Time trends of cause-specific mortality among resettlers in Germany, 1990 through 2009

International Migration and Cardiovascular Health: Unraveling the Disease Burden Among Migrants to North America and Europe

Europe and North America are the 2 largest recipients of international migrants from low-resource regions in the world. Here, large differences in cardiovascular disease (CVD) morbidity and death exist between migrants and the host populations. This review discusses the CVD burden and its most important contributors among the largest migrant groups in Europe and North America as well as the consequences of migration to high-income countries on CVD diagnosis and therapy. The available evidence indicates that migrants in Europe and North America generally have a higher CVD risk compared with the host populations. Cardiometabolic, behavioral, and psychosocial factors are important contributors to their increased CVD risk. However, despite these common denominators, there are important ethnic differences in the propensity to develop CVD that relate to pre- and postmigration factors, such as socioeconomic status, cultural factors, lifestyle, psychosocial stress, access to health care and health care usage. Some of these pre- and postmigration environmental factors may interact with genetic (epigenetics) and microbial factors, which further influence their CVD risk. The limited number of prospective cohorts and clinical trials in migrant populations remains an important culprit for better understanding pathophysiological mechanism driving health differences and for developing ethnic-specific CVD risk prediction and care. Only by improved understanding of the complex interaction among human biology, migration-related factors, and sociocultural determinants of health influencing CVD risk will we be able to mitigate these differences and truly make inclusive personalized treatment possible.

The Incidence of Intestinal Gastric Cancer among Resettlers in Germany-Do Resettlers Remain at an Elevated Risk in Comparison to the General Population?

Objective: Previous studies have shown that the incidence of gastric cancer (GC), and particularly intestinal GC, is higher among resettlers from the former Soviet Union (FSU) than in the general German population. Our aim was to investigate if the higher risk remains over time. Methods: GC cases between 1994 and 2013, in a cohort of 32,972 resettlers, were identified by the respective federal cancer registry. Age-standardized rates (ASRs) and standardized incidence ratios (SIRs) were analyzed in comparison to the general population for GC subtypes according to the Laurén classification. Additionally, the cohort was pooled with data from a second resettler cohort from Saarland to investigate time trends using negative binomial regression. Results: The incidence of intestinal GC was elevated among resettlers in comparison to the general population (SIR (men) 1.64, 95% CI: 1.09–2.37; SIR (women) 1.91, 95% CI: 1.15–2.98). The analysis with the pooled data confirmed an elevated SIR, which was stable over time. Conclusion: Resettlers’ higher risk of developing intestinal GC does not attenuate towards the incidence in the general German population. Dietary and lifestyle patterns might amplify the risk of GC, and we believe that further investigation of risk behaviors is needed to better understand the development of disease pattern among migrants.

[Persons with migration background in the German National Cohort (NAKO)-sociodemographic characteristics and comparisons with the German autochthonous population]

BACKGROUND

Persons with a migration background (PmM) as a population group usually differ from the autochthonous population in terms of morbidity, mortality, and use of the health care system, but they participate less frequently in health studies. The PmM group is very heterogeneous, which has hardly been taken into account in studies so far.

OBJECTIVES

Sociodemographic characteristics of PmM in the NAKO health study (age, sex, time since migration, education) are presented. In addition, it is examined through an example whether migration background is related to the use of cancer screening for colorectal cancer (hemoccult test).

METHODS

Data of the first 101,816 persons of the NAKO were analyzed descriptively and cartographically. The migration background was assigned on the basis of the definition of the Federal Statistical Office, based on nationality, country of birth, year of entry, and country of birth of the parents.

RESULTS

Overall, the PmM proportion is 16.0%. The distribution across the 18 study centers varies considerably between 6% (Neubrandenburg) and 33% (Düsseldorf). With 153 countries of origin, most countries are represented in the NAKO. All variables show clear differences between the different regions of origin. In the hemoccult test, persons of Turkish origin (OR = 0.67) and resettlers (OR = 0.60) have a lower participation rate. PmM born in Germany do not differ in this respect from the autochthonous population (OR = 0.99).

CONCLUSION

PmM in the NAKO are a very heterogeneous group. However, due to the sample size, individual subgroups of migrants can be studied separately with respect to region of origin.

A cross-national perspective of migration and cancer: incidence of five major cancer types among resettlers from the former Soviet Union in Germany and ethnic Germans in Russia

Background

Few studies compared cancer incidence among migrants both to their host countries and to their population of origin. We aimed to compare cancer incidence of ethnic Germans who migrated from the former Soviet Union to Germany (resettlers) to those living in Russia as well as to the German and the Russian general populations.

Methods

The cancer registry of North Rhine-Westphalia identified incident cases of stomach, colorectal, lung, breast and prostate cancer in resettlers and the general population of the administrative district of Münster (Germany) between 2004 and 2013. The Tomsk cancer registry collected the same data in ethnic Germans and the general population of the Tomsk region (Russia). We used standardised incidence rate ratios (SIRs) to compare rates of resettlers and ethnic Germans with the respective general populations.

Results

The total number of person-years under risk was 83,289 for ethnic Germans, 8,006,775 for the population of Tomsk, 219,604 for resettlers, and 20,516,782 for the population of Münster. Incidence of the five investigated cancer types among ethnic Germans did not differ from incidence of the general population of Tomsk. Compared to the general population of Tomsk, incidence among resettlers was higher for colorectal cancer in both sexes (females: SIR 1.45 [95% CI 1.14–1.83], males: SIR 1.56 [95% CI 1.23–1.97]), breast cancer in females (SIR 1.65 [95% CI 1.40–1.95]), and prostate cancer (SIR 1.64 [95% CI 1.34–2.01]). Incidence rates of these cancer types among resettlers were more similar to rates of the general population of Münster. Incidence of stomach and lung cancer did not differ between resettlers and the general population of Tomsk.

Conclusions

After an average stay of 15 years, we observed that incidence of colorectal, breast and prostate cancer among resettlers converged to levels of the general population of Münster. Resettler’s incidence of stomach and lung cancer, however, was comparable to incidence in their population of origin. Causes must be investigated in subsequent analytical studies.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-6058-6) contains supplementary material, which is available to authorized users.

All-cause mortality among three generations of Moluccans in the Netherlands

BACKGROUND

Mortality variations have been reported for ethnic minority groups compared with their host populations. It is uncertain how this mortality variations change over time as younger generations become older and mix with the host population. This study aimed to examine all-cause mortality among three generations of Moluccans in the Netherlands, and to compare Moluccans with a mixed and non-mixed ethnic background.

METHODS

We used data from the death and municipality registry for the years 2000 through 2013, including all registered Dutch inhabitants. A list of Moluccan surnames was used to select the Moluccan population. Mortality differences were calculated by Poisson regression, controlling for sex, age and district socio-economic status.

RESULTS

High all-cause mortality rates were observed in all generations of Moluccans although the extent of the differences between Moluccans and the Dutch were smaller in second (1.15, 1.07-1.23) and third generation (1.14, 1.00-1.29) compared with the first generation (1.55, 1.49-1.60). Higher all-cause mortality is also reflected in the higher mortality from most causes of death except neoplasms and external causes. Both mixed and non-mixed Moluccans showed high all-cause mortality among the first (child) and second generation compared with the Dutch.

CONCLUSION

Our findings show a higher all-cause mortality in three generations of Moluccans compared with the Dutch. The results show that mortality inequalities may persist, though in an attenuated form, over generations among ethnic minorities.

Aussiedler Mortality (AMOR): cohort studies on ethnic German migrants from the Former Soviet Union

PURPOSE

The Aussiedler Mortality cohorts represent the unique migrant group of ethnic Germans (resettlers) from the former Soviet Union who migrated to Germany mainly after the fall of the iron curtain in 1989. Resettlers are the second largest migrant group in Germany and their health status was largely unknown before the cohorts were set up.

PARTICIPANTS

Four retrospective register-based cohorts were set up in different federal states of Germany, each focussing on different health aspects. In total, the cohorts include 92 362 resettlers (men: 51.5%, women: 48.5%) who immigrated between 1990 and 2005 with a mean age at immigration of 36.6 years (range 0-105 years). Resettlers are of German ancestry and they are immediately granted the German citizenship with all rights and duties.

FINDINGS TO DATE

Vital status and causes of death (International Classification of Diseases codes based on death certificates or record linkage) were collected for three cohorts as well as cancer incidence and incidence of acute myocardial infarction in three of the cohorts. Currently, an observation period of 20 years (1990-2009) is covered. Overall mortality among resettlers was surprisingly lower in comparison to the German population with standardised mortality ratios of 0.87 (95% confidence limits 0.84-0.91) for women and 0.96 (0.92-0.99) for men, and even stronger for cardiovascular diseases (women: 0.84 (0.79-0.89); men: 0.80 (0.75-0.86). However, observed differences can neither be explained by the 'healthy migrant effect' nor by common behavioural risk factors and may be related to factors which have not yet been studied.

FUTURE PLANS

The existing cohorts will be continued and prospective studies on resettlers are underway: one cohort will be followed-up prospectively and two other large prospective cohort studies in Germany will be used for a detailed assessment of lifestyle, environmental and genetic/epigenetic factors on the mortality and morbidity pattern of resettlers.

Non-communicable diseases in migrants: an expert review

BACKGROUND

Non-communicable diseases (NCDs) remain a major challenge in the 21st century. High-income countries (HICs) populations are ethnically and culturally diverse due to international migration. Evidence suggests that NCDs rates differ between migrants and the host populations in HICs. This paper presents a review of NCDs burden among migrant groups in HICs in Europe, North America and Australia with a major focus on cardiovascular diseases (CVDs), cancer and diabetes.

METHODS

We performed a narrative review consisting of scholarly papers published between 1960 until 2018.

RESULTS

CVD risk differs by country of origin, country of destination and duration of residence. For example, stroke is more common in sub-Sahara African and South-Asian migrants, but lower in North African and Chinese migrants. Chinese migrants, however, have a higher risk of haemorrhagic stroke despite the lower rate of overall stroke. Coronary heart disease (CHD) is more common in South-Asian migrants, but less common in sub-Saharan and north African migrants although the lower risk of CHD in these population is waning. Diabetes risk is higher in all migrants and migrants seem to develop diabetes at an earlier age than the host populations. Migrants in general have lower rates of overall cancer morbidity and mortality than the host populations in Europe. However, migrants have a higher infectious disease-related cancers than the host populations in Europe. In North America, the picture is more complex. Data from cross-national comparisons indicate that migration-related lifestyle changes associated with the lifestyle of the host population in the country of settlement may influence NCDs risk among migrants in a very significant way.

CONCLUSION

With exception of diabetes, which is consistently higher in all migrant groups than in the host populations, the burden of NCDs among migrants seems to depend on the migrant group, country of settlement and NCD type. This suggests that more work is needed to disentangle the key migration-related lifestyle changes and contextual factors that may be driving the differential risk of NCDs among migrants in order to assist prevention and clinical management of NCDs in these populations.

Global patterns of mortality in international migrants: a systematic review and meta-analysis

BACKGROUND

258 million people reside outside their country of birth; however, to date no global systematic reviews or meta-analyses of mortality data for these international migrants have been done. We aimed to review and synthesise available mortality data on international migrants.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and Google Scholar databases for observational studies, systematic reviews, and randomised controlled trials published between Jan 1, 2001, and March 31, 2017, without language restrictions. We included studies reporting mortality outcomes for international migrants of any age residing outside their country of birth. Studies that recruited participants exclusively from intensive care or high dependency hospital units, with an existing health condition or status, or a particular health exposure were excluded. We also excluded studies limited to maternal or perinatal outcomes. We screened studies using systematic review software and extracted data from published reports. The main outcomes were all-cause and International Classification of Diseases, tenth revision (ICD-10) cause-specific standardised mortality ratios (SMRs) and absolute mortality rates. We calculated summary estimates using random-effects models. This study is registered with PROSPERO, number CRD42017073608.

FINDINGS

Of the 12 480 articles identified by our search, 96 studies were eligible for inclusion. The studies were geographically diverse and included data from all global regions and for 92 countries. 5464 mortality estimates for more than 15·2 million migrants were included, of which 5327 (97%) were from high-income countries, 115 (2%) were from middle-income countries, and 22 (<1%) were from low-income countries. Few studies included mortality estimates for refugees (110 estimates), asylum seekers (144 estimates), or labour migrants (six estimates). The summary estimate of all-cause SMR for international migrants was lower than one when compared with the general population in destination countries (0·70 [95% CI 0·65-0·76]; I2=99·8%). All-cause SMR was lower in both male migrants (0·72 [0·63-0·81]; I2=99·8%) and female migrants (0·75 [0·67-0·84]; I2=99·8%) compared with the general population. A mortality advantage was evident for refugees (SMR 0·50 [0·46-0·54]; I2=89·8%), but not for asylum seekers (1·05 [0·89-1·24]; I2=54·4%), although limited data was available on these groups. SMRs for all causes of death were lower in migrants compared with the general populations in the destination country across all 13 ICD-10 categories analysed, with the exception of infectious diseases and external causes. Heterogeneity was high across the majority of analyses. Point estimates of all-cause age-standardised mortality in migrants ranged from 420 to 874 per 100 000 population.

INTERPRETATION

Our study showed that international migrants have a mortality advantage compared with general populations, and that this advantage persisted across the majority of ICD-10 disease categories. The mortality advantage identified will be representative of international migrants in high-income countries who are studying, working, or have joined family members in these countries. However, our results might not reflect the health outcomes of more marginalised groups in low-income and middle-income countries because little data were available for these groups, highlighting an important gap in existing research. Our results present an opportunity to reframe the public discourse on international migration and health in high-income countries.

FUNDING

Wellcome Trust, National Institute for Health Research, Medical Research Council, Alliance for Health Policy and Systems Research, Department for International Development, Fogarty International Center, Grand Challenges Canada, International Development Research Centre Canada, Inter-American Institute for Global Change Research, National Cancer Institute, National Heart, Lung and Blood Institute, National Institute of Mental Health, Swiss National Science Foundation, World Diabetes Foundation, UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, and European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group Research Funding for the ESCMID Study Group for Infections in Travellers and Migrants.

Cancer Incidence and Mortality Among Ethnic German Migrants From the Former Soviet Union

Germany is a country known for immigration. In 2015, 21% of the general population in Germany consisted of individuals with a migration background. This article focuses on cancer-specific incidence and mortality among one of the biggest migrant groups in Germany: the resettlers. Resettlers are ethnic Germans who mainly immigrated from the Russian federation and other countries of the former Soviet Union after its collapse in 1989. We investigated differences between resettlers and the general German population, regarding (i) incidence and mortality of malignant neoplasms, (ii) time trends of the corresponding incidence and mortality, and (iii) cancer stage at diagnosis. We provide data from two resettler cohorts covering an observation time of 20 years: one cohort on cancer incidence (N = 32,972), and another cohort on mortality (N = 59,390). Cancer-specific standardized incidence ratios (SIR) and standardized mortality ratios (SMR) for all malignant neoplasms combined and the most common cancer-sites were calculated between resettlers and the general German population. Time trend analyses using Poisson regression were performed to investigate the developments of SIRs and SMRs. To investigate differences in stage at diagnosis, logistic regression was performed, calculating Odds Ratios for condensed cancer stages. We observed higher incidence and mortality of stomach cancer [SIR (men) 1.62, 95%CI 1.17-2.19; SMR (men) 1.62, 95%CI 1.31-2.01; SIR (women) 1.32, 95%CI 0.86-1.94; SMR (women) 1.52, 95%CI 1.19-1.93] and higher mortality of lung cancer [SMR (men) 1.34, 95%CI 1.20-1.50] among resettlers compared to the general German population, but lower incidence and mortality of colorectal (both sexes), lung (women), prostate and female breast cancer. However, time trend analyses showed converging incidence risks of cause-specific incidence over time, whereas differences of mortality did not show changes over time. Results from logistic regression suggest that resettler men were more often diagnosed with advanced cancer stages compared to the Münster population. Our findings suggest that risk factor patterns of the most common cancer-sites among resettlers are similar to those observed within the Russian population. Such increases in prostate, colorectal and breast cancer incidence may be the consequence of improved detection measures, and/or the adaptation of resettlers to the German lifestyle.

Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review

Background

Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.

Purpose

To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.

Data Sources

Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.

Study Selection

Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.

Data Extraction

2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.

Data Synthesis

Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.

Limitation

Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.

Conclusion

Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences.

Primary Funding Source

National Institute on Drug Abuse and Bureau of Justice Assistance.

Stage of cancer diagnoses among migrants from the former Soviet Union in comparison to the German population - are diagnoses among migrants delayed?

BACKGROUND

In this study, we compared stage at diagnosis, standardized incidence ratio (SIR) and standardized mortality ratio (SMR) of most frequent cancer diagnoses between re-settlers (Aussiedler) from the former Soviet Union and the general population in the Saarland in Germany to assess possible delays in diagnosis of cancer among this migrant group.

METHODS

Lung cancer, colorectal cancer, breast cancer, prostate cancer, malignant melanoma of the skin and stomach cancer diagnoses among a cohort of 18,619 re-settlers living in the Saarland between 1990 and 2009 were identified by the federal state's cancer registry. Vital status was available for the respective time-period and used to calculate SIR and SMR in comparison to the autochthonous population. Tumor stages were condensed into local and advanced stages. Odds ratios (OR) for an advanced tumor stage were modeled in dependence of re-settler-status and relevant covariates by logistic regression. Missing values were addressed in a sensitivity analysis. The influence of duration of stay in Germany on advanced stage diagnosis was analyzed among re-settlers.

RESULTS

SIR and SMR of lung and breast cancer were lower among female re-settlers, while SIR and SMR of colorectal and prostate cancer were lower among male re-settlers. SIR and SMR of stomach cancer were elevated among both sexes. Female re-settlers showed an elevated OR for being diagnosed with advanced stage breast cancer. Both male and female re-settlers showed an elevated OR when observing all six sites combined (OR among males 1.47, p = 0.04; OR among females 1.37, p = 0.05). The result of elevated ORs was supported in the sensitivity analysis. Finally, male re-settlers showed a weak association between duration of stay in Germany and reduced risk for advanced stage diagnosis.

CONCLUSION

Re-settlers were more likely to be diagnosed at an advanced tumor stage. These findings are in line with previous research having shown unfavorable health care utilization of re-settlers. Overall, low mortality rates despite an increased risk of advanced stage at diagnosis argue for a sufficient follow-up care, comparable to the autochthonous population.

Migration pattern and mortality of ethnic German migrants from the former Soviet Union: a cohort study in Germany

OBJECTIVE

We aimed to investigate all-cause and cause-specific mortality among ethnic German migrants from the former Soviet Union by different immigration periods to describe associations with migration pattern and mortality.

DESIGN

We used pooled data from three retrospective cohort studies in Germany.

PARTICIPANTS

Ethnic German migrants from the former Soviet Union (called resettlers), who immigrated to Germany since 1990 to the federal states North Rhine-Westphalia and Saarland and to the region of Augsburg (n=59 390).

OUTCOME

All-cause and cause-specific mortality among resettlers in comparison to the general German population, separated by immigration period.

METHODS

Immigration periods were defined following legislative changes in German immigration policy (1990-1992, 1993-1995, 1996+). Resettlers' characteristics were described accordingly. To investigate mortality differences by immigration period, we calculated age-standardised mortality rates (ASRs) and standardised mortality ratios (SMRs) of resettlers in comparison to the general German population. Additionally, we modelled sex-specific ASRs with Poisson regression, using age, year and immigration period as independent variables.

RESULTS

The composition of resettlers differed by immigration period. Since 1993, the percentage of resettlers from the Russian Federation and non-German spouses increased. Higher all-cause mortality was found among resettlers who immigrated in 1996 and after (ASR 628.1, 95% CI 595.3 to 660.8), compared with resettlers who immigrated before 1993 (ASR 561.8, 95% CI 537.2 to 586.4). SMR analysis showed higher all-cause mortality among resettler men from the last immigration period compared with German men (SMR 1.11, 95% CI 1.04 to 1.19), whereas resettlers who immigrated earlier showed lower all-cause mortality. Results from Poisson regression, adjusted for age and year, corroborated those findings.

CONCLUSIONS

Mortality differences by immigration period suggest different risk-factor patterns and possibly deteriorated integration opportunities. Health policy should guard the consequences of immigration law alterations with respect to changing compositions of migrant groups and their health status.