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Innovative model for screening adults and children for infectious diseases fleeing from conflict in Afghanistan

Links to all 5 aspects of the framework

1) Commit to action on inclusion health

2) Understand the characteristics and needs of inclusion health groups locally

3) Develop the workforce for inclusion health

4) Developing integrated and accessible services for inclusion health

5) Demonstrate impact and improvement for inclusion health

Permission: has been granted and we give permission for NHS England to utilise these are case examples. Two logos are attached.

Organisation/s: These were Manchester University NHS Foundation Trust, gtd healthcare and Manchester Integrated Care Partnership.

The challenge: In 2021, a large-scale evacuation of people from Afghanistan took place. 8000 Afghans were relocated to the UK and temporarily housed in hotels as part of the Afghan Relocations and Assistance Policy and Specification. A quarter of these were expected to be housed in bridging hotels in Manchester.

Tuberculosis (TB) is a contagious bacterial infection which causes disease primarily in the lungs but can affect many other areas within the body. It is the second leading infectious killer globally behind COVID -19. Latent TB infection (LTBI) occurs when TB lies dormant within the body. 25% of the world’s population is thought to be infected with latent TB (1.7billion) and 10 % will go on to develop active TB. Within the UK 80% of all new cases of active TB cases are from those born in countries of high incidence. Hence, to reduce the burden of TB within the UK, those at risk of Latent TB must be identified early and treated effectively (appendices 3&4).

Afghanistan has a high incidence of TB (193/100,000) population. The current TB rate in the UK is 15/100,000 population. Usually, migrants arriving from Afghanistan would have been screened for active TB prior to obtaining a visa necessary for travel to the UK, screening for latent TB being completed within 2 years of entry

Our ambition was to develop and deliver an innovative model which delivered this screening in three months rather than the 2 years of entry to the UK. This would have, high participation rates, reducing the burden of TB within this group and to the UK population through spread of TB. The model that we would develop would take services to this group and be responsive to the cohorts needs, in addition, give high levels of satisfaction to staff.

Public Health outcomes:

-Safest consistent approach of care through agreed clinical pathways and clear organizational responsibilities

-Completion of TB screening within 2 months

-Adults and children with active TB disease were identified and treatment initiated within 5 working days (thereby preventing ongoing transmission of TB)

-Adults and children with latent TB infection were identified and referred to TB Clinic and treatment was offered within 6-8 weeks of detection (thereby preventing TB disease in the future)

-Systematic hand-over of patient care when patients move from Manchester by both TB and primary care teams.

In 2021 people fleeing from conflict in Afghanistan, Manchester expected 25% of the UK cohort. Tuberculosis is a contagious infectious disease that can be fatal. Afghanistan has a high burden of TB; usual screening was not possible. An innovative model was delivered within 3 months, the full process usually takes 2 years to complete.

The approach/solution: We identified key stakeholders within all the organisation involved and brought together a task and finish group to explore and agree on a clinical model and a shared understanding of roles, responsibilities and risks of all the organizations involved. Funding was requested and agreed upon. The task group developing the implementation plan and operationalising this. Outcomes were fed into the nationally which informed the policy as it developed and other programs.

Insights and impacts: 561 Afghans were screened for both active disease and latent TB infection within 3 months of entry to the UK. 38 persons with LTBI were identified. In addition, we have signposted individuals and families to other support services, thereby facilitating access to good quality primary and secondary care services (for example, 4 adults found to have Hepatitis B have been referred to Infectious Disease Team).

  • Safest consistent approach of care through agreed clinical pathways and clear organizational responsibilities

Multi-professional and multi-organizational teams developed pathways and documentation with clear lines of clinical and administrative responsibility. All supporting materials were available in all the languages spoken by the group. Our primary healthcare provider is on-site and supports patients at all stages and has mechanisms set up to communicate in various methods (written, face to face, WhatsApp groups).

  • Completion of initial screening within 2 months

started in December 2021 following GP registration. Screening of 344 children was undertaken prior to Christmas and required 4 days of Mantoux testing and reading undertaken over a 2-week period. This was facilitated by 5 interpreters (Dari, Farsi, and Pashto). 217 adults were offered blood testing and chest Xray in January 2022 organized and facilitated by clinical and administration staff again supported by interpreters. Results were collated by the TB Collaborative Project Manager and the Screening TB multi-disciplinary meeting was staffed by senior member of the Adult and Paediatric TB Clinical Team.

  • Adults and children with active TB disease were identified and treatment was initiated within 5 working days (thereby preventing ongoing transmission of TB)

No persons with active TB were identified.

  • Adults and children with latent TB infection were identified and referred to TB Clinic and treatment was offered within 6-8 weeks of detection (thereby preventing TB disease in the future)

30 (14%) adults and 8 (2%) children were identified with latent TB infection and have been referred for and treatment commenced.

We screened all the population for HIV, Hepatitis B and C. 4 cases of hepatitis B and received appropriate therapy.

  • Systematic hand-over of patient care when patients move from Manchester by both TB and primary care teams

If there has been relocation from the hotel to alternative accommodation, both primary and secondary care providers have liaised with the next services to ensure continuity of care.

The results and lessons from screening are now being utilized for screening at other hotels. The model has been discussed at a national level and the impact of the approach to hard-to-reach groups has been shared and accepted for abstract publication.

The results of our chest X-rays in children have been shared with the National TB team and have been instrumental in a change in National policy. New entrant children from Afghanistan will now only have a chest x-ray if they have symptoms or a positive Mantoux (TB) test, thus reducing the radiological burden to this group of children.

The success of our TB screening has enabled us to utilize the existing paradigm in other locations. Adjustments made the population cultures and values, numbers to be screened, clinical and administrative teams as well as hotel infrastructure.

The success of our TB screening has enabled the existing model for New Migrant TB Screening which had essentially halted over the COVID Pandemic. Previously, this was a secondary care hospital-based driven service delivered by TB Teams and had been very poorly attended (75% DNA rate) with low completion rates amongst those identified with latent TB. Managing migrants, refugees, and asylum seekers has proved challenging, and our recent experiences working collaboratively with our primary care partners have demonstrated that difficult-to-access patients may benefit from a more personalized and locally delivered service. The UK is also during bringing people fleeing from conflict in Ukraine, the learning from this programme is being developed to support this group. Thus, it is likely that future development of the New Migrant Screening will be community-based with an embedded primary care structure to facilitate general well-being and health screening with the ability to screen for infectious diseases and other long term health conditions.

What people said:

Feedback from families: "…We have experienced many blighted and unfavourable conditions in 2021. All this time you tried to support Afghan refugees and their families. We will never forget your spiritual and practical support to save our lives and make us happy, as you have been working day and night- and spending-time helping refugees and coordinating with other teams for better facilities. For this, we thank you."

" I wanted to take this opportunity to say how we appreciate your dedication.

We will never forget your assistance, generosity and sympathies for our people during a very Critical Situation."

This project was also recognised locally and nationally by the 2022 HSJ patient Safety awards as a finalist in three categories: Best use of Integrated Care and Partnership working in Patient Safety Award, Improving Health outcomes for ethnic minority communities and early-stage patient safety innovation of the year

Tips for success: The results and lessons from screening are now being utilized for screening at other hotels. The model has been discussed at a national level and the impact of the approach to hard-to-reach groups has been shared and accepted for abstract publication. This was a challenging time; the cross organisational working will facilitate further transformation at a quicker pace. So many people contributed to this programme and recognising this has been important and a key driver.

What next: There has been a great deal of learning from this which is being spread across all areas of the organizations involved and those that are networked in across the Northwest and Nationally.