Ending tuberculosis calls for leaving no one behind
Authors: Masoud Dara, Rony Zachariah
Journal: The Lancet Infectious Diseases (2018)

In The Lancet Infectious Diseases, Timothy Walker and colleagues1Walker TM Merker M Knoblauch AM A cluster of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the Horn of Africa: a molecular epidemiological study.Lancet Infect Dis. 2018; (published online Jan 8.)http://dx.doi.org/10.1016/S1473-3099(18)30004-5Summary Full Text Full Text PDF PubMed Scopus (93) Google Scholar report on a cluster of 29 multidrug-resistant tuberculosis cases among asylum seekers arriving in Europe from the Horn of Africa. They use whole-genome sequencing to identify the transmission links and describe the cross-border collaboration and control measures. Their study is of interest as it sheds light on the importance of early tuberculosis detection and highlights the potential of wide application of molecular epidemiology techniques. Tuberculosis is the ninth-leading cause of death worldwide; resistance to antibiotics has increased and constitutes a major obstacle to effective tuberculosis control globally.2WHOGlobal tuberculosis report 2017. World Health Organization, Geneva2017Google Scholar Diagnosis of tuberculosis and particularly multidrug-resistant tuberculosis is often delayed or missed and treatment is lengthy, with diverse adverse events. On average, only 54% of patients with multidrug-resistant tuberculosis are successfully treated. In 2016, roughly 600 000 new cases occurred globally with resistance to rifampicin, the most effective first-line drug, of which 490 000 were multidrug resistant. Drug resistance among new (16%) and retreated (48%) cases is particularly high in eastern Europe and central Asia, part of the WHO European Region.3European Centre for Disease Prevention and ControlTuberculosis surveillance and monitoring in Europe 2017. European Centre for Disease Prevention and Control, Stockholm2017Google Scholar Among African countries, Somalia has one of the highest prevalences of multidrug-resistant tuberculosis among patients who were previously treated (about half). Countries like Somalia, from where some migrants are coming, have been ravaged by decades of civil war, which dilapidated their health systems with unavoidable effects on tuberculosis management. Identification and management of tuberculosis in populations on the move have been important aspects of immigration health for more than a century.4Dara M Gushulak BD Posey DL Zellweger JP Migliori GB The history and evolution of immigration medical screening for tuberculosis Expert.Rev Anti Infect Ther. 2013; 11: 137-146Crossref PubMed Scopus (31) Google Scholar In recent years, Europe has witnessed a sharp increase in migrant flows from the Middle East and Africa. Conflict, persecution, and poverty have been push factors behind an unprecedented million people fleeing to Europe in 2015, and this trend continues.5The UN Refugee AgencyA million refugees and migrants flee to Europe in 2015.http://www.unhcr.org/news/press/2015/12/567918556/million-refugees-migrants-flee-europe-2015.htmlDate: Dec 22, 2015Google Scholar The abilities to detect tuberculosis early and provide effective and continuing care in such populations are essential to curtail further transmission. In 2015, we did a survey6Dara M Solovic I Sotgiu G et al.Tuberculosis care among refugees arriving in Europe: a ERS/WHO Europe Region survey of current practices.Eur Respir J. 2016; 48: 808-817Crossref PubMed Scopus (71) Google Scholar together with the European Respiratory Society on policies and practices of tuberculosis screening and management among migrants in Europe. The survey revealed diverse approaches across Europe. Data coming from the Netherlands show that the yield of tuberculosis screening on arrival for migrants coming from low-incidence to middle-incidence countries might be low;7de Vries G van Rest J Meijer W Wolters B van Hest R Low yield of screening asylum seekers from countries with a tuberculosis incidence of <50 per 100 000 population.Eur Respir J. 2016; 47: 1870-1872Crossref PubMed Scopus (32) Google Scholar however, tuberculosis among migrants coming from high-incidence countries, particularly in the first few years, calls for specific actions and regular follow-up. A challenge also exists related to communication and building of confidence. Many asylum seekers do not speak the language of the host country and have gone through considerable hardships, including violence and torture and, more importantly, fear of deportation. Thus, a compelling need exists to foster a human approach to migrants, while introducing intensive tuberculosis screening and contact tracing. Engagement of diaspora and migrant communities in the host countries would be one way of promotion of culturally sensitive approaches, including an increased awareness of the importance of early tuberculosis detection. Migrant populations also need to be aware that no one is deported solely on the basis of their health status. Rapid molecular diagnostic tools such as GeneXpert MTB/RIF can have a crucial role.8WHOXpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children. World Health Organization, Geneva2013Google Scholar Although screening of migrant populations on arrival is vital, we believe it is equally important to ensure a continuum of care for those who are moving across borders. One way to ensure this care would be to use existing communication tools, such as the WHO-European Respiratory Society online platform.9De Colombani P Dupasquier S Migliori GB Dara M Cross-border management of tuberculosis cases through an updated ERS/WHO TB consilium.Eur Respir J. 2015; 46: PA1535Google Scholar More importantly, we believe that a need exists for intensified global efforts to prevent and control tuberculosis and multidrug-resistant tuberculosis, with a focus on settings where transmission is occurring, in the country of origin or during travel of migrants. Whole-genome sequencing could have an important role in mapping tuberculosis transmission chains and outbreak investigations, not only for migrants, but also for other key populations and settings, such as prisons and health-care facility contact investigations. Increased access and use of this tool will need to be coupled with research and innovation for a new vaccine, better point-of-care diagnostics than at present, and shorter and more effective treatment regimens so as to leave no one behind. These measures will establish whether or not the Sustainable Development Goal of ending tuberculosis by 2030 will be reached.10UNSustainable development goal 3: ensure healthy lives and promote well-being for all at all ages.http://www.un.org/sustainabledevelopment/health/Google Scholar We declare no competing interests. A cluster of multidrug-resistant Mycobacterium tuberculosis among patients arriving in Europe from the Horn of Africa: a molecular epidemiological studyOur data suggest that source cases are linked to an M tuberculosis clone circulating in northern Somalia or Djibouti and that transmission probably occurred en route before arrival in Europe. We hypothesise that the shared mutation of tlyA is a drug resistance mutation and phylogenetic marker, the first of its kind in M tuberculosis sensu stricto. Full-Text PDF Open Access