Title: Impact, acceptability and cost-effectiveness of identifying infectious diseases amongst migrants in primary care
Funder: Department of Health and Social Care

Abstract: Background Migration is an important determinant of population change in the United Kingdom. Data indicate that migrants are at increased risk of several infectious diseases (including tuberculosis (TB), HIV, hepatitis B and hepatitis C) and have poorer outcomes. Early diagnosis and management of these conditions can improve outcomes by preventing morbidity, mortality and onward transmission and is supported by national guidelines. However routine testing of migrant groups is not being undertaken. Integrating testing for a range of infectious diseases at new patient registration with primary care would, for the first time, allow one to determine the acceptability, effectiveness and cost-effectiveness of delivering a wider migrant health programme in primary care. Hypothesis The introduction, and delivery, of a programme of routine testing of migrants for selected infectious diseases at the time of registration in primary care will increase the number of tests undertaken for, and diagnoses of, these conditions in primary care. Study design Observational cohort study with interrupted time-series analysis before and after the introduction of routine testing of migrants for infectious diseases (latent TB, HIV, hepatitis B and hepatitis C) when first registering with primary care within Leicester, UK. The study population will be adult foreign-born migrants registering with one of the participating practices in Leicester, UK. Study inclusion criteria include age 16-65 years, born overseas, country of birth with TB incidence 150/100,000 (Africa and Southeast Asia), and UK arrival within the last five years. The primary outcome will be the number and rate of new diagnoses of latent TB in migrants; secondary outcomes will be the number and rate of new diagnoses of HIV, hepatitis B and hepatitis C. Migrants eligible for testing will be identified at first registration with participating practices, consented and offered blood tests for latent TB, HIV, hepatitis B, and hepatitis C. Following consent/data-sharing agreements, monthly GP registration/consultation data will be collected for sixty time-points (five years at monthly intervals) before the intervention/policy change (retrospective data) and twenty-seven time-points (two-years and three-months at monthly intervals) after the intervention (prospective data; a three-month lag-period after the service starts will be excluded from analysis). Data will be downloaded from practices by the Greater East Midlands-Commissioning Support Unit and linked with secondary care databases to allow final diagnoses to be made. Data will be pseudonymised with no personal confidential data, before being securely transferred to the Fellow. The key analysis will assess trends in the monthly number and rate of testing and diagnosis for latent TB, HIV, hepatitis B and hepatitis C (separately) to determine the effect of the policy change. This will use segmented regression analyses; if autocorrelation is significant we will use autoregressive integrated moving average models. Integrated qualitative and economic analyses will also be undertaken. Expected outcomes Introducing a policy of routine testing of migrants for latent TB, HIV, hepatitis B and hepatitis C at the point of registration with primary care will increase the number of tests undertaken for, and diagnoses of, latent TB, HIV, hepatitis B and hepatitis C in primary care. This study will also provide information about the prevalence of infectious diseases in migrant communities, the cost-effectiveness of testing and the knowledge, attitudes and practices towards migrant screening amongst migrants and healthcare workers. Anticipated benefits Policy-relevant findings which will provide data about the outcomes of routine testing for infectious diseases in migrants registering in primary care, the attitudes of migrant service-users and healthcare workers towards testing and the cost-effectiveness of undertaking such tests. Taken together the data will result in changes in clinical guidelines/pathways, inform UK health policy and ultimately result in improved, cost-effective, equitable care provided by the NHS.

Lay abstract: Background People born in some parts of the world are much more likely to suffer from serious infectious illnesses, for example tuberculosis, hepatitis and HIV. Although early testing for these illnesses is recommended by the UK government, it is rarely done. Early testing could identify such illnesses before they have become worse or spread to others. However, we do not know if people would agree to early tests, just how effective early testing would be, and whether it would be good value for money. Aims As part of a new strategy in Leicester, UK, people born overseas will be offered testing for certain infectious illnesses (tuberculosis, HIV and viral hepatitis) when they register with a GP in the city. We aim to find out whether offering early tests for these infectious illnesses in this way will result in GPs actually doing more tests and identifying more people with these infectious illnesses. Study design and methods We will gather data on testing for, and identification of, these diseases from GP surgeries in Leicester, UK. The data will be anonymised that is, no one can identify which people were tested. We will see if there is a change in the number of tests done for infectious illnesses and the number of new cases of infectious illnesses identified by GPs following the introduction of a new testing strategy. We will also interview people born abroad and GPs to see what they think about testing for these infections. Finally, we will calculate whether testing people born abroad for infections offers good value for money for the NHS. Patient and public involvement We have undertaken group discussions with people born abroad to get their views on this topic and how we should undertake the work. They have been very supportive and provided important information about how to take the work forward, which topics to concentrate upon and how to involve people in the study. During the course of the project we will continue to work with people born abroad to guide and advise us about the work. We have also been working with GPs in Leicester to get their views on this testing programme and they are also highly supportive.Dissemination The results of this project will be publicised through the media newspapers, TV, radio and social media. We will hold workshops and awareness raising sessions in migrant communities in Leicester. We will also present the research findings at local, national and international meetings before going on to publish them in medical journals for the benefit of the wider scientific community.

Research activity codes: 4.3 INFLUENCES AND IMPACT;7.3 MANAGEMENT AND DECISION MAKING
Health categories: INFECTION