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An Evaluation of TB Screening for Asylum Seekers and Refugees in Bristol

An Evaluation of TB Screening for Asylum Seekers and Refugees in Bristol. Faustina Montsho-Hammond Health Protection Nurse Practitioner: SW(North) HPU 03/11/2011. Project Approval Cardiff University- School of Medicine Avon Primary Care Research Collaborative. Overview.

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An Evaluation of TB Screening for Asylum Seekers and Refugees in Bristol

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  1. An Evaluation of TB Screening for Asylum Seekers and Refugees in Bristol Faustina Montsho-Hammond Health Protection Nurse Practitioner: SW(North) HPU 03/11/2011 Project Approval Cardiff University- School of Medicine Avon Primary Care Research Collaborative

  2. Overview • Background and public health importance of TB screening • Evaluation question and sub-questions • Evaluation method and model • Findings and conclusions • Some challenges/limitations • Recommendations

  3. Background • Current evidence: TB transmission between new entrants and host population • Demographic changes and communicable diseases • Global population mobility and TB epidemics: 19th Vs 21st Century Western Europe → Africa; Asia and the Americas • TB prevalence in Europe •  TB risk in foreign born Vs host population • Public health importance • TB burden and impact of screening • Changing epidemiology • TB control strategies and policies

  4. 2008 Estimated TB incidence rates Source: WHO 2009 • A third of the world population (>2 billion)is infected with TB • 1 in 10 will develop active disease in their lifetime

  5. Evaluation Question • What is the impact of the TB screening programme for ASaR in Bristol? • Sub-questions • Are the goals and objectives of the programme appropriate? • Are the goals and objectives of the programme being met? • Objectives • To carry out a structured literature review of relevant published and unpublished studies on TB screening for ASaR in Europe. • To describe the TB Screening Programme for ASaR in Bristol • To conduct a descriptive analysis of ASaR who were seen at the Haven and screened for TB between March 2008 and February 2009. • To collate and analyse gathered evidence and findings.

  6. Evaluation Methods • Structured literature review • Published and unpublished literature on TB screening for ASaR in Europe (2000-2010) • Retrospective data review • TB screening data on ASaR who were screened through the Haven between March 2008 and February 2009

  7. Evaluation Model

  8. About the literature review • Search strategy • 3 electronic databases Medline; EMBASE; and PubMed • Key words • 1) Refugee* OR immigrant* OR migrant* OR Asylum seeker* • 2) Tuberculosis AND Screening • 3) 1 AND 2 • 4) Limit to humans; English language; 2000-2010 • Inclusion criteria • Objective measurement of screening- uptake; referrals ; TB diagnosis; BCG coverage. • No restriction on study design. • Analysis: Quality assessment : Adaptation of Newcastle-Ottawa Scale • Data synthesis: Tabulation by study question/ outcomes/differences /consistency

  9. Retrospective Data Collection • EMIS GP electronic records • Password protected Excel database; • Variables against anonymised patient ID#. • Outcome measures. • Population characteristics: Age gender, Ethnicity etc • Screening procedure: X-ray; Mantoux test; iGRA; • Immediate screening outcomes: Active TB; LTBI; BCG Vaccination status; Referrals etc • Other sources • 2008-2009 The Haven annual report • 2005 The Haven evaluation report

  10. Data analysis • Data Validation • SPSS Version 16.0 for statistical analysis. • Data recoded • Age → 3 Age groups (0-15; 16-35; 36+years) • Country of origin → country groups (SSA; Other HIC >40/100 000; LIC <40/100 000 (WHO 2008) • Descriptive statistics • Frequencies; Data summaries; Graphics • Patient demographics • screening outcomes • Comparisons between groups

  11. Results • Literature review • 400 citations→21 included→15 Studies from 6 European countries(Switzerland; Ireland; Norway; Netherlands; Italy; UK; ) • Themes • Implementation of TB screening for ASaR (n=2) • Screening methods (n=2) • Screening uptake and follow-up (n=4) • Determinants of TB among ASaR (n=2) • TB incidence and prevalence (n=5) • BCG Coverage  • Retrospective Data review • 169 TB screening records reviewed • 148/169 (87.6%) screened for TB

  12. The Haven : Overview Launch: March 2004 • Purpose To meet initial primary health care needs of new ASaR in the Bristol and S/Glos areas • Location: • Shared office space in a Health centre • Team • 1 GP; 1 SpHV; 1 HA Nurse; 1 Admin support worker. • TB screening programme aims • Active TB; LTBI; BCG vaccination; Education

  13. TB screening activities and process • Commencing screening • Interviews ; X-rays for eligibles; TST (mantoux) selected group • Liaison: • TB nurses for follow/up; • Referrals ( in/out) • TB services; GP registration; Dispersal centres. • Home visits • BCG vaccination • Information and advice. • Developing guidelines

  14. TB Screening Uptake • 148/169 (87.6%) TB screened • From 25 different countries • SSA (42%) 62/148 • Other HIC 36% (54/148) of • LIC 22% • Mean age 29.4 years Number of ASaR who were screened for TB (n=148) by age group and country group of origin: The Haven 2008-2009

  15. TB diagnosis by country group of origin(n=9) TB diagnosis among ASaR who were screened for TB (n=9): The Haven 2008-2009 TB diagnosis by gender and age group(n=9) TB Prevalence: Combined= 6.1%; SSA 11.3% ; >40/100 000= 3.7%; < 40/100 000= 0%

  16. BCG vaccination coverage

  17. Screening outcomes for TST positive ASaR who were referred to respiratory physicians (n=13) by TST indurations

  18. Limitations/challenges • Literature review • Defining High risk countries: >40/100 000 ; >50/100 000; >100/100 000; • Possible underestimation of prevalence • Inconsistency in screening tools/methods • Retrospective data review • Uncertainties when using retrospective data (information bias) missing outcomes • Small sample size→ TB Prevalence- descriptive results to maintain patient confidentiality • Limited access to screening records • Resource constraints :Reduction in scope/ limited stakeholder views • Addressing challenges • Clear proposal and ethics: Evaluation question and outcome measures • Data collection pilot; rescheduling; continuous communication with staff • Patience and flexibility

  19. Conclusion • Programme Impact: Immediate outcomes • Good filter for TB diagnostic tests ( Limitations of using TST) •  Uptake/follow-up; 99.3% referrals; >99% GP registrations • Limited impact - undocumented immigrants • Appropriateness of TB screening goals: • Consistency between literature review findings and program goals • Screening guidelines and prioritised groups • ASAR subgroups- Factors in countries of origin; places of refuge; Global socioeconomic & political climate • Drivers for programme success • Service configuration; screening processes; prescription patterns • Staff size- experience; enthusiasm; overstretched • Limited accommodation; a very well perceived service

  20. Recommendations • Office accommodation • Vital service delivery from limited office accommodation • Evaluations of similar programmes • To generate understanding of most current evidence of good screening models • More user-friendly electronic records • Easy audit and research • One-stop shop screening services • Improve coordination between screening and prescription tasks • Audit of BCG vaccination • Vaccinate the unvaccinated to improve coverage among ASaR • GP involvement • TB assessment for new ASaR from HIC at registration

  21. Acknowledgements • SW (North) HPU • Avon Primary Care Research Collaborative • Dr Shantini Paranjothy- Cardiff University • Ginny Burdis – The Haven • Paola Sileno -The Haven • Avneet Singh -SW (North) HPU • Sam Organ-SW (North) HPU

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