Communicable Disease - current knowledge, impact and issues for new migrant communities Dr. Mamoona Tahir, Consultant in Communicable Diseases Public Health England

Overview Who are the migrants? Are migrants more likely to experience ill health? Why are the migrants at increased risk? More likely to experience poor outcomes? What can be done to improve migrants health

Who are migrants? A person who moves from one place to another in order to find work or better living conditions (Oxford dictionary definition) Foreign born, foreign national or people who have moved to the UK for more than one year (International Migration Organisation & Oxford Migration Observatory)

Countries of last residence of UK migrants Source: Long-Term International Migration (LTIM), Office for National Statistics

Reasons for migrating to the UK: Source: Long-Term International Migration (LTIM), Office for National Statistics

Migration pattern closely linked to disease epidemiology

UK born population Non-UK born population Burden of infectious disease Most non-UK born people do not have infectious diseases …... but much of the burden of infectious diseases falls on the non-UK born population

The majority of cases of… TB (73% of cases reported in the UK in 2010) HIV (almost 60% of newly diagnosed cases reported in the UK in 2010) Malaria (77% of cases reported in the UK between 2005 and 2010) …do occur in people who were born abroad Enteric fever (63% of cases reported in England, Wales and Northern Ireland between 2007 and 2010)

Why are migrants at increased risk? Higher disease burden Poor living conditions Experiences during migration Socioeconomic conditions in the UK Factors relating to ethnicity and cultural practices Awareness and health seeking behaviour Frequent travel to country of birth

Missed opportunities for health intervention in at risk migrant groups? TB; no co-ordinated UK system currently for detection of infection/cases HIV; unrecognised infection and late diagnoses Hep B and C; unrecognised infection and late diagnoses Chagas; unrecognised Parasitic worms; unrecognised Enteric fever; VFR travellers to ISC; no immunisation Malaria; VFR travellers to west Africa; no chemoprophylaxis Non-infectious health conditions; diabetes, IHD, genetic disorders, maternity care, FGM, nutritional, chemical exposures, mental health, etc.

11 Tuberculosis in the UK: 2013 report Figure : Tuberculosis case reports and rates by region*, England, 2012 * HPA region CI – 95% confidence intervals Source: Enhanced Tuberculosis Surveillance (ETS), Office for National Statistics (ONS) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England

Fig: Tuberculosis case reports by place of birth and country, UK, 2012 Source: Enhanced Tuberculosis Surveillance (ETS), Enhanced Surveillance of Mycobacterial Infections (ESMI) Data as at July 2013 Prepared by: TB Section, Centre for Infectious Disease Surveillance and Control, Public Health England 12 Tuberculosis in the UK: 2013 report

TB in West Midlands A total of 1,085 TB cases were reported in the West Midlands in 2012, a rate of 19.2 (95% CIs: ) per 100,000 population Highest rates in urban areas – similar to low incidence countries such as Western Europe 75% of West Midlands cases from 5 LA areas. Rates consistently high and increasing trends Nearly two thirds of TB cases (64.6%) reported in the West Midlands in 2012 were in people born outside the UK. Two thirds of these were born in South Asia and a fifth born in sub-Saharan Africa. Concentration in big cities/urban areas — two themes: – non-UK born/immigrants (high incidence countries) -Socially at risk – homeless, drug/alcohol misuse, prison history 13

Country of origin of TB cases

16 Data sources: Enhanced Tuberculosis Surveillance (ETS) downloaded on 10 th March Prepared by: Field Epidemiology Service (Birmingham), Public Health England Tuberculosis rates by Upper Tier Local Authority, West Midlands, 2013* *Rates were calculated using 2012 mid-year population estimates from ONS

Treatment outcome

In ,658 individuals were diagnosed with HIV in UK 65% of people diagnosed between 2001 and 2010 in whom the country of birth was recorded, were born abroad Among these 80% of infection were acquired heterosexually Africa was reported as the region of birth for the majority (87%) of heterosexual non-UK born new diagnoses. Forty-eight per cent of African born- heterosexuals reported South Eastern Africa as their region of birth Human Immune deficiency Virus

HIV

These sentinel surveillance data exclude dried blood spot, oral fluid, reference testing, and testing from hospitals referring all samples. Data are de-duplicated subject to availability of date of birth, soundex and first initial. All data are provisional. A combination of self-reported ethnicity, and OnoMap and NamPehchan name analyses software were used to classify individuals according to broad ethnic group. Source: Public Health England, LabBase cleaned dataset. Hepatitis B

In 2012, there were 13 laboratory reports of hepatitis C per 100,000 population for residents of the West Midlands, compared to 20 for residents of England. Since 2010 the gap between rates in the West Midlands and rates in England has been widening. 21 Epidemiology of hepatitis B and C in Birmingham and Solihull Source: Public Health England, Labbase Data are summarised by region of residence, not region of laboratory. Data are assigned to region by patient postcode where present; if patient postcode is unknown, data are assigned to region of registered GP practice; where both patient postcode and registered GP practice are unknown data are assigned to region of laboratory. Includes individuals with a positive test for hepatitis C antibody (a marker of past infection) and/or detection of hepatitis C RNA (a marker of persistent infection). Due to the variability in the quality of laboratory reports, we are unable to estimate the actual proportion of cases with evidence of past infection or persistent infection. Hepatitis C

At the West Midlands sentinel laboratory, Asians had the highest positivity rate. Lower positivity rates for those of black and other/mixed ethnicity are based on a relatively small number of tests. Data is for all tests processed by the West Midlands sentinel laboratory, irrespective of residence. 22 Epidemiology of hepatitis B and C in Birmingham and Solihull Source: Public Health England, Sentinel Surveillance of hepatitis. * Excludes dried blood spot, oral fluid, reference testing, and testing from hospitals referring all samples. Data are de-duplicated subject to availability of date of birth, soundex and first initial. Excludes individuals aged less than one year, in whom positive tests may reflect the presence of passively-acquired maternal antibody rather than true infection. All data are provisional. § A combination of self-reported ethnicity, and OnoMap and NamPehchan name analyses software were used to classify individuals according to broad ethnic group. Hepatitis C

Reporting of patient residence information is incomplete; From 2008 to 2012, around half of laboratory reports included the patient’s postcode; therefore rates shown on the map are likely to be underestimates. Where patient residence information was reported, the wards with the highest rates per 100,000 population were Bordesley Green, Washwood Heath and Sparkbrook. 24 Epidemiology of hepatitis B and C in Birmingham and Solihull

Recommendations Migrants and VFR /Travellers awareness of the risk of catching the disease, mode of acquisition and how they can protect themselves. Increased awareness among general public Primary care practitioners play a vital role in early identification of infectious diseases Early identification of risk and diagnosis of infection can improve health outcome

Recommendations Practitioners are encouraged to consider their patients’ country of birth when evaluating their risk exposures and to guide their differential diagnosis of presenting symptoms Many UK practitioners may be unfamiliar with the clinical presentation of some infectious diseases that are rarely diagnosed in the UK need for non-UK born communities to have access to culturally competent and language supported services importance of considering health needs relevant to an individual’s country of birth

Summary Migrants experience a high burden of infectious diseases in West Midlands Reflective of incidence in the country of origin. The late diagnosis of HIV suggests the needs of the migrant are not being met GPs could play a role in screening migrant for HIV, Hepatitis and TB for migrants from high incidence countries Practitioners awareness of needs of the migrants is important