Voluntary health screening is offered to all new residents at what is now the only major reception centre for asylum seekers/refugees in Ireland – the Direct Provision Reception Centre at Balseskin in Finglas, Dublin. While this voluntary screening is taken up by almost three out of every four residents, there is a problem in Ireland with following up those who screen positive for infectious diseases. 

Asylum seekers are defined as people who exercise their right to seek protection under the 1951 UN Geneva Convention.¹ Sociopolitical events on the world stage determine the numbers applying and their countries of origin. Refugees are people who have been granted leave to remain in the host country on specific grounds which prevent return to their own country. Ireland up to recently has agreed to accept 200 programme refugees yearly, sent by the European Commissioner for Refugees.² 

Balseskin has accommodation for over 300 asylum seekers/refugees but currently averages 200 clients. A previous paper published in Forum explored the complex health needs of asylum seekers.³ This paper focuses on infectious diseases screened positive at the centre over a nine-year period (2004-2012).

The number of asylum seekers/refugees admitted to the Balseskin centre has fallen over the period of this study from 3,054 in 2004 to 879 in 2012. This study highlights the number of clients screened positive by our health screening team for HIV, hepatitis B and hepatitis C, with a special focus on cases of tuberculosis, during the nine years 2004-2012 inclusive.

Methodology

Voluntary health screening is offered to all new residents. This consists of a holistic comprehensive interview, including a full medico/psycho/social history and a TB questionnaire. Routine chest x-rays (CXR), blood tests for HIV, hepatitis B and C, varicella zoster antibodies and syphilis (if history suggests the need) are done with fully informed consent. The service operates independently of the asylum/immigration/legal process and is based on the recommended guidelines from the Department of Health (2001 and 2004). Clients are informed of their results and referrals are made to other services as the need arises. Clients are dispersed to other centres throughout Ireland regularly, and attend GPs as soon as medical cards are issued at their new location.

Results of nine-year study

The number of asylum seekers/refugees accommodated in the centre during the nine years (2004-2012) totalled 15,687. The number invited for voluntary health screening was 13,673, out of which 10,014 attended – an uptake of 73.23%. 

HIV screening

Out of these, the total number who screened positive for HIV was 175 (1.7%), of whom 126 (72%) were female and 49 (28%) were male.

The vast majority of the HIV positive people, 173 (98%),  came from Sub-Saharan Africa. The remaining two came from Iran and Georgia. The top seven countries of origin were Zimbabwe (45), South Africa (27), Nigeria (27), Malawi (13), DR Congo (12), Cameroon (11) and Uganda (5). 

There were three times more women than men who screened positive. Many had been physically and sexually abused in their country of origin, and some gave stories of being trafficked to Ireland for sex and slave labour. There were three deaths: two females from Nigeria and Zimbabwe from causes related to HIV, and one male from the Horn of Africa, who committed suicide in hospital (after an attempt to drown in the River Liffey was aborted by a passer-by). 

Among this HIV positive group, 17 were treated for latent TB, 10 for pulmonary TB and two for extra pulmonary TB (lymphadenitis and TB involving the knee). 

Hepatitis B 

The total number screened positive for chronic hepatitis B was 361 (3.6%), of whom 80 (22.1%) were female and 281 (77.8%) were male.

The majority, 286 (79.2%), came from Africa, with the top countries of origin being Nigeria (104), Sudan (22), Somalia (21), DR Congo (21) and the remaining 118 from Africa, came from a wide scatter of countries across the continent including Uganda, Eritrea, Kenya, Malawi, Burundi, Rwanda, Zimbabwe, South Africa, Ghana, Ivory Coast, Cameroon, Liberia and Togo. 

The high incidence may be related to male circumcision and scarifications done with unsterile blades outside the professional healthcare system in their home country. The numbers screened, showing resolved HBV, were four times greater, which indicates high transmission rates. It should be noted that one of the commonest cancers in Africa is liver cancer, which is possibly related to hepatitis B infection.

The remaining 75 (20.7%) of hepatitis B-positive clients came from Eastern European countries (mainly Georgia, Romania, Albania, Moldova and Kosovo) and from Asia (Pakistan, Afghanistan and Iran).

Hepatitis C 

The total number screened positive for chronic hepatitis C was 96 (0.95%), of whom 10 (10.4%) were female and 86 (89.5%) were male.

The majority, 32 (33.3%), came from Eastern Europe and Asia, including Georgia, many of whom had a history of intravenous drug use (IVDU), and Pakistan, 22 (22.9%), who had no history of IVDU. The remainder came from a wide scatter of countries, including Moldova, Russia, Ukraine, Afghanistan, Kosovo, Mongolia and Macedonia. 

There were two deaths among the Hepatitis C-positive clients, one from Asia, who was found dead in a flat after he moved out from direct provision. The other death was a young Eastern European, who died suddenly in his room. The Coroner’s Court delivered a verdict of acute heart failure from congenital heart disease (tricuspid valve Epstein anomaly) and a toxic level of heroin in his blood. 

Pregnant HIV positive women 

The total number of pregnant women who were HIV positive was 42 (0.41%). All of these came from Sub-Saharan Africa. Over 50% (22) required Caesarean section, as many were late bookers and this is the recommended mode of delivery for women with viral load of >400 copies/ml at 36 weeks gestation. 

Tuberculosis

Clients are routinely screened for TB which includes a CXR. The questionnaire identifies any history of tuberculosis contact, homelessness, living in hostels, prisons and long journeys in closely packed vehicles/boats, history of HIV, intravenous drug use (IVDU) and those originating from Sub-Saharan Africa, as these groups have a high incidence of TB.

Clients with symptoms of productive cough, night sweats, weight loss and fever are isolated and given three sterile bottles for collection of sputum for AFB stain and culture. An urgent CXR is arranged and they are given strict instructions on respiratory and cough etiquette, that is, use of tissues, proper disposal of tissues and washing of hands.

They are referred to the respiratory clinic at the Mater Hospital for further follow up, which may include Mantoux testing, interferon-gamma release assays (Quantiferon test) and bronchoscopy to collect secretions if client fails to produce sputum. 

The director of public health is notified if a diagnosis is confirmed. Treatment is initiated by the respiratory team, which usually consists of isoniazid, rifampin, ethambutol and pyrazinamide for the initial two months, followed by isoniazid and rifampin for four months in patients with sensitive strains. 

Direct observation therapy (DOT) is important for compliance and regular monitoring of side effects on liver (isoniazid/rifampin), eyes (ethambutol) and peripheral nerves (pyridoxine prophylaxis). 

The total number of TB cases was 58 (0.57%), of whom 27 (0.26%) were female and 31 (0.30%) were male. This further broke down as follows:

• Pulmonary TB – 28 (0.27%), of which 10 were HIV-related
• Latent TB – 23 (0.22%), of which 17 were HIV-related
• Extrapulmonary TB – seven (0.06%), of which two with disseminated TB were HIV-related
• Two with cervical/supraclavicular TB, two with spinal TB and one with abdominal TB were HIV unrelated.

Of these, 45 came from Sub-Saharan Africa, and eight from Asia and Eastern Europe (Georgia (3), Pakistan (3), Armenia (1) and Bangladesh (1) respectively.

There were two deaths from TB. An Eastern European man was urgently admitted to hospital with respiratory distress. He died from advanced pulmonary TB, which was found on post mortem. Two Sub-Saharan women who were HIV positive died from disseminated TB in hospital.

Discussion

TB remains an important public health problem in Ireland. There were 420 cases (9.2 per 100,000) reported in 2010, 424 cases (9.2 per 100,000) in 2011 and 368 (8 per 100,000) in 2012. In 2010, figures showed 185 cases were notified in the HSE East area.⁵

The World Health Organization has estimated that globally there were 8.7 million new cases of TB in 2011 (125 per 100,000) and that 1.4 million died. There were 13% co-infected with HIV and the burden of TB is highest in Asia and Africa. Almost 80% of TB cases among people living with HIV reside in Africa. Of the 15 countries with the highest estimated TB incidence rates per capita, 12 are in Africa.⁶

Our own study shows that 46% were co-infected with HIV and 84% came from Sub-Saharan Africa. 

The problem in Ireland is follow-up. Many of our clients are dispersed to other parts of Ireland. It is important for GPs to know that we encourage clients to collect their results, and that we forward results confidentially to the senior medical officers, area medical officers, GPs and public health nurses responsible for their welfare at their new direct provision accommodation centre nationwide. 

We communicate with our colleagues by phone about clients dispersed with more urgent health issues for follow up locally. Unfortunately, we are not informed of our client’s new location until the day of their dispersal. There is room for improvement in inter-agency work with asylum seekers, while continuing to practise in accordance with healthcare ethics.

Because of gradual withdrawal of community care area staff nationwide from the healthcare of asylum seekers, as with other areas of the health service, the GP does not always receive the designated GP green form recording results. Clients may also go out to private accommodation to stay with friends and relatives, and do not always give a forwarding address. They do not have access to a medical card while outside the asylum system, which further complicates matters. The duplication of screening tests already done at initial screening is wasteful and unnecessary. 

However, as clients have to stay many years in direct provision, while awaiting a decision on their immigration status, repeat screening may be a wise decision. 

The situation is getting more complex and there is a need perhaps for HSE health liaison personnel at national immigration/justice/reception integration levels, to co-ordinate the healthcare of asylum seekers, and to whom healthcare staff nationwide can appeal to, in a professional confidential way. 

Authors: Maureen Brennan is area medical officer, PJ Boyle is a clinical nurse specialist (asylum seekers’ health), and Ann Maria O’Brien and Kay Murphy are nurse/midwives at the Asylum Seekers/Refugees Health Centre, Finglas, Dublin

References 

1. Geneva Convention, 1951
2. Verbal communication ORAC 2012 (Office of Refugee Application Commissioner)
3. Boyle PJ, O’Brien AM; Murphy K, Brennan M. Complex health needs of asylum seekers. Forum 2008; 25(1): 10-12
4. Guidelines on the prevention and control of tuberculosis in Ireland 2009; Health Protection Surveillance Centre 2010 (www.hpsc.ie)
5. Infectious Disease Bulletin Summer 2012; Dept Public Health HSE East Dublin, Kildare,Wicklow.
6. WHO Regional Office for Africa World TB Day 2012 (www.afro.who.int/en/clusters-a-programmes/dpc/tuberculosis/overview.html)