Migration-Specific Aspects Disclosures of GeoSentinel Salary and - PDF document

Migration-Specific Aspects Disclosures of GeoSentinel Salary and travel support: David Hamer, MD • GeoSentinel funding from US CDC, Department of Global Health Boston University School of Public Health ISTM, and Public Health Agency of Section of Infectious Diseases, Dept. of Medicine, Canada Boston Medical Center GeoSentinel Global Talk Outline Surveillance Network • GeoSentinel overview • Established in 1995 by CDC and • Overview of global migrant health International Society for Travel Medicine data in GeoSentinel (ISTM) • Clinic-based global surveillance system • Examples of two recent analyses - De-identified patient information - Syrian migrants - International travelers and immigrants - Eritrean migrants and P. vivax - Central electronic database • Conclusions and future directions - Link time and place of exposure - Detect new infections and patterns - Monitor disease burden and distribution Migrant-Relevant Variables Collected in How does GeoSentinel work? GeoSentinel Data analysis by Sites Patients with migration-related Demographics Travel History Clinical Information condition Reports • Inpatient/outpatient • Gender • Migration • Main presenting history • Age Surveillance Data GeoSentinel Site symptoms • Country or or • Country • Underlying Central Database Affiliate Members countries of conditions - Birth exposure to • Diagnosis Secondary - Citizenship current illness Rapid Query • Diagnostic Response - Residence • Seen during method(s) Response Arm before age 10 Loop migration or • Diagnosis status - Current (C/P) after GeoS Sites and Affiliate Members +/- residence • Antibiotic immigration ISTM Membership +/- susceptibility data (9 Partners (e.g. ProMED, ECDC, PHAC, select pathogens) WHO, TropNet, EpiCore, and Healthmap) 1

Sentinel Sites Contributing Data GeoSentinel Sites and Affiliate (as of September 2018) Members 72 GeoSentinel sites in 31 countries: - 27 North America - 25 Europe - 10 Asia - 3 Africa - 3 South America - 2 Middle East - 2 Oceana 221 Affiliate members Data Summary Top 10 Diagnoses: Immigrants & VFRs (Last 2 Years) Numbers of patient encounters: Diagnosis N of Diagnoses (%) • 321,057 patients total ( ∼ 14% migrants) Healthy 1366 (8.5) • 507,420 final diagnoses Latent TBI 1133 (7.0) (as of 31 August 2018) Blastocystis spp. 866 (5.4) Malaria, P. falciparum 810 (5.0) GeoS records cover traveler, immigrant, and Vitamin D deficiency/insufficiency 723 (4.5) refugee exposures in 251 countries and Strongyloides , simple intestinal 607 (3.8) territories Eosinophilia 596 (3.7) Schistosomiasis 404 (2.5) Hepatitis B, chronic (> 6 mo) 388 (2.4) Chagas disease, chronic 385 (2.4) Overview of GeoSentinel Results: Demographics Migrant Health Data N = 33,862 • 45% female • Data (purpose of travel = migration) • Mean age ± SD: 32 ± 17 years extracted from the database for 1997 – - Range 0– 103 y August 2018 • 87% seen as outpatients • Data stratified into major regions of origin • Top region of origins: • Timing of migration analyzed by year for - Sub-Saharan Africa (32%) each major region of origin - Southeast Asia (20%) • Top 10 diagnoses summarized for each - South Asia (12%) - South America (8%) major region - Caribbean and Middle East (6% each) - Note of caution: this preliminary analysis uses data that have not been cleaned 2

Results: Timing of Migration Sub-Saharan Africa: Top 10 Diagnoses • Sub-Saharan Africa Dental Problem Non-Pathogenic - Roughly similar proportions of immigrants (Abcess, Protozoa (not … Caries, other) seen at GeoSentinel sites since 2006 • Southeast Asia Anemia Blastocystis Sp. - Peak years of migration were 2002-2008 Schistosomiasis with steady proportions since then until Other Hepatitis B, Vitamin D 2015 Chronic Deficiency • South Asia Strongyloides - Low proportions until 2010 then a Latent TB (Not Active) steady flow until 2017 Eosinophilia SE Asia: Top 10 Diagnoses South Asia: Top 10 Diagnoses HEPATITIS B, MTB, DENTAL PROBLEM CHRONIC MICRONUTRIENT PULMONARY (ABSCESS, CARIES, HEALTHY BLASTOCYSTIS DEFICIENCY EOSINOPHILIA Sp. OTHER) ABNORMAL URINALYSIS MTB NON PATHOGENIC PROTOZOA ANEMIA BLASTOCYSTIS Other VITAMIN D Sp. DEFICIENCY / HEPATITIS B, NON PATHOGENIC INSUFFICIENCY CHRONIC PROTOZOA LATENT TUBERCULOSIS HEALTHY VITAMIN D DEFICIENCY LATENT STRONGYLOIDES TUBERCULOSIS Caribbean: Top 10 Diagnoses South America: Top 10 Diagnoses NON DENTAL LATENT PATHOGENIC PROBLEM TUBERCULOSIS BLASTOCYSTI EOSINOPHILIA PROTOZOA (ABSCESS, S Sp. NEUROCYSTICERCOSIS CARIES, OTHER) H.PYLORI HYPERTENSION HEALTHY EOSINOPHILIA STRONGYLOIDES ANEMIA Other Other HEPATITIS B, STRONGYLOIDES MTB, CHRONIC CHAGAS PULMONARY DISEASE, ANEMIA LATENT TB HEPATITIS CHRONIC B, CHRONIC 3

Middle East: Top 10 Diagnoses Major Regional Similarities DENTAL PROBLEM • Common health problems: (ABSCESS, VITAMIN D CARIES, DEFICIENCY/INSUFFICIENCY OTHER) NON - Latent TB infection PATHOGENIC BLASTOCYSTIS PROTOZOA - Anemia Sp. GIARDIA - Eosinophilia - Dental problems HEPATITIS B, LATENT Other CHRONIC TUBERCULOSIS - Chronic hepatitis B ECHINOCOCCOSIS - Carriage non-pathogenic protozoa HEALTHY MTB - Vitamin D deficiency Major Regional Similarities and Differences • Notable differences between regions - Schistosomiasis (sub-Saharan Africa) - Active tuberculosis (South Asia) - Strongyloidiasis (SSA, SE Asia, Middle East, Caribbean) - Chagas disease (South America) - Neurocysticercosis (South America) Aleppo, Syria (Photo by Jawad al Rifai/Anadolu Agency/Getty Images) GeoSentinel Syrian Minors: Results (N = 458) • 94% male • Age ranges: 16-17 y - 64% 2 groups of Syrian refugees analyzed: 13-15 y - 28% 6 -12 y - 8% • 488 minor Syrian migrants screened in Berlin from 2013 to 2015 • Number of transit countries varied from 1-7 with Turkey, Greece, Serbia, • 44 ill adult Syrian migrants seen in 8 countries Macedonia, and Hungary most common between 2011 and 2015 4

GeoSentinel Analysis: Syrian Minors: Diagnoses Syrian Migrants (N = 44) • No diagnosis: • Age range: 1 – 67 y (median 35 y) 66% • 1+ GI protozoa: • 66% male 22% • Main countries of evaluation: Norway - Giardia: 7% • Eosinophilia: (15); USA (9); Denmark (7); Canada (6) 17% • Most common diagnoses: • Anemia: 7% - Cutaneous leishmaniasis (32%) • Schisto (+ serology) 1% - Active TB (11%) • Dental problems 5% - Chronic viral hepatitis (9%) • Other: fungal skin infections, scabies, - Latent TB infection (9%) URI - Vitamin D deficiency (9%) Malaria in Eritrean Migrants: A Malaria in Eritrean Migrants: GeoSentinel Analysis Species and Transit Routes Schlagenhauf P et al. under review • P. vivax (84%), P. falciparum (8%), and • Identified 146 malaria cases in Eritrean P. ovale 3% migrants from 1999 – Sept. 2017 • Severe malaria (6%) (5/9 with P. vivax ) - Marked increase in 2014-15 • Country of acquisition of malaria • 10 sites reported patients - mainly in difficult to define Norway, Switzerland, Sweden, Israel, - Possibly Eritrea or in transit through Ethiopia or Sudan and Germany - Major transit routes through Egypt, Turkey, • Majority were young male Uganda, and Syria refugees/asylum seekers Conclusions Malaria in Eritrean Migrants • GeoSentinel network includes centers that • About 1/3 had malaria during migration see migrants for screening and/or evaluation of acute illness • Most had onset of symptoms median 39 • Useful for comparing differences based on days after arriving in their host country country of origin, migration route, and • Analysis highlights several challenges: differences in screening procedures • Great potential for multi-site studies - Complex migration routes - Difficulty identifying country of exposure • Recent GeoSentinel migrant data will be - Delay in diagnosis and treatment presented by Dr. Elizabeth Barnett this afternoon (IDs in Migrants session 15:30) 5

Challenges With Collection of Future Directions for GeoSentinel Migrant Health Data • Special projects on specific aspects of • Variable definitions and understanding of migrant health (e.g. missed opportunities for refugee/migrant status screening NCDs, micronutrient deficiencies) • Confidentiality issues (e.g. migration route) • Difficulty associating specific diseases with • Chagas disease (lead = Clara Crespillo, country of origin vs. migration route Madrid) • Site differences in approach to evaluating • Schistosomiasis (lead = Emmanuel Bottieau, migrant health issues (e.g. screening Antwerp) procedures, evaluation for NCDs) • Strongyloidiasis (lead = Andrea Boggild, • Limited data on psychiatric illness, trauma Toronto) Acknowledgments • Site directors and co-directors • GeoSentinel leadership team • CDC team – esp. Kristina Angelo, Calvin Patimeteeporn • ISTM administrative team • Special advisors • Funding from CDC (U50CK00189), ISTM and PHAC 6