Advertisement

Screening for Infectious Diseases on Arrival and Integrated Healthcare for Refugees and Asylum Seekers During the First Months After Arrival

  • Berit LangeEmail author
  • Annabelle Bockey
  • Winfried Kern
  • Siegbert Rieg
Chapter
Part of the Migration, Minorities and Modernity book series (MMMO, volume 4)

Abstract

Germany’s experiences during the arrival of a large number of refugees in 2015 and 2016 have revealed a substantial need for coordinated and integrated healthcare. This includes evidence-based management and prevention of infectious diseases on arrival, easily accessible healthcare during the time after arrival and good integration into regular healthcare afterwards. While there is no evidence of the major transmission of infectious diseases from arriving refugees to the general population, the risk of transmission within groups of refugees, in particular in combination with crowded living conditions and the compounding effect of previous flight experience, is relevant. Screening for infectious diseases can identify only a proportion of infectious diseases and needs to take into account the dynamics of the risks associated with the different periods of flight/migration. In Germany, initial chest X-ray screening for pulmonary tuberculosis among adults by local health authorities is the only infectious disease screening that is uniformly applied across all states and counties. Apart from this screening, practices vary across different regions and states due to the non-existence of overall recommendations. We give an overview of existing evidence and guidelines on infectious disease screening of refugees for tuberculosis, HIV and hepatitis B & C and describe the practical experience of an integrated healthcare model for arriving refugees in Freiburg, including the management (although not initial screening) of infectious diseases. We also present an argument for screening to be integrated into the regular provision of healthcare during the first few months after arrival beyond just a one-off chest X-ray.

References

  1. Abarca Tomas, B., Pell, C., Bueno Cavanillas, A., Guillen Solvas, J., Pool, R., & Roura, M. (2013). Tuberculosis in migrant populations. A systematic review of the qualitative literature. PLoS ONE, 8(12), e82440.CrossRefGoogle Scholar
  2. Aldridge, R. W., Yates, T. A., Zenner, D., White, P. J., Abubakar, I., & Hayward, A. C. (2014). Pre-entry screening programmes for tuberculosis in migrants to low-incidence countries: A systematic review and meta-analysis. Lancet Infectious Diseases, 14(12), 1240–1249.CrossRefGoogle Scholar
  3. Alvarez-Del Arco, D., Monge, S., Azcoaga, A., Rio, I., Hernando, V., Gonzalez, C., et al. (2013). HIV testing and counselling for migrant populations living in high-income countries: A systematic review. European Journal of Public Health, 23(6), 1039–1045.CrossRefGoogle Scholar
  4. Alvarez-Del Arco, D., Monge, S., Caro-Murillo, A. M., Ramírez-Rubio, O., Azcoaga-Lorenzo, A., Belza, M. J., et al. (2014). HIV testing policies for migrants and ethnic minorities in EU/EFTA member states. European Journal of Public Health, 24(1), 139–144.CrossRefGoogle Scholar
  5. Alvarez-Del Arco, D., Monge, S., Rivero-Montesdeoca, Y., Burns, F., Noori, T., & Del Amo, J. (2017). Implementing and expanding HIV testing in immigrant populations in Europe: Comparing guideline’s recommendations and expert’s opinions. Enfermedades Infecciosas y Microbiologia Clinica, 35(1), 47–51.CrossRefGoogle Scholar
  6. Arshad, S., Bavan, L., Gajari, K., Paget, S. N. J., & Baussano, I. (2010). Active screening at entry for tuberculosis among new immigrants: A systematic review and meta-analysis. European Respiratory Journal, 35(6), 1336–1345.CrossRefGoogle Scholar
  7. Ärztekammer Schleswig-Holstein. (2016). Ärztliche Versorgung von Flüchtlingen in Schleswig-Holstein. https://www.aeksh.de/aerzte/arztinfo/aerztliche-versorgung-von-fluechtlingen-schleswig-holstein. Accessed February 16, 2018.
  8. BAMF. (2016). Aktuelle Zahlen zu Asyl, Januar 2016. Nürnberg: Bundesamt für Migration und Flüchtlinge.Google Scholar
  9. Beermann, S., Rexroth, U., Kirchner, M., Kühne, A., Vygen, S., & Gilsdorf, A. (2015). Asylsuchende und Gesundheit in Deutschland: Überblick über epidemiologisch relevante Infektionskrankheiten. Deutsches Ärzteblatt, 112(42), A1717–A1720.Google Scholar
  10. Bellos, A., Mulholland, K., O’brien, K. L., Qazi, S. A., Gayer, M., & Checchi, F. (2010). The burden of acute respiratory infections in crisis-affected populations: A systematic review. Conflict and Health, 4, 3.Google Scholar
  11. Blondell, S. J., Kitter, B., Griffin, M. P., & Durham, J. (2015). Barriers and facilitators to HIV testing in migrants in high-income countries: A systematic review. AIDS and Behavior, 19(11), 2012–2024.CrossRefGoogle Scholar
  12. Bottcher, S., Neubauer, K., Baillot, A., Rieder, G., Adam, M., & Diedrich, S. (2015). Stool screening of Syrian refugees and asylum seekers in Germany, 2013/2014: Identification of Sabin like polioviruses. International Journal of Medical Microbiolog, 305(7), 601–606.CrossRefGoogle Scholar
  13. Bozorgmehr, K., Nost, S., Thaiss, H. M., & Razum, O. (2016). Die gesundheitliche Versorgungssituation von Asylsuchenden. Bundesweite Bestandsaufnahme über die Gesundheitsämter. Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 59(5), 545–555.CrossRefGoogle Scholar
  14. Bozorgmehr, K., Joggerst, B., Wagner, U., & Stock, C. (2017a). Yield of tuberculosis screening in asylum-seekers by country of origin: Analysis of screening data in a German federal state (2002–2015). European Respiratory Journal, 49(4), 1602327.CrossRefGoogle Scholar
  15. Bozorgmehr, K., Razum, O., Saure, D., Joggerst, B., Szecsenyi, J., & Stock, C. (2017b). Yield of active screening for tuberculosis among asylum seekers in Germany: A systematic review and meta-analysis. Eurosurveillance, 22(12), 30491.CrossRefGoogle Scholar
  16. Bozorgmehr, K., Wahedi, K., Noest, S., Szecsenyi, J., & Razum, O. (2017c). Infectious disease screening in asylum seekers: Range, coverage and economic evaluation in Germany, 2015. Eurosurveillance, 22(40), 16–00677.CrossRefGoogle Scholar
  17. De Vito, E., Parente, P., De Waure, C., Poscia, A., & Ricciardi, W. (2017). A review of evidence on equitable delivery, access and utilization of immunization services for migrants and refugees in the WHO European Region. Health Evidence Network Synthesis Report 53. Copenhagen: World Health Organization Regional Office for Europe.Google Scholar
  18. Deutsche AIDS-Hilfe. (2014). Deutsche AIDS-Hilfe: HIV-Zwangstests in Bayern jetzt abschaffen. http://www.aidshilfe.de/de/aktuelles/meldungen/deutsche-aids-hilfe-hiv-zwangstests-bayern-jetzt-abschaffen. Accessed February 16, 2018.
  19. Deutsche AIDS-Hilfe. (2015). Deutsche AIDS-Hilfe fordert bessere Gesundheitsversorgung für Flüchtlinge. http://www.aidshilfe.de/de/aktuelles/meldungen/deutsche-aids-hilfe-fordert-bessere-gesundheitsversorgung-fuer-fluechtlinge. Accessed February 16, 2018.
  20. Diel, R., Lampenius, N., & Nienhaus, A. (2015). Cost effectiveness of preventive treatment for tuberculosis in special high-risk populations. Pharmacoeconomics, 33(8), 783–809.CrossRefGoogle Scholar
  21. Eichner, M., & Brockmann, S. O. (2013). Polio emergence in Syria and Israel endangers Europe. Lancet, 382(9907), 1777.CrossRefGoogle Scholar
  22. Eljedi, A., Mikolajczyk, R. T., Kraemer, A., & Laaser, U. (2006). Health-related quality of life in diabetic patients and controls without diabetes in refugee camps in the Gaza strip: A cross-sectional study. BMC Public Health, 6, 268.CrossRefGoogle Scholar
  23. Fiebig, L., Hauer, B., Andres, M., & Haas, W. (2017). Tuberculosis screening in asylum seekers in Germany, 2015: Characteristics of cases and yield. European Respiratory Journal, 50(4), 1602550.CrossRefGoogle Scholar
  24. Freistaat Sachsen. (2015). VwV Asylbewerbergesundheitsbetreuung – VwV AsylGesBetr. Gemeinsame Verwaltungsvorschrift des Sächsischen Staatsministeriums für soziales und Verbraucherschutz und des Sächsischen Staatsministeriums des lnnern zur gesundheitlichen Betreuung von Asylbewerbern und unbegleiteten minderiährigen Ausländern durch die Gesundheitsämter im Freistaat Sachsen. SächsABl.SDr, 422.Google Scholar
  25. Greenaway, C., Sandoe, A., Vissandjee, B., Kitai, I., Gruner, D., Wobeser, W., et al. (2011). Tuberculosis: Evidence review for newly arriving immigrants and refugees. Canadian Medical Association Journal, 183(12), E939–E951.CrossRefGoogle Scholar
  26. Greenaway, C., Thu Ma, A., Kloda, L. A., Klein, M., Cnossen, S., Schwarzer, G., et al. (2015). The seroprevalence of hepatitis c antibodies in immigrants and refugees from intermediate and high endemic countries: A systematic review and meta-analysis. PLoS ONE, 10(11), e0141715.CrossRefGoogle Scholar
  27. Grote, U., Wildenau, G., & Jablonka, A. (2015). Primärärztliche Versorgung von Flüchtlingen in Deutschland. Anasthesiologie und Intensivmedizin, 56, 654–660.Google Scholar
  28. Hahne, S. J., Veldhuijzen, I. K., Wiessing, L., Lim, T. A., Salminen, M., & Laar, M. (2013). Infection with hepatitis B and C virus in Europe: A systematic review of prevalence and cost-effectiveness of screening. BMC Infectious Diseases, 13, 181.CrossRefGoogle Scholar
  29. Hauer, B. (2017). Kommentar des Robert Koch-Instituts zu den Beiträgen zum Tuberkulosescreening bei Asylsuchenden in Deutschland 2015. Epidemiologisches Bulletin, 43, 495–496.Google Scholar
  30. Haukaas, F. S., Arnesen, T. M., Winje, B. A., & Aas, E. (2017). Immigrant screening for latent tuberculosis in Norway: A cost-effectiveness analysis. The European Journal of Health Economics, 18(4), 405–415.CrossRefGoogle Scholar
  31. Heuvelings, C. C., De Vries, S. G., Greve, P. F., Visser, B. J., Belard, S., Janssen, S., et al. (2017). Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: A systematic review. Lancet Infectious Diseases, 17(5), e144–e158.CrossRefGoogle Scholar
  32. IOM. (2016). Mixed migration flows in the Mediterranean and beyond. Compilation of available data and information. Geneva: International Organization for Migration.Google Scholar
  33. Kärki, T., Napoli, C., Riccardo, F., Fabiani, M., Dente, M., Carballo, M., et al. (2014). Screening for infectious diseases among newly arrived migrants in EU/EEA countries—Varying practices but consensus on the utility of screening. International Journal of Environmental Research and Public Health, 11(10), 11004–11014.CrossRefGoogle Scholar
  34. Kimbrough, W., Saliba, V., Dahab, M., Haskew, C., & Checchi, F. (2012). The burden of tuberculosis in crisis-affected populations: A systematic review. Lancet Infectious Diseases, 12(12), 950–965.CrossRefGoogle Scholar
  35. Klinkenberg, E., Manissero, D., Semenza, J. C., & Verver, S. (2009). Migrant tuberculosis screening in the EU/EEA: Yield, coverage and limitations. The European Respiratory Journal, 34(5), 1180–1189.CrossRefGoogle Scholar
  36. Kunst, H., Burman, M., Arnesen, T. M., Fiebig, L., Hergens, M. P., Kalkouni, O., et al. (2017). Tuberculosis and latent tuberculous infection screening of migrants in Europe: Comparative analysis of policies, surveillance systems and results. International Journal of Tuberculosis and Lung Disease, 21(8), 840–851.CrossRefGoogle Scholar
  37. Lange, B., Bockley, A., Braun, C., Janda, A., Stete, K., Müller, & A.-M., et al. (2018). Medizinethische Herausforderungen der Gesundheitsversorgung in der Erstaufnahme für Geflüchtete am Beispiel des Aufbaus eines integrierten Versorgungsmodells in der Erstaufnahme in Freiburg. Zeitschrift für Medizinische Ethik (in press).Google Scholar
  38. Lange, B., Stete, K., Bozorgmehr, K., Camp, J., Kranzer, K., Kern, W., et al. (2016). Gesundheitsversorgung geflüchteter Menschen. Eine kurze Übersicht mit einem Schwerpunkt auf Infektionserkrankungen. Deutsche Medizinische Wochenschrift, 141(11), 772–776.CrossRefGoogle Scholar
  39. Mipatrini, D., Stefanelli, P., Severoni, S., Rezza, G. (2017). Vaccinations in migrants and refugees: A challenge for European health systems. A systematic review of current scientific evidence. Pathogens and Global Health, 111(2), 59–68.Google Scholar
  40. Mockenhaupt, F. P., Barbre, K. A., Jensenius, M., Larsen, C. S., Barnett, E. D., Stauffer, W., et al. (2016). Profile of illness in Syrian refugees: A GeoSentinel analysis, 2013–2015. Eurosurveillance, 21(10), 30160.CrossRefGoogle Scholar
  41. Norredam, M., Olsbjerg, M., Petersen, J. H., Juel, K., & Krasnik, A. (2012). Inequalities in mortality among refugees and immigrants compared to native Danes—A historical prospective cohort study. BMC Public Health, 12, 757.CrossRefGoogle Scholar
  42. Pareek, M., Watson, J. P., Ormerod, L. P., Kon, O. M., Woltmann, G., White, et al. (2011). Screening of immigrants in the UK for imported latent tuberculosis: A multicentre cohort study and cost-effectiveness analysis. Lancet Infectious Diseases, 11(6), 435–444.Google Scholar
  43. Pfeil, J., Kobbe, R., Trapp, S., Kitz, C., & Hufnagel, M. (2015). Empfehlungen zur infektiologischen Versorgung von Flüchtlingen im Kindes- und Jugendalter in Deutschland. Monatsschrift für Kinderheilkunde, 163(12), 1269–1286.CrossRefGoogle Scholar
  44. Razum, O., Bunte, A., Gilsdorf, A., Ziese, T., & Bozorgmehr, K. (2016). Gesundheitsversorgung von Geflüchteten: Zu gesicherten Daten kommen. Deutsches Ärzteblatt, 113(4), A130–A134.Google Scholar
  45. RKI. (2015a). Konzept zur Umsetzung frühzeitiger Impfungen bei Asylsuchenden nach Ankunft in Deutschland. Epidemiologisches Bulletin, 41, 439–448.Google Scholar
  46. RKI. (2015b). Thorax-Röntgenuntersuchungen bei Asylsuchenden gemäß § 36 Absatz 4 IfSG. Stellungnahme des Robert Koch-Instituts. https://www.rki.de/DE/Content/InfAZ/T/Tuberkulose/Tuberkulose_Roentgen-Untersuchungen_Asylsuchende.html. Accessed February 16, 2018.
  47. RKI. (2015c). Überblick über die Epidemiologie der Masern in 2014 und aktuelle Situation in 2015 in Deutschland. Epidemiologisches Bulletin, 10, 69–82.Google Scholar
  48. RKI. (2016). Dem Robert Koch-Institut übermittelte meldepflichtige Infektionskrankheiten bei Asylsuchenden in Deutschland. Berlin: Robert Koch-Institute.Google Scholar
  49. RKI. (2017). Bericht zur Epidemiologie der Tuberkulose in Deutschland für 2016. Berlin: Robert Koch-Institute.Google Scholar
  50. Rossi, C., Shrier, I., Marshall, L., Cnossen, S., Schwartzman, K., Klein, M. B., et al. (2012). Seroprevalence of chronic hepatitis B virus infection and prior immunity in immigrants and refugees: A systematic review and meta-analysis. PLoS ONE, 7(9), e44611.CrossRefGoogle Scholar
  51. Sandgren, A., Schepisi, M. S., Sotgiu, G., Huitric, E., Migliori, G. B., Manissero, D., et al. (2014). Tuberculosis transmission between foreign- and native-born populations in the EU/EEA: A systematic review. European Respiratory Journal, 43(4), 1159–1171.CrossRefGoogle Scholar
  52. Schneeberger Geisler, S., Helbling, P., Zellweger, J. P., & Altpeter, E. S. (2010). Screening for tuberculosis in asylum seekers: Comparison of chest radiography with an interview-based system. International Journal of Tuberculosis and Lung Disease, 14(11), 1388–1394.Google Scholar
  53. Sharma, S., Carballo, M., Feld, J. J., & Janssen, H. L. (2015). Immigration and viral hepatitis. Journal of Hepatology, 63(2), 515–522.CrossRefGoogle Scholar
  54. Shea, K. M., Kammerer, J. S., Winston, C. A., Navin, T. R., & Horsburgh, C. R., Jr. (2014). Estimated rate of reactivation of latent tuberculosis infection in the United States, overall and by population subgroup. American Journal of Epidemiology, 179(2), 216–225.CrossRefGoogle Scholar
  55. Sing, A., & Hierl, W. (2015). Gesundheitsuntersuchung nach dem Asylverfahrensgesetz. Bayerisches Ärzteblatt, 9, 422–423.Google Scholar
  56. UNHCR. (2017). Desperate journeys. Refugees and migrants entering and crossing Europe via the Mediterranean and Western Balkans routes. Geneva: United Nations High Commissioner for Refugees.Google Scholar
  57. Walker, T. M., Lalor, M. K., Broda, A., Saldana Ortega, L., Morgan, M., Parker, L., et al. (2014). Assessment of mycobacterium tuberculosis transmission in Oxfordshire, UK, 2007–12, with whole pathogen genome sequences: An observational study. Lancet Respiratory Medicine, 2(4), 285–292.CrossRefGoogle Scholar
  58. WHO. (2013). Systematic screening for active tuberculosis. Principles and recommendations. Ganeva: World Health Organization.Google Scholar
  59. WHO. (2015). WHO Guidelines on the management of latent tuberculosis infection. Geneva: World Health Organization.Google Scholar
  60. WHO. (2017). WHO Guidelines on hepatitis B and C testing. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Berit Lange
    • 1
  • Annabelle Bockey
    • 2
  • Winfried Kern
    • 1
  • Siegbert Rieg
    • 1
  1. 1.Division of Infectious Diseases, Department of Medicine II, Faculty of MedicineUniversity of FreiburgFreiburgGermany
  2. 2.Centre for Medicine and Society, University of FreiburgFreiburgGermany

Personalised recommendations