Extrapulmonary tuberculosis among migrants in Europe, 1995 to 2017

Abstract

Objectives: The proportion of tuberculosis (TB) cases occurring in migrants in Europe is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality, yet its extent in migrant populations is unclear. We assessed patterns of extrapulmonary TB in migrants across the European Union (EU)/European Free Trade Association (EFTA). We investigated the proportion of extrapulmonary TB cases among migrants versus non-migrants, and variations by specific site of disease, reporting European region, and migrant region of origin.

Methods: We carried out a cross-sectional secondary database analysis, utilizing 23 years of data collected between 1995 and 2017 from the European Surveillance System of the European Centre for Disease Prevention and Control for 32 EU/EFTA countries.

Results: In total, 1 270 896 TB cases were included, comprising 326 987 migrants (25.7%) and 943 909 non-migrants (74.3%). Of TB cases among migrants, 45.2% (n = 147 814) were extrapulmonary compared to 21.7% (n = 204 613) among non-migrants (p < 0.001). Lymphatic, bone/joint and peritoneal/digestive TB were more common among migrant than non-migrant extrapulmonary cases. A lower proportion of extrapulmonary TB was seen in Eastern Europe (17.4%, n = 98 656 of 566 170) and Southern Europe (29.6%, n = 62 481 of 210 828) compared with Western (35.7%, n = 89 498 of 250 517) and Northern Europe (41.8%, n = 101 792 of 243 381). Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary disease, with 62.0% (n = 55 401 of 89 353) and 54.5% (n = 38 327 of 70 378) of cases, respectively, being extrapulmonary.

Conclusions: Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than in non-migrants. There is a need to improve clinical awareness of extrapulmonary TB and to integrate its detection into screening programmes.

Keywords: Europe; Extrapulmonary tuberculosis; Health services research; Migrant; Tuberculosis.

Fig. 1

Sample flow chart. EU/EFTA, European Union/European Free Trade Association; TB, tuberculosis.

Fig. 2

Site of tuberculosis (TB) among migrant and non-migrant TB cases in the European Union/European Free Trade Association (EU/EFTA), 1995–2017 (n = 1 270 896). Extrapulmonary TB is defined as any case of TB involving organs or anatomical sites other than the lungs, with or without coexistent lung disease. p value calculated using χ² test (χ² = 6.7 × 10⁴, p < 0.001).

Fig. 3

Proportion of pulmonary and extrapulmonary tuberculosis (TB) among migrant and non-migrant TB cases in selected countries of the European Union/European Free Trade Association (EU/EFTA), 1995–2017. Extrapulmonary TB is defined as any case of TB involving organs or anatomical sites other than the lungs, with or without coexistent lung disease. The boxes in the figure illustrate the proportion of pulmonary and extrapulmonary TB cases that occur in migrants in each country. On the map, the different shadings of the countries represent the proportions of individuals with foreign citizenship living in that country on 1st January 2016 (source: Eurostat, online data code: migr_pop1ctz).

Fig. 4

Site of tuberculosis (TB) among migrant TB cases in the European Union/European Free Trade Association (EU/EFTA) by region of origin, 1995–2017 (n = 261 074). Extrapulmonary TB is defined as any case of TB involving organs or anatomical sites other than the lungs, with or without coexistent lung disease. ∗p < 0.001, a greater proportion of TB is pulmonary. †p <0.001, a greater proportion of TB is extrapulmonary. p values are two-sided, calculated using one-sample test of proportion (H₀ = the proportions of pulmonary and extrapulmonary TB are equal).