Dear Editor,
Since the start of the Russian invasion of Ukraine in February 2022, millions of people have fled from the war zone. Germany has been one of the main destinations, with over one million registered refugees up to November 2022.1 Although TB incidence had steadily declined in Ukraine in recent years, it is still a high-priority country in the European region with 73 TB cases/100,000 population.2 In addition, it is a high-burden country for drug-resistant TB, with 31% multidrug-resistant TB (MDR-TB) for newly diagnosed cases and 45% among those previously treated.3 The ongoing war is an increasing threat to TB prevention and care because of delays in diagnosis, as well as interruptions to care or lack of treatment. It is also likely that we will see an increase in TB infections (TBI) because of higher reactivation and transmission risks due to war-related factors.4
To prepare for the expected number of people with TB among Ukrainian refugees, WHO Euro provided a TB calculator for member countries based on refugee demographics. The estimated incidence of TB is 0.05% for women and 0.06% for men, with approximately 33% of cases classified as MDR-TB. Among these cases, approximately 27% are classified as pre-extensively drug-resistant TB (XDR-TB). The European Centre of Disease Control/WHO Euro has not recommended universal TB screening for this refugee population due to the projected low yield of such screening.5 However, in Germany, the Infection Protection Act requires TB screening for people moving into shared accommodation. A certificate based on chest X-ray (CXR) and/or other methods approved by the federal authorities, such as interferon-gamma release assays (IGRA), is required to demonstrate there is no evidence of infectious TB. There is no national TBI screening programme for migrants, but IGRA is used as a pre-test to screen for active TB in some settings. Communities are responsible for the screening, and strategies may vary according to the number of refugees, allocated resources and procedures available at the point of care.
To get an overview of the screening methods and their yield we conducted a survey within the nationwide TB working group (Arbeitskreis Tuberkulose) from 9th March to 30th November 2022 and retrieved local screening results through a questionnaire. We asked about the number of persons screened >15 years of age, the primary screening method used (CXR, IGRA) and the results of the screening. If available, gender information was collected. If IGRA was positive, people were sent for CXR, and if CXR was abnormal, people were examined for TB.
A total of 36 public health institutes from nine federal states responded, corresponding to 10% of all public health institutes in Germany. The number of examined refugees per federal state were as follows: Hamburg: 6,875 (26%); Baden-Wuerttemberg: 6,281 (24%); Bavaria: 4,982 (19%); North Rhine-Westphalia: 2,055 (8%); Rhineland-Palatinate: 1,894 (7%); Saxony: 2,975 (11%); Hesse: 888 (3%); Thuringia: 177 (1%) Lower Saxony: 69 (0.3%). A total of 26,196 refugees from Ukraine older than 15 years were included. Refugees with known TB were excluded. Gender information was available for 42% of all examined (11,037/26,196) with 6,661/11,037 (60%) females (Table). TB was found in 45/21,519 people screened with CXR (detection rate 0.2%), three more people with TB were found when IGRA was used as pre-test for TB screening (detection rate: 3/4,677, 0.1%). In total, TB was found in 48/26,196 (detection rate: 0.2%) and treatment was started. The yield of TB was 183/100,000 in the screened population (95% confidence interval [CI] 131–235/100,000), with a number needed to screen of 545. The TBI detection rate with IGRA screening was 13% (597/4,677; 95% CI 11.8–13.7). Microbiological confirmation of Mycobacterium tuberculosis (either as positive sputum smear, polymerase chain reaction or culture-result) and information about resistance pattern were available for 85% of the people with TB (41/48). Of 48 patients with TB diagnosis, 6 had a negative microbiological result. In 1/48, microbiological information was missing. All of these cases were treated based on clinical judgement. The diagnosis of MDR-TB was confirmed in 42% (20/48) of all people with TB; 5/48 (10%) people had pre-XDR-/XDR-TB, i.e., 25% of the people with MDR-TB (5/20). In addition, four patients had either INH monoresistance or polyresistance other than MDR-TB.
Table.
Results of TB screening in Ukrainian refugees aged >15 years
| Screening group | IGRA n |
CXR n |
Total n |
|---|---|---|---|
| Number of people screened, n (%) | 4,677 (18) | 21,519 (82) | 26,196 (100) |
| Positive IGRA result | 597 | ||
| CXR suspicious for TB | 58 | 279 | |
| People with TB found | 3 | 45 | 48 |
| TB detection rate, % | 0.1 | 0.2 | 0.2 |
| MDR-TB, n/N (%)* | 1/3 (33) | 19/45 (42) | 20/48 (42) |
n = proportion of people with TB.
IGRA = interferon-γ release assay; CXR = chest X-ray; MDR-TB = multidrug-resistant TB.
Compared to the WHO TB calculator, we found a higher yield of TB among those screened with CXR, whereas the yield for the IGRA-screened group was as expected. In addition, MDR-TB was detected in 42% of all people with TB, which is higher than expected in the WHO TB calculator, but comparable numbers of MDR-TB were found in other studies.6 XDR-TB was estimated for 27% of MDR-TB cases according to WHO, which is close to our findings of 25%. The higher TB and MDR-TB detection rate in the CXR fraction could be due to the higher proportion of men in the refugee population screened compared to estimates based on the WHO TB calculator. Screening was only mandatory for refugees staying in shared accommodation, and this group may differ from those accommodated privately. The TBI rate (13%) was found to be lower than initially anticipated, given that a recent modelling calculation had projected a TBI rate of 22% for Ukraine.7
To our knowledge, this is the first dataset available for TB screening of refugees from Ukraine since the beginning of the war, and our reported figures are higher than expected. Although TB services in Ukraine have been reported to be functional in August 2022,8,9 there is a high likelihood that these will become less effective as the war continues, resulting in a higher incidence of TB.10–12 The limitations of our study include a possible selection bias, as the survey did not include data from all public health services in Germany. Additional information such as bacille Calmette-Guérin vaccination status, age (other than age groups) or previous treatment, were not available. Nevertheless, these real-life data give us perspective on the WHO TB calculator and may help to plan reasonable screening strategies in this ongoing crisis.
Structured data collection, including full demographic information and centralised data management and evaluation, would be desirable and help to adopt screening procedures for those experiencing the greatest impact and offering the best benefit for patients.
Acknowledgements
The authors thank the following persons and teams for their contributions: A Neuwirth (Calw), Sabine Hofmann (Chemnitz), A Martin (Darmstadt-Dieburg), C Breuer (Dresden), U Lang (Düsseldorf), C Schwarzbach (Hamburg), S Yazici (Hannover), N Funke (Köln), M Steinmüller (Lahn-Dill-Kreis), Y Wachsmuth and L Graf (Leipzig), R Schmidt-Ott (Upper Bavaria including Munich), C Cassier (Münster), E Wolf (Kreis Offenbach), U Zelmer; and E Thumm (Reutlingen), A Möhlenbruch (Rhein-Neckar-Kreis), B Naumann (Saale-Holzland-Kreis), B Tegtmeyer (Sigmaringen), A Hildebrand (Stuttgart); C Bartz and W Heinen (Trier).
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