Dataset Information

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015.

ABSTRACT:

Background

Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of screening yield.

Methods

We combined individual data of 119,037 asylum seekers screened for TB in Germany (2002-2015) with TB estimates of the World Health Organization (WHO) (1990-2014) for their 81 countries of origin. Adjusted rate ratios (aRR) and 95% credible intervals (CrI) of the observed yield of screening were calculated in Bayesian Poisson regression models by categories of WHO-estimated TB incidence. We assessed changes in sensitivity depending on screening thresholds, used WHO TB estimates as prior information to predict TB in asylum seekers, and modelled country-specific probabilities of numbers needed to screen (NNS) conditional on different screening thresholds.

Results

The overall yield was 82 per 100,000 and the annual yield ranged from 44.1 to 279.7 per 100,000. Country-specific yields ranged from 10 (95%- CrI: 1-47) to 683 (95%-CrI: 306-1336) per 100,000 in Iraqi and Somali asylum seekers, respectively. The observed yield was higher in asylum seekers from countries with a WHO-estimated TB incidence >?50 relative to those from countries ?50 per 100,000 (aRR: 4.17, 95%-CrI: 2.86-6.59). Introducing a threshold in the range of a WHO-estimated TB incidence of 50 and 100 per 100,000 resulted in the lowest "loss" in sensitivity. WHO's TB prevalence estimates improved prediction accuracy for eight of the 11 countries, and allowed modelling country-specific probabilities of NNS.

Conclusions

WHO's TB data can inform the estimation of screening yield and thus be used to improve screening efficiency in asylum seekers. This may help to develop more targeted screening strategies by reducing uncertainty in estimates of expected country-specific yield, and identify thresholds with lowest loss in sensitivity. Further modelling studies are needed which combine clinical, diagnostic and country-specific parameters.

SUBMITTER: Bozorgmehr K

PROVIDER: S-EPMC6448304 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

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Publications

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015.

Bozorgmehr Kayvan K Preussler Stella S Wagner Ulrich U Joggerst Brigitte B Szecsenyi Joachim J Razum Oliver O Stock Christian C

BMC infectious diseases 20190403 1

<h4>Background</h4>Screening programmes for tuberculosis (TB) among immigrants rarely consider the heterogeneity of risk related to migrants' country of origin. We assess the performance of a large screening programme in asylum seekers by analysing (i) the difference in yield and numbers needed to screen (NNS) by country and WHO-reported TB burden, (ii) the possible impact of screening thresholds on sensitivity, and (iii) the value of WHO-estimated TB burden to improve the prediction accuracy of ...[more]

PMID: 30943917

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Project description:Screening asylum-seekers for active pulmonary tuberculosis is common practice among many European countries with low incidence of tuberculosis. The reported yields vary substantially, partly due to the heterogeneous and dynamic nature of asylum-seeking populations. Rather than screening all new arrivals (indiscriminate screening), a few countries apply targeted screening based on incidence of tuberculosis in asylum-seekers' country of origin. However, evaluations of its cost-effectiveness have been scarce. The aim of this modelling study was to assess whether the introduction of a screening threshold based on the tuberculosis incidence in the country of origin is sensible from an economic perspective. To this end, we compare the current, indiscriminate screening policy for pulmonary tuberculosis in Germany with a hypothetical targeted screening programme using several potential screening thresholds based on WHO-reported incidence of tuberculosis in countries of origin. Screening data is taken from a large German federal state over 14 years (2002-2015). Incremental cost-effectiveness is measured as cost per case found and cost per case prevented. Our analysis shows that incremental cost-effectiveness ratios (ICERs) of screening asylum-seekers from countries with an incidence of 50 to 250/100,000 range between 15,000€ and 17,000€ per additional case found when compared to lower thresholds. The ICER for screening asylum-seekers from countries with an incidence <50/100,000 is 112,000€ per additional case found. Costs per case prevented show a similar increase in costs. The high cost per case found and per case prevented at the <50/100,000 threshold scenario suggests this threshold to be a sensible cut-off for targeted screening. Acknowledging that no screening measure can find all cases of tuberculosis, and that reactivation of latent infections makes up a large proportion of foreign-born cases, targeting asylum-seekers from countries with an incidence above 50/100,000 is likely to be a more reasonable screening measure for the prevention and control of tuberculosis than indiscriminate screening measures.

Project description:BackgroundThe provision of high-quality medical care to asylum seekers represents a key challenge in many countries of the European Union. Especially continuity of care has been difficult to achieve as the migrant trajectory moves asylum seekers across and within European countries. Patient-held personal health records (PHR) have been proposed to facilitate the transfer of medical history between health sectors and providers, but so far there is no data to support its use in the migrant setting. The present paper addresses this knowledge gap by exploring the experiences and practices of healthcare providers in reception centers for asylum seekers using a patient-held PHR as well as the perceived associated benefits and shortcomings.MethodsEarly evaluation by means of a multi-sited qualitative study in six asylum seeker reception centers in five cities in the German state of Baden-Wuerttemberg, conducted between November 2016 and January 2017. The PHR evaluated in this study was implemented in five of these reception centers between February and October 2016; the remaining one only receiving patients with the PHR through transfer from the other facilities. 17 interviews were conducted with physicians and nurses working at these reception centers exploring their experiences, routines, and perspectives regarding the patient-held PHR. The interviews were recorded, transcribed and analyzed following the approach of thematic analysis.ResultsHealthcare providers recognise the potential of a patient-held PHR to improve access to medical history. They use the PHR to document their medical consultations and to collect other medical reports. However, physician adherence to the patient-held PHR was described as unsatisfactory, in particular among external doctors, thus limiting its immediate benefit. Reasons given for this low adherence included lack of information before implementation, demanding working conditions with little support, low perceived benefits depending on the degree of fragmentation of settings, parallel existence of other documentation platforms and strained patient relationships.ConclusionA patient-held PHR could improve the availability of health-related information in reception centers if a context-sensitive implementation process achieves high adherence to the PHR among physicians as well as high patient compliance and includes guidelines regarding its adequate integration into local routines.

Dataset Information

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015.

Background

Methods

Results

Conclusions

Publications

Using country of origin to inform targeted tuberculosis screening in asylum seekers: a modelling study of screening data in a German federal state, 2002-2015.

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