Tuberculosis in migrants moving from high-incidence to low-incidence countries: a population-based cohort study of 519 955 migrants screened before entry to England, Wales, and Northern Ireland.

BACKGROUND: Tuberculosis elimination in countries with a low incidence of the disease necessitates multiple interventions, including innovations in migrant screening. We examined a cohort of migrants screened for tuberculosis before entry to England, Wales, and Northern Ireland and tracked the development of disease in this group after arrival. METHODS: As part of a pilot pre-entry screening programme for tuberculosis in 15 countries with a high incidence of the disease, the International Organization for Migration screened all applicants for UK visas aged 11 years or older who intended to stay for more than 6 months. Applicants underwent a chest radiograph, and any with results suggestive of tuberculosis underwent sputum testing and culture testing (when available). We tracked the development of tuberculosis in those who tested negative for the disease and subsequently migrated to England, Wales, and Northern Ireland with the Enhanced Tuberculosis Surveillance system. Primary outcomes were cases of all forms of tuberculosis (including clinically diagnosed cases), and bacteriologically confirmed pulmonary tuberculosis. FINDINGS: Our study cohort was 519 955 migrants who were screened for tuberculosis before entry to the UK between Jan 1, 2006, and Dec 31, 2012. Cases notified on the Enhanced Tuberculosis Surveillance system between Jan 1, 2006, and Dec 31, 2013, were included. 1873 incident cases of all forms of tuberculosis were identified, and, on the basis of data for England, Wales, and Northern Ireland, the estimated incidence of all forms of tuberculosis in migrants screened before entry was 147 per 100 000 person-years (95% CI 140-154). The estimated incidence of bacteriologically confirmed pulmonary tuberculosis in migrants screened before entry was 49 per 100 000 person-years (95% CI 45-53). Migrants whose chest radiographs were compatible with active tuberculosis but with negative pre-entry microbiological results were at increased risk of tuberculosis compared with those with no radiographic abnormalities (incidence rate ratio 3·2, 95% CI 2·8-3·7; p<0·0001). Incidence of tuberculosis after migration increased significantly with increasing WHO-estimated prevalence of tuberculosis in migrants' countries of origin. 35 of 318 983 pre-entry screened migrants included in a secondary analysis with typing data were assumed index cases. Estimates of the rate of assumed reactivation tuberculosis ranged from 46 (95% CI 42-52) to 91 (82-102) per 100 000 population. INTERPRETATION: Migrants from countries with a high incidence of tuberculosis screened before being granted entry to low-incidence countries pose a negligible risk of onward transmission but are at increased risk of tuberculosis, which could potentially be prevented through identification and treatment of latent infection in close collaboration with a pre-entry screening programme. FUNDING: Wellcome Trust, UK National Institute for Health Research, UK Medical Research Council, Public Health England, and Department of Health Policy Research Programme.

Prevalence of and risk factors for active tuberculosis in migrants screened before entry to the UK: a population-based cross-sectional study.

BACKGROUND: An increasing number of countries with low incidence of tuberculosis have pre-entry screening programmes for migrants. We present the first estimates of the prevalence of and risk factors for tuberculosis in migrants from 15 high-incidence countries screened before entry to the UK. METHODS: We did a population-based cross-sectional study of applicants for long-term visas who were screened for tuberculosis before entry to the UK in a pilot programme between Oct 1, 2005, and Dec 31, 2013. The primary outcome was prevalence of bacteriologically confirmed tuberculosis. We used Poisson regression to estimate crude prevalence and created a multivariable logistic regression model to identify risk factors for the primary outcome. FINDINGS: 476 455 visa applicants were screened, and the crude prevalence of bacteriologically confirmed tuberculosis was 92 (95% CI 84-101) per 100 000 individuals. After adjustment for age and sex, factors that were strongly associated with an increased risk of bacteriologically confirmed disease at pre-entry screening were self-report of close or household contact with an individual with tuberculosis (odds ratio 11·6, 95% CI 7·0-19·3; p<0·0001) and being an applicant for settlement and dependant visas (1·3, 1·0-1·6; p=0·0203). INTERPRETATION: Migrants reporting contact with an individual with tuberculosis had the highest risk of tuberculosis at pre-entry screening. To tackle this disease burden in migrants, a comprehensive and collaborative approach is needed between countries with pre-entry screening programmes, health services in the countries of origin and migration, national tuberculosis control programmes, and international public health bodies. FUNDING: Wellcome Trust, Medical Research Council, and UK National Institute for Health Research.

Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study.

BACKGROUND: Trafficking is a crime of global proportions involving extreme forms of exploitation and abuse. Yet little research has been done of the health risks and morbidity patterns for men, women, and children trafficked for various forms of forced labour. METHODS: We carried out face-to-face interviews with a consecutive sample of individuals entering 15 post-trafficking services in Cambodia, Thailand, and Vietnam. We asked participants about living and working conditions, experience of violence, and health outcomes. We measured symptoms of anxiety and depression with the Hopkins Symptoms Checklist and post-traumatic stress disorder with the Harvard Trauma Questionnaire, and used adjusted logistic regression models to estimate the effect of trafficking on these mental health outcomes, controlling for age, sector of exploitation, and time in trafficking. FINDINGS: We interviewed 1102 people, of whom 1015 reached work destinations. Participants worked in various sectors including sex work (329 [32%]), fishing (275 [27%]), and factories (136 [13%]). 481 (48%) of 1015 experienced physical violence, sexual violence, or both, with 198 (35%) of 566 women and girls reporting sexual violence. 478 (47%) of 1015 participants were threatened and 198 (20%) were locked in a room. 685 (70%) of 985 who had data available worked 7 days per week and 296 (30%) of 989 worked at least 11 hours per day. 222 (22%) of 983 had a serious injury at work. 61·2% (95% CI 58·2-64·2) of participants reported symptom of depression, 42·8% (39·8-45·9) reported symptoms of anxiety, and 38·9% (36·0-42·0) reported symptoms of post-traumatic stress disorder. 5·2% (4·0-6·8) had attempted suicide in the past month. Participants who experienced extremely excessive overtime at work, restricted freedom, bad living conditions, threats, or severe violence were more likely to report symptoms of depression, anxiety, and post-traumatic stress disorder. INTERPRETATION: This is the first health study of a large and diverse sample of men, women, and child survivors of trafficking for various forms of exploitation. Violence and unsafe working conditions were common and psychological morbidity was associated with severity of abuse. Survivors of trafficking need access to health care, especially mental health care. FUNDING: Anesvad Foundation and International Organization for Migration International Development Fund.

Discussions with adults and youth to inform the development of a community-based tobacco control programme.

Project Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth (ACTIVITY) is a community-based group randomized intervention trial focused on disadvantaged youth (aged 10-19 years) residing in 14 low-income communities (slums and resettlement colonies) in Delhi, India. This article discusses the findings of Focus Group Discussions (FGDs) conducted to inform the development and test the appropriateness of Project ACTIVITY's intervention model. The findings of the FGDs facilitated the understanding of factors contributing to increased tobacco uptake and cessation (both smoking and smokeless tobacco) among youth in this setting. Twenty-two FGDs were conducted with youth (10-19 years) and adults in two urban slums in Delhi. Key findings revealed: (i) youth and adults had limited knowledge about long-term health consequences of tobacco use; (ii) socio-environmental determinants and peer pressure were important variables influencing initiation of tobacco use; (iii) lack of motivation, support and sufficient skills hinder tobacco cessation and (iv) active involvement of community, family, religious leaders, local policy makers and health professionals is important in creating and reinforcing tobacco-free norms. The results of these FGDs aided in finalizing the intervention model for Project ACTIVITY and guided its intervention development.

The cost-effectiveness of a school-based smoking prevention program in India.

Intervention programs aimed at preventing tobacco use among youth have been shown to be effective in curbing tobacco use onset and progression. However, the effects of even very successful tobacco prevention programs may not always impress policy-makers and lay audiences. Economic analysis potentially strengthens the case. In this paper, we evaluate the cost-effectiveness of a youth tobacco use prevention program which has been translated and implemented in India, a developing country. Although programs like these are inexpensive to implement in the USA, they are even less expensive in India due to low labor costs. Our results show that the costs per quality-adjusted life-year added, due to averted smoking, was $2057, even without including averted medical costs. If we ignore student time, cost-effectiveness improves by roughly 10%. To put the cost-effectiveness of this smoking prevention program into context, it is over 24 times more cost-effective than dialysis in the USA, which costs $50,000 for a life-year.

Weight-related concerns and weight-control behaviors among overweight adolescents in Delhi, India: a cross-sectional study.

BACKGROUND: Obesity is emerging as a public health problem among adolescents in India. The aim of this study was to describe specific weight-related concerns among school-going youth in Delhi, India and to assess the prevalence of weight control behaviors, including healthy and unhealthy ones. Differences by weight status, gender, grade level, and school-type (a proxy for SES in this setting) are considered. METHODS: This study is cross-sectional by design. A sample of eighth and tenth graders (n=1818) enrolled in Private (middle-high SES) and Government (low SES) schools (n=8) in Delhi, India participated. All students' height and weight were measured. Students participated in a survey of weight-related concerns and weight-control behaviors, as well. Mixed-effects regression models were used to test for differences in weight-related concerns and weight-control behaviors across key factors of interest (i.e., weight status, gender, grade level, and SES). RESULTS: The combined prevalence of obesity and overweight was 16.6%, overall. Controlling one's weight was important to overweight and non-overweight youth, alike (94.2% v. 84.8%, p<0.001). Significantly more overweight or obese youth reported trying to control their weight last year, compared to those who were not overweight (68.1% v. 18.0%, p<0.001). Healthy weight control behaviors were more common than unhealthy or extreme practices, although the latter were still prevalent. Half of the overweight or obese students misclassified their weight status, while about 1 in 10 non-overweight youth did the same. Body dissatisfaction was highest among overweight youth and girls. CONCLUSIONS: Interventions to promote healthy weight control should be pertinent to and well-received by school-going youth in India. Healthy weight control practices need to be explicitly encouraged and unhealthy practices reduced. Future interventions should address issues specific to body image, too, as body dissatisfaction was not uncommon among youth.

Using salivary cotinine to validate self-reports of tobacco use by Indian youth living in low-income neighborhoods.

BACKGROUND: Self-reported tobacco use among young people can underestimate the actual prevalence of tobacco use. Biochemical validation of self-reports is particularly recommended for intervention studies where cessation outcomes are to be measured. Literature on biochemical validation of self-reports of multiple forms of tobacco use in India is sparse, particularly among young people. METHODS: The study was conducted during the baseline household survey of a community-based tobacco prevention and cessation intervention trial for youth (10-19 years old) residing in slum communities in Delhi, India in 2009. Salivary cotinine measurement on 1,224 samples showed that youth were under-reporting use of chewing and smoking tobacco. RESULTS: Self-reports had a low sensitivity (36.3%) and a positive predictive value of 72.6%. No statistically significant difference in under- reporting was found between youth in the control and intervention conditions of the trial, which will be taken into consideration in assessing intervention outcomes at a later time point. CONCLUSION: Biochemical validation of self-reported tobacco use should be considered during prevention and cessation studies among youth living in low-income settings in developing countries like India. IMPACT: The future results of biochemical validation from Project ACTIVITY (Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth) will be useful to design validation studies in resource-poor settings.

Is tobacco use associated with academic failure among government school students in urban India?

BACKGROUND: Not much is known about the academic correlates of tobacco use among students in developing countries. This study investigated associations between multiple forms of tobacco use, psychosocial risk factors, and academic failure among 10- to 16-year-old government school students in Delhi and Chennai, India. METHODS: This study was a secondary analysis of data gathered from students in 7 government schools during a larger tobacco intervention trial in India. Mixed-effects regression analyses were carried out on a cross-sectional sample of 3799 students and a retrospective cohort of 2586 students. Data on tobacco use and risk factors were collected from self-reported student surveys in 2006 and 2004. Using school records, academic failure was defined as repeating the same grade level once or twice between 2004 and 2006. RESULTS: In 2006, academic failure was significantly more prevalent among students who reported use of chewing tobacco, bidis, or cigarettes, as compared with nonusers. Students with academic failure had greater social susceptibility and intentions for future tobacco use, and poor knowledge and self-efficacy for avoiding tobacco. Cohort analyses showed that students who had reported tobacco use in 2004 were more likely to have academic failure by 2006, as compared with nonusers. CONCLUSIONS: School health programs that incorporate tobacco control measures should be offered to government school students with poor academic outcomes in India, along with remedial education efforts. School-based longitudinal research is needed to assess effects of tobacco use in early adolescence on academic, social, and behavioral outcomes in later adolescence and young adulthood.

Westernization and tobacco use among young people in Delhi, India.

Few studies have explored the relationship between acculturation and health in non-immigrant populations. The purpose of this study was to investigate the relationship between "westernization" and tobacco use among adolescents living in Delhi, India. A bi-dimensional model of acculturation was adapted for use in this study to examine (a) whether young people's identification with Western culture in this setting is related to tobacco use, and (b) whether their maintenance of more traditional Indian ways of living is related to tobacco use. Multiple types of tobacco commonly used in India (e.g., cigarettes, bidis, chewing tobacco) were considered. Socioeconomic status (SES), gender, and grade level were examined as potential effect modifiers of the relationship between "westernization" and tobacco use. The study was cross-sectional by design and included 3512 students in eighth and tenth grades who were enrolled in 14 Private (higher SES) and Government (lower SES) schools in Delhi, India. A self-report survey was used to collect information on tobacco use and "westernization." The results suggest that young people's identification with Western influences may increase their risk for tobacco use, while their maintenance of traditional Indian ways of living confers some protection. Importantly, these effects were independent of one another. Boys benefitted more from protective effects than girls, and tenth graders gained more consistent benefits than eighth graders in this regard, too. Negative effects associated with identification with Western ways of living were, in contrast, consistent across gender and grade level. The positive and negative effects of acculturation on adolescent tobacco use held for all tobacco products considered here. Future interventions designed to curb youth tobacco use in India may benefit by paying closer attention to cultural preferences of these young consumers.

Tobacco control among disadvantaged youth living in low-income communities in India: introducing Project ACTIVITY.

OBJECTIVE: To provide an overview of Project ACTIVITY, a group randomized intervention trial designed to test the efficacy of a community-based, comprehensive approach to tobacco control for youth (10-19 years) living in low- income communities in India. In doing so, details regarding baseline characteristics of the study sample are provided. METHODS: Fourteen slum communities in Delhi, India were matched and randomized to intervention (n=7) and control (n=7) conditions. The intervention included multiple strategies to promote prevention and cessation of tobacco use among youth. A census was conducted in selected blocks in all study communities (n=78,133), as well as a baseline survey of eligible youth (n=6,023). Main outcomes measures on the survey included ever use, past six months use and current use of multiple forms of tobacco. Mixed effects regression models were used to examine differences between study conditions in (a) demographic characteristics and (b) the prevalence of tobacco consumption. RESULTS: Census data revealed that 31.9% of sampled population was in the age group of 10-19 years. No differences between study conditions in demographic characteristics (e.g. age, gender, religion, education, and occupation) among either adults or youth were noted (p> 0.05). The baseline survey data revealed the prevalence of ever tobacco use among youth was 7.99%, past six months use was 5.70%, and current use was 4.88%. No differences between study conditions in these prevalence rates were observed, either (p>0.05). CONCLUSION: The two study conditions in Project ACTIVITY are comparable. The evaluation should provide a robust test of this intervention's efficacy.

Patterns of tobacco use and psychosocial risk factors among students in 6th through 10th grades in India: 2004-2006.

INTRODUCTION: In 2004, baseline surveys of Project MYTRI, a randomized intervention trial in Chennai and Delhi, India, found that tobacco use among 6th graders was greater than that among 8th graders. These results were surprising - typically, tobacco use increases with grade level. The present study aimed to assess whether this unique differential was sustained over time, as students moved into higher grades. METHODS: Self-reported data from a sample of youth (n=3,404) present at three annual surveys (2004, 2005, 2006) were analyzed. Mixed-effects regression models were used to compare prevalence of lifetime tobacco use and nine psychosocial risk factor scales between two student cohorts, 6th grade (or younger) cohort and 8th grade (or older) cohort. Stratified analyses were also conducted by gender, age, city and school type. RESULTS: From 2004 to 2006, the 6th grade (or younger) cohort of students reported higher rates of lifetime tobacco use, and these differences were maintained over two years, even when the study sample was stratified by gender, age, city and school type. Similarly, students in the 6th grade (or younger) cohort scored greater risk for tobacco use on all psychosocial risk factors analyzed here. DISCUSSION: Tobacco use was found to be problematic among students in two Indian cities, particularly so for those in younger grades. Projections of health impact due to tobacco may be larger than anticipated if these adolescents continue to use tobacco as young adults. Further epidemiologic research and interventions to curb tobacco use among young(er) adolescents are warranted.