1. Latent Tuberculosis among Displaced Populations Rapid Diagnosis and Control Nikolaou Aristidis MD, MSc

2. MIGRATION V S TB

3. Immigrants : ↑ ↑ risks of transmission infectious diseases (TB) i) overcrowded camps ii) poor living conditions iii) poor access to healthcare provision ≠ At entry: 40 times more at risk active TB ≠ local general population (Figuera-Munoz, 2008) (Rieder, 1994) (Arshad, 2010)

4. TB incidence ↓ ≠ Burden ↓ in industrialized countries ≠ high in developing → Immigrants carry LTBI → at increased risk of reactivation cases (among overall TB cases) EU: up to 82% foreign-born cases (among overall TB cases) → In low-incidence countries → % increasing since 1990s ↑ even ↑ risk among foreign-born even 20 yrs after migration (Klinkenberg, 2009) (Dasgupta, 2000)

5. Factors influencing TB incidence country of origin age sociodemographic factors exposure and travel to country of origin access to care drug resistance immune incompetence (Klinkenberg, 2009)

6. Reactivation of prior TB infections Recent TB infection or reinfection due to travel to the home country Recent infection or reinfection within the new country ( Klinkenberg, 2009 )

7. Special Health Needs/Obstacles Language Stigmatization Poor cultural awareness Psychological distress Disruption of families and social networks Economic difficulties Difficult to trust doctors (Figuera-Munoz, 2008)

8. LATENT TB INFECTION

9. LTBI → Exposure to Mycobacterium tuberculosis → Latent TB Infection Usually, Usually, healthy life without developing active TB disease ≠ 2 billion people LTBI ≠ <10 million a year active TB disease 5 - 10% infected persons develop active TB disease 50%, within the first two years (CDC, 2010)

10. LTBI Usually, → Usually, Skin Test (Mantoux) or Blood Test (Quantiferon) → TB infection Normal chest x-ray and Negative sputum test TB bacteria in body (alive but inactive) Not feel sick – No symptoms Cannot spread TB bacteria (CDC, 2010)

11. SCREENING

12. Medical Screening → Objective → early preventive or curative intervention → Disease → relatively common and treatable → Test → i) inexpensive ii) easy to administer iii) cause no discomfort to the patient iv) high sensitivity and specificity (Dasgupta, 2005) (Rieder, 1994)

13. TB screening Targeted groups: i) persons with a high risk of being infected by tuberculosis (curative treatment) ii) persons at high risk of developing tuberculosis (preventive intervention) Screening tools : i) chest radiography relatively high sensitivity ii) tuberculin skin-testing limited specificity = + Tuberculin skin test = identification of these groups + indicator of need of radiographic examination (Rieder, 1994)

14. Screening strategies Pre-entry/ pre-migration screening Port of arrival screening Reception/ holding/ transit centre screening Community post-arrival screening Occasional screening Follow-up screening (Klinkenberg, 2009)

15. → Active screening among foreigners → before dispersed in the country (before or after arrival) → (specifically designed centers) Screening for tuberculosis (before or after arrival) → prevent unnecessary transmission (specifically designed centers) (country of origin) + Targeted screening of immigrants (country of origin) + surveillance for recently arrived populations (Figuera-Munoz, 2008)

16. TB screening among EU TB screening in 22/24 (96%) countries Compulsory basis in 12/22 (55%) countries Only 4 systematically collecting data The Nordic: The Nordic: to all new asylum seekers The Netherlands: The Netherlands: on arrival (again 6, 12, 18, and 24 months) Austria, France, Spain, and Britain: Austria, France, Spain, and Britain: induction or reception centers Italy and Germany: Italy and Germany: Regional variations in the provision Greece: Greece: immigrants who applied for a work permit (Norredam, 2005)

17. Suggestions Systematic recording and reporting of screening performance Preventive strategy : i) improving housing conditions (decrease the risk of tuberculosis transmission) ii) enhancing tuberculosis case finding iii) setting case management within Directly Observed Treatment program Good follow-up system (Klinkenberg, 2009) (Arshad, 2010)

18. Ideal long-term TB control strategy → Global investment TB control in high-incidence countries → → Global reduction in tuberculosis incidence → ↓ ↓ TB risk (migrants from high incidence to low incidence regions) More Humanitarian / More Cost-effective (Dasgupta, 2005)

19. NOT or Equal Rights for health NOT entrance rejection or expelling and repatriating + Active screening + access to healthcare facilities: i) shorten the infectious periods ii) interfere with the transmission network iii) reduce risk of developing active TB iv) improve the control of potential tuberculosis reservoirs (Arshad, 2010) (Rieder, 1994)

20. Thank you