Zahedan University of Medical Sciences launches an active Tuberculosis screening program among Afghan refugees amid COVID-19 pandemic

Zahedan University of Medical Sciences has launched an active TB screening program targeting Afghan refugees in September 2020. The program will be conducted with the participation of 92 screening teams comprising Community Health Volunteers (CHVs) along with disease prevention and control experts from Zahedan University of Medical Sciences. This national project is supported by the Global Fund TB in collaboration with Iran’s Ministry of Health and is being simultaneously implemented in Afghanistan and Pakistan. The program has been planned to be implemented during one month time, and the target group of this project is 70,000 Afghan refugees with legal residential permits.

Report from: Zahedan University of Medical Sciences, Vice Chancellery for Health
Published on: 22 September 2020

Every year, 10 million people fall ill with tuberculosis (TB). Despite being a preventable and curable disease, 1.5 million people die from TB each year – making it the world’s top infectious killer (1). About half of all people with TB can be found in 8 countries: Bangladesh, China, India, Indonesia, Nigeria, Pakistan, Philippines and South Africa (1) .

The incidence of tuberculosis (TB) in Iran is 14 cases per 100,000 population which is more than 10 times below the average global rate of 131 cases per 100,000 population (2). During the past 50 years TB incidence in Iran has decreased has fallen 13 times. Between March 2017 and March 2018, some 8,819 individuals were diagnosed with TB of whom 14 percent were foreign nationals- mostly Afghan nationals. Province of Golestan, northern Iran, and southeastern province of Sistan and Baluchestan, have the highest incidence of TB across the country, with a significant number of Afghan Refugees living in Sistan and Balocuhestan Province.

Some of Iran neighboring countries such as Tajikistan and Pakistan have the highest incidence of tuberculosis which known as a challenge for tuberculosis control in Iran while Saudi Arabia and Turkey have the lowest incidence. The estimated incidence of TB in Afghanistan and Pakistan, in 2017 has been reported at 189 and 267 cases per 100,000 populations, respectively (3).

Figure 1. Incidence of A, Tuberculosis and B, Tuberculosis with HIV Cases (3).

According to the United Nations High Commissioner for Refugees (UNHCR), Iran is one of the 10 countries hosting the largest number of refugees in the world, the vast majority from Afghanistan (4). Cultural and language similarities and sharing a common religion with Iranian nationals has been a major drive for migration of a large number of refugees from Afghanistan to Iran during the last 40 years. The vast majority of Afghans live in urban areas alongside host communities. It has been estimated that around 2 million have been living in Iran for the last four decades, of whom 40% are registered with asylum cards, 2% hold long-term residence permits, 22% possess short-term passports, and 36% live in Iran with no official documents (5).

A systematic review and meta-analysis published in 2015 on the major infectious diseases affecting the Afghan immigrant population of Iran, reported that the proportion of Afghan immigrants afflicted with tuberculosis was (29%), multiple-drug-resistant tuberculosis (56%), of total national figures (6).

In Iran, the basic Primary Health Care services, including tuberculosis prevention and treatment services are provided free-of-charge through Universal Health Coverage plan for 95% of the population (5). Iranian healthcare units provide free-of-charge and quality primary health care services for the refugees. Active screening of close contacts of smear positive TB patients and high risk groups including such as prisoners, people who received organ transplants, people living with HIV, and foreign refugees is one of the main strategies adopted by the Iran"s Ministry of Health (MoH) to tackle TB across the country. In some cases such as TB and COVID-19 patients hospital services are also provided free-of-charge, regardless of the nationality of the patients. However, as a result of low health literacy and lack of awareness of diseases, refugees have always hesitated to refer to the medical centers even in cases of serious illnesses (7). Underutilization of PHC services have been particularly observed in the illiterate, the middle-aged and above, and undocumented refugees (8).

Achievements and challenges of tuberculosis control program among non-Iranian population covered by Zahedan University of Medical Sciences

Given the proximity of Sistan and Balouchestan Province to Pakistan and Afghanistan, and its long common border with neighboring countries, a significant legal and illegal population movement takes place in the region, and Sistan and Balouchestan has been estimated to host more than 100 thousand Afghan refugees. Between 2009 and 2019, on average more than 30% (ranging from 21% to 43%) of new smear positive TB cases in the areas covered by ZAUMS were non- Iranian nationals, and more than 90% of these cases were Afghan refugees.

Figure 2. The distribution of new smear positive TB cases identified in Zahedan University of Medical Sciences by nationality from 2008 to 2018

Although the proportion of non-Iranian TB patients has increased during the recent years, due to the special working conditions and housing of this population, it is more difficult to provide preventive and medical services and implement DOTS visits in this high risk group. The success rate of TB treatment is one of the most important indicators of the TB control program, and currently the expected goal is 90%. As it has been presented in Figure 3, the TB treatment success rate in the non-Iranian population has fluctuated a lot (changing from 76% to 92%), which is partly caused by changing regional conditions, displacements, economic problems, etc.

Figure 3. The percentage of TB treatment success rate in the Iranian and non-Iranian TB patients in the areas covered by Zahedan University of Medical Sciences, 2008-2018

Fortunately, with the strengthening of DOTS strategy activities and some improvements in the communication between healthcare providers and the non-Iranian TB patient, and the follow up of cases even if those patients leave the country during the course of treatment, the number of absences from treatment decreased from 11% in 2010 to zero in 2018.

Tuberculosis (TB) Screening Program among Afghan refugees in the context of coronavirus disease

Given the fact that non-Iranian population are considered as a high risk group for contracting TB, tuberculosis Screening among Afghan refugees by ZAUMS has been carried out in several academic studies and interventions during the past years, including: Tuberculosis screening in residents of Mirjavah border areas (mostly non-Iranians) in 2005, Screening of the Afghan population living in Shirabad region on the outskirts of Zahedan city that hosts a population of more than 56,000 population with about one third of them are non-Iranian people, to compare the effect of active and passive disease detection in high risk population, and more recently tuberculosis awareness and screening campaign in the suburbs of Zahedan (about 320,000 people) during 5 rounds of activities during the years 2017 and 2018.

Policies widely adopted in response to the ongoing pandemic of Covid-19, particularly lockdowns and reassignments of health personnel and equipment, are impacting the performance of TB prevention and care programmes. A global TB case detection decrease by an average 25% over a period of 3 months will lead to a 13% increase TB deaths, bringing the total to 1.66 (1.3 – 2.1) million TB deaths in 2020, near the global level of TB mortality of the year 2015 (9). On the other hand, the response to the Covid-19 pandemic may bring opportunities for synergies including increased levels of TB screening, particularly among high risk groups such a Afghan refugees.

Zahedan University of Medical Sciences has launched an active TB screening program targeting Afghan refugees in September 2020. The program will be conducted with the participation of 92 active screening teams comprising Community Health Volunteers (CHVs) along with Disease Prevention and Control Officers from Zahedan University of Medical Sciences. This national project is supported by the Global Fund TB in collaboration with Iran’s Ministry of Health and is being simultaneously implemented in Afghanistan and Pakistan. The program has been planned to be implemented during one month time, and the target group of this project is 70,000 Afghan refugees with legal residential permits.

The TB screening program in the non-Iranian population is a good opportunity to detect cases in a timely manner and provide treatment to this group. The diagnostic and both outpatient and inpatient treatment services for Afghan TB cases identified during the program will be free-of-charge, as it has been the case ever since the TB prevention and control program has been started in Iran.

References:

1. World Health Organization. Tuberculosis: World Health Organization; 2020 [Available from: https://www.who.int/health-topics/tuberculosis#tab=tab_1.

2. Tehran Times. Tuberculosis in Iran 10 times below global prevalence 2020 [Available from: https://www.tehrantimes.com/news/428676/Tuberculosis-in-Iran-10-times-below-global-prevalence.

3. Tavakoli A. Incidence and Prevalence of Tuberculosis in Iran and Neighboring Countries. Zahedan J Res Med Sci. 2017;19(7):e9238.

4. UN High Commissioner for Refugees (UNHCR). UNHCR and Climate Change, Disasters, and Displacement: UN High Commissioner for Refugees (UNHCR); 2017 [Available from: https://www.refworld.org/docid/59413c7115.html.

5. Letafat M, Beyranvand T, Aryankhesal A, Behzadifar M, Behzadifar M. Universal Health Coverage (UHC) in Iran. Iranian journal of public health. 2018;47(7):1061-2.

6. Pourhossein B, Irani AD, Mostafavi E. Major infectious diseases affecting the Afghan immigrant population of Iran: a systematic review and meta-analysis. Epidemiology and health. 2015;37:e2015002.

7. Azizi N, Delgoshaei B, Aryankhesal A. Lived Experience of Afghan Refugees in Iran Concerning Primary Health Care Delivery. Disaster medicine and public health preparedness. 2019;13(5-6):868-73.

8. Salmani I, Seddighi H, Nikfard M. Access to Health Care Services for Afghan Refugees in Iran in the COVID-19 Pandemic. Disaster medicine and public health preparedness. 2020:1-2.

9. Glaziou P. Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. medRxiv. 2020:2020.04.28.20079582.