The immune status of migrant populations in Europe and implications for vaccine-preventable disease control: a systematic review and meta-analysis

BACKGROUND

Ensuring vaccination coverage reaches established herd immunity thresholds (HIT) is the cornerstone of any vaccination programme. Diverse migrant populations in European countries have been associated with cases of vaccine-preventable diseases (VPD) and outbreaks, yet it is not clear to what extent they are an under-immunised group.

METHODS

We did a systematic review and meta-analysis to synthesise peer-reviewed published primary research reporting data on the immune status of migrants in EU/EEA countries, the UK and Switzerland, calculating their pooled immunity coverage for measles, mumps, rubella, and diphtheria using random-effects models. We searched on Web of Science, Embase, Global Health and MEDLINE (January 1st 2000 to June 10th 2022), with no language restrictions. The protocol is registered with PROSPERO (CRD42018103666).

FINDINGS

Of 1103 abstracts screened, 62 met eligibility criteria, of which 39 were included in the meta-analysis. The meta-analysis included 75 089 migrants, predominantly from outside Europe. Pooled immunity coverage among migrant populations was well below the recommended HIT for diphtheria (n = 7, 57.4% [95% CI: 43.1-71.7%] I2 = 99% vs HIT 83-86%), measles (n = 21, 83.7% [95% CI: 79.2-88.2] I2 = 99% vs HIT 93-95%), and mumps (n = 8, 67.1% [95% CI: 50.6-83.6] I2 = 99% vs HIT 88-93%), and midway for rubella (n = 29, 85.6% [95% CI: 83.1-88.1%] I2 = 99% vs HIT 83-94%), with high heterogeneity across studies.

INTERPRETATION

Migrants in Europe are an under-immunised group for a range of important VPDs, with this study reinforcing the importance of engaging children, adolescents, and adults in 'catch-up' vaccination initiatives on arrival for vaccines, doses, and boosters they may have missed in their home countries. Co-designing strategies to strengthen catch-up vaccination across the life-course in under-immunised groups is an important next step if we are to meet European and global targets for VPD elimination and control and ensure vaccine equity.

Community engagement to co-design and deliver public health interventions in newly arrived migrants

Alison Crawshaw will talk about her participatory research that uses design thinking to develop community-based strategies to improve health outcomes in migrant populations. She will summarise the benefits of using community-based approaches and co-designing public health initiatives with affected migrant communities, bringing in lessons learned from a recent project with the Congolese community in London.

Participatory approaches in the development of health interventions for migrants: a systematic review

OBJECTIVE

Analysis of participatory approaches to developing health interventions for migrants and how approaches embody core participatory principles of inclusivity and democracy.

DESIGN

A systematic review of original articles. Electronic searches within the databases MEDLINE, Embase, Global Health and PsychINFO (from inception-November 2020).

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original peer-reviewed articles reporting research to develop and implement a health intervention for migrants, incorporating participatory approaches. We defined migrants as foreign-born individuals. Only articles reporting the full research cycle (inception, design, implementation, analysis, evaluation, dissemination) were included.

DATA EXTRACTION

We extracted information related to who was involved in research (migrants or other non-academic stakeholders), the research stage at which they were involved (inception, design, implementation, analysis, evaluation, dissemination), the method of their involvement and how this aligned with the core principles of participatory research-categorising studies as exhibiting active or pseudo (including proxy and indirect) participation.

RESULTS

1793 publications were screened, of which 28 were included in our analysis. We found substantial variation in the application of participatory approaches in designing health interventions targeting migrants: across 168 individual research stages analysed across the 28 studies, we recorded 46 instances of active participation of migrants, 30 instances of proxy participation and 24 instances of indirect participation. All studies involved non-academic stakeholders in at least one stage of the research, only two studies exhibited evidence of active participation of migrants across all research stages. Evidence is limited due to the variability of terms and approaches used.

CONCLUSIONS

Important shortfalls in the meaningful inclusion of migrants in developing health interventions exist, suggesting a more rigorous and standardised approach is warranted to better define and deliver participatory research and improve quality.

REGISTRATION

This review followed Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and is registered on the Open Science Framework (osf.io/2bnz5).

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: A systematic review

BACKGROUND

Migrants in high-income countries may be at increased risk of COVID-19 due to their health and social circumstances, yet the extent to which they are affected and their predisposing risk factors are not clearly understood. We did a systematic review to assess clinical outcomes of COVID-19 in migrant populations, indirect health and social impacts, and to determine key risk factors.

METHODS

We did a systematic review following PRISMA guidelines (PROSPERO CRD42020222135). We searched multiple databases to 18/11/2020 for peer-reviewed and grey literature on migrants (foreign-born) and COVID-19 in 82 high-income countries. We used our international networks to source national datasets and grey literature. Data were extracted on primary outcomes (cases, hospitalisations, deaths) and we evaluated secondary outcomes on indirect health and social impacts and risk factors using narrative synthesis.

RESULTS

3016 data sources were screened with 158 from 15 countries included in the analysis (35 data sources for primary outcomes: cases [21], hospitalisations [4]; deaths [15]; 123 for secondary outcomes). We found that migrants are at increased risk of infection and are disproportionately represented among COVID-19 cases. Available datasets suggest a similarly disproportionate representation of migrants in reported COVID-19 deaths, as well as increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected. Migrants experience risk factors including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

CONCLUSIONS

Migrants in high-income countries are at high risk of exposure to, and infection with, COVID-19. These data are of immediate relevance to national public health and policy responses to the pandemic. Robust data on testing uptake and clinical outcomes in migrants, and barriers and facilitators to COVID-19 vaccination, are urgently needed, alongside strengthening engagement with diverse migrant groups.

The Kock pouch reconsidered: an alternative surgical technique

The psychological impact stoma surgery can have on an individual is well documented within the literature (White and Hunt, 1997; Borwell, 2009; Williams, 2005; Brown, 2005). For many years, surgeons have explored and developed innovations in surgical techniques, in particular restorative procedures with a view of preventing permanent stoma formation; ileal anal pouch (IAP) now being the surgical procedure of choice for treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, high morbidity rates are associated with pouch longevity (Castillo et al 2005; Nessar and Wu, 2012) and once removed can lead to a high-output ileostomy with risks of electrolyte imbalance and malabsorption. This then creates the dilemma of whether the Kock pouch (KP) should be offered as a surgical option. This article offers a historical perspective of the KP and its place in the surgical management of UC and FAP. This article also presents results from a recent audit funded by the Ileostomy Association (IA), highlighting how patients manage their KP and the importance of maintaining bowel control and being free of an incontinent stoma as a means of coming to terms with their condition.

Another day, another dollar... another consultation

The Department of Health (DH) has once again left the field of stoma care and incontinence nursing in a state of uncertainty over its future. Following its recent publication of responses to the latest consultation into the provision of stoma and incontinence products and services, it determined that no decisions could be made at this point (DH, 2007).

Peri-operative radiotherapy for rectal cancer: the case for a selective pre-operative approach - the third way

Peri-operative radiotherapy has been used widely in addition to surgery in an attempt to reduce local recurrence (LR) following surgical resection of rectal cancer. Currently different groups follow different approaches with some routinely administering one weeks pre-operative radiotherapy to all cases of operable mobile cancer with others favouring postoperative chemoradiotherapy for selected high risk groups. In this review we bring together the changes in surgery, pathology and imaging that have occurred in recent years and together with the data from recent randomized pre-operative radiotherapy trials propose a logical and optimal way of managing rectal cancer. This third way is selective and pre-operative and should ensure a low rate of LR with radiotherapy reserved for those cases that need it.

Diagnosis and eradication of Helicobacter pylori in patients with duodenal ulceration in the community

OBJECTIVE

To determine the value of Helicobacter pylori (Hp) serology in diagnosis of active Hp infection in patients with documented duodenal ulcer (DU) and to directly compare the efficacy and side-effects profiles of metronidazole or tinidazole in a triple therapy regimen to eradicate active Hp infection.

DESIGN OF STUDY

Prospective, single-blinded, randomised trial.

METHODS

One hundred patients from General Practice with documented DU and Hp seropositivity had a C14 Urea Breath Test (UBT). Those who tested positive were randomised to receive one-week, twice daily omeprazole 20 mgs and clarithromycin 250 mgs in combination with metronidazole 400 mgs (OCM) or tinidazole 500 mgs (OCT). Eradication was confirmed by a repeat UBT.

RESULTS

Eighty five sero-positive patients had a positive pre-treatment UBT. On intention to treat basis, OCT (100%) had a significantly better eradication rate than OCM (87.8%), p = 0.023. There was no difference in side effects.

CONCLUSION

(1) Positive Hp serology in patients with DU does not always mean active infection and (2) for patients in the community with active Hp and DU disease OCT is significantly better than OCM for eradicating Hp.

Carcinoma of the breast and hormone replacement therapy for osteoporosis

The benefits of hormone replacement therapy for postmenopausal women, especially in the prevention and treatment of osteoporosis, are well known. It is still not clear whether oestrogen replacement therapy can be given safely to women with breast cancer. The incidence and survival of breast cancer is rising in the UK and increasing numbers of young women with breast cancer treated systemically experience an early menopause and are at prolonged risk of osteoporosis. This review discusses the risk/benefit analysis of oestrogen replacement therapy for breast cancer patients, and alternative therapies: SERMs, phyto-oestrogens and bisphosphonates. A schedule for monitoring osteoporosis for breast cancer patients with a therapeutic early menopause is suggested.

A phase II and pharmacokinetic study with oral piritrexim for metastatic breast cancer

Piritrexim is a lipid-soluble antifolate which, like methotrexate, has a potent capacity to inhibit dihydrofolate reductase. We performed a multicentre phase II study with piritrexim in patients with locally advanced or metastatic breast cancer. Twenty-four patients of which sixteen had received prior chemotherapy, were initially treated with 25 mg piritrexim orally administered trice daily for four days, repeated weekly, with provision for dose escalation or reduction according to observed toxicity. Of twenty-one patients evaluable for tumour response, one patient achieved a partial response which lasted for 24 weeks. Three patients had stable disease during 12 weeks of treatment, seventeen had progressive disease. Pirtrexim was generally well tolerated, in eighteen patients the dose could be escalated. Myelotoxicity was the most frequent observed toxicity of this piritrexim regimen. Leucopenia and thrombocytopenia grade 3/4 occurred in 38% of the patients sometime during treatment. Pharmacokinetic analysis of piritrexim in three patients during the first treatment cycle, revealed peak levels 1 to 2 h after an oral dose, with a trend towards a higher peak plasma levels and AUCs on the fourth dosing day compared with the first dosing day. In conclusion, orally administered piritrexim appears to be a regimen with little activity in patients with locally advanced or metastatic breast carcinoma.