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ID AHD – Infections in Immigrants & Refugees

Amro Qaddoura

Adult ID SSR

University of Alberta

Supervisor:

Dr. Ameeta Singh

January 11, 2022

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Outline

Refugee travel
Health assessments
Common infections
Uncommon infections
One Health
Summary
Discussion and questions

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Canadian CMAJ Guidelines (2011)

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Review of ID in Refugees & Asylum Seekers

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Refugee Origins 2018

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“It is awful to leave your country … family and friends, your job – everything – all of your memories of life is there – you have to leave everything.”

Akram 2005.

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Asylum-Seeker Origins 2018

“It is awful to leave your country … family and friends, your job – everything – all of your memories of life is there – you have to leave everything.”

Akram 2005.

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Forced Displacements (UNHCR 2020)

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USA highest by number. But countries like Canada, NZ, Sweden are most by overall population size.

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Health Screening

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Predeparture Health Assessment

Different process in different locations – will focus on CMAJ guidelines
Can start a year or before planned departure

Components:

H&P
TB: medical history + CXR; LTBI in some groups
HIV and Syphilis
Hepatitis B in some groups
Other illnesses (details in subsequent slides)

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Principles

Clinical preventive care informed by region of origin and migration history
Higher barriers: forced migration, low income, and limited EN/FR proficiency
Vaccination and screening provided to at-risk migrants (pre-COVID)

Vaccines: MMR, dTAP, polio, VZV, Hep A/B, HPV (and others)
Screening: Hep B/C, HIV, TB, intestinal parasites, iron def, dental plan, vision loss, mental health, cervical cancer (and others)

Detecting and addressing: malaria, depression, PTSD, child maltreatment, intimate partner violence, DM, and unmet contraceptive needs

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Why does it matter for ID?��Potentially Preventable and Treatable Conditions

More than half (11/20) are related to ID where we have a direct role in preventing and treating!

A sound understanding of the other high priority conditions and appropriate referral is also important.

Items 11 &14 group multiple different conditions into one category.

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Why does it matter to ID (Cont’d)?

30-50% susceptible to tetanus, 32-54% susceptible to one of MMR, and tropical countries 5-10 times more susceptible to varicella
Hep B: 20-80% of immigrants who come from countries where Hep B is prevalent are not immune
TB: Foreign-born patients account for ~65% of active TB; LTBI screening
HIV & Hep C: stigma; early detection and treatment important
Strongyloidiasis & Schistosomiasis: can persist for decades. Can lead to serious morbidity and even death through disseminated disease
Malaria: delay in Dx and Tx can lead to death (especially P falciparum)

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Summary of Recommendations for ID��(COVID Aside)

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MMR

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Recommendation	Rationale
Records of two doses: no further action No records (adults): vaccinate all adult immigrants with one dose of MMR No or uncertain records (children): age-appropriate MMR vaccines.	~100% protected against measles after two doses; ~95% against rubella after one dose. Mumps variable. Vaccination dramatically reduced incidence and mortality from MMR – absolute difference 95.9-99% reduction of cases and almost 100% mortality. MMR safe and effective. No increased risk of autism. Mumps & rubella not part of routine vaccine in many countries. ~20-30% of adult immigrants may be susceptible to rubella – at risk of their child having congenital rubella.

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dTAP

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Recommendation	Rationale
Records of complete series: no further action. No records (adults): vaccinate all adult immigrants using a primary series of diphtheria, tetanus, and inactivated polio (3 doses), the first of which to include acellular pertussis. No or uncertain records (children): age-appropriate vaccines for diphtheria, pertussis, tetanus, and polio. Routine tetanus recommendations as per routine criteria (most patients: q10yrs).	Vaccination dramatically reduced incidence and mortality from these conditions – absolute difference 92.9-99.9% reduction of cases and 99.2-100% for mortality compared to pre-vaccine era. No associated increase in SAE. ~40-50% of adult immigrants susceptible to tetanus. ~60% susceptible to diphtheria. Prevent individual morbidity/mortality. Prevent outbreaks.

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Varicella

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Recommendation	Rationale
Ensure that immigrants and refugees of all ages are immune to varicella. Vaccinate all immigrant children < 13 years of age with varicella vaccine without prior serologic testing. Screen all immigrants and refugees from tropical countries ≥ 13 years of age for serum varicella antibodies, and vaccinate those found to be susceptible.	Vaccination dramatically decreases ambulatory care visits (NNV 794) and mortality (NNV 3,031,773) in all age groups. Adverse effects minimal: injection site redness/pain, fever, myalgias. >30% of adolescents and adult immigrants from tropical countries susceptible to varicella – occurs at older age and lack/inadequate vaccination program. Hence, increased risk of severe varicella. Why age 13? Cost-effectiveness! Most cost-effective to vaccinate if no prior screening with seroprevalence <84% Serotest when seroprevalence 85-95% (some adolescents, most adults) If serologic testing is a barrier or increases cost, vaccination without prior serologic testing should be offered.

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Hep B

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Recommendation	Rationale
SCREENING: Adults and children from countries where seroprevalence of chronic Hep B is moderate or high (i.e., ≥ 2%). Evaluate need for treatment, and screen risk groups for HCC. Lifelong monitoring is required.	Reduces progression to liver failure (NNT 19). HCC screening (U/S & AFP) in risk groups reduces mortality (NNS 2058). Prevalence of chronic Hep B higher among immigrants and refugees than North Americans (mean 4% vs < 0.5%). Toxicity varies by treatment regimen, but most therapies are well tolerated.
VACCINE: Screen for prior immunity to Hep B in adults and children from countries where seroprevalence of chronic Hep B is moderate or high (i.e., ≥ 2%). Vaccinate susceptible patients.	Universal perinatal and childhood vaccination in countries where chronic Hep B is endemic has dramatically reduced chronic infection (NNV 12, 95% CI 11–12) – recall much higher NNV of 794 for Varicella! Trend towards decreased mortality from HCC (relative risk 0.725, 95% CI 0.518–1.015) 15 years after initiation of vaccination programs. In countries with low seroprevalence (i.e., <2%), vaccination of adults decreases development of acute infection. Adverse reactions to vaccination are minor and self-limited.

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TB

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Recommendation	Rationale
<20 yo: Screen with TST for LTBI if from region with high incidence of TB (smear-positive pulmonary TB >15 per 100,000). Tx for LTBI recommended after ruling out active TB. >20 yo: Screen all refugees 20-50 yo with a TST from countries with a high incidence of TB as soon as possible after their arrival in Canada. Screen all other adult immigrants who have risk factors that increase the risk of active TB. Tx for LTBI recommended after ruling out active TB.	Balance of potential benefits of Tx (reducing lifetime risk of active TB) vs potential harm – e.g. INH hepatotoxicity, poor effectiveness because of suboptimal uptake of screening and treatment. The NNT and NNH for various groups are in notes. A decision to screen is a decision to offer treatment and to ensure adherence to treatment with appropriate counselling and monitoring. Factors that increase risk of active TB: HIV, transplantation / immunosuppressant therapy (esp TNF-a inhibitors), leukemia / lymphoma, silicosis, HD, H&N carcinoma, recent TB infxn (<2y), fibronodular disease on CXR, glucocorticoids, DM, young (0-4 yo) when infected, underweight, cigarette smoking, refugee, granuloma on CXR.

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Additional Info about Active TB

Variable incidence/prevalence in different studies

Select population of 44 Syrian refugees residing in EU prevalence 11% (n = 5)
Prevalence in African asylum seekers in Malta during 2010-11 was ~1%
Greek-Turkish border 2011 migrant population primarily from Pakistan and Afghanistan was ~8%, and in border-crossers in Europe it was ~10%
Two US studies: rare, but LTBI was high in refugees from the Middle East (18%) and sub-Saharan Africa (43%)
Think of extrapulmonary TB – more common in immigrants

Preferred screening method

CXR preferred, but interview proposed as flexible and cost-cutting alternative

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Additional Info about LTBI

Variable prevalence

CDC report (2007-2009, Iraqi refugees): 14%
Small Syrian study: 4%
EU border-crossers: 22%
Two US studies: high in refugees from the Middle East (18%) and sub-Saharan Africa (43%), but active TB was rare

Important barriers: language, fear of deportation, perceived and actual lack of access to healthcare, compliance with drug therapy and adverse effects
Dx and Tx strategy can be set up even in difficult conditions (eg: Jordanian refugee camp for refugees from Syria in 2014 with Tx adherence of 91%)

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Risk of Active TB

Lifetime risk of ~5-10%. Normal immunity ~0.6%; HIV+ ~10% or greater

The 0.6% figure helps determine RvB for offering Tx for LTBI (esp if drug-drug interactions with rifampin, or INH and hepatotoxicity)

Risk of active TB within first two years after infxn is age-dependent:

Infants: ~50%
1-2 y.o.: ~12-25%
2-5 y.o.: ~5%
5-10 y.o.: ~2%

Higher in older age

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HIV

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Recommendation	Rationale
“Screen for HIV, with informed consent, all adolescents and adults from countries where HIV is prevalent (> 1%).”	Dramatic mortality reduction with treatment and high-risk behavior. Prevalence of HIV infection is higher among immigrants from countries where HIV is prevalent (> 1%) than among other Canadians (< 0.18%) Harms included adverse drug reactions requiring change in regimen. Less value to uncertain risk of couple discord and risk of discrimination.

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Hep C

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Recommendation	Rationale
Screen for anti-HCV in all immigrants and refugees from regions with an expected prevalence of disease ≥ 3%. If positive, requires management including checking viral load and evaluating patient for treatment.	Prevalence of chronic Hep C higher among immigrants than in the general Canadian-born population (~3% vs 0.8%). Up to 18% in certain populations. Immigrants more likely to have concurrent infection (eg: Hep B or HIV) which increases Hep C disease progression. Immigrants at increased risk of death from viral hepatitis, cirrhosis, & HCC.

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Syphilis

Mandatory for >15 y.o.
Also done in <15 y.o. if born to parents positive for syphilis

Is the mandatory requirement really necessary?

May not be needed as it’s likely that the vast majority of testing results in new diagnoses of late syphilis or non-venereal treponematoses

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Strongyloidiasis

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Recommendation	Rationale
Screen refugees newly arriving from Southeast Asia and Africa with serologic tests for Strongyloides, and if positive treat with ivermectin (1^st line) or albendazole (if contraindication to ivermectin).	Strongyloides affects ~100 million people worldwide. Refugees from SE Asia and Africa have highest risk of infection. Sub-clinical or low-grade diseases can persist for decades. If immunosuppressed, can become life-threatening disseminated disease. Treatment with ivermectin is highly effective (NNT 2, 95% CI ~1-3), with favourable AE profile. Higher value placed on available highly sensitive/specific serologic test and effective treatment that can prevent potentially life-threatening disease, rather than potential limitations of serologic testing in distinguishing current from remote infection.

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Schistosomiasis

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Recommendation	Rationale
Screen refugees newly arriving from Africa with serologic tests for Schistosoma, and if positive treat with praziquantel.	Schistosoma infects ~200 million people worldwide, with ~85% living in Africa. Refugees from Africa have the highest risk of infection. Subclinical infections or low-grade disease can persist for decades and may cause future morbidity or death. Serologic testing is a sensitive diagnostic modality. Treatment with praziquantel is highly effective (NNT 4, 95% CI ~1-124) and has a favourable AE profile. Higher value placed on available highly sensitive/specific serologic test and effective treatment that can prevent future morbidity or death, rather than potential limitations of serologic testing in distinguishing current from remote infection.

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Malaria

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Recommendation	Rationale
Do not conduct routine screening for malaria. Be alert for symptomatic malaria in migrants who have lived or travelled in malaria-endemic regions within the previous three months. Perform timely diagnostic inquiry and testing in those with any symptoms (malaria symptoms are non-specific and may include malaise, fever, myalgia, headache).	Those from malaria-endemic regions (especially sub-Saharan Africa) are vulnerable to potentially life-threatening acute P falciparum for first 3 months after arrival. Value for routine screening for asymptomatic individuals is lacking. Also, performance characteristics uncertain in asymptomatic individuals.

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Other Infections

Shigellosis: 1.4/100,000 in EU (2014), majority travel-related.
Leishmaniasis: steep rise seen in 2013 among Syrian refugees in Lebanese refugee camps; An EU study found that 32% (n = 14) of a select population Syrian refugees had cutaneous leishmaniasis.
MRSA/ESBL/CPO carriage: limited data. Trend towards being more common than autochthonous population, but variable.
Giardia intestinalis and Entamoeba histolytica: 3.1% and 1.2%, respectively, in a CDC report of resettled Iraqi refugees.
STI’s: variable, even among refugees from same region

Chlamydia – 0-3.3% in refugees from Middle East; 0-1.4% in Eastern Europe
Gonorrhea – 0-0.2% in refugees from sub-Saharan Africa and SE Asia
Syphilis – 1-3% (may be higher now)

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Other Infections Cont’d

Cutaneous diphtheria
Louse-born relapsing fever: 27 cases in EU (2015) taking route through Libya. Majority of cases thought to be acquired in home country or enroute
Less common parasites: cysticercosis, echinococcosis, fasciola, filariasis, leishmania, amoebic liver abscess, opisthorchis, T. saginata

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Summary of Recommendations for ID��(COVID Next Slides)

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COVID

All non-essential travel discouraged
Work directly with United Nations Refugee Agency (UNHCR) and International Organization for Migration (IOM) – different polices in place
Fully vaccinated (accepted vaccines) and no signs/symptoms – pre-entry testing and possible quarantine 🡪 monitor for s/s for 14 days

Negative test or prior positive test result between 14 and 180 days ago

Unvaccinated – may require testing prior to exiting airport +/- quarantine
Refugees – next slide

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COVID Cont’d – Refugees

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One Health

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Principles

Clinical preventive care informed by region of origin and migration history
Higher barriers: forced migration, low income, and limited EN/FR proficiency
Vaccination and screening provided to at-risk migrants (pre-COVID)

Vaccines: MMR, dTAP, polio, VZV, Hep A/B, HPV (and others)
Screening: Hep B/C, HIV, TB, intestinal parasites, iron def, dental plan, vision loss, mental health, cervical cancer (and others)

Detecting and addressing: malaria, depression, PTSD, child maltreatment, intimate partner violence, DM, and unmet contraceptive needs
One Health

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Thank you!

References:

Refugee Origins 2018. Worldmapper. Retrieved from: https://worldmapper.org/maps/refugee-origins-2018/
Asylum-seeker origins 2018. Worldmapper. Retrieved from: https://worldmapper.org/maps/asylum-seeker-origins-2018/
Pottie K et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ. 2011;183(12). DOI:10.1503/cmaj.090313.
Eiset AH & Wejse C. Review of infectious diseases in refugees and asylum seekers—current status and going forward. Public Health Rev. 2017;38(22). DOI: 10.1186/s40985-017-0065-4.
Global Trends: Forced Displacement in 2020. UNHCR. Retrieved from: https://www.unhcr.org/flagship-reports/globaltrends/
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ECDC. Shigellosis among refugees in the EU. 2015. http://ecdc.europa.eu/en/publications/Publications/Shigella-RRA-24-11-2015-Austria-Greece-Slovenia.pdf.
How the coronavirus disease (COVID-19) is affecting immigration, refugees, citizenship and passport services. Government of Canada. Retrieved from: https://www.canada.ca/en/immigration-refugees-citizenship/services/coronavirus-covid19.html
Coronavirus disease (COVID-19): Refugees, asylum claimants, sponsors and PRRA applicants. Government of Canada. Retrieved from: https://www.canada.ca/en/immigration-refugees-citizenship/services/coronavirus-covid19/refugees.html
Unified definition of One Health adopted by global animal, environment and health organisations. Doherty Institute. Retrieved from: https://www.doherty.edu.au/news-events/news/unified-definition-of-one-health-adopted-by-global-animal-environment-and-h
Sutradhar I & Zaman MH. One Health approaches to improve refugee health. Lancet Glob Health. 2021;9(12):e1646-e1647. DOI: 10.1016/S2214-109X(21)00416-2.