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BackgroundPopulation breast screening services in England were suspended in March 2020 due to the COVID-19 pandemic. Here, we estimate the number of breast cancers whose detection may be delayed because of the suspension, and the potential impact on cancer deaths over 10 years.MethodsWe estimated the number and length of screening delays from observed NHS Breast Screening System data. We then estimated additional breast cancer deaths from three routes: asymptomatic tumours progressing to symptomatically diagnosed disease, invasive tumours which remain screen-detected but at a later date, and ductal carcinoma in situ (DCIS) progressing to invasive disease by detection. We took progression rates, prognostic characteristics, and survival rates from published sources.ResultsWe estimated that 1,489,237 women had screening delayed by around 2–7 months between July 2020 and June 2021, leaving 745,277 outstanding screens. Depending on how quickly this backlog is cleared, around 2500–4100 cancers would shift from screen-detected to symptomatic cancers, resulting in 148–452 additional breast cancer deaths. There would be an additional 164–222 screen-detected tumour deaths, and 71–97 deaths from DCIS that progresses to invasive cancer.ConclusionsAn estimated 148–687 additional breast cancer deaths may occur as a result of the pandemic-related disruptions. The impact depends on how quickly screening services catch up with delays.

Rates of migration to Europe, and within Europe, have increased in recent years, with considerable implications for health systems. Migrants in Europe face a disproportionate burden of tuberculosis, HIV, and hepatitis B and C, yet experience a large number of barriers to accessing statutory health care on arrival. A better understanding of how to deliver effective and cost-effective screening, vaccination, and health services to this group is now crucial. We did a systematic review to document and assess the effectiveness and cost-effectiveness of approaches used for infectious diseases screening, and to explore facilitators and barriers experienced by migrants to accessing screening programmes. Following PRISMA guidelines, we searched Embase, PubMed, PsychINFO, the Cochrane Library, and Web of Science (1989 to July 1, 2015, updated on Jan 1, 2018), with no language restrictions, and systematically approached experts across the European Union (EU) for grey literature. Inclusion criteria were primary research studies assessing screening interventions for any infectious disease in the migrant (foreign-born) population residing in EU or European Economic Area (EEA) countries. Primary outcomes were the following effectiveness indicators: uptake of screening, coverage, infections detected, and treatment outcomes. Of 4112 unique records, 47 studies met our inclusion criteria, from ten European countries (Belgium, Denmark, France, Italy, the Netherlands, Norway, Spain, Sweden, Switzerland, and the UK) encompassing 248 402 migrants. We found that most European countries screening migrants focus on single diseases only—predominantly active or latent tuberculosis infection—and specifically target asylum seekers and refugees, with 22 studies reporting on other infections (including HIV and hepatitis B and C). An infection was detected in 3·74% (range 0·00–95·16) of migrants. Latent tuberculosis had the highest prevalence across all infections (median 15·02% [0·35–31·81]). Uptake of screening by migrants was high (median 79·50% [18·62–100·00]), particularly in primary health-care settings (uptake 96·77% [76·00–100·00]). However, in 24·62% (0·12–78·99) of migrants screening was not completed and a final diagnosis was not made. Pooled data highlight high treatment completion in migrants (83·79%, range 0·00–100·00), yet data were highly heterogeneous for this outcome, masking important disparities between studies and infections, with only 54·45% (35·71–72·27) of migrants with latent tuberculosis ultimately completing treatment after screening. Coverage of the migrant population in Europe is low (39·29% [14·53–92·50]). Data on cost-effectiveness were scarce, but suggest moderate to high cost-effectiveness of migrant screening programmes depending on migrant group and disease targeted. European countries have adopted a variety of approaches to screening migrants for infections; however, these are limited in scope to single diseases and a narrow subset of migrants, with low coverage. More emphasis must be placed on developing innovative and sustainable strategies to facilitate screening and treatment completion and improve health outcomes, encompassing multiple key infections with consideration given to a wider group of high-risk migrants. Policy makers and researchers involved with global migration need to ensure a longer-term view on improving health outcomes in migrant populations as they integrate into health systems in host countries.

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.

Group B Streptococcus (GBS) can cause invasive disease (iGBS) in young infants, typically presenting as sepsis or meningitis, and is also associated with stillbirth and preterm birth. GBS vaccines are under development, but their potential health impact and cost-effectiveness have not been assessed globally. We assessed the health impact and value (using net monetary benefit (NMB), which measures both health and economic effects of vaccination into monetary units) of GBS maternal vaccination in an annual cohort of 140 million pregnant women across 183 countries in 2020. Our analysis uses a decision tree model, incorporating risks of GBS-related health outcomes from an existing Bayesian disease burden model. We extrapolated country-specific GBS-related healthcare costs using data from a previous systematic review and calculated quality-adjusted life years (QALYs) lost due to infant mortality and long-term disability. We assumed 80% vaccine efficacy against iGBS and stillbirth, following the WHO Preferred Product Characteristics, and coverage based on the proportion of pregnant women receiving at least 4 antenatal visits. One dose was assumed to cost $50 in high-income countries, $15 in upper-middle income countries, and $3.50 in low-/lower-middle-income countries. We estimated NMB using alternative normative assumptions that may be adopted by policymakers. Vaccinating pregnant women could avert 127,000 (95% uncertainty range 63,300 to 248,000) early-onset and 87,300 (38,100 to 209,000) late-onset infant iGBS cases, 31,100 deaths (14,400 to 66,400), 17,900 (6,380 to 49,900) cases of moderate and severe neurodevelopmental impairment, and 23,000 (10,000 to 56,400) stillbirths. A vaccine effective against GBS-associated prematurity might also avert 185,000 (13,500 to 407,000) preterm births. Globally, a 1-dose vaccine programme could cost $1.7 billion but save $385 million in healthcare costs. Estimated global NMB ranged from $1.1 billion ($-0.2 to 3.8 billion) under the least favourable normative assumptions to $17 billion ($9.1 to 31 billion) under the most favourable normative assumptions. The main limitation of our analysis was the scarcity of data to inform some of the model parameters such as those governing health-related quality of life and long-term costs from disability, and how these parameters may vary across country contexts. In this study, we found that maternal GBS vaccination could have a large impact on infant morbidity and mortality. Globally, a GBS maternal vaccine at reasonable prices is likely to be a cost-effective intervention.

Background Tunisia, situated at the crossroads of North Africa and Europe, has increasingly become an important origin, destination, and transit point for sub-Saharan migrants and refugees in recent decades. Despite growing migration flows, there remains a paucity of research on how these populations navigate healthcare access in Tunisia. This study addresses this gap by exploring migrants’ experiences with and perceptions of Tunisia’s healthcare system, with a focus on barriers to and facilitators of healthcare. Methods A qualitative study was conducted in four urban areas (Tunis, Medenine, Sousse, and Sfax) with concentrated migrant populations between May and December 2023. A purposive sample of migrants, migrant community leaders, and nongovernmental organization (NGO) staff were engaged through semi-structured interviews and focus-group discussions. Data were analysed via thematic analysis, combining inductive and deductive coding via NVivo 14 software, guided by an adaptation of Levesque’s conceptual framework. Results In total, 120 migrants and 43 NGO staff members participated in the study. The participants identified structural barriers such as legal status limitations, language barriers, and financial constraints, as well as social and cultural issues such as stigma and distrust of health system. While informal networks provide critical health information, they often lead to fragmented care. The private sector was perceived as better quality but unaffordable for the majority of migrants. Key facilitators included NGO support for referrals and coordination, particularly for undocumented migrants. Access was further hindered by communication gaps and limited awareness of the healthcare process. Conclusions Our study underscores the complex interplay of structural and individual barriers to accessing healthcare for migrants in Tunisia. Addressing these challenges requires culturally sensitive policies, multilingual resources, simplified administrative processes, and expanded health insurance coverage. Strengthening collaboration between NGOs, healthcare providers, and policymakers is essential to ensure equitable healthcare access for migrants.

IntroductionGlobal migration has steadily risen, with 16% of the UK population born abroad. Migrants (defined here as foreign-born individuals) face unique health risks, including potential higher rates and delays in diagnosis of infectious and non-communicable diseases, compounded by significant barriers to healthcare. UK Public Health guidelines recommend screening at-risk migrants, but primary care often faces significant challenges in achieving this, exacerbating health disparities. The Health Catch-UP! tool was developed as a novel digital, multidisease screening and catch-up vaccination solution to support primary care to identify at-risk adult migrants and offer individualised care. The tool has been shown to be acceptable and feasible and to increase migrant health screening in previous studies, but to facilitate use in routine care requires the development of an implementation package. This protocol describes the development and optimisation of an implementation package for Health Catch-UP! following the person-based approach (PBA), a participatory intervention development methodology, and evaluates our use of this methodological approach for migrant participants.Methods and analysisThrough engagement with both migrants and primary healthcare professionals (approximately 80–100 participants) via participatory workshops, focus groups and think-aloud interviews, the study aims to cocreate a comprehensive Health Catch-UP! implementation package. This package will encompass healthcare professional support materials, patient resources and potential Health Catch-UP! care pathways (delivery models), developed through iterative refinement based on user feedback and behavioural theory. The study will involve three linked phases (1) planning: formation of an academic–community coalition and cocreation of guiding principles, logic model and intervention planning table, (2) intervention development: focus groups and participatory workshops to coproduce prototype implementation materials and (3) intervention optimisation: think-aloud interviews to iteratively refine the final implementation package. An embedded mixed-methods evaluation of how we used the PBA will allow shared learning from the use of this methodology within the migrant health context.Ethics and disseminationEthics approval granted by the St George’s University Research Ethics Committee (REC reference: 2024.0191). A community celebration event will be held to recognise contributions and to demonstrate impact.

Background Migrants to the UK face disproportionate risk of infections, non-communicable diseases, and under-immunisation compounded by healthcare access barriers. Current UK migrant screening strategies are unstandardised with poor implementation and low uptake. Health Catch-UP! is a collaboratively produced digital clinical decision support system that applies current guidelines (UKHSA and NICE) to provide primary care professionals with individualised multi-disease screening (7 infectious diseases/blood-borne viruses, 3 chronic parasitic infections, 3 non-communicable disease or risk factors) and catch-up vaccination prompts for migrant patients. Methods We carried out a mixed-methods process evaluation of Health Catch-UP! in two urban primary healthcare practices to integrate Health Catch-UP! into the electronic health record system of primary care, using the Medical Research Council framework for complex intervention evaluation. We collected quantitative data (demographics, patients screened, disease detection and catch-up vaccination rates) and qualitative participant interviews to explore acceptability and feasibility. Results Ninety-nine migrants were assessed by Health Catch-UP! across two sites (S1, S2). 96.0% ( n  = 97) had complete demographics coding with Asia 31.3% ( n  = 31) and Africa 25.2% ( n  = 25), the most common continents of birth (S1 n  = 92 [48.9% female ( n  = 44); mean age 60.6 years (SD 14.26)]; and S2 n  = 7 [85.7% male ( n  = 6); mean age 39.4 years (SD16.97)]. 61.6% ( n  = 61) of participants were eligible for screening for at least one condition and uptake of screening was high 86.9% ( n  = 53). Twelve new conditions were identified (12.1% of study population) including hepatitis C ( n  = 1), hypercholesteraemia ( n  = 6), pre-diabetes ( n  = 4), and diabetes ( n  = 1). Health Catch-UP! identified that 100% ( n  = 99) of patients had no immunisations recorded; however, subsequent catch-up vaccination uptake was poor (2.0%, n  = 1). Qualitative data supported acceptability and feasibility of Health Catch-UP! from staff and patient perspectives, and recommended Health Catch-UP! integration into routine care (e.g. NHS health checks) with an implementation package including staff and patient support materials, standardised care pathways (screening and catch-up vaccination, laboratory, and management), and financial incentivisation. Conclusions Clinical Decision Support Systems like Health Catch-UP! can improve disease detection and implementation of screening guidance for migrant patients but require robust testing, resourcing, and an effective implementation package to support both patients and staff.

Background Migrants in the UK and Europe face vulnerability to vaccine-preventable diseases (VPDs) due to missed childhood vaccines and doses and marginalisation from health systems. Ensuring migrants receive catch-up vaccinations, including MMR, Td/IPV, MenACWY, and HPV, is essential to align them with UK and European vaccination schedules and ultimately reduce morbidity and mortality. However, recent evidence highlights poor awareness and implementation of catch-up vaccination guidelines by UK primary care staff, requiring novel approaches to strengthen the primary care pathway. Methods The ‘Vacc on Track’ study (May 2021–September 2022) aimed to measure under-vaccination rates among migrants in UK primary care and establish new referral pathways for catch-up vaccination. Participants included migrants aged 16 or older, born outside of Western Europe, North America, Australia, or New Zealand, in two London boroughs. Quantitative data on vaccination history, referral, uptake, and sociodemographic factors were collected, with practice nurses prompted to deliver catch-up vaccinations following UK guidelines. Focus group discussions and in-depth interviews with staff and migrants explored views on delivering catch-up vaccination, including barriers, facilitators, and opportunities. Data were analysed using STATA12 and NVivo 12. Results Results from 57 migrants presenting to study sites from 18 countries (mean age 41 [SD 7.2] years; 62% female; mean 11.3 [SD 9.1] years in UK) over a minimum of 6 months of follow-up revealed significant catch-up vaccination needs, particularly for MMR (49 [86%] required catch-up vaccination) and Td/IPV (50 [88%]). Fifty-three (93%) participants were referred for any catch-up vaccination, but completion of courses was low (6 [12%] for Td/IPV and 33 [64%] for MMR), suggesting individual and systemic barriers. Qualitative in-depth interviews ( n  = 39) with adult migrants highlighted the lack of systems currently in place in the UK to offer catch-up vaccination to migrants on arrival and the need for health-care provider skills and knowledge of catch-up vaccination to be improved. Focus group discussions and interviews with practice staff ( n  = 32) identified limited appointment/follow-up time, staff knowledge gaps, inadequate engagement routes, and low incentivisation as challenges that will need to be addressed. However, they underscored the potential of staff champions, trust-building mechanisms, and community-based approaches to strengthen catch-up vaccination uptake among migrants. Conclusions Given the significant catch-up vaccination needs of migrants in our sample, and the current barriers to driving uptake identified, our findings suggest it will be important to explore this public health issue further, potentially through a larger study or trial. Strengthening existing pathways, staff capacity and knowledge in primary care, alongside implementing new strategies centred on cultural competence and building trust with migrant communities will be important focus areas.

IntroductionThis systematic review investigates the burden, clinical outcomes and risk factors of neglected tropical diseases (NTDs) and malaria in the Middle East and North African region, highlighting the urgency and scope of these health challenges.MethodsWe searched six databases for peer-reviewed literature and additional sources to capture grey literature in any language from 2000 to 28 August 2024. Studies were included if they provided primary data on outcomes in migrants. Primary outcomes were prevalence, incidence and mortality. Peer-reviewed articles were critically appraised using Joanna Briggs Institute tools, while the AACODS (Authority, Accuracy, Coverage, Objectivity, Date and Significance) checklist was used for grey literature. Estimates were pooled using random-effects meta-analysis where possible or synthesised narratively.ResultsWe included 39 studies with 81 678 migrants across 11 countries for NTDs and 16 studies encompassing 12 823 migrants across five countries for malaria. The pooled prevalence of specific NTDs among migrants was 4.7% for hookworm (95% CI 0.9% to 11.3%, I²=99%), 1.8% for Trichuris trichiura (95% CI 0.3% to 4.3%, I²=98%), 1.75% for Ascaris lumbricoides (95% CI 0.6% to 3.5%, I²=96%) and 1.8% for taeniasis (95% CI 0.3% to 4.4%, I²=98%). Compared with non-migrants, migrants exhibited higher prevalence rates for hookworm (1.8% vs 0.03%), Ascaris lumbricoides (0.3% vs 0%), Trichuris trichiura (0.5% vs 0%), dengue (26% vs 3.5%) and chikungunya (4.2% vs 0.5%). Migrants had a higher proportion of confirmed cases of schistosomiasis (0.21–20.3% vs 0–0.013%), cystic echinococcosis (7.4% vs 3.5%) and dengue (57.2% vs 56.4%) among suspected cases compared with non-migrants. Case fatality rates were 3.1% for dengue and 0.2–1.5% for malaria. Malaria incidence was only reported in Sudan (internally displaced persons: 6.8/1000; refugees: 2.72/1000; refugees <5 years old: 7.3/1000). While hospitalisation and intensive care unit rates for malaria were 25.8% and 1.3%, respectively, severe malaria was higher in non-migrants compared with migrants in Qatar (50% vs 5.2%, respectively).ConclusionsDespite a wide range of diseases reported in 55 studies, there were gaps in the evidence, primarily related to risk factors, clinical outcomes and the subregion of North Africa. We generally found that migrants were disproportionately affected by both NTDs and malaria, especially in the Middle East. PROSPERO registration number CRD42023407748

Migrants in the Middle East and North Africa (MENA) region face an increased tuberculosis (TB) risk due to socioeconomic and structural barriers. This systematic review synthesises evidence on TB burden, clinical outcomes, and epidemiological characteristics among migrants in MENA. We searched six electronic databases and grey literature sources for studies published between 2000 and September 2024 in any language. Eligible studies reported primary data on TB prevalence, incidence, treatment outcomes, and clinical or epidemiological features in migrants. Pooled estimates were calculated using DerSimonian & Laird's random-effects model where applicable or narratively synthesised. Of the 779 records identified, we included 57 studies, comprising 95,190 TB cases and 3,532,359 migrants across 12 MENA countries. TB incidence was consistently higher in migrants than non-migrants (26.7–69.8/100,000 vs. 11.5–16.8/100,000). Migrants had lower TB-related mortality (pooled OR 0.8, 95 % CI 0.7–0.9; I2 = 2.9 %), however, treatment success rates were consistently below the WHO-recommended 90 % threshold. Migrant TB patients were younger (mean age difference: 12.8 years; 95 % CI 8.8–16.0; I2 = 86.5 %) and predominantly male (sex ratio: 1:5). Drug-resistant TB was more common among migrants, though this was not always statistically significant (multi-drug-resistant TB: pooled OR 1.2; 95 % CI 0.9–1.6; I2 = 40.2 %), while extrapulmonary TB was more prevalent among non-migrants (33.4–83.4 % vs. 16.6–72.9 %). Migrants in MENA region experience disproportionate TB burden and poorer treatment outcomes, underscoring the need for targeted interventions. Enhanced data, especially from North Africa, is essential to support regional TB elimination aligned with World Health Organization and Sustainable Development Goals. •TB incidence and drug resistance are higher among migrants in MENA than non-migrants.•Migrant TB patients are younger, have lower mortality rates, but poorer treatment success.•Data on TB among North African migrants is critically scarce.•Migrant-focused strategies and better data are urgently needed to meet WHO's End TB targets.