1. The Impact of Migration on TB Epidemiology in Europe
Dr Dominik Zenner
National TB Section, PHE Colindale
Respiratory Diseases Department

2. Outline I have no conflicts of interest to declare
Global migration patterns
The epidemiology of TB
Global picture
TB in persons of foreign origin in Europe
Intervention opportunities to control TB among migrants
Screening opportunities – an example from the UK
Conclusions
I have no conflicts of interest to declare

3. Global Migration Globally 244m international migrants (UNDP)
Most common destinations Europe and Asia (151m)

4. Migration
Most migration is south-south, mostly labour and students, some refugees
International migrants are highly heterogeneous, most are very healthy
Risk of ID depends on sender country incidence, type of migrant, route of migration, access to care and other host country factors…

5. TB is truly global
Worldwide, in estimated 10.4m new cases, about 0.5m new MDR
60% of new cases in 6 countries: India, Indonesia, China, Nigeria, Pakistan and South Africa – at least four of these were part of the British Empire…
1.4m TB deaths and 1.2m TBHIV co-infected in 2015

6. TB cases in persons of foreign origin, EU/EEA, 2015
Proportion of cases
< 1%
1 to 9.9%
10 to 49.9%
50 to 74.9%
≥ 75%
Not reporting
29.8% of TB cases in persons of foreign origin (range 0.2–89.5%)
Source: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2017
Source: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2017

7. Percentage of TB notifications in foreign born for selected OECD high-income countries
Pareek M, Greenaway C, Noori T, Munoz J, Zenner D.
The impact of migration on tuberculosis epidemiology and control in high-income countries: a review. BMC Medicine. 2016;14:48.

8. TB cases in persons of foreign origin, EU/EEA, 2006–2015
Percentage of cases in persons of foreign origin increased from 17.6% in 2006 to 29.8% in 2015
Rate per total population stable between 3.1 and 3.5
Source: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2017
Source: European Centre for Disease Prevention and Control/WHO Regional Office for Europe. TB surveillance and monitoring in Europe, 2017

9. Intervention opportunities
Early detection and treatment
Overarching opportunities
Social protection
Awareness
BCG
Pareek M, Greenaway C, Noori T, Munoz J, Zenner D.
The impact of migration on tuberculosis epidemiology and control in high-income countries: a review. BMC Medicine. 2016;14:48.

10. Migrant access to health care
“I have already indicated the dangers arising from the spread of the bacilli-containing excretions of consumptives, and have urged moreover that prophylactic measures should be taken against the contagious disease”
Robert Koch, 1901
Rapid diagnosis, early treatment and contact tracing are key to TB control
Early detection and treatment of TB in migrants is in PH interest of receiving states
“Strategy and action plan for refugee and migrant health” (WHO EURO, September 2016.
Contains nine strategic areas to improve the health system response along with information and surveillance for refugees and migrants in Europe.
Aim of the plan to “to protect and improve the health of refugee and migrant populations, within a framework of humanity and solidarity and without prejudice to the effectiveness of health care provided to the host population”

11. Enlightened self interest
“An enlightened self-interest, which, when well understood, they tell us will identify with an interest more enlarged and public.”
Edmund Burke

12. Screening. A UK example

13. Tuberculosis in England: 2016 report
TB case notifications and rates by place of birth and ethnic group, England, 2015
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS), Labour Force Survey (LFS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England
Please note: rates by ethnic group are displayed as labels.

14. 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
Slide acknowledgement: TMHS, PHE Colindale

15. Tuberculosis in England: 2016 report
Time between entry to the UK and TB notification for non-UK born cases, England,
Tuberculosis in England: 2016 report
Source: Enhanced Tuberculosis Surveillance system (ETS)
Data extracted: April 2016
Prepared by: TB Section, National Infection Service, Public Health England

16. The TB strategy for England
…with the aim of achieving a year-on- year decrease in incidence, a reduction in health inequalities and, ultimately, the elimination of TB as a public health problem in England
Improving access and early diagnosis
High quality diagnostics
High quality treatment and care services
Contact tracing
Vaccination
Tackling drug resistance 
Tackling TB in underserved populations
New entrant screening for LTBI
Effective Surveillance and Monitoring
Workforce strategy

17. A national LTBI testing programme in England
Primary care based testing
Secondary care based treatment
National protocols and pathways
Fully-funded
Monitoring and evaluation
Eligibility criteria
Born or spent >6 m in high TB incidence country (≥150/100,000 or SSA)
Entered the UK within the last 5 years (including entry via other countries)
Aged between years.
No history of TB or LTBI
Not previously screened for LTBI in UK

18. Screening for active TB
UK Pre-entry screening scheme for active pulmonary TB in 101 countries
For all migrants on visas >6m and from countries with TB rate >40/100,000

19. Number of pulmonary TB cases diagnosed by pre-entry screening and identified within one year of UK entry from high TB incidence countries, 2006 to 2015

20. Key messages
In many low incidence countries including Europe, a large proportion of TB cases occurs amongst migrants from high incidence countries
The risk varies significantly by type of migrant, country of origin, socioeconomic factors, route of travel and access to care
TB control strategies in Europe are naturally focussed on high risk groups, including migrants from high incidence countries
A significant proportion of TB cases among migrants in Europe are thought to be due to reactivation
Various screening strategies – active/ latent, on-entry/pre-entry/post-entry exist
Early detection, appropriate treatment and good contact tracing are the mainstay of TB control in Migrants and good access to care is fundamental