Faustina Montsho-HammondHealth Protection Nurse Practitioner: SW(North) HPU

03/11/2011

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Project ApprovalCardiff University- School of Medicine

Avon Primary Care Research Collaborative

Background and public health importance of TB screening

Evaluation question and sub-questions Evaluation method and model Findings and conclusions Some challenges/limitations Recommendations

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

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A third of the world population (>2 billion)is infected with TB1 in 10 will develop active disease in their lifetime

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published and unpublished studies on TB screening for ASaR in Europe.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.

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• Structured literature review• Published and unpublished literature on TB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

Adaptation of Donabedian’s model (2003) 7

Process·TB screening process and protocol

·Programme activities

Outcome: ·Screening uptake

·Diagnosis of active TB ·Diagnosis of LTBI

· BCG Vaccination·TB information and advice

·Referrals

Structure·Programme Overview

·Inputs·Patient demographics

Environment

Socio-political context

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

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

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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

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

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; Education12

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

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Number of ASaR who were screened for TB (n=148) by age group and country group of origin: The Haven 2008-2009

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

TB diagnosis by gender and age group(n=9)

TB diagnosis by country group of origin(n=9)

15TB Prevalence: Combined= 6.1%; SSA 11.3% ; >40/100 000= 3.7%; < 40/100 000= 0%

BCG vaccination by originNo evidence of vaccination

BCG/ scar or vaccination history

Total BCG coverage (%)

Sub-Saharan Africa 25 37 62 59.7%

Other HIC TB incidence >40/100 000

15 39 54 72.2%

Country TB incidence <40/100 000

7 25 32 78.1%

BCG vaccination by age group0-5 years 2 5 7 71.4%16-35 years 36 73 109 66.9%36 years and above 9 23 32 71.8%

47 101 148 68.2%16

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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

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

1. Office accommodation Vital service delivery from limited office accommodation

2. Evaluations of similar programmes To generate understanding of most current evidence of good

screening models 3. More user-friendly electronic records

Easy audit and research4. One-stop shop screening services

Improve coordination between screening and prescription tasks5. Audit of BCG vaccination

Vaccinate the unvaccinated to improve coverage among ASaR6. GP involvement

TB assessment for new ASaR from HIC at registration

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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