Dr. Raz Mohammed WALIChief Migration Health Physician

NTP National Seminar: 14-15 July 2014Pukhra, 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 sub-

offices, 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)

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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)

5. Immigrants (Nepalis)10,600 exams CY2013 and 5200, CY2014TB Rx (Aus)

6. TB Reach >20,000 Tests>4,000 TB including >250 RIF ResistantMOHP

4. Harmonization of TB diagnostic &Treatment protocol for Non-resettlement refugee: 100s of TB cases treated so far (passive vs active case finding?)

2. Non-USRP Refugees HAP (AUS,CAN,UK,NZ,NL,NOR)4,557 in CY2013,

3. Public Health Support activitiesInfectious disease surveillance, operational researches

7- Labor Migration health study:Three countries project (Nepal, Bangladesh and Pakistan)

Health Assessment Program

Initial med exam (IME)•Counseling•Physical examination•CXR•Laboratory investigation•Vaccination

– 2nd dose vaccination (2013)– Hep B screening (2014)

On hold with regular follow up•TB suspects •TB Treatment•Drug abuse •Alcohol dependent•Psychiatric evaluation•Chronic disease

Re-med :Undergone the same IME procedure (except vaccination)

Medical Escort & Trv. Assistance•POE•Final destination

Prior departure

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)

Pre-Embarkation Check (PEC)

•24 hours prior departure Damak– Physical assessment- Pregnancy Test- Albendazole Deworming- Medication supplies for 4-8 weeks coverage

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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)

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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)

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TB Isolation Center

14 huts to isolate

•8 months MDR case•2 months, non-MDR highly infectious (smear positive)

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Active TB case findingProtocol of USRP

CDC migration Requirements: Technical Instructions for tuberculosis screening and treatment using cultures and DOT, (Oct 2009)

Applicant 2-14 years of age

Tuberculin Skin Test or IGRA

TST ≥ 10 mm or IGRA positive

Chest Radiograph

Medical History, examination, or CXR suggestive for tuberculosis

Individual known HIV infection

Medical HistoryPhysical Examination

Applicant ≥ 15 years of age

3 sputum smear & Culture

DST for all positive 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%

Active TBPer 100,000

733 681 907 989 1,009 658 833

Active TB

TB Suspects(Abn. CXR+Clinical ground)

No of CXRs

Passive case findingHarmonization of TB diagnostic and treatment Protocol Project

Chest Radiograph

Medical History, examination, or CXR suggestive for tuberculosis

Individual known HIV infection

Medical HistoryPhysical Examination

3 sputum smear& Culture

DST for positive culture IOM

Health Care provider for refugee in the camp

AMDA

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 only2009-2012 (b): Culture performed from clinically suspects

2013: Culture perform from clinically suspect& CXR suggested TB

Overall Active Case Findings Rate (CXR)

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Overall Passive Case Findings Rate (Clinic)

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Smear& Culture

Health AssessmentProgram

Refugee Resettlement

2008-2013

Refugee Non-Resettlement

2009-2013

Nepalese migrants MHAC2011-2013

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%

% Among TB suspects referred for Smear &CultureConcentrated Smear read by Fluorescent microscopy

Culture by Liquid MGIT960 system& duplicate LJ solid

Drug Susceptibility Testing pattern

Refugees Nepalese Migrants

Pan-Susceptible 89.5% 89.9%

MDR 1.7% 2.5%

XDR - -

Inconclusive 1.4% -

Mono-Resistant 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% -

% Among TB suspects

Overall INH resistance rate in the country is estimated to be around 7.5%

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