Dr. Raz Mohammed WALI
Chief Migration Health Physician
NTP National Seminar:
14-15 July 2014
Pukhra, 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 suboffices, 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)
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)
2. Non-USRP Refugees HAP (AUS,CAN,UK,NZ,NL,NOR)
4,557 in CY2013,
3. Public Health Support activities
Infectious disease surveillance, operational
researches
4. Harmonization of TB diagnostic &Treatment
protocol for Non-resettlement refugee: 100s of
TB cases treated so far (passive vs active case finding?)
5. Immigrants (Nepalis)
10,600 exams CY2013 and 5200, CY2014
TB Rx (Aus)
6. TB Reach >20,000 Tests
>4,000 TB including >250 RIF Resistant
MOHP
7- Labor Migration health study:
Three countries project (Nepal,
Bangladesh and Pakistan)
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Health Assessment
Program
Initial med exam (IME)
Re-med :
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•
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•
•
Undergone the same IME procedure
(except vaccination)
Counseling
Physical examination
CXR
Laboratory investigation
Vaccination
– 2nd dose vaccination (2013)
– Hep B screening (2014)
Medical Escort & Trv.
Assistance
• POE
• Final destination
On hold with regular follow up
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•
•
•
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•
TB suspects
TB Treatment
Drug abuse
Alcohol dependent
Psychiatric evaluation
Chronic disease
Prior departure
Pre-Embarkation Check
(PEC)
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)
•
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
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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 finding
Protocol of USRP
CDC migration Requirements: Technical Instructions for tuberculosis screening and treatment
using cultures and DOT, (Oct 2009)
Medical History
Physical Examination
Applicant
2-14 years of age
Applicant
≥ 15 years of age
Tuberculin Skin Test
or IGRA
Chest Radiograph
TST ≥ 10 mm or
IGRA positive
 Medical History, examination, or
CXR suggestive for tuberculosis
 Individual known HIV infection
DST for all positive
culture
3 sputum smear &
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%
733
681
907
989
1,009
658
833
No of CXRs
TB Suspects
(Abn. CXR+Clinical ground)
Active TB
Active TB
Per 100,000
Passive case finding
Harmonization of TB diagnostic and treatment Protocol Project
Symptomatic
refugees
Medical History
Physical Examination
AMDA
Health Care provider for refugee in the camp
Chest
Radiograph
DST for positive
culture
 Medical History, examination, or CXR
suggestive for tuberculosis
 Individual known HIV infection
3 sputum smear
& Culture
IOM
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 only
2009-2012 (b): Culture performed from clinically suspects
2013: Culture perform from clinically suspect& CXR suggested TB
Overall Active Case Findings Rate (CXR)
14
Overall Passive Case Findings Rate (Clinic)
69
82
81
82
86
18
19
18
14
2010b
2011b
2012b
2013c
100
31
2008a
2009b
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Smear& Culture
Health Assessment
Program
Refugee
Resettlement
Refugee
Non-Resettlement
2008-2013
2009-2013
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%
Nepalese migrants MHAC
2011-2013
% Among TB suspects referred for Smear &Culture
Concentrated Smear read by Fluorescent microscopy
Culture by Liquid MGIT960 system& duplicate LJ solid
Drug Susceptibility Testing pattern
Refugees
Nepalese
Migrants
89.5%
89.9%
MDR
1.7%
2.5%
XDR
-
-
1.4%
-
Pan-Susceptible
Inconclusive
Mono-Resistant
% Among TB suspects
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%
-
Overall INH resistance rate in the country is estimated to be around 7.5%
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