Abstract
A coordinated effort is needed in Europe to ensure adequate diagnosis and treatment of tuberculosis among refugees http://ow.ly/YEfXp
To the Editor:
We read with interest the study by de Vries et al. [1] reporting on the results of tuberculosis screening among recently arrived migrants and refugees in the Netherlands.
This study brings several issues for debate in a moment where migration to Europe generates concerns and potential risks for stigmatisation and discrimination. In 2015, >1 million migrants and refugees reached Europe by different routes, more than four times more people than in 2014 (when there were only 219 000) [2, 3].
Migrants and refugees are among the most vulnerable groups for tuberculosis infection and disease, due to multiple reasons including their precarious living and travelling conditions. In addition, they are often coming from countries with higher tuberculosis incidence than the host countries [4–6]. In addition to being a human right, adequate management of tuberculosis and latent tuberculosis infection (LTBI) in migrants and refugees is important to optimise tuberculosis control and elimination strategies in Europe, as tuberculosis does not respect borders [4–6]. It is important to underline that the increasing number of arrivals makes it more and more difficult to implement adequate tuberculosis screening and treatment strategies in centres hosting migrants/refugees or countries through which they are transiting.
A challenge in developing and adapting evidence-based screening policies is a lack of information on the exact number of migrants/refugees to be screened. Health authorities in the Netherlands decided, rationally, to evaluate the yield of screening for refugees coming from countries with an incidence <50 per 100 000 inhabitants to evaluate whether previous decisions had to be confirmed or modified. In the Dutch setting, the yield of screening proved to be rather low among Syrian refugees and other asylum seekers: the tuberculosis prevalence of screening in this population was 26 per 100 000 population, meaning that 3787 individuals need to be screened to identify one tuberculosis case. 12 cases of pulmonary tuberculosis were diagnosed (seven from Syria), four being sputum smear positive and the others culture positive.
In our opinion, two interesting pieces of information need to be discussed. 1) Four individuals with an originally negative chest radiography developed tuberculosis in the following 6 months. The information on their LTBI status was not reported [1]. If tuberculosis elimination has to be reached, we probably need to become more “aggressive” in our prevention approach, focusing on LTBI diagnosis and treatment [5–7]. Although some refugees originate from relatively low tuberculosis incidence countries, they may have been infected during their joint travel and accommodation with refugees coming from high tuberculosis incidence countries. LTBI may turn into disease after arriving in the host countries. 2) The importance of ensuring universal access to tuberculosis services is confirmed by the self-reporting of a tuberculosis case after screening discontinuation [1].
The findings of this study show how important is, at the national level, to base decisions on evidence, to ensure proper surveillance, and to monitor/evaluate quality data on migrants and refugees. There is a need for improved surveillance and cross-border data exchange for those refugees moving from one country to another.
However, the findings of this study cannot be automatically extended to other settings, as the profile of refugees reaching northern Europe may differ from that observed in other European countries.
The recently approved tuberculosis elimination framework [5], which includes eight areas for action, calls for more efforts by national programmes to target LTBI as well as tuberculosis disease, within the framework of an integrated European effort to coordinate policies and share best practices.
More evidence is needed on the screening policies in Europe, as little is known and from only a few countries [8–10].
Most of the evidence (table 1) results from a systematic review of the screening policies performed in the European Union [9]. Overall, the coverage of screening practices was higher in asylum seekers (94%) than in other migrants (47.8%), with a median yield of 0.30% and 0.176%, respectively. In Switzerland [10], the yield of screening based on routine chest radiography (14.3 per 10 000) was only slightly higher than that achieved with individual assessment (12.4 per 10 000), based on an integrated scoring system capturing different criteria including the tuberculosis prevalence in the country of origin, personal and family tuberculosis history, and symptoms/general conditions as assessed by the interviewing nurse.
The few studies available [8–10] show that different screening policies and practices are implemented in Europe, chest radiography being common in all countries within differently organised algorithms that include symptom evaluation, bacteriology and, in some countries, LTBI diagnosis via the tuberculin skin test and/or interferon-γ release assays.
While 22 (71%) countries recently reported screening for LTBI in high-risk groups (which include asylum seekers and migrants), only six countries (Greece, the Netherlands, Portugal, the Former Yugoslav Republic of Macedonia, Slovakia and Switzerland) were able to report LTBI treatment completion rates, which ranged between 40% and 88% [9].
Improved surveillance and further studies are needed to ensure that quality diagnosis and treatment for tuberculosis and LTBI (when feasible) are provided to all migrants and refugees in Europe.
Footnotes
C. Gratziou is the ERS Advocacy Council Chair and Secretary for EU Affairs 2015–2018.
Conflict of interest: B. Ward and V. Teixeira are employees of the European Respiratory Society.
- Received February 13, 2016.
- Accepted February 15, 2016.
- Copyright ©ERS 2016