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Dr. Raz Mohammed WALI Chief Migration Health Physician NTP National Seminar: 14-15 July 2014 Pukhra, Nepal About IOM Migration for the benefit of all Healthy migration in healthy community International Organization for Migration (IOM) was established in 1951. The principal intergovernmental organization in the field of migration. IOM is committed to the principle that humane and orderly migration benefit migrants and societies. Working in more than 151 countries globally, more than 480 main and suboffices, 9 regional hubs, 156 member states including Nepal, 10 states and organizations observers – over a billion USD budget annually. Established in Nepal in 2006. Implementing several large and small projects in the country with the help of more than 383 national and international staff MHD Associates Programs (Nepal) 1. USRAP Health Assessment Program (HAP) FY2013 - 39,000 and FY 2014- 25,200 exams (IME, PDMS, PEC, 2nd dose vaccination and Medical case management) 2. Non-USRP Refugees HAP (AUS,CAN,UK,NZ,NL,NOR) 4,557 in CY2013, 3. Public Health Support activities Infectious disease surveillance, operational researches 4. Harmonization of TB diagnostic &Treatment protocol for Non-resettlement refugee: 100s of TB cases treated so far (passive vs active case finding?) 5. Immigrants (Nepalis) 10,600 exams CY2013 and 5200, CY2014 TB Rx (Aus) 6. TB Reach >20,000 Tests >4,000 TB including >250 RIF Resistant MOHP 7- Labor Migration health study: Three countries project (Nepal, Bangladesh and Pakistan) 3 Health Assessment Program Initial med exam (IME) Re-med : • • • • • Undergone the same IME procedure (except vaccination) Counseling Physical examination CXR Laboratory investigation Vaccination – 2nd dose vaccination (2013) – Hep B screening (2014) Medical Escort & Trv. Assistance • POE • Final destination On hold with regular follow up • • • • • • TB suspects TB Treatment Drug abuse Alcohol dependent Psychiatric evaluation Chronic disease Prior departure Pre-Embarkation Check (PEC) Prior Departure Medical Screening (PDMS) (Pre-departure medical screening) 3 weeks before departure at Damak - Physical assessment Chest X-ray (Class B1TB) Sputum smears only (Class B1 TB) • 24 hours prior departure Damak – - Physical assessment Pregnancy Test Albendazole Deworming Medication supplies for 4-8 weeks coverage 5 Facilities Group counseling and health education Clinic (clinical Evaluation) Radiology Laboratory, TB and Serology including media preparations Vaccine and reagents storage facilities DOT and TB isolation centers Pool of medical escorts and escort bags Pharmacy for necessary medicines including 1st and 2nd line TB drugs TB Laboratory Processing >120 sputum specimens/day Conc. smear read by Fluorescent Microscope MGIT960 Liquid & LJ Solid Culture Molecular Line Probe Assay (LPA) GeneXpert MTB/Rif First Line DST (S,H,R,E,Z) Second Line DST (AMK,KM,OLF,LEV,PAS,ETO,PAS,CS) 7 Radiology • DR (Digital Radiography) Capacity: 56,000 exposures per year, detector lasting for 7 years • CR(Computerize Radiography) Same capacity as to DR but – Require cassette to process the image ( 2 years lasting) – Take longer time/laborious to process an image – Heavy weight machine (400 kg) 8 TB Isolation Center 14 huts to isolate • 8 months MDR case • 2 months, non-MDR highly infectious (smear positive) 9 Active TB case finding Protocol of USRP CDC migration Requirements: Technical Instructions for tuberculosis screening and treatment using cultures and DOT, (Oct 2009) Medical History Physical Examination Applicant 2-14 years of age Applicant ≥ 15 years of age Tuberculin Skin Test or IGRA Chest Radiograph TST ≥ 10 mm or IGRA positive Medical History, examination, or CXR suggestive for tuberculosis Individual known HIV infection DST for all positive culture 3 sputum smear & Culture Identification in the level of MTB-Complex Overall Active Case Finding (Data of USRP resettlement program) Particulars 2008 2009 2010 2011 2012 2013 Total Total Exam (ind.) 8,454 15,855 17,415 16,785 19,518 12,163 90,190 6,905 12,750 13,404 12,257 15,167 10,216 70,699 82% 80% 77% 73% 78% 84% 78% 1,086 1,327 1,796 1,763 2,934 2,044 10,950 12.8% 8.4% 10.3% 10.5% 15.0% 16.8% 12.1% 62 108 158 166 197 80 771 0.7% 0.7% 0.9% 1.0% 1.0% 0.7% 0.9% 733 681 907 989 1,009 658 833 No of CXRs TB Suspects (Abn. CXR+Clinical ground) Active TB Active TB Per 100,000 Passive case finding Harmonization of TB diagnostic and treatment Protocol Project Symptomatic refugees Medical History Physical Examination AMDA Health Care provider for refugee in the camp Chest Radiograph DST for positive culture Medical History, examination, or CXR suggestive for tuberculosis Individual known HIV infection 3 sputum smear & Culture IOM Overall Passive case finding (Data of refugees non-resettlement program) Particular 2008a 2009b 2010b 2011b 2012b 2013c Total Clinically suspect 13 782 911 796 607 422 3,531 CXR Suggestive TB n/a n/a n/a n/a n/a 181 181 Active TB case (among suspects) 13 242 168 151 107 41-60 741 100% 31% 18% 19% 18% 14-23% 21% 2008 (a): Culture performed from Smear positive only 2009-2012 (b): Culture performed from clinically suspects 2013: Culture perform from clinically suspect& CXR suggested TB Overall Active Case Findings Rate (CXR) 14 Overall Passive Case Findings Rate (Clinic) 69 82 81 82 86 18 19 18 14 2010b 2011b 2012b 2013c 100 31 2008a 2009b 15 Smear& Culture Health Assessment Program Refugee Resettlement Refugee Non-Resettlement 2008-2013 2009-2013 Protocol Screening prior departure (Active case Finding) Seeking medical care when symptom present (Passive case Finding) Screening prior VISA issuing (Active case Finding) Smear positive- 1.3-1.5 % 8-9% 1.0-1.5% Culture positive- 4.0-6.0% 11-13% 5.0-5.5% Smear +ve/CS +Vs- 35% 73% 30% Smear -ve/CS +ve- 65% 27% 70% Nepalese migrants MHAC 2011-2013 % Among TB suspects referred for Smear &Culture Concentrated Smear read by Fluorescent microscopy Culture by Liquid MGIT960 system& duplicate LJ solid Drug Susceptibility Testing pattern Refugees Nepalese Migrants 89.5% 89.9% MDR 1.7% 2.5% XDR - - 1.4% - Pan-Susceptible Inconclusive Mono-Resistant % Among TB suspects Refugees Nepalese Migrants Streptomycin (S) 0.6% 0.6% Isoniazid (I) 3.9% 3.8% Rifampicin(R) 0.2% - Ethambutol (E) 0.8% 1.3% - - Pyrazinamide (Z) Poly-Resistant Refugees Nepalese Migrants S,I 1.4% 1.9% I,Z 0.3% - S,I,Z 0.1% - I,E,Z 0.1% - Overall INH resistance rate in the country is estimated to be around 7.5% 18