Higher Rate of Tuberculosis in Second Generation Migrants Compared to Native Residents in a Metropolitan Setting in Western Europe

Trends in pulmonary tuberculosis mortality between 1985 and 2018: an observational analysis

BACKGROUND

Pulmonary tuberculosis (TB) is a major source of global morbidity and mortality. Latent infection has enabled it to spread to a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of TB cases related to the HIV epidemic, and the spread of multidrug-resistant TB. Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality.

METHODS

We utilized the World Health Organization (WHO) mortality database from 1985 through 2018 to analyze TB mortality using the International Classification of Diseases-10 codes. Based on the availability and quality of data, we investigated 33 countries including two countries from the Americas; 28 countries from Europe; and 3 countries from the Western Pacific region. Mortality rates were dichotomized by sex. We computed age-standardized death rates per 100,000 population using the world standard population. Time trends were investigated using joinpoint regression analysis.

RESULTS

We observed a uniform decrease in mortality in all countries across the study period except the Republic of Moldova, which showed an increase in female mortality (+ 0.12 per 100,000 population). Among all countries, Lithuania had the greatest reduction in male mortality (-12) between 1993-2018, and Hungary had the greatest reduction in female mortality (-1.57) between 1985-2017. For males, Slovenia had the most rapid recent declining trend with an estimated annual percentage change (EAPC) of -47% (2003-2016), whereas Croatia showed the fastest increase (EAPC, + 25.0% [2015-2017]). For females, New Zealand had the most rapid declining trend (EAPC, -47.2% [1985-2015]), whereas Croatia showed a rapid increase (EAPC, + 24.9% [2014-2017]).

CONCLUSIONS

Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and successful treatment to the most vulnerable groups such as people of foreign origin from countries with a high burden of TB and incarcerated population. Incomplete reporting of TB-related epidemiological data to WHO excluded high-burden countries and limited our study to 33 countries only. Improvement in reporting is crucial to accurately identify changes in epidemiology, the effect of new treatments, and management approaches.

Epidemiological characteristics and risk factors of multidrug-resistant tuberculosis in Luoyang, China

Objective

We aimed to examine the prevalence of multidrug-resistant tuberculosis (MDR-TB) in Luoyang, China, identify related risk factors, inform clinical practices, and establish standardized anti-tubercular treatment regimens.

Methods

We conducted a retrospective analysis of high-resolution melting curve (HRM) data from 17,773 cases (2,748 of which were positive) between June 2019 and May 2022 to assess the prevalence of MDR-TB and to identify its associated risk factors.

Results

Between June 2019 and May 2022, out of the 17,773 HRM results, 2,748 were HRM-positive, and 312 were MDR-TB cases. The detection rates for HRM-positive and MDR-TB were 17.0 and 12.1% for males, and 12.4 and 8.2% for females, respectively. The MDR-TB detection rate was higher in the urban areas (14.6%) than in the rural areas (10.6%) and more common among individuals under 51 years of age (14.1%) than those over 50 years of age (9.3%). Notably, the rate of detecting MDR-TB was 18.3% higher in new male patients than in new female patients, which was at 10.6%, and this difference was statistically significant (p < 0.001). Moreover, the rate of MDR detection in females who had received anti-tuberculosis treatment (21.3%) was higher than that in males (16.9%). In the multivariate model that considered the results of the sputum smear and detection time, MDR-TB was positively correlated with a history of tuberculosis (TB) treatment, being male, being younger than 51 years, and living in urban areas.

Conclusion

Local TB infections are complex and diverse; therefore, more comprehensive monitoring methods are needed to curb the spread of MDR-TB.

Latent tuberculosis infection prevalence in second generation immigrants from high to low TB burden countries

BACKGROUND

Latent tuberculosis infection (LTBI) diagnosis in a country with a low tuberculosis burden is complicated. Since the prevalence of LTBI in second generation immigrants has not been well recognized, we conducted a cross-sectional study which aimed to explore the differences in LTBI prevalence between offspring of immigrants from high tuberculosis (TB) burden countries and those whose parents were born in countries with a low TB burden.

METHODS

Between May 2014 and April 2018 young native Israelis who were required to perform pre-occupational tuberculin skin tests (TST) (medical and paramedical personnel or teaching assistants of immigrants from high TB burden countries) and who had a TST result of 10mm and above were tested for QuantiFERON-TB In Tube (QFT-GIT). Statistical comparisons were made between second generation immigrants and those with both parents from a low TB burden country.

RESULTS

Of 102 patients, 71 were born to parents both of whom were from low-risk countries, 14 to one parent from a high-risk country and 17 to parents both of whom were from a high-risk country. The odds ratio for LTBI was 4.5 (95% CI, 1.2...17.2; p=0.03) if both parents were born in a high-risk country compared to both parents being from a low-risk country and 4.01 (95% CI, 1.12...14.3; p=0.03) higher compared to persons for whom at least one parent was born in a low-risk country.

CONCLUSION

The risk for latent TB is significantly higher in second generation immigrants if both parents were born in a high-risk country. IGRA should be considered before treatment to patients with a positive TST if at least one parent was born in a low-risk country in order to confirm LTBI.

Regional distribution of Mycobacterium tuberculosis infection and resistance to rifampicin and isoniazid as determined by high-resolution melt analysis

Background

Identifying the transmission mode and resistance mechanism of Mycobacterium tuberculosis (MTB) is key to prevent disease transmission. However, there is a lack of regional data. Therefore, the aim of this study was to identify risk factors associated with the transmission of MTB and regional patterns of resistance to isoniazid (INH) and rifampicin (RFP), as well as the prevalence of multidrug-resistant tuberculosis (MDR-TB).

Methods

High-resolution melt (HRM) analysis was conducted using sputum, alveolar lavage fluid, and pleural fluid samples collected from 17,515 patients with suspected or confirmed MTB infection in the downtown area and nine counties of Luoyang City from 2019 to 2021.

Results

Of the 17,515 patients, 82.6% resided in rural areas, and 96.0% appeared for an initial screening. The HRM positivity rate was 16.8%, with a higher rate in males than females (18.0% vs. 14.1%, p < 0.001). As expected, a positive sputum smear was correlated with a positive result for HRM analysis. By age, the highest rates of MTB infection occurred in males (22.9%) aged 26–30 years and females (28.1%) aged 21–25. The rates of resistance to RFP and INH and the incidence of MDR were higher in males than females (20.5% vs. 16.1%, p < 0.001, 15.9% vs. 12.0%, p < 0.001 and 12.9% vs. 10.2%, p < 0.001, respectively). The HRM positivity rate was much higher in previously treated patients than those newly diagnosed for MTB infection. Notably, males at the initial screening had significantly higher rates of HRM positive, INH resistance, RFP resistance, and MDR-TB than females (all, p < 0.05), but not those previously treated for MTB infection. The HRM positivity and drug resistance rates were much higher in the urban vs. rural population. By multivariate analyses, previous treatment, age < 51 years, residing in an urban area, and male sex were significantly and positively associated with drug resistance after adjusting for smear results and year of testing.

Conclusion

Males were at higher risks for MTB infection and drug resistance, while a younger age was associated with MTB infection, resistance to INH and RFP, and MDR-TB. Further comprehensive monitoring of resistance patterns is needed to control the spread of MTB infection and manage drug resistance locally.

Dynamics of Mycobacterium tuberculosis Lineages in Oman, 2009 to 2018

Study aim. Effective Tuberculosis (TB) control measures in Oman have reduced the annual incidence of tuberculosis cases by 92% between 1981 and 2016. However, the current incidence remains above the program control target of <1 TB case per 100,000 population. This has been partly attributed to a high influx of migrants from countries with high TB burdens. The present study aimed to elucidate Mycobacterium tuberculosis infection dynamics among nationals and foreigners over a period of 10 years. Methods. The study examined TB cases reported between 2009 and 2018 and examined the spatial heterogeneity of TB cases and the distribution of M. tuberculosis genotypes defined by spoligotypes and MIRU-VNTR among Omanis and foreigners. Results. A total of 484 spoligoprofiles were detected among the examined isolates (n = 1295). These include 943 (72.8%) clustered and 352 (27.2%) unique isolates. Diverse M. tuberculosis lineages exist in all provinces in Oman, with most lineages shared between Omanis and foreigners. The most frequent spoligotypes were found to belong to EAI (318, 30.9%), CAS (310, 30.1%), T (154, 14.9%), and Beijing (88, 8.5%) lineages. However, the frequencies of these lineages differed between Omanis and foreigners. Of the clustered strains, 192 MTB isolates were further analysed via MIRU-VNTR. Each isolate exhibited a unique MIRU-VNTR profile, indicative of absence of ongoing transmission. Conclusions. TB incidence exhibits spatial heterogeneity across Oman, with high levels of diversity of M. tuberculosis lineages among Omanis and foreigners and sub-lineages shared between the two groups. However, MIRU-VNTR analysis ruled out ongoing transmission.

Immigrant generational status and the uptake of HIV screening services among heterosexual men of African descent in Canada: Evidence from the weSpeak study

Objective

Canada became a preferred destination for many non-European and non-American migrants since the introduction of favorable immigration policies in the late 1960 s. Blackimmigrants from the African and Caribbean regions however are a known vulnerable population to HIV infection in Canada. Even though first-generation immigrants might differ from subsequent generations in terms of culture and beliefs which are important for health outcomes and behaviors, research examining disparities in their use of preventative healthcare is limited. This study aimed to examine generational disparities in the uptake of HIV screening services among a sample of heterosexual Black men in Ontario, Canada.

Methods

We used data from a cross-sectional survey sample (n = 829) that was collected from heterosexual Black men in four Ontarian cities (Toronto, Ottawa, London and Windsor) between March 2018 and February 2019. We used the negative log-log link function of the binomial family to examine the independent relationship between immigration status and the uptake of HIV testing and the cumulative effect of other predictor variables on HIV testing in nested models.

Results

Findings from multivariate analysis show second-generation immigrants were significantly less likely to test for HIV compared with their first-generation immigrant counterparts. After controlling for theoretically relevant variables, the second-generation immigrants were 53% less likely to test for HIV. We further observed that participants with good knowledge of HIV transmission (OR=1.05; p > 0.05) and those who were older were more likely to test for HIV. Those with masculine tendencies (OR=0.98; p > 0.05) and those who reported not having sexual partner were less likely to test (OR=0.57; p > 0.01). Religion emerged as a significant predictor of HIV testing as Christians (OR=1.62; p > 0.05) and other believers (OR=1.59; p > 0.05) were more likely to test for HIV when compared to their Muslim counterparts.

Conclusion

HIV prevention policies may need not only prioritize first-generation immigrants, but the wellbeing of their descendants as well. This could be achieved by implementing programs that will enhance second-generation immigrants’ use of HIV screening services. Additionally, HIV educational programs would be of relevance and especially so as respondents with good knowledge of HIV transmission consistently demonstrated higher likelihood of testing for their HIV status.

Targeting screening and treatment for latent tuberculosis infection towards asylum seekers from high-incidence countries - a model-based cost-effectiveness analysis

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.

Impact of Protracted Displacement on Delay in the Diagnosis Associated with Treatment Outcomes: A Cross-Sectional Study in Internally Displaced Tuberculosis Patients of Pakistan

Human displacement is on the rise globally, and the increase in the burden of tuberculosis (TB) is also attributed to migrations worldwide. A significant number of such displacements occur in regions with considerably higher areas of TB burden. Displacements may delay TB diagnosis and treatment, which will possibly lead to TB transmission among healthy individuals. In this study, we assessed the association of existing determinants after a protracted internal displacement of people with delay in TB diagnosis and treatment outcomes. A cross-sectional study was conducted on internally displaced TB patients (IDPs), registered at selected health facilities in three urban districts of Pakistan from March 2019 to February 2020. The univariate and multivariate logistic regression model was used to assess the delay in diagnosis and treatment outcomes. IDPs with delay in initiation of treatment beyond 30 days were at high possibility of unsuccessful TB treatment outcomes (adjusted odds ratio AOR, 2.60; 95% CI 1.06–6.40). Furthermore, the multivariate regression analysis showed a statistically significant association (p > 0.05) between TB patients who were aged 55 to 65 years (AOR, 2.66; 95% CI 1.00–7.07), female patients (AOR, 2.42; 95% CI 1.21–4.81), visited non-formal health provider (AOR, 8.81; 95% CI 3.99–19.46), self-medication (AOR, 2.72; 95 % CI 1.37–5.37), poor knowledge of TB (AOR, 11.39; 95% CI 3.31–39.1), and perceived stigma (AOR, 8.81; 95% CI 3.99–19.4). Prolonged delay in treatment was associated with unfavorable treatment outcomes among IDPs. Migrants and IDPs are more likely to experience an interruption in care due to overall exclusion from social and health care services. Therefore, it is imperative to understand the barriers to providing public health care services, particularly in preventing and treating TB.

Paediatric tuberculosis during universal and selective Bacillus Calmette-Guérin vaccination policy: a nationwide population-based retrospective study, Finland, 1995-2015

Introduction

In 2006, the Bacillus Calmette–Guérin (BCG) vaccination policy in Finland changed from universal to selective.

Aim

We assessed the impact of the policy change on tuberculosis (TB) morbidity in children under 5 years and epidemiological trends of paediatric TB in Finland.

Methods

We conducted a nationwide, population-based, retrospective registry study of all newly diagnosed active TB cases younger than 15 years in Finland from 1995 to 2015 by linking data from the National Infectious Diseases Register, Finnish Care Register for Health Care, medical patient records and Finnish Population Information System. We compared the TB incidence rate ratio of under 5 year-olds with universal and selective BCG vaccinations with a Poisson log-linear model and analysed incidence trends among those younger than 15 years with a negative binomial model.

Results

We identified 139 paediatric TB cases: 50 native (including 24 second-generation migrants) and 89 foreign-born children. The TB rate of under 5 year-olds remained stable after changing to selective BCG vaccination (incidence rate ratio (IRR): 1.3; 95% confidence interval (CI): 0.7–2.3). TB rate in the native population under 15 years increased slightly (IRR = 1.06; 95% CI: 1.01–1.11).

Discussion

Paediatric TB cases in Finland were concentrated in families with migrant background from high-TB incidence countries. The native TB morbidity in under 5-year-olds did not increase after the BCG policy revision, suggesting that selective vaccinations can prevent TB in the most vulnerable age group in low-incidence settings. Second-generation migrants under 15 years in Finland with high TB risk are probably increasing.

Estimating and Explaining the Prevalence of Tuberculosis for Asylum Seekers Upon Their Arrival in Germany

Up until recently incidences of tuberculosis (TB) had been declining for many years in Germany. The rise in TB cases coincided with a large increase in the number of people applying for asylum. We combine data from various sources to estimate the at-entry prevalence of TB for asylum seekers from 18 countries of origin and rely on survey data to explain the varying risk of suffering from TB. Our results reveal that asylum seekers from Eastern Africa show a much higher risk of suffering from TB than asylum seekers from Afghanistan, Syria, or Iraq. The survey data suggests that asylum seekers from Africa were by far more underprivileged in their respective countries of origin and experienced a higher risk of contracting TB on their way to Germany. Information about the socio-economic situation and the circumstances of the journey to Germany may help to improve TB surveillance.

[Barriers and Potential Improvements in the Diagnosis and Treatment of Asylum Seekers with Tuberculosis in Germany: A Qualitative Study]

Since 2014, the number of new cases of tuberculosis (TB) has risen in Germany by about 20%. This coincides with a large number of people applying for asylum in Germany. Some of them are from countries in which TB is much more prevalent than in Germany. The objectives of this contribution are to identify and explain barriers in the diagnosis and treatment of asylum seekers with TB and potential improvements in those fields. Data are derived from 14 problem-centred interviews that were carried out with doctors and staff from public health offices, representing the views of experts in the field of health care. On the one hand, the results suggest that structural factors are responsible for some of the barriers mentioned by the experts. For example, the restricted access to health care for asylum seekers leads to a delayed diagnosis since they visit the doctor too late (if at all). Accordingly, a nationwide implementation of an electronic health card for asylum seekers was proposed. On the other hand, individual and cultural factors play important roles as well. To those belong language barriers: they not only complicate history taking and diagnosis, but also educating patients about their disease and therapy. Moreover, the lack of knowledge concerning the German health care system increases the risk of treatment interruptions. To alleviate those problems, experts propose to carry out train-the-trainer-programmes and to install "guides" who pilot asylum seekers with TB through the German health care system.

Foreign background and older age of children were associated with infection in Swedish tuberculosis contacts

AIM

We present our results using interferon-gamma release assays in any child <18 years or tuberculin skin tests in Bacille Calmette-Guérin unvaccinated children for tuberculosis contact investigation in Stockholm, Sweden.

METHODS

During 2000-2019, we investigated 892 children with a median age of seven years. We explored associations between TB infection and characteristics such as closeness to contact, age, sex, BCG status and foreign origin.

RESULTS

The overall rates were for TB infection 10.2% (n = 91) and for TB disease 1.1% (n = 10). In addition to infectiousness of index case and closeness of contact, foreign background, male sex and increasing age were independently associated with infection. In foreign-born children, the rates of tuberculosis infection and disease were 18.7% and 3.9%, respectively. In 18/46 (39%) infected foreign-born children, a baseline negative tuberculosis test supported a diagnosis of recent infection.

CONCLUSION

Foreign background, older age and male sex were associated with infection. In a significant proportion of infected children, a previous negative test made recent infection likely.

Trends and risk factors for death and excess all-cause mortality among notified tuberculosis patients in the UK: an analysis of surveillance data

Introduction

In the UK, several hundred patients notified with tuberculosis (TB) die every year. The aim of this article is to describe trends in deaths among notified TB patients, explore risk factors associated with death and compare all-cause mortality in TB patients with age-specific mortality rates in the general UK population.

Methods

We used 2001–2014 data from UK national TB surveillance to explore trends and risk factors for death, and population mortality data to compare age-specific death rates among notified TB patients with annual death rates in the UK general population.

Results

The proportion of TB patients in the UK who died each year declined steadily from 7.1% in 2002 to 5.5% in 2014. One in five patients (21.3%) was diagnosed with TB post-mortem. Where information was available, almost half of the deaths occurred within 2 months of starting treatment. Risk factors for death included demographic, disease-specific and social risk factors. Age had by far the largest effect, with patients aged ≥80 years having a 70 times increased risk of death compared with those aged <15 years. In contrast, excess mortality determined by incidence ratios comparing all-cause mortality among TB patients with that of the general population was highest among children and the working-age population (15–64 years old).

Conclusions

Efforts to control TB and improve diagnosis and treatment outcomes in the UK need to be sustained. Control efforts need to focus on socially deprived and vulnerable groups. There is a need for further in-depth analysis of deaths of TB patients in the UK to identify potentially preventable factors.

Despite an overall decline in death among TB patients in the UK, patients with TB are still 6 times more likely to die during follow-up than the annual death rate in the general populationhttp://bit.ly/2MqDw9Q

Enhanced surveillance for tuberculosis among foreign-born persons, Finland, 2014-2016

BACKGROUND

Tuberculosis (TB) in foreign-born residents is increasing in many European countries including Finland. We conducted enhanced TB surveillance to collect supplementary information on TB cases among recent immigrants and their children to provide data for revising TB control policies in Finland to take into account the decrease in native cases and increase in foreign-born cases.

METHODS

TB cases were identified from the National Infectious Diseases Register. Data on foreign-born (if not available, most recent nationality other than Finnish) TB cases notified during 2014-2016 (country of birth, date of arrival to Finland, participation in TB screening, date of first symptoms, and details of possible contact tracing) were requested from physicians responsible for regional communicable disease control through a web-based questionnaire.

RESULTS

Questionnaires were returned for 203 (65%) of 314 foreign-born TB cases; 36 (18%) were paediatric cases TB was detected in arrival screening in 42 (21%) and during contact tracing of another TB case in 18 (9%); 143 (70%) cases sought care for symptoms or were identified by chance (e.g. chest x-ray because of an accident). Of cases with data available, 48 (24%) cases were diagnosed within 3 months of arrival to Finland, 55 (27%) cases between 3 months and 2 years from arrival, and 84 (42%) cases after 2 years from arrival. Of all the foreign-born cases, 17% had been in a reception centre in Finland and 15% had been in a refugee camp abroad.

CONCLUSIONS

In addition to asylum seekers and refugees, TB screening should be considered for immigrants arriving from high TB incidence countries, since the majority of TB cases were detected among persons who immigrated to Finland due to other reasons, presumably work or study. Further evaluation of the target group and timing of TB screening is warranted to update national screening guidance.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

Factors influencing the higher incidence of tuberculosis among migrants and ethnic minorities in the UK

Migrants and ethnic minorities in the UK have higher rates of tuberculosis (TB) compared with the general population. Historically, much of the disparity in incidence between UK-born and migrant populations has been attributed to differential pathogen exposure, due to migration from high-incidence regions and the transnational connections maintained with TB endemic countries of birth or ethnic origin. However, focusing solely on exposure fails to address the relatively high rates of progression to active disease observed in some populations of latently infected individuals. A range of factors that disproportionately affect migrants and ethnic minorities, including genetic susceptibility, vitamin D deficiency and co-morbidities such as diabetes mellitus and HIV, also increase vulnerability to infection with Mycobacterium tuberculosis (M.tb) or reactivation of latent infection. Furthermore, ethnic socio-economic disparities and the experience of migration itself may contribute to differences in TB incidence, as well as cultural and structural barriers to accessing healthcare. In this review, we discuss both biological and anthropological influences relating to risk of pathogen exposure, vulnerability to infection or development of active disease, and access to treatment for migrant and ethnic minorities in the UK.

A systematic review of economic evaluations of interventions to tackle tuberculosis in homeless people

Objective

To analyze economic evaluations of interventions related to tuberculosis (TB) diagnostics/screening, treatment, and prevention in homeless people.

Methods

A systematic review was conducted. The eligibility criteria were original studies reporting economic evaluation results. The search was not restricted by language or year. A critical appraisal approach was used.

Results

A total of 142 studies were identified, including five research articles (three full economic evaluations and two partial) that were selected for the final review. Most of the studies were conducted in the United States, adopted a public health perspective, and analyzed active TB. Interventions related to diagnostics/screening (the use of interferon-gamma release assay (IGRA) and mobile screening units), treatment (incentives for continuing treatment, and housing programs), and prevention (with the Bacillus Calmette–Guérin (BCG) vaccine) were identified.

Conclusions

No high-quality data were found on cost-effectiveness of interventions on TB diagnostics/screening, treatment, or prevention in homeless people. However, active searching for cases via mobile screening, and financial incentives, could help increase treatment adherence, and the use of IGRA helps boost detection. TB in homeless people is neglected worldwide, especially in developing countries, where this disease tends to afflict more people made vulnerable by their precarious living conditions. Public funding mechanisms should be created to develop cross-sectoral actions targeting homeless people, as the complex dynamics of this group tend to hamper prevention and diagnosis of TB and the completion of TB treatment.

Serology of Viral Infections and Tuberculosis Screening in an IBD Population Referred to a Tertiary Centre of Southern Italy

Background

With the introduction of more potent immunosuppressive agents in inflammatory bowel disease, prevention of opportunistic infections has become necessary by introducing screening programs. Prevalence of the most important infectious agents may vary in different geographical areas. The aim of our study was to assess the immune status for hepatitis B, varicella, mononucleosis, and cytomegalovirus infection together with the determination of the hepatitis C and tuberculosis status in Southern Italy.

Methods

Prevalence of latent tuberculosis, together with serology of hepatitis B and C, Epstein-Barr virus, varicella zoster, and cytomegalovirus were collected by analysing retrospectively the clinical charts of IBD patients. Data were integrated with demographic and clinical features.

Results

Data from 509 IBD patients divided in two age groups showed a prevalence of HBV infection in nonvaccinated patients of 9%. Seroprotection (HBsAb) in vaccinated IBD patients was lower (p < 0.0001) compared with that in controls. Prevalences of herpesvirus infections fluctuate between 51% (CMV) and 85% (EBV) and 84% (VZV) in younger patients. Latent tuberculosis and hepatitis C infection were found only in patients > 37 years of age.

Conclusions

In younger patients, high susceptibility rates for primary herpesvirus infections should determine the choice of treatment. Loss of HBV seroprotection in already vaccinated patients should be considered for booster vaccination programs.

Tuberculosis notification rate decreases faster in residents of native origin than in residents of foreign origin in the EU/EEA, 2010 to 2015

To estimate trends in tuberculosis (TB) notification rates by geographical origin, we retrieved surveillance data from 2010 to 2015 for 29 European Union and European Economic Area countries. The TB notification rate decreased at an annual rate of 5.3%. The decrease in notification rate was higher in native residents (7.0%) than in those of foreign origin (3.7%). Targeted screening and facilitated access to care and treatment could help prevent and control TB in migrants.

Yield of active screening for tuberculosis among asylum seekers in Germany: a systematic review and meta-analysis

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.

Mobility patterns of persons at risk for drug-resistant tuberculosis in Mumbai, India

SETTING

Tuberculosis (TB) hospital in Mumbai, India.

OBJECTIVE

To describe the mobility patterns of persons with suspected drug-resistant tuberculosis (DR-TB) and to assess whether there were significant differences in demographic or risk characteristics based on mobility.

DESIGN

Observational cohort study of TB clinic patients at risk for DR-TB.

RESULTS

Among 602 participants, 37% had ever moved from their place of birth; 14% were local movers (within state), and 23% were distant movers, between states or countries. Univariate multinomial logistic regression models showed that distant movers were more likely than non-movers to have lower income, less education, a greater number of previous TB episodes, and to have ever smoked. Compared to non-movers, local movers were more likely to have lower income and were more likely to have seen a doctor in the past 2 years. Clinical outcomes, including DR-TB, diabetes, and human immunodeficiency virus (HIV), did not differ between the three mobility groups.

CONCLUSION

Mobility was common among patients at risk for DR-TB in Mumbai. TB programs should consider the implications of mobility on the protracted treatment for DR-TB in India.

[Migration and infectious disease surveillance in Germany: Analyses of Tuberculosis, HIV and Syphilis surveillance data]

BACKGROUND

Migration is an important factor impacting on infectious disease epidemiology. The timely identification of groups at risk and prevention needs resulting from migration is indispensable to adequately design and implement public health measures. It remains to be assessed to which extent surveillance data for notifiable diseases can directly generate meaningful migration-specific information.

OBJECTIVES

The objectives of this study are to review indicators of migration background utilized in the German infectious disease surveillance, as well as to assess their limitations.

METHODS

We describe the indicators of migration used for mandatorily notifiable diseases and pathogens and their legal basis in the Protection against Infection Act and conduct a descriptive analysis of surveillance data for tuberculosis (TB), HIV and syphilis from 2002-2013.

RESULTS

Migration status is collected only for five infectious diseases and operationalization varies. For TB (country of birth) and HIV (country of origin) a foreign origin was more frequent than for syphilis (country of origin); namely 46, 30 and 13% of cases with available information, respectively. In all three examples, there are indications of risk profiles that are specific for particular groups of migrants.

DISCUSSION

A standardization of indicators of migration in infectious disease surveillance is important to enhance data comparability between diseases and pathogens as well as across countries. Routine surveillance already partly allows migration sensitive analyses, yet further research is needed to guide interpretation of the complex relationship between migration and infectious diseases and plan public health measures adequately.

Consequences of tuberculosis among asylum seekers for health care workers in Germany

Background

Immigrants have been contributing to the incidence of tuberculosis (TB) in Germany for many years. The current wave of migration of asylum seekers to Germany may increase that figure. Healthcare workers (HCW) who look after refugees not only in hospitals and medical practices but also in aid projects may be exposed to cases of TB.

Methods

The incremental TB cases arising from imported TB as well as from TB cases that developed later in refugees were calculated in a Markov model over a period of 5 years. Infectious and non-infectious susceptible TB and multidrug-resistant TB (MDR-TB) cases were determined separately. In addition, the total amount of latent TB in contact persons and the risk of infection by HCW were estimated. Due to uncertainty of future refugee flows to Europe, different scenarios were considered in univariate and multivariate sensitivity analysis.

Results

Assuming a decrease in immigration by half each year to the bottom line of 2014, and in light of the current number of 800,000 asylum seekers, we calculated an additional 10,090 TB cases by the end of the fifth year (5976 cases of infectious pulmonary TB and 143 cases of pulmonary MDR-TB). In case of an unchanging influx of asylum seekers over the 5-year period, 19,031 TB cases would arise, 377 of which infectious MDR-TB. Eighty -seven ensuing TB cases would develop in HCW in the same period, 3 of which MDR-TB cases.

Conclusions

Although the total number of TB cases in HCW expected to ensue from the current influx of asylum seekers is rather small, the 3 MDR-TB cases we calculated have to be taken seriously. We consider it essential to increase awareness of protective measures such as respiratory masks and, in the event of documented exposure, of supply-oriented occupational health screening.