- Email: [email protected]
Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening
Journal of Hospital Infection xxx (2015) 1e3 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Opinion
Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening
For many months, hundreds of thousands of refugees have been fleeing to Western Europe from regions such as Syria, Iraq, Afghanistan, Eritrea, and the Balkan countries. In the first 10 months of 2015 there were 362,153 applications for asylum in Germany alone, with an unknown number of additional persons who had not yet applied for asylum, or who had not even registered.1 Providing adequate medical care for migrants has posed an enormous challenge to the healthcare systems of the transit and destination countries. In Germany, screening programmes have been implemented targeting several specific infectious diseases, i.e. scabies, pediculosis, tuberculosis, and in some federal states human immunodeficiency virus (HIV) and hepatitis B infection. An analysis revealed that the proportion of asylum seekers among tuberculosis cases significantly increased beginning in 2014, and health authorities expect a further rise in the future.2,3 Also, the number of persons from Africa and Eastern Europe with newly diagnosed HIV infection is rising.4 Despite widespread fear of importation of diseases by refugees, which is politically misused, so far there is no evidence of relevant transmission of these conditions from refugees to other persons.2,4,5 There have been observations of refugee patients with infections caused by MRSA or other multidrug-resistant organisms (MDROs) (Prof. Dr A. Stich, personal communication), and if the prevalence of MDROs in refugees resembled the experience from other disaster settings this would cause concerns due to the scope of the current crisis.6 However, at least within our university hospital healthcare system, a single MRSA isolate from an uncomplicated furuncle has been the only MDRO detected among refugee patients since September 2015, a period when more than 100,000 refugees were passing through Munich. Still, even if refugees were a high-risk patient group the majority would not be MDRO-carriers and significant absolute numbers might remain undetected in the absence of systematic screening.7 Therefore, considering the high number of potential healthcare contacts and the crowded living conditions, an evidence-based targeted strategy to screen for and treat MDROs in refugee patients appears desirable.6e9 This could also help to move the public focus from a general
sentiment of threat by the refugees towards concern about the health of individual patients. However, due to the virtually complete lack of refugee-specific data there is no guidance on how to address this. It may be possible to identify opportunities to systematically obtain the data needed by considering the different institutions that refugees will be in contact with in the city of Munich, Germany (Figure 1). Immediately upon arrival, and even before registration and distribution to other regions, refugees are offered a free medical examination [labelled (1) in Figure 1]. In Munich, about 8000 refugees made use of this offer every month in 2015, with a maximum of 62,000 patients in September 2015 (Dr S. Hilferink, personal communication). Whereas manifest infectious diseases may be diagnosed in the course of this examination, it is not suitable for routine screening for MDROs, most importantly because follow-up is virtually impossible. The mandatory health examination (2) performed by the health department (based on x62, German Asylum Procedure Act) following registration for refugees staying in Munich would be an opportunity for sentinel studies or even universal screening. In the absence of reliable data showing either a relevant risk by MDROs among refugees or cost-effectiveness of addressing the issue, it is unlikely that authorities will allocate additional funds and personnel for testing and follow-up of about 2200 persons every month. Also, even for already established testing (e.g. HIV), communication of results to patients often proves challenging. One reason for this is the various types of housing (3), accommodating up to 1200 persons in one facility, partly in temporary lightweight buildings, gyms, or other less than ideal conditions.10 Often, refugees are moved from one location to another, not only within a city, but also between cities or even between federal states. Nevertheless, outbreak investigations based in the housing facilities could provide important insights. Medical care for incident conditions is free of charge for registered refugees (based on x4 and x6, German Asylum Seekers Benefits Act). Outpatient care (4) is offered by a variety of providers, ranging from organizations contracted by the government to hospital clinics to private practitioners. Not even the number of these healthcare contacts is known at present, let alone robust information on diagnoses or details of the care. Again, inability to follow-up is an important issue preventing implementation or evaluation of MDRO screening in this setting. Inpatient hospital admission (5) screening therefore seems to be the most feasible option for MDRO screening among refugees, with a number of important advantages: (i) it is easily implementable; (ii) follow-up of inpatients is easy, and specific measures can be implemented immediately; (iii) it has the
http://dx.doi.org/10.1016/j.jhin.2015.11.014 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014
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Opinion / Journal of Hospital Infection xxx (2015) 1e3
Figure 1. Schematic representation of potential risks for multidrug-resistant organism (MDRO) acquisition and opportunities for MDRO detection among refugees arriving in Munich, Germany. x, health department; D, outpatient clinics and practices; H, hospital; HIV, human immunodeficiency virus; HBV, hepatitis B virus; CXR, chest X-ray; IGRA, interferon-g release assay; GI, gastrointestinal.
largest potential for a significant short-term impact, medically for the individual refugee, epidemiologically for other patients, and economically for the institution; (iv) data may be generated and published independently of the health departments. Sentinel studies, outbreak investigations and certainly hospital admission screening can help us to rapidly define the prevalence of and specific risk factors for colonization and infection by MDROs among refugees. These data will enable us to more efficiently target screening measures (if at all necessary) and to plan adequate antimicrobial therapy. Fear-based random or universal screening approaches are not acceptable alternatives. It is clear that we need to focus on specific threats to refugees, not those imagined to be posed by them. For better infection control we should specifically care for patients, not generally worry about bugs. Conflict of interest statement None declared. Funding sources None.
References 1. German Federal Office for Migration and Refugees. Press release. Available at: http://www.bamf.de/SharedDocs/Meldungen/DE/ 2015/20151106-asylgeschaeftsstatistik-oktober.html?nn¼1367522 [last accessed November 2015].
2. Michels H, Bartz C. Tuberkulose-Screening im Rahmen der infektionshygienischen Untersuchung Asylbegehrender in RheinlandPfalz, Trier [Tuberculosis screening by means of the infection control examination of asylum seekers in Rhineland-Palatinate, city of Trier]. Epid Bull 2015;11/12:88e89. 3. Robert Koch Institut. Thorax-Ro ¨ntgenuntersuchungen bei Asylsuchenden gema ¨ß x 36 Absatz 4 IfSG. Stellungahme des Robert KochInstituts [Chest X-ray studies for asylum seekers according to x 36 section 4 Infection Protection Act. Statement of the Robert Koch Institute]. Available at: http://www.rki.de/DE/Content/InfAZ/T/ Tuberkulose/Tuberkulose_Roentgen-Untersuchungen_ Asylsuchende.html; jsessionid¼1C0F54CB33FE403F9CA77C476605D583.2_cid390? nn¼2375460 [last accessed October 2015]. 4. Robert Koch Institut. Scha ¨tzung der Pra ¨valenz und Inzidenz von HIV-Infektionen in Deutschland, Stand Ende 2014 [Estimate of prevalence and incidence of HIV-infections in Germany, end of 2014]. Epid Bull 2015;45:475e486. 5. Fro ¨hlich A. Bu ¨rgermeister bezeichnet Flu ¨chtlinge als ansteckend [Mayor calls refugees contagious]. Available at: http://www. tagesspiegel.de/berlin/jueterbog-in-brandenburgbuergermeister-bezeichnet-fluechtlinge-als-ansteckend/ 12557320.html. Der Tagesspiegel online November 11th, 2015. 6. Seybold U, White N, Wang YF, Halvosa JS, Blumberg HM. Colonization with multidrug-resistant organisms in evacuees after Hurricane Katrina. Infect Control Hosp Epidemiol 2007;28:726e729. 7. Kaspar T, Schweiger A, Droz S, Marschall J. Colonization with resistant microorganisms in patients transferred from abroad: who needs to be screened? Antimicrob Resist Infect Control 2015;4:31. 8. Seybold U, Schubert S, Bogner JR, Hogardt M. Staphylococcus aureus infection following nasal colonization: an approach to rapid
Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014
Opinion / Journal of Hospital Infection xxx (2015) 1e3 risk stratification in a university healthcare system. J Hosp Infect 2011;79:297e301. 9. Cairns S, Packer S, Reilly J, Leanord A. Targeted MRSA screening can be as effective as universal screening. BMJ 2014;349:g5075. 10. City of Munich. Flu ¨chtlingsunterku ¨nfte in Mu ¨nchen [Accomodation for refugees in Munich]. Available at: http://www.muenchen.de/ rathaus/Stadtverwaltung/Sozialreferat/Fluechtlinge/ Unterkuenfte.html [last accessed October 2015].
U. Seybolda,* J. Wagenerb J. Jungb S. Sammeta a Ludwig-Maximilians-Universita¨t, Division of Infectious Diseases, Medizinische Klinik und Poliklinik IV e Klinikum der Universita¨t, Munich, Germany
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Ludwig-Maximilians-Universita¨t, Max von PettenkoferInstitute of Hygiene and Medical Microbiology, Department of Bacteriology, Munich, Germany * Corresponding author. Address: Division of Infectious Diseases, Medizinische Klinik und Poliklinik IV, Klinikum der Universita ¨t, Ludwig-Maximilians-University, Pettenkoferstr. 8a, D- 80336 Munich, Germany. Tel.: þ49 89 4400 53550; fax: þ49 89 4400 53593. E-mail address: [email protected] (U. Seybold) Available online xxx
Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Opinion
Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening
For many months, hundreds of thousands of refugees have been fleeing to Western Europe from regions such as Syria, Iraq, Afghanistan, Eritrea, and the Balkan countries. In the first 10 months of 2015 there were 362,153 applications for asylum in Germany alone, with an unknown number of additional persons who had not yet applied for asylum, or who had not even registered.1 Providing adequate medical care for migrants has posed an enormous challenge to the healthcare systems of the transit and destination countries. In Germany, screening programmes have been implemented targeting several specific infectious diseases, i.e. scabies, pediculosis, tuberculosis, and in some federal states human immunodeficiency virus (HIV) and hepatitis B infection. An analysis revealed that the proportion of asylum seekers among tuberculosis cases significantly increased beginning in 2014, and health authorities expect a further rise in the future.2,3 Also, the number of persons from Africa and Eastern Europe with newly diagnosed HIV infection is rising.4 Despite widespread fear of importation of diseases by refugees, which is politically misused, so far there is no evidence of relevant transmission of these conditions from refugees to other persons.2,4,5 There have been observations of refugee patients with infections caused by MRSA or other multidrug-resistant organisms (MDROs) (Prof. Dr A. Stich, personal communication), and if the prevalence of MDROs in refugees resembled the experience from other disaster settings this would cause concerns due to the scope of the current crisis.6 However, at least within our university hospital healthcare system, a single MRSA isolate from an uncomplicated furuncle has been the only MDRO detected among refugee patients since September 2015, a period when more than 100,000 refugees were passing through Munich. Still, even if refugees were a high-risk patient group the majority would not be MDRO-carriers and significant absolute numbers might remain undetected in the absence of systematic screening.7 Therefore, considering the high number of potential healthcare contacts and the crowded living conditions, an evidence-based targeted strategy to screen for and treat MDROs in refugee patients appears desirable.6e9 This could also help to move the public focus from a general
sentiment of threat by the refugees towards concern about the health of individual patients. However, due to the virtually complete lack of refugee-specific data there is no guidance on how to address this. It may be possible to identify opportunities to systematically obtain the data needed by considering the different institutions that refugees will be in contact with in the city of Munich, Germany (Figure 1). Immediately upon arrival, and even before registration and distribution to other regions, refugees are offered a free medical examination [labelled (1) in Figure 1]. In Munich, about 8000 refugees made use of this offer every month in 2015, with a maximum of 62,000 patients in September 2015 (Dr S. Hilferink, personal communication). Whereas manifest infectious diseases may be diagnosed in the course of this examination, it is not suitable for routine screening for MDROs, most importantly because follow-up is virtually impossible. The mandatory health examination (2) performed by the health department (based on x62, German Asylum Procedure Act) following registration for refugees staying in Munich would be an opportunity for sentinel studies or even universal screening. In the absence of reliable data showing either a relevant risk by MDROs among refugees or cost-effectiveness of addressing the issue, it is unlikely that authorities will allocate additional funds and personnel for testing and follow-up of about 2200 persons every month. Also, even for already established testing (e.g. HIV), communication of results to patients often proves challenging. One reason for this is the various types of housing (3), accommodating up to 1200 persons in one facility, partly in temporary lightweight buildings, gyms, or other less than ideal conditions.10 Often, refugees are moved from one location to another, not only within a city, but also between cities or even between federal states. Nevertheless, outbreak investigations based in the housing facilities could provide important insights. Medical care for incident conditions is free of charge for registered refugees (based on x4 and x6, German Asylum Seekers Benefits Act). Outpatient care (4) is offered by a variety of providers, ranging from organizations contracted by the government to hospital clinics to private practitioners. Not even the number of these healthcare contacts is known at present, let alone robust information on diagnoses or details of the care. Again, inability to follow-up is an important issue preventing implementation or evaluation of MDRO screening in this setting. Inpatient hospital admission (5) screening therefore seems to be the most feasible option for MDRO screening among refugees, with a number of important advantages: (i) it is easily implementable; (ii) follow-up of inpatients is easy, and specific measures can be implemented immediately; (iii) it has the
http://dx.doi.org/10.1016/j.jhin.2015.11.014 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014
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Opinion / Journal of Hospital Infection xxx (2015) 1e3
Figure 1. Schematic representation of potential risks for multidrug-resistant organism (MDRO) acquisition and opportunities for MDRO detection among refugees arriving in Munich, Germany. x, health department; D, outpatient clinics and practices; H, hospital; HIV, human immunodeficiency virus; HBV, hepatitis B virus; CXR, chest X-ray; IGRA, interferon-g release assay; GI, gastrointestinal.
largest potential for a significant short-term impact, medically for the individual refugee, epidemiologically for other patients, and economically for the institution; (iv) data may be generated and published independently of the health departments. Sentinel studies, outbreak investigations and certainly hospital admission screening can help us to rapidly define the prevalence of and specific risk factors for colonization and infection by MDROs among refugees. These data will enable us to more efficiently target screening measures (if at all necessary) and to plan adequate antimicrobial therapy. Fear-based random or universal screening approaches are not acceptable alternatives. It is clear that we need to focus on specific threats to refugees, not those imagined to be posed by them. For better infection control we should specifically care for patients, not generally worry about bugs. Conflict of interest statement None declared. Funding sources None.
References 1. German Federal Office for Migration and Refugees. Press release. Available at: http://www.bamf.de/SharedDocs/Meldungen/DE/ 2015/20151106-asylgeschaeftsstatistik-oktober.html?nn¼1367522 [last accessed November 2015].
2. Michels H, Bartz C. Tuberkulose-Screening im Rahmen der infektionshygienischen Untersuchung Asylbegehrender in RheinlandPfalz, Trier [Tuberculosis screening by means of the infection control examination of asylum seekers in Rhineland-Palatinate, city of Trier]. Epid Bull 2015;11/12:88e89. 3. Robert Koch Institut. Thorax-Ro ¨ntgenuntersuchungen bei Asylsuchenden gema ¨ß x 36 Absatz 4 IfSG. Stellungahme des Robert KochInstituts [Chest X-ray studies for asylum seekers according to x 36 section 4 Infection Protection Act. Statement of the Robert Koch Institute]. Available at: http://www.rki.de/DE/Content/InfAZ/T/ Tuberkulose/Tuberkulose_Roentgen-Untersuchungen_ Asylsuchende.html; jsessionid¼1C0F54CB33FE403F9CA77C476605D583.2_cid390? nn¼2375460 [last accessed October 2015]. 4. Robert Koch Institut. Scha ¨tzung der Pra ¨valenz und Inzidenz von HIV-Infektionen in Deutschland, Stand Ende 2014 [Estimate of prevalence and incidence of HIV-infections in Germany, end of 2014]. Epid Bull 2015;45:475e486. 5. Fro ¨hlich A. Bu ¨rgermeister bezeichnet Flu ¨chtlinge als ansteckend [Mayor calls refugees contagious]. Available at: http://www. tagesspiegel.de/berlin/jueterbog-in-brandenburgbuergermeister-bezeichnet-fluechtlinge-als-ansteckend/ 12557320.html. Der Tagesspiegel online November 11th, 2015. 6. Seybold U, White N, Wang YF, Halvosa JS, Blumberg HM. Colonization with multidrug-resistant organisms in evacuees after Hurricane Katrina. Infect Control Hosp Epidemiol 2007;28:726e729. 7. Kaspar T, Schweiger A, Droz S, Marschall J. Colonization with resistant microorganisms in patients transferred from abroad: who needs to be screened? Antimicrob Resist Infect Control 2015;4:31. 8. Seybold U, Schubert S, Bogner JR, Hogardt M. Staphylococcus aureus infection following nasal colonization: an approach to rapid
Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014
Opinion / Journal of Hospital Infection xxx (2015) 1e3 risk stratification in a university healthcare system. J Hosp Infect 2011;79:297e301. 9. Cairns S, Packer S, Reilly J, Leanord A. Targeted MRSA screening can be as effective as universal screening. BMJ 2014;349:g5075. 10. City of Munich. Flu ¨chtlingsunterku ¨nfte in Mu ¨nchen [Accomodation for refugees in Munich]. Available at: http://www.muenchen.de/ rathaus/Stadtverwaltung/Sozialreferat/Fluechtlinge/ Unterkuenfte.html [last accessed October 2015].
U. Seybolda,* J. Wagenerb J. Jungb S. Sammeta a Ludwig-Maximilians-Universita¨t, Division of Infectious Diseases, Medizinische Klinik und Poliklinik IV e Klinikum der Universita¨t, Munich, Germany
3
b
Ludwig-Maximilians-Universita¨t, Max von PettenkoferInstitute of Hygiene and Medical Microbiology, Department of Bacteriology, Munich, Germany * Corresponding author. Address: Division of Infectious Diseases, Medizinische Klinik und Poliklinik IV, Klinikum der Universita ¨t, Ludwig-Maximilians-University, Pettenkoferstr. 8a, D- 80336 Munich, Germany. Tel.: þ49 89 4400 53550; fax: þ49 89 4400 53593. E-mail address: [email protected] (U. Seybold) Available online xxx
Please cite this article in press as: Seybold U, et al., Multidrug-resistant organisms among refugees in Germany: we need evidence-based care, not fear-based screening, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.11.014