Expert Panel: [ARCHIVED] Tuberculosis Among Migrants

When: Jan. 16, 2017 - Jan. 20, 2017 | Community: MDR-TB Treatment & Prevention  

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Panelists of Tuberculosis Among Migrants and GHDonline staff

What are the principle risk factors for active Tuberculosis in migrants and how can they be mitigated

Posted: 17 Jan, 2017   Recommendations: 7   Replies: 18

Dear colleagues
I have read with interest the discussion over the last 24 hours or so, on this most fascinating subject of TB among migrants. Already the discussion has moved on from how to measure and analyse TB in migrants, to the complexities that contribute to how migrants present in terms of TB and other health matters but as Kedir Abdulsemed and Elizabeth Glarer contributions have already identified, migration is not a static phenomenon and that the transitory pathways are sometimes just of great a concern as the individual characteristics of the migrant. I have noted also that the discussion thread has not yet really picked up on the “TB carrier status” through latent TB and what this may mean and how we might measure and analyse this in migrants. I would be most interested to hear views from the TB community on this.
For those who do not know me – my area of work is in immigration and while this inevitably involves TB, it is the factors that contribute to “migration health” that interest me most. Noting that while a lot of the discussion has focussed on migration from high to low burden TB countries, it is important to note that most migration happens between high to high burden countries and even when travelling from high to low, the transitory pathways can take migrants back to high!!
In this context I would like to hear what contributors or other experts feel are the principle risk factors for active TB (or reactivation) and how they can be mitigated. Inevitably this will also need to address drug-resistance.
I have posted some publications including a few articles from an excellent series on migration in the 21st century that might stimulate some thinking of health determinants in migrants that might have some influence on risk factors for TB.
My apologies in advance for any delay in responding to your comments, given it is the middle of the night in Australia!! I will get back to you as soon as I can in the morning (my time)
Kind regards, Paul

Replies

 

egh Eduardo Gotuzzo Replied at 7:40 AM, 17 Jan 2017

as you know we publish our experience in toscany with peruvian people .dr
alessandro bartolni y his group
2 important finding
at least 60% occur in the first 5 yars of arrival
2.when we suty molecular strain we found at least 42% are the same strain
and thismeans the secundary cases
are very improtant becuase even are from immigrants they adquired
localfrom famlies meber or firends
the initial screening is very useful however is very improtant to made
imporatn screening in house hold memeber
special the informal immigrants of the familis becuase the arrive late to
health system relete to afriad to be deported as usally in USA

regards
eduardo Gotuzzo

2017-01-17 4:52 GMT-05:00 Paul Douglas via GHDonline <
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Elizabeth Glaser Replied at 1:11 PM, 17 Jan 2017

Hi Paul,
You ask, what are the principle risk factors for active Tuberculosis in migrants and how can they be mitigated?
I am not trying to be reductionist, but when I think of risk for TB activation in any person, biggest contributors are :Poverty , malnutrition, co-morbid conditions ( HIV, addictions, mental illness, diabetes), lack of access to initiate or complete care, poverty , poverty , poverty , poverty, poverty, and stigma.

Some might say that one's level of education may improve ones chances of getting care, but at least for latent TB, that might not be the case. Years ago one of my jobs as nurse for the ID clinic at a large academic medical center was to screen hospital staff for TB. Our facility had staff from all over the world, some just arrived, such as the residents and post docs, and others, such as support staff, that had immigrated to the US many years ago.

When a staff person had a positive TB test with negative chest x-ray , we went over recommendations including treatment for latent TB. Inevitably some staff would deny that the test was positive, citing false positives due to BCG ( which was unlikely given the time since receiving the vaccine) , others would say that it was not possible that they had TB.

We could not force anyone to take prophylaxis even though some of the clinical staff were caring for elderly or immunocompromised patients - people that would be very vulnerable if the staff person ever had active disease, yet these were the staff most likely to refuse treatment.

By contrast the support staff seemed more amenable to taking and completing the treatment , especially since the cost of the drug and labs were being covered by the hospital. As long as we could provide access and cover costs they wanted the treatment.

All migrants are not the same. Anecdotally, it seemed that those from higher socioeconomic and educational backgrounds were more likely to refuse treatment and demonstrate some evidence of denial and stigma. One staff person , a post doc in a bench science, simply said " I called my mother and she said that I cannot have TB". I will never forget that person's response because it taught me that the association between poverty and TB could manifest in many ways if one had TB then the implication was that one came from a poor background -poverty and TB was not only a physical and economic phenomenon , but a psychosocial one as well.

Elizabeth

marie goretti baransabira Replied at 1:14 PM, 17 Jan 2017

Thank you for the discussion
For the migrants , I think ,in order to improve refugees life safe from the TB,if we can make early diagnosis of TB based on the signs and symptoms, systematically before admission int he camps.Then suspected cases are isolated until TB will be excluded or TB treatment has been initiated.
The risk factors which contribute to TB,like malnutrition have to be evaluate and new life style involving people education are necessary.

Dylan Tierney Replied at 4:44 PM, 17 Jan 2017

Echoing my comment from yesterday, one clear theme that is emerging from the discussion is the complexity and diversity of the topic “Tuberculosis Among Migrants”.

I struggle to come up with a definition of migrant that could possibly incorporate all of the factors that likely weigh on their tuberculosis risk. An Indian graduate student with subclinical pulmonary tuberculosis migrating to the US for a post-doctoral fellowship is very different from the Swazi miner with cavitary MDR-TB migrating home after working in the South African mines. They have different manifestations of disease (on a spectrum), different motivations for migration, and different barriers to accessing health care, among a constellation of other differences that will likely determine their health.

One important way out of the quagmire of complexity, however, is to make comparisons with groups with similar characteristics. Paul has couched his initial question around risk for “active TB”, as the characteristic of interest. I’ll put forward a further clarifying point: when speaking about active TB, we should be clear to say whether we are interested in risk factors for those who are *migrating* with active TB (i.e., who leave their home country with active TB), or those who *develop* active TB upon arrival at their destination (i.e., who leave their home country with TB infection or contract it along the way). Both groups are important to consider, as has been mentioned.

Focusing on people migrating with active TB, the next question that arises for me when thinking about risk factors is “compared to what?”. Do we know that there is a difference in the prevalence of active TB among migrants compared to the baseline prevalence in the community or population from which the migrant originated? Could it be higher? Do people with active TB migrate at a higher frequency than the general population, possibly to seek better medical care? Could it be lower? Do people with active TB migrate at a lower frequency than the general population, possibly because they are too sick to migrate? Answers to these questions may help us refine our list of risk factors.

Paul Douglas Panelist Replied at 4:48 PM, 17 Jan 2017

Thank you Elizabeth. Yes all migrants are definitely not the same and where they have come from, the reasons for travelling, the way and duration that the migration has taken and the circumstances after arrival all contribute to the underlying determinants and consequent risk of being infected and developing the disease. This is summarised quite nicely in the journal article on pages 17 and 18 MIGRATION POLICY PRACTICE Vol. IV, Number 1, February–March 2014 and is worth considering for all migrants. In other words we cannot have a one rule fits all. Screening post-migration continues to be worthwhile with many studies showing this. Targeting specific populations also enhances the finds as identified in the study by Flynn. There are many studies out there that show that migrants moving from higher risk to lower risk countries are important to be targeted as outlined in the article by Zenner et al that I have attached. What would be more interesting though is whether someone has research or outcomes on specific cohorts on these 'higher risk migrants?
The specific risk factors have been analysed in migrants and approached at Individual factors such as poor living and working conditions, poverty, malnutrition, substance abuse; or Social Barriers including language, cultural beliefs, legal rights and visa status, migrant-unfriendly health services; or Economic factors - costs of care from family and income loss; governmental costs to health systems. But what can we do to mitigate these?

Attached resources:

Paul Douglas Panelist Replied at 4:58 PM, 17 Jan 2017

Maria makes a good point - early screening is important to identify disease but as identified in the attached study by Walter and others - the risks are still there 9 years later! So how do we mitigate against this earlier? Should we screen all new migrants for latent infection from higher burden countries? should this be targeted t cohorts within this group. The article from Taylor on screening children for LTBI premigration with a strong follow up process might be a great way of mitigating disease with longer term benefits. Currently, many immigrant and refugee children with LTBI are not completing preventive therapy - targeting specific populations may make this more effective.

Attached resources:

Arturo Eligan Replied at 2:26 AM, 18 Jan 2017

Good day Paul Douglas.

I am glad to see you in this expert panel discussion.
I met you in the IPPA conference in Prague last year and it is nice to know that you are active in GHDOnline.
My name is Arturo Eligan, I am one of the panel physicians at AMC in Afghanistan. I have some concerns about TB among migrants being screened in our clinic but let me start with the diagnostics. Based on the Panel Member instructions Australian Immigration Medical Examination July 2016 Manual (p. 64), we use Chest Xray in adults and TST/IGRA among children. For those who need further TB investigation we do Sputum test/culture/DST. With the advent of new diagnostics for TB screening like Genexpert, what is the DIBP's recommendation. Our clinic just acquired Genexpert for Gonorrhea screening but how could we potentially use it for TB screening. CDC also does not have a clear recommendation about Genexpert use in TB screening.

Thank you.

Mark Harrington Replied at 2:32 AM, 18 Jan 2017

CDC has strongly endorsed GX along with the US TB Task Force + PEPFAR!

Tushar Patial Replied at 2:50 AM, 18 Jan 2017

Hello everyone,

I'm Dr Tushar Patial from India. We too had a similar problem of deciding how to use genexpert for detection of Tuberculosis. A study of nearly 35,000 people in our country compared gx with microscopy. Not only were a higher proportion of Tuberculosis patients detected, but Rifampicin resistant cases were also detected higher than Baseline.
Please find links attached.

Regards,
Dr Tushar Patial.

Mark Harrington Replied at 2:53 AM, 18 Jan 2017

Great work, Tushar -- thanks and congratulations!

> Tushar Patial
> <http://email.ghdonline.org/c/eJxlkEtqxTAMRVcTz2r8Sexk4EGhvG0E90VJTOMPtkJ4u6_S...>
> replied to a discussion
> <http://email.ghdonline.org/c/eJxlkM9uwyAMh58m3IgAN6Q95DBp6mtENCGJ1fBH4Kzq28_Z...>
> in Tuberculosis Among Migrants
> <http://email.ghdonline.org/c/eJxlkMGOhCAQRL9GbkNoWkAPHDbZzG8YVFSyAgZ7YubvF3eT...>:
>
>
> Hello everyone,
>
> I'm Dr Tushar Patial from India. We too had a similar problem of deciding
> how to use genexpert for detection of Tuberculosis. A study of nearly
> 35,000 people in our country compared gx with microscopy. Not only were a
> higher proportion of Tuberculosis patients detected, but Rifampicin
> resistant cases were also detected higher than Baseline.
> Please find links attached.
>
> Regards,
> Dr Tushar Patial.
>
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Matthew Burman Replied at 5:44 AM, 18 Jan 2017

Dear Paul and everyone,

I am a research fellow based in London, and I am working on a trial investigating the delivery of LTBI screening and treatment amongst recent migrants from high TB burden countries (with Heinke Kunst and Dominik Zenner).

This is a really fascinating and complex problem. In our particular setting (high income, “nearly" low-incidence), 86% of active disease are in the non-UK born, and local evidence (http://thorax.bmj.com/content/71/8/749.full) suggests at least two thirds of active cases may be reactivation. Therefore, LTBI is the major risk factor that can be mitigated in our setting. The UK is now offering all recent migrants (<5 years since entry), aged 16-35 from countries with TB incidence >150 per 100 000) IGRA testing for LTBI and this occurs in primary care (GPs/Family doctors). And this is identifying large number of patients with LTBI. In Newham, with a population of 400,000, more than 900 patients were identified with positive IGRAs in the first year of the programme.

However it is clear that many do not accept screening, and many then decline treatment. Improving uptake of screening and treatment would therefore be very clear mechanism to mitigate the risk of active TB developing in our setting. But how to do this is difficult.

Making screening mandatory will increase uptake and completion, and in the UK pre-entry screening has had a significant impact on Active TB cases numbers since it was introduced. However, most people would agree it is unethical to make LTBI mandatory as we do not yet have the diagnostic tools available to adequately identify those most at risk of developing active TB, and LTBI does not pose the public health risk of active disease (https://www.ncbi.nlm.nih.gov/pubmed/25574909).

Something we have found from workshops we have run with migrant groups is that baseline understanding and knowledge about the concept of Latent Tuberculosis is almost completely absent. Whereas many, even most, had basic knowledge of active TB, perhaps not surprising as people have moved from countries where TB is much more common than the UK. The concept of LTBI can be quite challenging to understand, and I recognise as Elizabeth stated in earlier comments that health care workers are often unwilling to undertake LTBI treatment. However, I would say that our experience when speaking to people in the community was that once the concept was explained there was an interest and willingness to be tested. And those we see in clinic are usually keen to be treated.

I would therefore suggest that in our setting, improving public knowledge and understanding of LTBI could have a very positive impact on screening and treatment, and therefore LTBI prevalence. This of course requires access to healthcare too, which is another factor that is likely to impact on reducing TB amongst migrants.

I would also be fascinated to hear what others thought about why TB risk is highest after migration. I completely agree with the earlier comments that social risk factors are central to this, but there are other interesting areas that could be significant. For example, observational data has shown interesting correlations between vitamin D status and extra pulmonary disease which is something disproportionately affecting our non-UK born TB patients (http://thorax.bmj.com/content/70/12/1171).

Many thanks,

Matt Burman

Research Fellow/Respiratory Registrar
Queen Mary University of London

Arturo Eligan Replied at 9:53 AM, 18 Jan 2017

Good day Paul Douglas.

I am glad to see you in this expert panel discussion.
I met you in the IPPA conference in Prague last year and it is nice to know that you are active in GHDOnline.
My name is Arturo Eligan, I am one of the panel physicians at AMC in Afghanistan. I have some concerns about TB among migrants being screened in our clinic but let me start with the diagnostics. Based on the Panel Member instructions Australian Immigration Medical Examination July 2016 Manual (p. 64), we use Chest Xray in adults and TST/IGRA among children. For those who need further TB investigation we do Sputum test/culture/DST. With the advent of new diagnostics for TB screening like Genexpert, what is the DIBP's recommendation. Our clinic just acquired Genexpert for Gonorrhea screening but how could we potentially use it for TB screening. CDC also does not have a clear recommendation about Genexpert use in TB screening.

Thank you.

Arturo Eligan Replied at 9:56 AM, 18 Jan 2017

Dear Mark Harrington,
I'm posting here part of the reply of CDC on Genexpert use for TB screening among immigrants:

Regarding the use of GeneXpert for diagnosing TB, CDC/DGMQ does not consider this technology established enough to replace MTB culture at this time. GeneXpert is not as sensitive as MTB culture in certain populations and also does not give the full resistance profile with DST. MTB culture is still considered to be the gold standard for TB diagnosis, and for that reason, CDC/DGMQ does not plan to change the culture requirement for immigration purposes in the near future. GeneXpert, however, can be a useful tool in making treatment decisions for smear positive cases while cultures are pending and therefore can be used to better inform treatment regimens and to rule out drug resistance if DR/MDR TB is suspected. Therefore, GeneXpert testing can be performed in addition to MTB culture, but it cannot replace MTB culture to satisfy immigration requirements.

We hope this is helpful. Please let us know if you have any additional questions or concerns.

Regards,
CDC QAP

Paul Douglas Panelist Replied at 4:20 PM, 18 Jan 2017

Dear Arturo Eligan

Greetings to you in Kabul. It is great to hear that you now have a geneXpert machine as we believe from DIBP that this is a wonderful adjunct in the management of TB. While for premigration screening we still ask that cultures and DST be undertaken for clients requiring further investigation, as the National TB Advisory Committee in Australia sees this as being the gold standard, The newer molecular technologies play a role in early identification of drug resistance and as such earlier introduction of better therapies. It does not however replace culture and DST. We are also increasingly seeing it used in countries where panel physicians believe that clients may be encouraged to "pre-treat" prior to medical examinations and where growth of the bacteria is inhibited. Genexpert is a great way of identifying such cases!!

Who knows what the future holds though with rapidly improving technology in this area and evidence starting to support a more major role of these. However for the moment the instruction is still to undertaken smears/culture and DST and using these technologies for earlier confirmation and management.

All the best, Paul

Paul Douglas Panelist Replied at 4:33 PM, 18 Jan 2017

Great comments Matt and a welcome addition. The UK sounds very much like Australia where we see nearly 90% of our TB notifications in the overseas born and we believe the overwhelming majority of these are part of reactivation, given that we have robust screening tools premigration. We have recently added screening for latent TB premigration for children aged 2-10 years coming from countries with incidence of 40 per 100 000 or more and have now screened well over 30 000 children in 12 months. The results coming back from this are quite interesting and not necessarily what we would have expected, with TST positivity around 6% and IGRA at 1.9% (different countries have access to different screening algorithms). We have compared high TB incident rates (>300) to other cohorts and found this is not a significant indicator of positivity. I think in terms of migration we must look deeper in respect of reasons for migration, and population cohorts as it is not straight forward and if we most want to target those at greatest risk to ensure they complete treatment for LTBI , then this is vital. Interestingly the rates of LTBI in refugee cohorts has been relatively low. Again though we need to look at subpopulations as we think the impact of large numbers of Syrian refugees where TB incidence in the premigration group is ~70 per 100 000, that this is pulling down the rate of LTBI. You may be interested in some of the work being done for managing LTBI in California with Kathy Floyd's group who are seeing very high uptake of LTBI treatment and compliancy rates of up to 80%. I agree this is the next great challenge for low incidence countries and collaboration on strategies and effective outcomes is warranted

Paul

Matthew Burman Replied at 4:39 AM, 19 Jan 2017

Dear Paul,

Your early data for screening children sounds very interesting. I have no experience of screening in this age group, but the data fits with some general trends we have seen locally.

The current IGRA positivity rate in our screened population runs at just under 20% (using a >150 per 100 000). However, there was a period when the age range in our local screening programme was up to 50. When we looked at rates by age range we found IGRA positivity rates rose with age. As the number of years in the UK was fixed eg <5, we felt that risk of IGRA positivity was simply related to length of exposure in a high risk setting: older people have spent longer potentially exposed to TB before they moved to the UK. Do you think this might partially explain your findings in Australia? I also wondered what the age distribution was in your population. If a significant proportion of your population were under 5, is there also a risk that the tests themselves are are less reliable for this age range?

I completely agree that there is a lot more to consider with migration that TB incidence in country of origin. We do not collect data locally on the reason someone has migrated or the route of migration. Our population has both economic migrants and asylum seekers. Our opinion, looking at rates of IGRA positivity by country of origin, was that patients more likely to have been fleeing conflict or travelling overland eg from countries such as Afghanistan, have higher rates of positivity than those from countries such as from India, Bangladesh and Pakistan, who in our local population are often travelling for economic reasons, when we compare IGRA positivity to the WHO incidence in country of origin (which might not be wholly accurate in itself). The difficult question is whether we can justify collecting routine data on reasons for and routes of migration?

The changes in migration patterns in Europe, with huge increases from countries with traditionally low TB incidence like Syria will certainly affect yield from screening, and we still don't have consensus on how to deal with this in Europe. The recent discussions in the ERJ, if anyone wants to hear two sides of the argument from Dutch and Belgium perspectives, about the value of screening this population by Gerard de Vries (http://erj.ersjournals.com/content/early/2016/03/10/13993003.00099-2016) and Wouter Arrazola de Oñate(http://erj.ersjournals.com/content/48/4/1253), show how important robust screening data is to formulate policy. Personally, I find the dutch perspective more compelling given their impressive rates of culture confirmation.

Thank you very much for the info on Kathy Floyd's Group, I am very new to this area and am really keen to find out more, I will look into her work. Completion rates of 80% are brilliant! It sounds we have a lot to learn from what they are doing.

Thanks,

Matt

Paul Douglas Panelist Replied at 6:13 PM, 19 Jan 2017

Cheers Matthew

Yes it is very interesting. I have discussed our results with a number of paediatric TB specialists who have postulated similar theories to yours - that is length of exposure. Although what was interesting in our data were some of the outliers where the highest rate of LTBI was from Russia (27%), followed by Lithuania. While these countries have high rates of MDRTB the incidence of TB in the general population is comparatively low say compared to PNG (where the positivity was 1%)!! A lot more analysis required I think!

It has been interesting read the flow of comments overnight about LTBI screening and treatment programmes. There is an good trial going here in Australia in Victoria where they are having GPs under the guidance of a TB programme provide screening and treatment, which for a country like Australia could work really well and greatly improve treatment completion we hope.

All the best, Paul

Matthew Burman Replied at 3:52 AM, 20 Jan 2017

Paul,

Your data sounds like it is going to raise lots of very interesting questions? Rates of 27% in Russia are hard to explain? I can't wait to see it published. That level of variation does makes you wonder about the virulence of the local strains?

Would you be able forward me the details of the team in Victoria who are working on LTBI management in the community? Our trial is looking at a model of community LTBI screening and treatment that is managed by GPs and Community Pharmacists. I'd be really keen to talk to them in more detail about their programme, and see how we could learn from their experiences.

Matt

This Expert Panel is Archived.

While this Expert Panel is no longer active, we invite you to review and recommend past replies and resources. Membership for this Expert Panel is closed, but we hope you'll join us in one of the many communities on GHDonline.

Panelists of Tuberculosis Among Migrants and GHDonline staff