Tuberculosis and the impact of migration in Europe and Italy

Transcription

1 Tuberculosis and the impact of migration in Europe and Italy Dennis Falzon, MD Monothematic Conference Associazione italiana per lo studio del fegato Milan, Italy 14 October 2011

2 Overview of the presentation Update on the global TB situation Trends in TB in Europe and Italy TB in patients of foreign origin Migration in the world today 4

3 Update on the global TB situation (1) All forms of TB, 2010 Estimated number of cases, million ( million) Estimated number of deaths, million* ( million) HIV associated TB, 2010 Multidrug resistant TB, million ( million) 650,000 (460, ,000) 350,000 (320, ,000) ~150,000 5 * Excluding deaths attributed to HIV/TB Source: Statistics prepared for the WHO Global Tuberculosis Control Report 2011

4 Update on the global TB situation (2) 6 Countries in capitals are high burden for TB incidence

5 Update on the global TB situation (3) 7

6 Update on the global TB situation (4) 8

7 Trends in TB in Europe (1) TB notification rates, European region, ECDC WHO/EUR

8 Trends in TB in Europe (2) TB case notification in the European Union Reversal in TB rates in early 1990s in several countries 100 TB cases / (log10 scale) New EU states (2004) Western EU * Countries with data represented in the groupings - Western EU: Austria, Belgium, Cyprus, Denmark, Finland, France, Germany, Ireland, Italy, Luxembourg, Malta, Netherlands, Portugal, Spain, Sweden, United Kingdom. New EU states (2004): Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia (Malta & Cyprus included under Western EU). Main source of data for : Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report WHO/HTM/TB/ ; rest of data collected by EuroTB 10

9 Trends in TB in Europe (3) Importance of immigrants in TB epidemiology in W. Europe Disparities in case definitions, completeness of reporting, information on ethnic origin Attempts at defining different forms of foreigners, minimum dataset Recommendation for mandatory lab & physician notification 11 Eur Respir J. 1994, 7,

10 Trends in TB in Europe (4) Total TB notifications by previous treatment history and total TB case rates, EU/EEA, ECDC WHO/EUR

11 Trends in TB in Europe (5) TB cases by geographic origin, EU & West,* TB cases National Foreign Unknown 35,000 30,000 25,000 20,000 15,000 10,000 5, * Excluding countries with incomplete data for any one year or change in criterion of origin: Andorra, Bulgaria, Cyprus, Greece, Luxembourg, Monaco, Poland, San Marino, Spain. Cases from Romania (>25,000 yearly; <0.1% foreign) are not included. 13 EuroTB ECDC WHO/EUR

12 Trends in TB in Europe (6) Provenance of TB cases of foreign origin, EU/EEA,* 2009 Other/Unknown 12% W. Pacific 1% EU/EEA 10% European Region, not EU/EEA 10% Americas 4% Africa 29% Rest of Asia 34% * 16,296 cases of foreign origin in 28 EU/EEA countries 14 ECDC WHO/EUR

13 Trends in TB in Europe (7) Genetic diversity of M. tuberculosis isolates in Norway, Twelve years of M. tuberculosis importation as a result of immigration from high incidence countries had little influence on the transmission of this pathogen in the receiving low incidence country. To prevent future increase of transmission of TB, the current control strategies of low incidence countries are adequate but must be maintained 15 Dahle UR, Eldholm V, Winje BA, Mannsåker T, Heldal E. Impact of immigration on the molecular epidemiology of Mycobacterium tuberculosis in a low incidence country. Am J Respir Crit Care Med Nov 1;176(9):930 5

14 Trends in TB in Europe (8) Somali immigrants with TB, Denmark, DNA fingerprint patterns of isolates from >97% of all culturepositive TB patients in Denmark (N=3,320). 763 were Somali immigrants. 55% had identical DNA fingerprint patterns, 75% were most likely infected before arrival in Denmark 23% were most likely infected in Denmark by other Somalis 1.8% were most likely infected by Danes. Only 0.9% of all Danish tuberculosis patients were most likely infected by Somalis. 16 Lillebaek T, Andersen AB, Bauer J, Dirksen A, Glismann S, de Haas P, Kok Jensen A. Risk of Mycobacterium tuberculosis transmission in a low incidence country due to immigration from high incidence areas. J Clin Microbiol Mar;39(3):855 61

15 Trends in TB in Europe (9) Combined MDR TB by origin, Germany, % MDR of cases with DST results 6% 5% 4% 3% 2% 1% 0% Native Foreign born EuroTB

16 Trends in TB in Europe (10) Pooled TB case notification data from 14 European Union countries, Int J Tuberc Lung Dis Sep;10(9):954 8.

17 Trends in TB in Europe (11) Treatment outcome in culture confirmed pulmonary TB cases by geographic origin, EU/EEA countries, 2007 Success Death Failure Default Still on treatment Not known Foreign [4,780] National [32,380] 0% 20% 40% 60% 80% 100% 19 Using data published in Euro Surveill Mar 18;15(11).

18 Trends in TB in Europe (12) Association between death and several risk factors, 2003 (17 countries) Austria, Belgium, Cyprus, Czech Republic, Denmark, Estonia, Germany, Hungary, Ireland, Latvia, Lithuania, Malta, Netherlands, Portugal, Slovakia, Slovenia, Sweden * Among 13,470 cases with DST results Eur Respir J Jun;31(6):

19 Trends in TB in Europe (13) Determinants of success in pooled TB notifications in 13 European countries 21 Int J Tuberc Lung Dis. 2005; 9(11):

20 Recent trends in TB in Italy (1) 22

21 Recent trends in TB in Italy (2) TB notification rate has declined by 2.4% per year since 2005 to reach 6.5/100,000 population in 2009 (cf. 15.8/10 5 pop. for all EU/EEA countries combined) The proportion of TB cases born outside the country increased from 34% to 47% between 2000 and In 2009, out of a total of 3,877 TB cases notified, 1,793 were born in Italy (46%), 618 in another European country (16%), 537 in Africa (14%), 436 in Asia (11%) and 493 elsewhere or unknown (13%). 23

22 Recent trends in TB in Italy (3) Many cases in foreign born individuals in 2009 were in the productive age groups (78% were aged years) in sharp contrast to the older age of the TB patient born in Italy (mean age 56 years). In 2009 in Italy, 4.5% of foreign and 1.5% of native TB cases had resistance to both isoniazid and rifampicin, the most effective bactericidal drugs against TB (termed multidrug resistance or MDR TB). One patient was reported to have even more extensive drug resistance or XDR TB. 24

23 Recent trends in TB in Italy (4) TB cases per 100,000 population, by Region, 2009* < * Calculated on resident population in each region as on 1 January 2010 Data for Basilicata and Umbria from 2005 Data and map template: E. Rizzuto, Ministero della Salute, Italy, October

24 Recent trends in TB in Italy (5) TB notifications in males (blue) and females (red) by Region, 2009* * No data for Basilicata and Umbria Source: E. Rizzuto, Min della Salute, Oct

25 Recent trends in TB in Italy (6) Odone et al. BMC Public Health 2011, 11:376 27

26 Recent trends in TB in Italy (7) TB cases per population, Liguria, European Journal of Public Health, Vol. 15, No. 4,

27 TB in patients of foreign origin (1) TB case rates by age group, sex and geographic origin, EU & West*, 2004 Cases / 100, Age-group >64 FOREIGN MALE FOREIGN FEMALE NATIONAL MALE NATIONAL FEMALE * Pooled data for 2004 from countries reporting population data by geographic origin: Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Netherlands, Norway, Slovenia, Sweden, Switzerland, United Kingdom 29

28 TB in patients of foreign origin (2) Cluster of 175 MDR TB cases with Beijing strain in 12 European countries Emerg Infect Dis Jul;15(7):

29 TB in patients of foreign origin (3) Somali immigrants with TB, Denmark, Emerg Infect Dis Jul;8(7):679 84

30 TB in patients of foreign origin (4) TB case rates by ethnicity, England & Wales, 2001 TB cases / 100,000 0 Black African Pakistani Indian White Source: National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. London: Royal College of Physicians,

31 TB in patients of foreign origin (5) TB HIV by place of birth and year of diagnosis, England & Wales, * % TB cases aged >14 years 33 Thorax 2007;62:

32 Migration in the world today (1) Any person who lives temporarily or permanently in a country where he or she was not born, and has acquired some significant social ties to this country (UN). Push and pull factors : disasters, violence, economic advantage, medical tourism Migration itself should not be a risk to health. Vulnerability and inequalities of access may however characterize any of the three phases surrounding migration process: Pre entry phase Transitional phase Post entry phase 34

33 Migration in the world today (2) About 740 million internal migrants worldwide who have moved within their own country's border (1) About 214 million international migrants globally in 2010, up from 155 million in 1990 (2) Every year, more than 5 million people cross international borders to go and live in a developed country Mass, short term labour migration fuelling high TB rates even outside high income settings (eg southern Africa) 35 1) UNDP. Human Development Report Overcoming barriers: Human mobility and development.united Nations Development Program, ) Trends in International Migrant Stock: The 2008 Revision. New York, UN Department of Economic and Social Affairs, Population Division, (United Nations database, POP/DB/MIG/Stock/Rev.2008)

34 Migration in the world today (3) 25 million foreigners live in the EU s 27 countries (3) >70% from E. & S E. Europe and North Africa In 2006, 1.8 million people from outside the EU settled in a new country of residence in the EU 3) European Centre for Disease Prevention and Control. Migrant health: Background note to the ECDC Report on migration and infectious diseases in the EU, Stockholm, July

35 Migration in the world today (4) In 2008, the World Health Assembly approved a Resolution (WHA61.17 Health of migrants) promoting migrant sensitive health policies. In 2010, WHO held a global consultation in Spain on migrants and health 37

36 Migration in the world today (5) Four thematic areas for action Monitoring migrant health Policy and legal framework Migrant sensitive health systems Partnerships, networks and multicountry frameworks 38

37 In conclusion (1) Immigration contributes importantly to TB in Europe, particularly in western countries In these countries persons of foreign origin are more vulnerable to TB, if from high TB prevalence settings drug resistant TB HIV associated TB, in certain cases loss to follow up of TB treatment 39

38 In conclusion (2) Migrants from high TB prevalence settings retain an increased risk of developing TB for years after resettlement Transmission from immigrants to locals is rare Barriers of access to care in the host country may be linked to language, culture, money, need to work and legal status. Migrants without documents may avoid the public health services, thus missing or delaying treatment 40

39 In conclusion (3) Migration is an important feature of TB epidemiology in Italy. The cases are increasingly concentrated in population groups at risk. Physicians should suspect TB in patients with respiratory syndromes and offer diagnostic testing early Refer for specialist treatment, especially in complicated cases, paediatric TB, HIV associated TB and drug resistant TB 41

40 Thanks & Acknowledgements A.I.S.F organizers and participants Dipartimento della Sanità Pubblica e Innovazione National TB authorities WHO/HQ, WHO/EUR, ECDC, IOM Authors as referenced 42

41 More information 1) 2) we do/healthtopics/communicable diseases/tuberculosis 3) health europe.org/ 4) ecdc.europa.eu/en/healthtopics/tuberculosis/ 43