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Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073834. [PMID: 35409517 PMCID: PMC8997607 DOI: 10.3390/ijerph19073834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/24/2022]
Abstract
Tuberculosis (TB) is an infectious disease associated with poverty. In the European Union TB tends to concentrate in urban settings. In Lisbon, previous studies revealed, the presence of migrant populations from a high endemic country, is one of the risk factors contributing to TB. To better understand TB in foreign-born individuals in the Lisbon Metropolitan Area, a mixed-method case study was undertaken on a TB treatment centre in a high-risk part of urban Portugal. Quantitatively, annual TB cases were analysed from 2008 to 2018, dividing foreign-origin cases into recent migrants and long-term migrants. Qualitatively, we explored recent migrants’ reasons, experiences and perceptions associated with the disease. Our results showed that foreign-born individuals accounted for 45.7% of cases, mainly originated from Angola, Guinea-Bissau, and Cabo Verde. TB in recent migrants increased over the years for Angola and Guinea-Bissau, while for Cabo Verde TB cases were due to migrants residing in Portugal for more than 2 years. Recent migrants’ reasons to travel to Portugal were to study, to live and work, tourism, and seeking better healthcare. Visiting family and friends, historical links and common language were key drivers for the choice of country. Recent migrants and long-term migrants may present distinct background profiles associated with diagnosed TB.
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Woldesemayat EM. Tuberculosis in Migrants is Among the Challenges of Tuberculosis Control in High-Income Countries. Risk Manag Healthc Policy 2021; 14:2965-2970. [PMID: 34285610 PMCID: PMC8285291 DOI: 10.2147/rmhp.s314777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/23/2021] [Indexed: 01/03/2023] Open
Abstract
The incidence of tuberculosis (TB) is high among migrants in high-income countries. The migration process could contribute to the high incidence of TB among them. Achieving TB elimination from these settings will be difficult unless countries address the burden of TB among migrants. The aim of this review was to describe the challenges of international migration on TB control in high-income, low TB incidence countries. Among migrants, there is a high prevalence of risk factors for TB, such as exposure to TB, HIV, malnutrition, substance use, delayed diagnosis, low education, poor health-seeking, the culture, stigma and marginalization. Discriminatory policies of TB care and social barriers such as language, cultural issues and unfriendly health services may also contribute to the high prevalence of TB among them. TB control among migrants in these settings is important as migrants are vulnerable to TB infection and disease, and implementing TB care among them is difficult; it is important to reduce the TB burden in migrants and the community at large and the high risk of multidrug-resistant TB (MDR-TB). TB elimination from high-income countries requires acquiring data and analyzing it to measure the burden, having migrant-sensitive health systems, having policy and legal frameworks and multi-country partnerships and conducting research.
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Perdigão J, Silva C, Maltez F, Machado D, Miranda A, Couto I, Rabna P, Florez de Sessions P, Phelan J, Pain A, McNerney R, Hibberd ML, Mokrousov I, Clark TG, Viveiros M, Portugal I. Emergence of multidrug-resistant Mycobacterium tuberculosis of the Beijing lineage in Portugal and Guinea-Bissau: a snapshot of moving clones by whole-genome sequencing. Emerg Microbes Infect 2020; 9:1342-1353. [PMID: 32538300 PMCID: PMC7473242 DOI: 10.1080/22221751.2020.1774425] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/17/2020] [Accepted: 05/14/2020] [Indexed: 11/22/2022]
Abstract
The Beijing genotype comprises a highly disseminated strain type that is frequently associated with multidrug resistant (MDR) tuberculosis (TB) and increased transmissibility but, countries such as Portugal and Guinea-Bissau fall outside the regions phylogeographically associated with this specific genotype. Nevertheless, recent data shows that this genotype might be gradually emerging in these two countries as an underlying cause of primary MDR-TB. Here, we describe the emergence of Mycobacterium tuberculosis Beijing strains associated with MDR-TB in Portugal and Guinea-Bissau demonstrating the presence of the well described superclusters 100-32 and 94-32 in Portugal and Guinea-Bissau, respectively. Genome-wide analysis and comparison with a global genomic dataset of M. tuberculosis Beijing strains, revealed the presence of two genomic clusters encompassing isolates from Portugal and Guinea-Bissau, GC1 (n = 121) and GC2 (n = 39), both of which bore SNP signatures compatible with the 100-32/B0/W148 and 94-32/Central Asia Outbreak clades, respectively. Moreover, GC2 encompasses a cross-border cluster between Portugal, Guinea-Bissau and Brazil thus supporting migration-associated introduction of MDR-TB and subsequent clonal expansion at the community-level. The comparison with global Beijing datasets demonstrates the global reach of the disease and its complex dissemination across multiple countries while in parallel there are clear microevolutionary trajectories towards extensively drug resistant TB.
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Affiliation(s)
- João Perdigão
- iMed.ULisboa – Instituto de Investigação do Medicamento, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Carla Silva
- iMed.ULisboa – Instituto de Investigação do Medicamento, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Fernando Maltez
- Serviço de Doenças Infecciosas, Hospital de Curry Cabral-CHLC, Lisboa, Portugal
| | - Diana Machado
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Anabela Miranda
- National Mycobacterium Reference Laboratory, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal
| | - Isabel Couto
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Paulo Rabna
- Instituto Nacional de Saúde Pública/Projecto de Saúde de Bandim (INASA/PSB), Bissau,Guiné-Bissau
| | | | - Jody Phelan
- London School of Hygiene & Tropical Medicine, London, UK
| | - Arnab Pain
- Pathogen Genomics Laboratory, BESE Division, King Abdullah University of Science and Technology (KAUST), Thuwal, Kingdom of Saudi Arabia
| | - Ruth McNerney
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Igor Mokrousov
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St Petersburg Pasteur Institute, St Petersburg, Russia
| | - Taane G. Clark
- London School of Hygiene & Tropical Medicine, London, UK
| | - Miguel Viveiros
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Isabel Portugal
- iMed.ULisboa – Instituto de Investigação do Medicamento, Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
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Perdigão J, Gomes P, Miranda A, Maltez F, Machado D, Silva C, Phelan JE, Brum L, Campino S, Couto I, Viveiros M, Clark TG, Portugal I. Using genomics to understand the origin and dispersion of multidrug and extensively drug resistant tuberculosis in Portugal. Sci Rep 2020; 10:2600. [PMID: 32054988 PMCID: PMC7018963 DOI: 10.1038/s41598-020-59558-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/13/2019] [Indexed: 01/12/2023] Open
Abstract
Portugal is a low incidence country for tuberculosis (TB) disease. Now figuring among TB low incidence countries, it has since the 1990s reported multidrug resistant and extensively drug resistant (XDR) TB cases, driven predominantly by two strain-types: Lisboa3 and Q1. This study describes the largest characterization of the evolutionary trajectory of M/XDR-TB strains in Portugal, spanning a time-period of two decades. By combining whole-genome sequencing and phenotypic susceptibility data for 207 isolates, we report the geospatial patterns of drug resistant TB, particularly the dispersion of Lisboa3 and Q1 clades, which underly 64.2% and 94.0% of all MDR-TB and XDR-TB isolates, respectively. Genomic-based similarity and a phylogenetic analysis revealed multiple clusters (n = 16) reflecting ongoing and uncontrolled recent transmission of M/XDR-TB, predominantly associated with the Lisboa3 and Q1 clades. These clades are now thought to be evolving in a polycentric mode across multiple geographical districts. The inferred evolutionary history is compatible with MDR- and XDR-TB originating in Portugal in the 70's and 80's, respectively, but with subsequent multiple emergence events of MDR and XDR-TB particularly involving the Lisboa3 clade. A SNP barcode was defined for Lisboa3 and Q1 and comparison with a phylogeny of global strain-types (n = 28 385) revealed the presence of Lisboa3 and Q1 strains in Europe, South America and Africa. In summary, Portugal displays an unusual and unique epidemiological setting shaped by >40 years of uncontrolled circulation of two main phylogenetic clades, leading to a sympatric evolutionary trajectory towards XDR-TB with the potential for global reach.
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Affiliation(s)
- João Perdigão
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal.
| | - Pedro Gomes
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Anabela Miranda
- Departamento de Doenças Infeciosas, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal
| | - Fernando Maltez
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
- Serviço de Doenças Infecciosas, Hospital de Curry Cabral, Lisboa, Portugal
| | - Diana Machado
- Unidade de Microbiologia Médica, Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Carla Silva
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal
| | - Jody E Phelan
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | | | - Susana Campino
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Isabel Couto
- Unidade de Microbiologia Médica, Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Miguel Viveiros
- Unidade de Microbiologia Médica, Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Taane G Clark
- Unidade de Microbiologia Médica, Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom
| | - Isabel Portugal
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, Portugal.
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