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Background In 2018, there were 70.8 million refugees, asylum seekers and persons displaced by wars and conflicts worldwide. Many of these individuals face a high risk for tuberculosis in their country of origin, which may be accentuated by adverse conditions endured during their journey. We summarised the prevalence of active and latent tuberculosis infection in refugees and asylum seekers through a systematic literature review and meta-analyses by country of origin and host continent. Methods Articles published in Medline, EMBASE, Web of Science and LILACS from January 2000 to August 2017 were searched for, without language restriction. Two independent authors performed the study selection, data extraction and quality assessment. Random effect models were used to estimate average measures of active and latent tuberculosis prevalence. Sub-group meta-analyses were performed according to country of origin and host continent. Results Sixty-seven out of 767 identified articles were included, of which 16 entered the meta-analyses. Average prevalence of active and latent tuberculosis was 1331 per 100 thousand inhabitants [95% confidence interval (CI) = 542–2384] and 37% (95% CI = 23–52%), respectively, both with high level of heterogeneity (variation in estimative attributable to heterogeneity [I2] = 98.2 and 99.8%). Prevalence varied more according to countries of origin than host continent. Ninety-one per cent of studies reported routine screening of recently arrived immigrants in the host country; two-thirds confirmed tuberculosis bacteriologically. Many studies failed to provide relevant information. Conclusion Tuberculosis is a major health problem among refugees and asylum seekers and should be given special attention in any host continent. To protect this vulnerable population, ensuring access to healthcare for early detection for prevention and treatment of the disease is essential.

Background: In 2017, there were 68·5 million refugees, asylum seekers and persons displaced by wars and conflicts worldwide. Tuberculosis prevalence in the country of origin and adverse conditions endured during their journey may increase their risk for tuberculosis. We summarized the prevalence of active and latent tuberculosis infection (LTBI) among refugees and asylum seekers through a literature systematic review and meta-analysis by country of origin. Methods: Articles published in Medline, EMBASE, Web of Science and LILACS from 2000 to August 2017 were searched for, without language restriction. Two independent reviewers performed all review steps. Random effect models were used to estimate pooled measures of active and latent tuberculosis infection (LTBI) prevalence. Sub-group analyses were performed according to the country of origin and host continent. Findings: Sixty-seven out of 767 identified papers were included, of which 16 entered the meta-analysis. Pooled prevalence by contry of origin of active and latent tuberculosis were 0·01 [95% confidence interval (CI)=0·00-0·02] and 0·41 (95% CI=0·25-0·57), respectively, both with high level of heterogeneity (I2=98·2% and 99·8%). Ninety-one per cent of studies reported routine screening of recently arrived immigrants in the host country; two-thirds confirmed tuberculosis bacteriologically. Interpretation: Tuberculosis is a major health problem among refugees and asylum seekers and should be given special attention. The high prevalence of active and latent tuberculosis indicates the need for ensuring access to healthcare for early detection, treatment and prevention of the disease, aiming protection of this vulnerable population. Funding: Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES). RP has had a study grant from the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES). CAPES is not responsible for any statement in this manuscript. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The authors declare: "Not applicable."

Submitted by Boris Flegr (boris@uerj.br) on 2020-07-05T16:09:25Z No. of bitstreams: 1 RaquelProenca dissertacao.pdf: 1669414 bytes, checksum: ef11a54a95ab016998ad159d9955fe3a (MD5) Made available in DSpace on 2020-07-05T16:09:25Z (GMT). No. of bitstreams: 1 RaquelProenca dissertacao.pdf: 1669414 bytes, checksum: ef11a54a95ab016998ad159d9955fe3a (MD5) Previous issue date: 2017-03-21 Coordenação de Aperfeiçoamento de Pessoal de Nível Superior In 2015, there were around 65.3 million refugees displaced by wars and conflicts, with 5.8 million more than in 2014, thus showing an increasing pattern. Compared with other categories of immigration visas, refugees and asylum seekers are at increased risk for tuberculosis (TB) as a result of the prevalence of the disease in their country of origin, exposure during migration and adverse conditions during this period. The main objective of this study was to analyse the prevalence and incidence of active and latent tuberculosis infection (LTBI) in refugees and asylum seekers through a systematic review of the literature. We conducted a search in Medline, EMBASE, Web of Science and LILACS of studies published from 2000 to August 2016, including cross-sectional, longitudinal studies or trials that described the prevalence and/or incidence of both active TB and/or LTBI among refugee and asylum seekers, without linguistic restriction. Studies with population of less than 30 individuals were excluded. The study selection, data extraction and assessment of the report quality were carried out by two independent reviewers and the differences were solved by a third reviewer. Six-hundred and twenty-four studies were identified, of which 54 were included in the review. Screening for TB (active or LTBI) of the individuals who arrived in the host country accounted for the reasons why individuals were screened in 94.3% of studies. We identify a high incidence rate (between 482 and 3,810 cases per 100,000 inhabitants) and prevalence (50% of studies between 500 and 2,500 per 100,000 inhabitants) of active TB. Regrading LTBI, 50% of the studies showed a prevalence ranging from 15 to 42%, reaching 85%. The prevalence of active and latent TB was higher among men, refugees from countries with high TB incidence, and low-income countries. The countries of origin with the largest number of refugees captured in the studies were: Iraq, Afghanistan, Thailand, Myanmar, and Bhutan. Twenty-one studies were conducted in the US, which has a restrictive immigration policy. Regarding the quality of the study reports, 87.5% of the cross-sectional studies and 92.9% of the cohort studies fulfilled at least 50% of the Strengthening the Reporting of Observacional Studies in Epidemiology (STROBE) criteria. These findings point to TB as a public health problem for this population, as it is necessary to ensure rapid access to refugees and health care in the host country, as well as to ensure that the non-refoulement principle stated at Genebra Convention (1951) will be respected. Em 2015 existiam cerca de 65,3 milhões de refugiados deslocados por guerras e conflitos, com 5,8 milhões de pessoas a mais do que em 2014, mostrando assim um padrão crescente. Comparado com os portadores das demais categorias de visto de imigração, os refugiados e requerentes de asilo possuem um risco aumentado para tuberculose (TB) como consequência da prevalência da doença em seu país de origem, exposição durante a migração e condições adversas nesse período. O objetivo desse estudo foi analisar dados disponíveis sobre a prevalência e a incidência da infeção latente por tuberculose (ILTB) e da TB ativa entre refugiados e requerentes de asilo por meio de uma revisão sistemática da literatura. Realizamos uma busca no Medline, EMBASE, Web of Science e LILACS até agosto de 2016, incluindo estudos observacionais transversais, longitudinais ou ensaios clínicos publicados desde 2000 que descreveram a prevalência e/ou incidência de TB ativa e/ou ILTB em imigrantes refugiados e requerentes de asilo, sem restrição linguística. Estudos com população de estudo inferior a 30 indivíduos foram excluídos. A seleção dos estudos, extração dos dados e avaliação da qualidade do relato foram realizadas por dois revisores independentes e as divergências foram resolvidas por um terceiro revisor. Foram identificados 624 estudos, sendo 54 desses incluídos. A triagem para TB (ativa ou ILTB) ao chegar ao país de acolhimento foi o motivo da captação em 94,3% dos estudos. Identificamos alta taxa de incidência (entre 482 e 3.810 casos por 100 mil habitantes) e de prevalência (50% dos estudos entre 500 e 2.500 casos por 100 mil habitantes) de TB ativa. Em relação à prevalência de ILTB, 50% dos estudos mostram entre 15 e 42%, chegando a 85%. Tanto TB ativa quanto ILTB foram mais frequentes entre os homens, entre refugiados provenientes de países de alta incidência de TB e de países de baixa renda. Os países de origem com maior número de refugiados foram Iraque, Afeganistão, Tailândia, Myanmar e Butão. Vinte e um estudos foram conduzidos nos EUA, que tem uma política restritiva de imigração. Quanto à avaliação da qualidade do relato dos estudos 87,5% dos estudos transversais e 92,9% dos estudos de coorte atenderam a pelo menos 50% dos critérios do Strengthening the Reporting of Observacional Studies in Epidemiology (STROBE). Os achados desse estudo apontam para a TB como um problema de saúde pública para essa população. Desta forma, é preciso assegurar o rápido acesso dos refugiados à assistência à saúde no país de acolhimento, bem como garantir que não serão devolvidos , como diz a Convenção de Genebra (1951).