Communicable Disease - current knowledge, impact and issues for new migrant communities

1. Communicable Disease - current knowledge, impact and issues for new migrant communities Dr. Mamoona Tahir, Consultant in Communicable Diseases Public Health England

2. Overview • Who are the migrants? • Are migrants more likely to experience ill health? • Why are the migrants at increased risk? • More likely to experience poor outcomes? • What can be done to improve migrants health

3. Who are migrants? • A person who moves from one place to another in order to find work or better living conditions • (Oxford dictionary definition) • Foreign born, foreign national or people who have moved to the UK for more than one year • (International Migration Organisation & Oxford Migration Observatory)

4. Countries of last residence of UK migrants Source: Long-Term International Migration (LTIM), Office for National Statistics

5. Reasons for migrating to the UK: 2001-2010 Source: Long-Term International Migration (LTIM), Office for National Statistics

6. Migration pattern closely linked to disease epidemiology

7. Most non-UK born people do not have infectious diseases … UK born population Non-UK born population Burden of infectious disease ... but much of the burden of infectious diseases falls on the non-UK born population

8. The majority of cases of… TB (73% of cases reported in the UK in 2010) HIV (almost 60% of newly diagnosed cases reported in the UK in 2010) Malaria (77% of cases reported in the UK between 2005 and 2010) Enteric fever (63% of cases reported in England, Wales and Northern Ireland between 2007 and 2010) …do occur in people who were born abroad

9. Why are migrants at increased risk? • Higher disease burden • Poor living conditions • Experiences during migration • Socioeconomic conditions in the UK • Factors relating to ethnicity and cultural practices • Awareness and health seeking behaviour • Frequent travel to country of birth

10. Missed opportunities for health intervention in at risk migrant groups? • TB; no co-ordinated UK system currently for detection of infection/cases • HIV; unrecognised infection and late diagnoses • Hep B and C; unrecognised infection and late diagnoses • Chagas; unrecognised • Parasitic worms; unrecognised • Enteric fever; VFR travellers to ISC; no immunisation • Malaria; VFR travellers to west Africa; no chemoprophylaxis • Non-infectious health conditions; diabetes, IHD, genetic disorders, maternity care, FGM, nutritional, chemical exposures, mental health, etc.

11. Figure : Tuberculosis case reports and rates by region*, England, 2012 11Tuberculosis in the UK: 2013 report

12. Fig: Tuberculosis case reports by place of birth and country, UK, 2012 12Tuberculosis in the UK: 2013 report

13. Country of origin of TB cases

15. Data sources: Enhanced Tuberculosis Surveillance (ETS) downloaded on 10th March 2014. Prepared by: Field Epidemiology Service (Birmingham), Public Health England Tuberculosis rates by Upper Tier Local Authority, West Midlands, 2013* *Rates were calculated using 2012 mid-year population estimates from ONS

16. Treatment outcome

17. Human Immune deficiency Virus In 2010 6,658 individuals were diagnosed with HIV in UK 65% of people diagnosed between 2001 and 2010 in whom the country of birth was recorded, were born abroad Among these 80% of infection were acquired heterosexually Africa was reported as the region of birth for the majority (87%) of heterosexual non-UK born new diagnoses. Forty-eight per cent of African born- heterosexuals reported South Eastern Africa as their region of birth

18. HIV

19. Hepatitis B

20. Epidemiology of hepatitis B and C in Birmingham and Solihull Hepatitis C • In 2012, there were 13 laboratory reports of hepatitis C per 100,000 population for residents of the West Midlands, compared to 20 for residents of England. • Since 2010 the gap between rates in the West Midlands and rates in England has been widening. Source: Public Health England, Labbase Data are summarised by region of residence, not region of laboratory. Data are assigned to region by patient postcode where present; if patient postcode is unknown, data are assigned to region of registered GP practice; where both patient postcode and registered GP practice are unknown data are assigned to region of laboratory. Includes individuals with a positive test for hepatitis C antibody (a marker of past infection) and/or detection of hepatitis C RNA (a marker of persistent infection). Due to the variability in the quality of laboratory reports, we are unable to estimate the actual proportion of cases with evidence of past infection or persistent infection.

21. Epidemiology of hepatitis B and C in Birmingham and Solihull Hepatitis C • At the West Midlands sentinel laboratory, Asians had the highest positivity rate. • Lower positivity rates for those of black and other/mixed ethnicity are based on a relatively small number of tests. • Data is for all tests processed by the West Midlands sentinel laboratory, irrespective of residence. Source: Public Health England, Sentinel Surveillance of hepatitis. * Excludes dried blood spot, oral fluid, reference testing, and testing from hospitals referring all samples. Data are de-duplicated subject to availability of date of birth, soundex and first initial. Excludes individuals aged less than one year, in whom positive tests may reflect the presence of passively-acquired maternal antibody rather than true infection. All data are provisional. § A combination of self-reported ethnicity, and OnoMap and NamPehchan name analyses software were used to classify individuals according to broad ethnic group.

23. Epidemiology of hepatitis B and C in Birmingham and Solihull • Reporting of patient residence information is incomplete; From 2008 to 2012, around half of laboratory reports included the patient’s postcode; therefore rates shown on the map are likely to be underestimates. • Where patient residence information was reported, the wards with the highest rates per 100,000 population were Bordesley Green, Washwood Heath and Sparkbrook.

24. Recommendations • Migrants and VFR /Travellers awareness of the risk of catching the disease, mode of acquisition and how they can protect themselves. • Increased awareness among general public • Primary care practitioners play a vital role in early identification of infectious diseases • Early identification of risk and diagnosis of infection can improve health outcome

25. Recommendations • Practitioners are encouraged to consider their patients’ country of birth when evaluating their risk exposures and to guide their differential diagnosis of presenting symptoms • Many UK practitioners may be unfamiliar with the clinical presentation of some infectious diseases that are rarely diagnosed in the UK • need for non-UK born communities to have access to culturally competent and language supported services • importance of considering health needs relevant to an individual’s country of birth

26. Summary • Migrants experience a high burden of infectious diseases in West Midlands • Reflective of incidence in the country of origin. • The late diagnosis of HIV suggests the needs of the migrant are not being met • GPs could play a role in screening migrant for HIV, Hepatitis and TB for migrants from high incidence countries • Practitioners awareness of needs of the migrants is important