Laura B Nellums

Extending migrant charging into emergency services

New proposals make the NHS the most restrictive healthcare system in Europe for undocumented migrants

Vaccination status and needs of asylum-seeking children in Denmark: a retrospective data analysis

Objectives Asylum seekers to Europe may come from war-torn countries where health systems have broken down, and there is evidence that asylum-seeking children have low coverage of childhood vaccinations, as well as uptake of immunisations in host countries. Such gaps in immunisation have important implications for effective national vaccination programmes. How we approach vaccination in children and adults entering Western Europe, where as a group they face barriers to health services and screening, is a growing debate; however, there are limited data on the vaccination status of these hard-to-reach communities, and robust evidence is needed to inform immunisation strategies. The aim of this study was to explore the vaccination status and needs of asylum-seeking children and adolescents in Denmark. Study design We conducted a retrospective data analysis of anonymised patient records for asylum-seeking children and adolescents extracted from the Danish Red Cross database. Methods We retrospectively searched the Danish Red Cross database for children and adolescents (aged 3 months–17 years) with active asylum applications in Denmark as of October 28, 2015. Data were extracted for demographic characteristics, vaccination status and vaccinations needed by asylum-seeking children presenting to Red Cross asylum centres for routine statutory health screening. Results We explored the vaccination status and needs of 2126 asylum-seeking children and adolescents. About 64% of the study population were male and 36% were female. Eight nationalities were represented, where 33% of the total of children and adolescents were not immunised in accordance with Danish national guidelines, while 7% were considered partly vaccinated, and 60% were considered adequately vaccinated. Afghan (57% not vaccinated/unknown) and Eritrean (54% not vaccinated/unknown) children were the least likely to be vaccinated of all nationalities represented, as were boys (37% not vaccinated/unknown) compared with girls (27% not vaccinated/unknown) and children and adolescents aged between 12 and 17 years (48% not vaccinated/unknown) compared with 6- to 11-year olds (26%) and 0- to 5-year olds (22%). The health screenings resulted in 1328 vaccinations. The most commonly needed vaccines were diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b, (DTaP/IPV/Hib) which comprised 49% of the vaccines distributed, followed by the pneumococcal vaccine (Prevnar) (28%) and measles, mumps and rubella (MMR) vaccine (23%). Conclusions The finding that nearly one-third of asylum-seeking children and adolescents in Denmark were in need of further vaccinations highlights the gaps in immunisation coverage in these populations. These results point to the need to improve access to health services and promote national vaccine programmes targeted at these communities to facilitate vaccination uptake and increase immunisation coverage to reduce the risk of preventable infectious diseases among asylum-seeking children.

How effective are approaches to migrant screening for infectious diseases in Europe? A systematic review

Rates of migration to Europe, and within Europe, have increased in recent years, with considerable implications for health systems. Migrants in Europe face a disproportionate burden of tuberculosis, HIV, and hepatitis B and C, yet experience a large number of barriers to accessing statutory health care on arrival. A better understanding of how to deliver effective and cost-effective screening, vaccination, and health services to this group is now crucial. We did a systematic review to document and assess the effectiveness and cost-effectiveness of approaches used for infectious diseases screening, and to explore facilitators and barriers experienced by migrants to accessing screening programmes. Following PRISMA guidelines, we searched Embase, PubMed, PsychINFO, the Cochrane Library, and Web of Science (1989 to July 1, 2015, updated on Jan 1, 2018), with no language restrictions, and systematically approached experts across the European Union (EU) for grey literature. Inclusion criteria were primary research studies assessing screening interventions for any infectious disease in the migrant (foreign-born) population residing in EU or European Economic Area (EEA) countries. Primary outcomes were the following effectiveness indicators: uptake of screening, coverage, infections detected, and treatment outcomes. Of 4112 unique records, 47 studies met our inclusion criteria, from ten European countries (Belgium, Denmark, France, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, and the UK) encompassing 248 402 migrants. We found that most European countries screening migrants focus on single diseases only-predominantly active or latent tuberculosis infection-and specifically target asylum seekers and refugees, with 22 studies reporting on other infections (including HIV and hepatitis B and C). An infection was detected in 3·74% (range 0·00-95·16) of migrants. Latent tuberculosis had the highest prevalence across all infections (median 15·02% [0·35-31·81]). Uptake of screening by migrants was high (median 79·50% [18·62-100·00]), particularly in primary health-care settings (uptake 96·77% [76·00-100·00]). However, in 24·62% (0·12-78·99) of migrants screening was not completed and a final diagnosis was not made. Pooled data highlight high treatment completion in migrants (83·79%, range 0·00-100·00), yet data were highly heterogeneous for this outcome, masking important disparities between studies and infections, with only 54·45% (35·71-72·27) of migrants with latent tuberculosis ultimately completing treatment after screening. Coverage of the migrant population in Europe is low (39·29% [14·53-92·50]). Data on cost-effectiveness were scarce, but suggest moderate to high cost-effectiveness of migrant screening programmes depending on migrant group and disease targeted. European countries have adopted a variety of approaches to screening migrants for infections; however, these are limited in scope to single diseases and a narrow subset of migrants, with low coverage. More emphasis must be placed on developing innovative and sustainable strategies to facilitate screening and treatment completion and improve health outcomes, encompassing multiple key infections with consideration given to a wider group of high-risk migrants. Policy makers and researchers involved with global migration need to ensure a longer-term view on improving health outcomes in migrant populations as they integrate into health systems in host countries.

Multidrug-resistant tuberculosis treatment adherence in migrants: a systematic review and meta-analysis

BackgroundMultidrug-resistant tuberculosis (MDR-TB) is a growing concern in meeting global targets for TB control. In high-income low-TB-incidence countries, a disproportionate number of MDR-TB cases occur in migrant (foreign-born) populations, with concerns about low adherence rates in these patients compared to the host non-migrant population. Tackling MDR-TB in this context may, therefore, require unique approaches. We conducted a systematic review and meta-analysis to identify and synthesise data on MDR-TB treatment adherence in migrant patients to inform evidence-based strategies to improve care pathways and health outcomes in this group.MethodsThis systematic review and meta-analysis was conducted in line with PRISMA guidelines (PROSPERO 42017070756). The databases Embase, MEDLINE, Global Health and PubMed were searched to 24 May 2017 for primary research reporting MDR-TB treatment adherence and outcomes in migrant populations, with no restrictions on dates or language. A meta-analysis was conducted using random-effects models.ResultsFrom 413 papers identified in the database search, 15 studies reporting on MDR-TB treatment outcomes for 258 migrants and 174 non-migrants were included in the systematic review and meta-analysis. The estimated rate of adherence to MDR-TB treatment across migrant patients was 71% [95% confidence interval (CI) = 58–84%], with non-adherence reported among 20% (95% CI = 4–37%) of migrant patients. A key finding was that there were no differences in estimated rates of adherence [risk ratio (RR) = 1.05; 95% CI = 0.82–1.34] or non-adherence (RR = 0.97; 95% CI = 0.79–1.36) between migrants and non-migrants.ConclusionsMDR-TB treatment adherence rates among migrants in high-income low-TB-incidence countries are approaching global targets for treatment success (75%), and are comparable to rates in non-migrants. The findings highlight that only just over 70% of migrant and non-migrant patients adhere to MDR-TB treatment. The results point to the importance of increasing adherence in all patient groups, including migrants, with an emphasis on tailoring care based on social risk factors for poor adherence. We believe that MDR-TB treatment targets are not ambitious enough.

Incidence of psychiatric disorders among accompanied and unaccompanied asylum-seeking children in Denmark: a nation-wide register-based cohort study

One in four asylum applicants in Europe are children, and 23% of whom are unaccompanied and may be at increased risk of mental illness. This study contributes to the limited evidence base by comparing the incidence of psychiatric disorders among unaccompanied and accompanied refugee children. We linked a cohort of refugee children who obtained right of residency in Denmark between 01 January 1993 and 31 December 2010 to the Danish Psychiatric Central Register, and calculated incidence rates per 100,000 person years and incidence rate ratios of overall psychiatric disorder, psychotic disorders, affective disorders, and neurotic disorders for accompanied and unaccompanied minors using Poisson regression. We adjusted the analyses for sex, age at residency, and age at arrival (aIRR). Stratified analyses were conducted by nationality. Unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 1.38, 95% CI 1.14–1.68) and neurotic disorders (aIRR: 1.67, 95% CI 1.32–2.13) than accompanied minors. Among children from Afghanistan, unaccompanied minors had significantly higher rates of any psychiatric disorder (aIRR: 2.23, 95% CI 1.26–3.93) and neurotic disorders (aIRR: 3.50, 95% CI 1.72–7.11). Among children from Iraq, unaccompanied minors had higher rates of any psychiatric disorder (aIRR: 2.02, 95% CI 1.18–3.45), affective disorders (aIRR: 6.04, 95% CI 2.17–16.8), and neurotic disorders (aIRR: 3.04, 95% CI 1.62–5.70). Unaccompanied children were found to experience a higher incidence of any psychiatric disorder and neurotic disorders. Strategies are needed to address the specific mental health and social needs of unaccompanied minors.

Time to rethink approaches to migrant health screening

The elimination of tuberculosis in Europe is a key public health priority, yet unprecedented levels of migration, especially from low-income or middle-income countries, pose challenges to achieving this goal. The overall incidence of tuberculosis in migrants is increasing in several countries, and—for example—migrants comprise more than 70% of all newly diagnosed cases in the UK, Sweden, the Netherlands, and Norway. Migrants are at higher risk of clinical tuberculosis as a result of coming from countries with a high burden of infection, the poverty they might face on arrival, and a plethora of barriers to accessing free statutory health care and screening. Yet what constitutes a cost-eff ective approach to migrant screening and understanding what to screen for, and who, where, and when to screen, remain contentious. In The Lancet, Robert W Aldridge and colleagues report the fi ndings of a large retrospective cohort study of more than half a million migrants requesting a longterm entry visa to the UK (2005–12) who were screened for active tuberculosis in 15 high-incidence countries of origin before migration. Pre-entry screening data for this cohort are published elsewhere. In the present study, the researchers explored what happens to migrants, free from active disease at the time of migration, after their arrival to the UK (mean followup 2·45 years per person). This research is timely, amid growing consensus that identifi cation and treatment of latent tuberculosis before the disease becomes active could support elimination eff orts, representing a shift from the historical Europe-wide approach of screening for active disease on, or soon after, arrival. Aldridge and colleagues report that migrants screened before entry pose a negligible public health risk in terms of onward transmission (only 35 assumed index cases with an estimated crude rate of fi ve per 100 000 person-years [95% CI 4–8]) but are at risk of developing active tuberculosis after arrival to the UK, with 79·6% of cases notifi ed after migration. The incidence of all forms of tuberculosis was lowest in the fi rst year after arrival, and then peaked in the fourth year (222 per 100 000 person-years [95% CI 198–249]) before declining, with many cases resulting from reactivation of latent infection (301 cases with crude estimated incidence of 46 per 100 000 person-years [95% CI 42–52]). The data show, not unexpectedly, that some groups of migrants were over-represented among reactivation cases, including migrants from high-incidence countries (ie, countries with >350 cases per 100 000 people) and those with a chest radiograph compatible with tuberculosis but not bacteriologically confi rmed when pre-screened in their countries of origin. Why the authors did not address the extent to which key risk factors such as socioeconomic deprivation in the host country and comorbidities (eg, HIV, diabetes mellitus) drive tuberculosis reactivation is unclear. Although these data are limited to a particular subset of migrants requesting a long-term entry visa to the UK, they have potential implications for screening policies for the wider population of migrants across Europe, and suggest that screening and treatment for latent tuberculosis in migrants from high-incidence countries before departure, and within 5 years of arrival in the host country, could strengthen control eff orts. This approach is likely to be cost-eff ective. Aldridge and colleagues’ data support the notion that to eliminate tuberculosis in low-burden settings multiple initiatives will be needed. The UK is one of a few European countries now screening individuals before they migrate, and is pioneering a national strategy for latent tuberculosis testing in newly arrived migrants. We strongly support innovations in migrant screening and health-care delivery. However, policy makers need to be aware that thousands of migrants in the UK Published Online October 11, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31703-2

National approaches to the vaccination of recently arrived migrants in Europe: A comparative policy analysis across 32 European countries

Background Migrants may be underimmunised and at higher risk of vaccine-preventable diseases, yet there has been no comprehensive examination of what policies are currently implemented across Europe targeting child and adult migrants. We analysed vaccination policies for migrants in 32 EU/EEA countries and Switzerland. Methods Using framework analysis, we did a comparative analysis of national policies and guidelines pertaining to vaccination in recently arrived migrants through a systematic guideline and literature review and by approaching national experts. Results Six (18.8%) of 32 countries had comprehensive policies specific to the vaccination of migrants (two focused only on child migrants, four on both adults and children). Nineteen (59.4%) countries applied their national vaccination schedule for migrant vaccinations, predominantly focusing on children; and five (15.6%) countries had circulated additional migrant-specific resources to relevant health-care providers. In six (18.8%) countries, policies on migrant vaccination focused on outbreak-specific vaccines only. In ten (31.3%) countries, policies focused on priority vaccinations, with polio being the vaccine most commonly administered and heterogeneity noted in vaccines recommended to adults, adolescents, and children. Eighteen (56.3%) countries recommended that an individual should be considered as unvaccinated where vaccination records were missing, and vaccines re-administered. Nine (28.1%) countries reported that specific vaccinations were mandatory. Conclusion There is considerable variation in policies across Europe regarding approaches to vaccination in adult and child migrants, and a lack of clarity on optimum ways forward, what vaccines to offer, with a need for robust research in this area. More emphasis must be placed on ensuring migrant-specific guidance is disseminated to front-line healthcare professionals to improve vaccine delivery and uptake in diverse migration populations across the region.