1. Dr. Raz Mohammed WALI Chief Migration Health Physician NTP National Seminar: 14-15 July 2014 Pukhra, Nepal

2. About IOM Migration for the benefit of all Healthy migration in healthy community International Organization for Migration (IOM) was established in 1951. The principal intergovernmental organization in the field of migration. IOM is committed to the principle that humane and orderly migration benefit migrants and societies. Working in more than 151 countries globally, more than 480 main and sub- offices, 9 regional hubs, 156 member states including Nepal, 10 states and organizations observers – over a billion USD budget annually. Established in Nepal in 2006. Implementing several large and small projects in the country with the help of more than 383 national and international staff

3. MHD Associates Programs (Nepal) 3 1. USRAP Health Assessment Program (HAP) FY2013 - 39,000 and FY 2014- 25,200 exams (IME, PDMS, PEC, 2 nd dose vaccination and Medical case management) 5. Immigrants (Nepalis) 10,600 exams CY2013 and 5200, CY2014 TB Rx (Aus) 6. TB Reach >20,000 Tests >4,000 TB including >250 RIF Resistant MOHP 4. Harmonization of TB diagnostic &Treatment protocol for Non-resettlement refugee: 100s of TB cases treated so far (passive vs active case finding?) 2. Non-USRP Refugees HAP (AUS,CAN,UK,NZ,NL,NOR) 4,557 in CY2013, 3. Public Health Support activities Infectious disease surveillance, operational researches 7- Labor Migration health study: Three countries project (Nepal, Bangladesh and Pakistan)

4. Health Assessment Program Initial med exam (IME) Counseling Physical examination CXR Laboratory investigation Vaccination –2 nd dose vaccination (2013) –Hep B screening (2014) On hold with regular follow up TB suspects TB Treatment Drug abuse Alcohol dependent Psychiatric evaluation Chronic disease Re-med : Undergone the same IME procedure (except vaccination) Medical Escort & Trv. Assistance POE Final destination

5. Prior departure Prior Departure Medical Screening (PDMS) (Pre-departure medical screening) 3 weeks before departure at Damak -Physical assessment -Chest X-ray (Class B1TB) -Sputum smears only (Class B1 TB) Pre-Embarkation Check (PEC) 24 hours prior departure Damak –Physical assessment -Pregnancy Test -Albendazole Deworming -Medication supplies for 4-8 weeks coverage 5

6. Facilities  Group counseling and health education  Clinic (clinical Evaluation)  Radiology  Laboratory, TB and Serology including media preparations  Vaccine and reagents storage facilities  DOT and TB isolation centers  Pool of medical escorts and escort bags  Pharmacy for necessary medicines including 1 st and 2 nd line TB drugs

7. TB Laboratory Processing >120 sputum specimens/day Conc. smear read by Fluorescent Microscope MGIT960 Liquid & LJ Solid Culture Molecular Line Probe Assay (LPA) GeneXpert MTB/Rif First Line DST (S,H,R,E,Z) Second Line DST (AMK,KM,OLF,LEV,PAS,ETO,PAS,CS) 7

8. Radiology DR ( Digital Radiography) Capacity: 56,000 exposures per year, detector lasting for 7 years CR (Computerize Radiography) Same capacity as to DR but –Require cassette to process the image ( 2 years lasting) –Take longer time/laborious to process an image –Heavy weight machine (400 kg) 8

9. TB Isolation Center 14 huts to isolate 8 months MDR case 2 months, non-MDR highly infectious (smear positive) 9

10. Active TB case finding Protocol of USRP CDC migration Requirements: Technical Instructions for tuberculosis screening and treatment using cultures and DOT, (Oct 2009) Applicant 2-14 years of age Tuberculin Skin Test or IGRA TST ≥ 10 mm or IGRA positive Chest Radiograph Medical History, examination, or CXR suggestive for tuberculosis Individual known HIV infection Medical History Physical Examination Applicant ≥ 15 years of age 3 sputum smear & Culture DST for all positive culture Identification in the level of MTB-Complex

11. Overall Active Case Finding (Data of USRP resettlement program)

12. Passive case finding Harmonization of TB diagnostic and treatment Protocol Project Chest Radiograph Medical History, examination, or CXR suggestive for tuberculosis Individual known HIV infection Medical History Physical Examination 3 sputum smear & Culture DST for positive culture IOM Health Care provider for refugee in the camp AMDA

13. Overall Passive case finding (Data of refugees non-resettlement program) Particular2008 a 2009 b 2010 b 2011 b 2012 b 2013 c Total Clinically suspect 13782911796607422 3,531 CXR Suggestive TB n/a 181 Active TB case (among suspects) 131324216815110741-60 741 100%31%18%18%19%19%18%18%14-23%21% 2008 (a): Culture performed from Smear positive only 2009-2012 (b): Culture performed from clinically suspects 2013: Culture perform from clinically suspect& CXR suggested TB

14. Overall Active Case Findings Rate (CXR) 14

15. Overall Passive Case Findings Rate (Clinic) 15

16. Smear& Culture Health Assessment Program Refugee Resettlement 2008-2013 Refugee Non-Resettlement 2009-2013 Nepalese migrants MHAC 2011-2013 Protocol Screening prior departure (Active case Finding) Seeking medical care when symptom present (Passive case Finding) Screening prior VISA issuing (Active case Finding) Smear positive-1.3-1.5 %8-9%1.0-1.5% Culture positive-4.0-6.0%11-13%5.0-5.5% Smear +ve/CS +Vs-35%73%30% Smear -ve/CS +ve-65%27%70% % Among TB suspects referred for Smear &Culture Concentrated Smear read by Fluorescent microscopy Culture by Liquid MGIT960 system& duplicate LJ solid

17. Drug Susceptibility Testing pattern RefugeesNepalese Migrants Pan-Susceptible 89.5%89.9% MDR 1.7%2.5% XDR -- Inconclusive 1.4%- Mono-ResistantRefugeesNepalese Migrants Streptomycin (S) 0.6% Isoniazid (I) 3.9%3.8% Rifampicin(R) 0.2%- Ethambutol (E) 0.8%1.3% Pyrazinamide (Z) -- Poly-ResistantRefugeesNepalese Migrants S,I 1.4%1.9% I,Z 0.3%- S,I,Z 0.1%- I,E,Z 0.1%- % Among TB suspects Overall INH resistance rate in the country is estimated to be around 7.5%

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