The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review

Abstract

BackgroundMigrants account for a large and growing proportion of tuberculosis (TB) cases in low-incidence countries in the European Union/European Economic Area (EU/EEA) which are primarily due to reactivation of latent TB infection (LTBI). Addressing LTBI among migrants will be critical to achieve TB elimination. Methods: We conducted a systematic review to determine effectiveness (performance of diagnostic tests, efficacy of treatment, uptake and completion of screening and treatment) and a second systematic review on cost-effectiveness of LTBI screening programmes for migrants living in the EU/EEA. Results: We identified seven systematic reviews and 16 individual studies that addressed our aims. Tuberculin skin tests and interferon gamma release assays had high sensitivity (79%) but when positive, both tests poorly predicted the development of active TB (incidence rate ratio: 2.07 and 2.40, respectively). Different LTBI treatment regimens had low to moderate efficacy but were equivalent in preventing active TB. Rifampicin-based regimens may be preferred because of lower hepatotoxicity (risk ratio = 0.15) and higher completion rates (82% vs 69%) compared with isoniazid. Only 14.3% of migrants eligible for screening completed treatment because of losses along all steps of the LTBI care cascade. Limited economic analyses suggest that the most cost-effective approach may be targeting young migrants from high TB incidence countries. Discussion: The effectiveness of LTBI programmes is limited by the large pool of migrants with LTBI, poorly predictive tests, long treatments and a weak care cascade. Targeted LTBI programmes that ensure high screening uptake and treatment completion will have greatest individual and public health benefit.

Cost-effectiveness of IGRA/QFT-Plus for TB screening of migrants in Oman

“…A recent review of treatment of LTBI in migrants found that overall poor compliance was key to poor performance (Greenaway et al, 2018). This is also emphasized in the analysis presented in the present study, which clearly demonstrated that cost-effectiveness depends on good compliance; community support is needed to increase compliance (Migliori et al, 2019).…”

“…Screening can be performed based on stratification by epidemiological risk factors (country of origin, time since arrival), demographic factors (age groups), co-morbidities, or social risk factors. There is no consensus on thresholds (Greenaway et al, 2018), and practices vary significantly between countries (Kunst Table 1 Incidence of imported TB in Oman 2018.…”

Tuberculosis screening during the 2015 European refugee crisis

“…In this context, screening for tuberculosis (TB) offered the opportunity to provide appropriate treatment of this severe infectious disease [8,9]. Different modes of screening are available for screening for TB, such as medical examination, chest X-ray (CXR), tuberculin skin testing or interferon gamma release essay (IGRA) [11][12][13]. According to the German Protection against Infection Act [14] and the German Asylum Procedure Act [15], refugees or asylum seekers staying in shared-accommodation are obligated to participate in examinations to exclude communicable diseases.…”

High Incidence of Active Tuberculosis in Asylum Seekers from Eritrea and Somalia in the First 5 Years after Arrival in the Netherlands

“…A study conducted in 11 selected countries of Europe indicated that these countries had very different methods and policies for migrant TB or LTBI screening (22). Systematic reviews have demonstrated that limited information is available on the yield and effectiveness of migrant LTBI screening (22,23). Furthermore, cost-effectiveness of LTBI screening as predicted in mathematical models is highly setting-specific, with best results achieved if restricted to migrants from high-incidence countries (24).…”