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UK pre-entry tuberculosis screening brief report 2013
UK pre-entry tuberculosis screening brief report 2013
About Public Health England
Public Health England’s mission is to protect and improve the nation’s health and to address inequalities through working with national and local government, the NHS, industry and the voluntary and community sector. PHE is an operationally autonomous executive agency of the Department of Health.
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© Crown copyright 2013 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v2.0. To view this licence, visit OGL or email [email protected]. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Any enquiries regarding this publication should be sent to [email protected]
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Published November 2013 PHE publications gateway number: 2013399
This document is available in other formats on request. Please call 020 8327 7018 or email [email protected]
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UK pre-entry tuberculosis screening brief report 2013
Acknowledgements
We gratefully acknowledge the provision of data by the International Organisation for
Migration and individual panel physicians. We would also like to acknowledge the
successful collaboration with the UK Home Office, and in particular the great support
from Richard Postill at the Home Office.
We also acknowledge the help and support of Robert Sookoo, Dr Nicol Black,
Sophia Masud and Dr Graham Bickler of Port Health Unit in Heathrow.
We are thankful for support of Dr Lucy Thomas, Debora Pedrazzoli and Kunju Shaji
of TB Surveillance Unit for the provision of ETS data.
Authors This report was prepared by Dr Morris Muzyamba, Dr Rob Aldridge, Nnenna Ekeke,
Professor Ibrahim Abubakar and Dr Dominik Zenner – Tuberculosis Section (TB
Screening Unit), Centre for Infectious Disease Surveillance and Control, Public
Health England (PHE).
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UK pre-entry tuberculosis screening brief report 2013
Executive summary
Introduction Pre-entry TB screening for active pulmonary disease in all long-term visa applicants coming from high incidence countries to the UK has been rolled out from September 2012, following a successful pilot from October 2005. It is anticipated that roll out will be complete on 31 March 2014. The system will then replace the on-entry screening at UK airports, which will cease at the same time. Pre-entry screening is administered through the UK Home Office. Public Health England (PHE) collaborates with Home Office to support these activities through quality assurance activities.
This is the first report on UK pre-entry TB screening. It is based on data from overseas clinics for the period between October 2005 and June 2013. It is worth noting that there were data quality issues, particularly in data from providers who were not part of the International Organisation of Migration (IOM). It is anticipated and necessary to improve data collection and data collection tools in the near future.
Key findings A total of 688,706 applicants were screened between October 2005 and June 2013. The median age was 24 years and the largest proportion of applicants was in the 2024 years age group (36.4%). The majority of applicants were male (65.3%). The largest screening volumes were in Pakistan (51.4%), Bangladesh (25.6%), and Thailand (8.7%). The majority of screening during the observation period occurred in IOM clinics and it is likely that the screening volume and case finding on non-IOM clinics including those covering India is likely to increase significantly.
A total of 541 cases of TB amongst individuals screened overseas for the UK were reported between 2005 and 2013. TB rates were higher for females than males and highest in the older age groups although the greatest number of TB cases was highest amongst the 20 – 34 year olds and most cases detected were amongst individuals applying for student visas.
Conclusion In conclusion this report provides a first summary of pre-entry screening activities for the UK. As this system is currently being developed, a lot more work needs to be done to improve data collection and further analysis to explain the observed variations in screening yields.
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UK pre-entry tuberculosis screening brief report 2013
Introduction Tuberculosis (TB) rates have been increasing during the last decade in the UK and has now stabilised at a high level. However, the incidence of TB in the UK remains high compared to most other Western European countries. In 2012, 8,751 TB cases were reported in the UK, an incidence of 13.9/100,000.1 TB in the UK is concentrated in urban areas and amongst specific risk groups, such as persons with socio-economic risk factors and particularly those who were born or spend significant time in high TB incidence countries. The high levels of TB in the UK amongst non-UK born individuals have raised the interest for the screening of active and latent TB in this group.
This report provides an overview on the preliminary results and information on the pre-entry screening programme for active pulmonary TB (PTB) in the United Kingdom.
Pre-entry screening The pre-entry screening programme involves a mandatory PTB screening of persons applying for a long-term (>6 months) UK visa from high incidence TB countries (>40/100,000). This programme aims to identify cases of active pulmonary TB in prospective migrants before arrival into the UK. This scheme is not set up to detect latent TB. Following a successful pilot in 15 countries (see Table 1 below) in collaboration with the IOM, the UK Government decided in May 2012 to roll out pre-migration TB screening to a further 86 high TB incidence countries. The UK pre-entry screening scheme has been informed by and has close similarities with other pre-entry screening approaches, most notably those used by the other partner countries from the five-country conference (Australia, Canada, New Zealand, USA and UK).
Screening is carried out in one of the panel clinics approved for UK screening. PTB screening is based on chest x-rays (CXR) and symptom enquiry, followed by sputum collection for smear and culture, where TB is suspected. Applicants found to have PTB, are required to successfully complete treatment before they can proceed to visa application.
Quality Assurance Public Health England (PHE) in collaboration with the Home Office is developing a Quality Assurance (QA) system in order to ensure the pre-entry screening programme is “fit for purpose” in delivering its stated objectives. To inform
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UK pre-entry tuberculosis screening brief report 2013
performance management of overseas clinics, a comprehensive system incorporating three important components is being established:
• epidemiological analysis of clinical information from IOM and non-IOM clinics and data matching to the UK Enhanced TB Surveillance system
• teleradiology to enable routine second reading of x-rays taken overseas in the UK
• a clinic visit and outreach programme to selected countries and sites of high priority
Figure 1: Quality Assurance and Performance Management as a system
Data collection Data for the epidemiological analysis is routinely collected from two sources: IOM clinics through a centralised secure web-based data collection system and data from individual non-IOM providers. In addition, snapshot surveys are done to collect cumulative data, where there are information needs. This short report includes the results of such a snapshot survey in India, covering activity for a period of eight months (August 2012 - March 2013).
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UK pre-entry tuberculosis screening brief report 2013
Demographics of applicants Data was available for a total of 688,706 UK visa applicants, who were screened for PTB from October 2005 to June 2013. Of these 671,038 (97.43%) were screened by IOM and 17,668 (2.57%) by non-IOM clinics. Screening was carried out in 19 countries among applicants of 142 nationalities; 16 of the countries had only IOM-led clinics and in three countries there were only non-IOM providers.
Information on age and sex was available for 99.8% for IOM clinics and 46% for non-IOM clinics. Of all the applicants where sex was known (98.6%), just under two thirds were male (65.31%). The median age was 24 years and the age group with the largest number of applicants was 20 to 24 year olds (36.4%) followed by 25 to 29 year olds (27.6%). There were very few applicants in age groups over 44 years.
Figure 2 shows the yearly number of applicants screened in the various countries. Across all years, 50.2% of applicants were screened in Pakistan and 25.1% in Bangladesh. It is worth noting that this largely reflects the screening volumes during the pilot phase and the geographical distribution of applicants will change as the remaining countries come on line.
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UK pre-entry tuberculosis screening brief report 2013
Table 1: Countries: where UK pre-entry screening will be taking place and phase of roll out, when they started screening.
101 High Tuberculosis Incidence Countries
Afghanistan3 Georgia4 PakistanP
Algeria4 GhanaP Panama4
Angola3 Guatemala4 Papua New Guinea3
Armenia4 Guinea3 Paraguay4
Azerbaijan4 Guinea-Bissau3 Peru3
BangladeshP Guyana3 Philippines1
Belarus4 Haiti3 Russian Federation3
Benin4 India1 Rwanda3
Bhutan3 Indonesia2 Sao Tome and Principe1
Bolivia3 Iraq4 Senegal3
Botswana3 Kazakhstan3 Sierra Leone2
Brunei Darussalam4 KenyaP Solomon Islands3
Burkina FasoP Kiribati3 SomaliaP
Burma3 North Korea3 South Africa1
Burundi3 South Korea3 South Sudan4
CambodiaP Kyrgyzstan3 Sri Lanka4
Cameroon3 LaosP SudanP
Cape Verdi3 Lesotho1 Suriname3
Central African Rep3 Liberia3 Swaziland3
Chad3 Madagascar3 Tajikistan3
China, Hong Kong SAR3 Malawi2 TanzaniaP
China, Macau3 Malaysia1 ThailandP
China3 Mali1 East Timor3
Congo, Dem Rep (Zaire)3 Mauritania3 TogoP
Congo3 Micronesia3 Turkmenistan4
Cote D'IvoireP Moldova3 Tuvalu3
Djibouti3 Mongolia3 Uganda2
Dominican Republic4 Morocco2 Ukraine3
Ecuador3 Mozambique3 Uzbekistan3
Equatorial Guinea3 Namibia3 Vanuatu4
EritreaP Nepal3 Vietnam2
Ethiopia2 NigerP Zambia2
Gabon3 Nigeria3 Zimbabwe2
Gambia2 Palau4
1 Phase 1: Commenced May 2012 2 Phase 2: Commenced 1st July 2013 3 Phase 3: To be completed by December 2013 4 Phase 4: To commence March 2014 P Pilot pre-entry scheme
IOM Pilot (15 countries)
2006 2011
Phase 1 (8 countries)
Sep Dec 2012
Phase 2 (10 countries)
Dec 12 June 13
Phase 3 (Rest of world)
Jun 13 March 14
Cessation of Port Entry
screening at LHR
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UK pre-entry tuberculosis screening brief report 2013
Figure 2: Yearly distribution of notified screens from January 2006 to June 2013 N
umbe
r of
app
lican
ts
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0 2006 2007 2008 2009 2010 2011 2012 2013
19,711
0
22,185
50,251
23,457
61,897
58,996
55,948
23,879
68,157
15,659
66,286
9,078
38,657
*
3,303
12,624
¥
Bangladesh Ghana Kenya Nepal Other Pakistan Philippines South Africa Sudan Tanzania Thailand India
*India data from aggregate returns for 8 months; August 2012 to June 2013. Data may not be complete due to late returns.¥ Data for 6 months
Screening result
Of the 671,038 applicants screened by IOM clinics, 665,474 (99.2%) had a CXR done. Reasons for not having a CXR were only known for 2,464 (44.3%) of the 5,564 individuals where CXRs were not done. A total of 593 did not have CXR because they were pregnant and 1,871 because they were children under 11 years old (Figure 3).
A total of 28,544 (4.3 %) applicants had either old or new lesions, which were consistent with TB, and were referred for sputum examination. Since October 2005 amongst all applicants a total of 31,922 sputum tests were taken, including 3,642 for persons who did not undergo CXR screening. Of these, 508 (1.59%) were positive for tuberculosis. In addition, as of 15th September 2013, 31 sputum tests were inconclusive and 358 were still pending. Thirty-three cases were diagnosed clinically and in total 541 pulmonary TB cases were found between October 2005 and June 2013. In addition to the 28,544 applicants with abnormal CXRs consistent with TB, 11,170 had other, non-TB specific abnormalities recorded.
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UK pre-entry tuberculosis screening brief report 2013
During the observation period, the number of clearance certificates, but no clinical outcome information was available for non-IOM clinics. In total, 17,532 (99.2%) applicants were issued with clearance certificates from non-IOM providers during the observation time.
Figure 3: Screening activities for the IOM providers from October 2005 to June 2013
Conclusion This is the first report of UK pre-entry screening. It provides a useful overview of screening activities and outcomes, but also illustrates the limitations of data.
Between 2005 and June 2013, most applicants were screened by IOM providers. The vast majority of applicants were screened in the Indian sub-continent and this reflects both migration trends and the timeline of clinic establishment. Most visa applicants were male young adults and mainly students.
Only a minority of applicants did not receive CXRs and most of these were either pregnant females or children aged less than 11 years old.
The overall yield of TB cases amongst IOM applicants was 80.6 per 100,000 applicants. In conclusion this descriptive analysis of pre-entry screening activities for the UK demonstrates the feasibility of overseas screening to detect active pulmonary TB and quantifies its effect. This is the first report of these screening activities and there are some limitations, mainly around data quality. It is hoped that improvements in data collection systems will also improve data quality, helping to gain a more detailed understanding of overseas screening activities in the future.
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UK pre-entry tuberculosis screening brief report 2013
References 1. Public Health England (PHE). Tuberculosis in the UK: 2013 report. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317139689583. Accessed October 2013.
2. UK Tuberculosis Technical Instructions (UKTBTI). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/11794 6/tb-technical-instructions.pdf. Accessed October 2013
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