischen Versorgung von Flüchtlingen im Kindes- und Jugendalter in Deutschland. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-015-0003-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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