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Tuberculosis screening and prevention in new immigrants 1983–88
Respiratory Medich, e (1990) 84, 269-271
Tuberculosis screening and prevention in new immigrants 1983-88 L. P. ORMEROD Chest Clinic, Blackburn Royal lnfirmary, Lancashire BB2 3LR, U.K.
Altiaough only 11 cases of active tuberculosis in new immigrants were found, 29.9% of those aged under 30 were tuberculin negative on entry and were given BCG vaccination. In addition 12.8% of children aged under 16 were strongly tuberculin positive and were given chemoprophylaxis. The defects of the official Port of Arrival system for reporting new immigrants are discussed. Entry screening of new immigrants allows worthwhile preventive action, BCG vaccination or chemoprophylaxis, in a substantial proportion of those screened.
Introduction Immigrants to the U.K. particularly from the Indian Subcontinent (ISC) have much higher incidence of tuberculosis than in the white population (1,2), the maximal incidence being between 2 and 5 years after initial entry (1-3). The Medical Officer for Environmental Health is informed of new immigrants through the Port of Arrival (POA) system, under the Commonwealth Immigration Act of 1971. Only a proportion of new long-stay immigrants are X-rayed on or prior to arrival, and the destination address given on the POA form is often only a staging address. Due to the greatly increased incidence of tuberculosis in the ISC ethnic group in particular, it is important that tuberculosis screening and prevention are carried out for this group. To try and obtain greater coverage of new immigrants, an arrangement was made in 1982 between the Blackburn, Hyndburn and Ribble Valley District Health Authority and our local Family Practitioner Committee (FPC), that our tuberculosis coordinator would be sent a monthly list of all new immigrant names (excluding new births) coming onto GP lists in
our health authority. These persons were visited by a health visitor and if they were recent arrivals to the country, tuberculosis screening was arranged. Our experience and results over the last 6 years are reported.
Methods Information on the arrival of new immigrants was found through either the POA or FPC systems. Those found by both systems were recorded under the POA system. The FPC referalls are those solely identified by local rather than the otficial POA channels. A tuberculin test [Tine; Lederle (4)] was administered at home, read in the weekly TB contact clinic 72 hours later by a consultant chest physician and a chest X-ray taken on those not X-rayed at the airport. The age, country of origin, and tuberculin test result were recorded for all patients seen. BCG vaccination was carried out for those aged under 30 years who had a negative tuberculin test. Children aged 0-15 whose tuberculin test was grade 2--4 positive without, or grade 3-4 positive with a
Table I Details ofyear seen and identifying system Year 1983 1984 1985 1986 1987 1988 Subtotal(ofeach group) Total(ofboth groups)
No. at Port of arrival
No. at Family Practitioner Committee
200 228 188 125 135 209 1085
136 143 157 100 211 199 948 2033
Received10July 1989and accepted26 January 1990. 0954-6111/90/040269+ 03 $03.00/0
9 1990Bailli~reTindall
270
L. P. O r m e r o d
history of BCG vaccination were given chemoprophylaxis using reported regimens (5). The remaining adults and children were followed-up by X-rays over a 2-year period.
Results Table I shows the number of immigrants screened in the years 1983-88, and from which system they were identified. Table 2 gives the countries of origin and the
Details of country of origin. Of those not traced: 146 gave nonexistent address (54 FPC and 92 POA); 121 had moved within U.K. before screening (62 FPC and POA 59); and 75 had returned to the ISC before screening (45 FPC and 30 POA) Table 2
Country of origin
Number
Pakistan India East Africa Rest of World*
876 576 96 143 1691 342
Total
screened
Discussion
*Hang Kong 5 t; Bangladesh 45; PhiLippines 6; China, Israel and /ran 5 each; Sri Lanka 4; Vietnam and Thailand 3 each; Singapore, Mauritius and Oman 2 each; Mexico, Qatar, Malaysia, Russia, Kuwait, Gambia, Argentina and Czechoslovakia 1 each.
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There is little published information on skin tuberculosis reactivity in new immigrants in the U.K. A survey from Harrow (6), in mainly East African Asians, including some on arrival, showed 98% were tuberculin negative at age 0-4, falling to 73.5% for age ( c ) East Africa
Indian
(b)
/'9 76
B C G v a c c i n a t i o n was given to 20/69 ( 2 9 % ) f r o m E a s t
Africa, 106/486 ( 2 1 . 4 % ) from India, 2 4 9 / 7 1 0 (35. I % ) from Pakistan, and 38/114 ( 3 3 % ) from the Rest of the W o r l d . O f traced visitors, 1379/1691 ( 8 1 . 5 % ) were aged under 30 years. Chemoprophylaxis w a s given to 40/322 (12.8%) children screened. Table 3 shows the entry screening results of the 57 cases of tuberculosis occurring in immigrants entering the U.K. between 1983 and 1988. These comprised 11 cases found on entry, 19 f o u n d to be clear on screening but who subseque~tly developed TB and 27 w h o presented de nova w i t h TB who had not been screened.
not traced
2033
(a) Pakistani
number of patients who could not be traced despite all efforts. Figure 1 gives the tuberculin test results by age for Pakistani, Indian, East African (of ISC ethnic origin) and the Rest of the World ethnic groups respectively. In the 6-year period 11 cases of tuberculosis were found on initial screening, and nine patients with abnormal chest X-rays were transferred to the Chest Clinic for investigation and follow-up. In addition, cases of malaria (3), rheumatic heart disease (2), congenital heart disease, hepatitis A and h e p a t o p u l m o n a r y amoebiasis (one each) were identified.
,
? ~ Age (years)
~" § ~
T o
'~ ~ ~
i
~§ ~, o~
,~
Age (years)
Fig. 1 Tuberculin test results according to age [by percentage of total (n) for each age band] and ethnic group (Tuberculin
test grade: m, 4; N, 3; m, 2; ~t, 1; rn, 0).
Tuberculosis screening on new immigrants Table 3
271
Entry screening of tuberculosis cases notified after entry 1983-88 Tuberculin test
Year entry
Found on entry
0
1
2
3
1983 1984 1985 1986 1987 1988
1 3 I 2 1 3
0 0 0 0 0 0
0 1 5 0 0 0
I 2 0 1 0 0
1 2 1 1 0 0
1 3 0 0 0 0
6 4 8 7 1 0
Totals
11
0
6
4
5
4
27
5-14 and to 38.5% by age 15-24. In Blackburn over 80% of new immigrants are aged under 30, and between 21.5 and 35.1% are tuberculin negative on entry. Although the number of cases of active tuberculosis found on entry was small (6.5 cases/1000), entry screening is clearly worthwhile since preventive measures against the development o f tuberculosis were possible in many cases. Of children 12.8% required chemoprophylaxis (7), the widespread use of which has reduced paediatric tuberculosis in the district (5). Similarly, BCG vaccination was possible for tuberculin negative individuals, this having a protective effect compared with the non-vaccinated, particularly in children (8). The current system for identifying new immigrants and arranging screening is clearly unsatisfactory, only 55% of new immigrants in this survey were identified through the official P O A system. An arrangement with the local FPC increased the new immigrants known to us by 45%. Even with the additional local FPC system however, some 15% failed to be screened for various reasons (Table 2). The ISC population of Blackburn is relatively stable, but in inner city areas the greater population mobility increases the difficulty of such screening programmes. TB Health visitors or community nursing input is essential for this form of screening, and shows that there is still a role for such staff. Although few cases of active tuberculosis were identified on entry, preventive intervention by BCG vaccination (240/1000) or chemoprophylaxis (47/
Not screened
1000) was possible in large numbers of children and young adults. It is possible that the continuing decline in tuberculosis incidence in the U.K. could be further accelerated by targeted preventive measures such as those described, to further reduce the incidence in these high risks groups (1-3). References
1. Medical Research Council Tuberculosis and Chest Diseases Unit. A National Survey of tuberculosis notifications in England and Wales 1978-9. Br MedJ 1980: 281: 895-898. 2. Medical Research Council Tuberculosis and Chest Diseases Unit. National Survey of notifications of tuberculosis in England and Wales 1983. Br MedJ 1985; 291: 658-661. 3. British Thoracic and Tuberculosis Association. Tuberculosis amongst immigrants related to length of residence in England and Wales. Br MedJ 1975; 3: 698-699. 4. Rudd RM, Gellert AR, Venning M. Comparison of Mantoux, Tine and 'Imotest' tuberculin tests. Lancet 1982; i1: 515-518. 5. Ormerod LP. Reduced incidence of paediatric tuberculosis following prophylactic chemotherapy in strongly tuberculin positive children. Arch Dis Child 1987; 62: 1005-I008. 6. Grenville-Mathers R, Clark JB. The development of tuberculosis in Afro-Asian immigrants. Tubercle 1979; 60: 25-29. 7. Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis; a code of practice. Br Med J 1983; 287:1118-1121. 8. Packe GE, Innes JA. Protective effect of BCG vaccination in infant Asians: a case-control study. Arch Dis Child 1988; 63:277-281.
Tuberculosis screening and prevention in new immigrants 1983-88 L. P. ORMEROD Chest Clinic, Blackburn Royal lnfirmary, Lancashire BB2 3LR, U.K.
Altiaough only 11 cases of active tuberculosis in new immigrants were found, 29.9% of those aged under 30 were tuberculin negative on entry and were given BCG vaccination. In addition 12.8% of children aged under 16 were strongly tuberculin positive and were given chemoprophylaxis. The defects of the official Port of Arrival system for reporting new immigrants are discussed. Entry screening of new immigrants allows worthwhile preventive action, BCG vaccination or chemoprophylaxis, in a substantial proportion of those screened.
Introduction Immigrants to the U.K. particularly from the Indian Subcontinent (ISC) have much higher incidence of tuberculosis than in the white population (1,2), the maximal incidence being between 2 and 5 years after initial entry (1-3). The Medical Officer for Environmental Health is informed of new immigrants through the Port of Arrival (POA) system, under the Commonwealth Immigration Act of 1971. Only a proportion of new long-stay immigrants are X-rayed on or prior to arrival, and the destination address given on the POA form is often only a staging address. Due to the greatly increased incidence of tuberculosis in the ISC ethnic group in particular, it is important that tuberculosis screening and prevention are carried out for this group. To try and obtain greater coverage of new immigrants, an arrangement was made in 1982 between the Blackburn, Hyndburn and Ribble Valley District Health Authority and our local Family Practitioner Committee (FPC), that our tuberculosis coordinator would be sent a monthly list of all new immigrant names (excluding new births) coming onto GP lists in
our health authority. These persons were visited by a health visitor and if they were recent arrivals to the country, tuberculosis screening was arranged. Our experience and results over the last 6 years are reported.
Methods Information on the arrival of new immigrants was found through either the POA or FPC systems. Those found by both systems were recorded under the POA system. The FPC referalls are those solely identified by local rather than the otficial POA channels. A tuberculin test [Tine; Lederle (4)] was administered at home, read in the weekly TB contact clinic 72 hours later by a consultant chest physician and a chest X-ray taken on those not X-rayed at the airport. The age, country of origin, and tuberculin test result were recorded for all patients seen. BCG vaccination was carried out for those aged under 30 years who had a negative tuberculin test. Children aged 0-15 whose tuberculin test was grade 2--4 positive without, or grade 3-4 positive with a
Table I Details ofyear seen and identifying system Year 1983 1984 1985 1986 1987 1988 Subtotal(ofeach group) Total(ofboth groups)
No. at Port of arrival
No. at Family Practitioner Committee
200 228 188 125 135 209 1085
136 143 157 100 211 199 948 2033
Received10July 1989and accepted26 January 1990. 0954-6111/90/040269+ 03 $03.00/0
9 1990Bailli~reTindall
270
L. P. O r m e r o d
history of BCG vaccination were given chemoprophylaxis using reported regimens (5). The remaining adults and children were followed-up by X-rays over a 2-year period.
Results Table I shows the number of immigrants screened in the years 1983-88, and from which system they were identified. Table 2 gives the countries of origin and the
Details of country of origin. Of those not traced: 146 gave nonexistent address (54 FPC and 92 POA); 121 had moved within U.K. before screening (62 FPC and POA 59); and 75 had returned to the ISC before screening (45 FPC and 30 POA) Table 2
Country of origin
Number
Pakistan India East Africa Rest of World*
876 576 96 143 1691 342
Total
screened
Discussion
*Hang Kong 5 t; Bangladesh 45; PhiLippines 6; China, Israel and /ran 5 each; Sri Lanka 4; Vietnam and Thailand 3 each; Singapore, Mauritius and Oman 2 each; Mexico, Qatar, Malaysia, Russia, Kuwait, Gambia, Argentina and Czechoslovakia 1 each.
96
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::::::::..:..'. 60
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.....v....
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:::::::::::: ::::::::::::
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Age (years)
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EE:iEE:J:iEi E:i:E:E:E:i:
80 ~:::::::
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( d ) Rest of World
/7
n
IO0 n ~ J
A
There is little published information on skin tuberculosis reactivity in new immigrants in the U.K. A survey from Harrow (6), in mainly East African Asians, including some on arrival, showed 98% were tuberculin negative at age 0-4, falling to 73.5% for age ( c ) East Africa
Indian
(b)
/'9 76
B C G v a c c i n a t i o n was given to 20/69 ( 2 9 % ) f r o m E a s t
Africa, 106/486 ( 2 1 . 4 % ) from India, 2 4 9 / 7 1 0 (35. I % ) from Pakistan, and 38/114 ( 3 3 % ) from the Rest of the W o r l d . O f traced visitors, 1379/1691 ( 8 1 . 5 % ) were aged under 30 years. Chemoprophylaxis w a s given to 40/322 (12.8%) children screened. Table 3 shows the entry screening results of the 57 cases of tuberculosis occurring in immigrants entering the U.K. between 1983 and 1988. These comprised 11 cases found on entry, 19 f o u n d to be clear on screening but who subseque~tly developed TB and 27 w h o presented de nova w i t h TB who had not been screened.
not traced
2033
(a) Pakistani
number of patients who could not be traced despite all efforts. Figure 1 gives the tuberculin test results by age for Pakistani, Indian, East African (of ISC ethnic origin) and the Rest of the World ethnic groups respectively. In the 6-year period 11 cases of tuberculosis were found on initial screening, and nine patients with abnormal chest X-rays were transferred to the Chest Clinic for investigation and follow-up. In addition, cases of malaria (3), rheumatic heart disease (2), congenital heart disease, hepatitis A and h e p a t o p u l m o n a r y amoebiasis (one each) were identified.
,
? ~ Age (years)
~" § ~
T o
'~ ~ ~
i
~§ ~, o~
,~
Age (years)
Fig. 1 Tuberculin test results according to age [by percentage of total (n) for each age band] and ethnic group (Tuberculin
test grade: m, 4; N, 3; m, 2; ~t, 1; rn, 0).
Tuberculosis screening on new immigrants Table 3
271
Entry screening of tuberculosis cases notified after entry 1983-88 Tuberculin test
Year entry
Found on entry
0
1
2
3
1983 1984 1985 1986 1987 1988
1 3 I 2 1 3
0 0 0 0 0 0
0 1 5 0 0 0
I 2 0 1 0 0
1 2 1 1 0 0
1 3 0 0 0 0
6 4 8 7 1 0
Totals
11
0
6
4
5
4
27
5-14 and to 38.5% by age 15-24. In Blackburn over 80% of new immigrants are aged under 30, and between 21.5 and 35.1% are tuberculin negative on entry. Although the number of cases of active tuberculosis found on entry was small (6.5 cases/1000), entry screening is clearly worthwhile since preventive measures against the development o f tuberculosis were possible in many cases. Of children 12.8% required chemoprophylaxis (7), the widespread use of which has reduced paediatric tuberculosis in the district (5). Similarly, BCG vaccination was possible for tuberculin negative individuals, this having a protective effect compared with the non-vaccinated, particularly in children (8). The current system for identifying new immigrants and arranging screening is clearly unsatisfactory, only 55% of new immigrants in this survey were identified through the official P O A system. An arrangement with the local FPC increased the new immigrants known to us by 45%. Even with the additional local FPC system however, some 15% failed to be screened for various reasons (Table 2). The ISC population of Blackburn is relatively stable, but in inner city areas the greater population mobility increases the difficulty of such screening programmes. TB Health visitors or community nursing input is essential for this form of screening, and shows that there is still a role for such staff. Although few cases of active tuberculosis were identified on entry, preventive intervention by BCG vaccination (240/1000) or chemoprophylaxis (47/
Not screened
1000) was possible in large numbers of children and young adults. It is possible that the continuing decline in tuberculosis incidence in the U.K. could be further accelerated by targeted preventive measures such as those described, to further reduce the incidence in these high risks groups (1-3). References
1. Medical Research Council Tuberculosis and Chest Diseases Unit. A National Survey of tuberculosis notifications in England and Wales 1978-9. Br MedJ 1980: 281: 895-898. 2. Medical Research Council Tuberculosis and Chest Diseases Unit. National Survey of notifications of tuberculosis in England and Wales 1983. Br MedJ 1985; 291: 658-661. 3. British Thoracic and Tuberculosis Association. Tuberculosis amongst immigrants related to length of residence in England and Wales. Br MedJ 1975; 3: 698-699. 4. Rudd RM, Gellert AR, Venning M. Comparison of Mantoux, Tine and 'Imotest' tuberculin tests. Lancet 1982; i1: 515-518. 5. Ormerod LP. Reduced incidence of paediatric tuberculosis following prophylactic chemotherapy in strongly tuberculin positive children. Arch Dis Child 1987; 62: 1005-I008. 6. Grenville-Mathers R, Clark JB. The development of tuberculosis in Afro-Asian immigrants. Tubercle 1979; 60: 25-29. 7. Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis; a code of practice. Br Med J 1983; 287:1118-1121. 8. Packe GE, Innes JA. Protective effect of BCG vaccination in infant Asians: a case-control study. Arch Dis Child 1988; 63:277-281.