Health service use and costs among migrants in an irregular situation: Cross-sectional register-based study from a voluntary-based clinic.

BACKGROUND: As few data based on actual demand for healthcare services in vulnerable migrant populations exist, we studied service use and healthcare costs in a cohort of migrants in an irregular situation. METHODS: In this single-centre retrospective register study, we examined the reasons for encounter, diagnoses, service use and costs of healthcare among patients at a voluntary clinic for migrants in an irregular situation in Helsinki, Finland. ICPC-2 classification and national unit costs for primary healthcare were used for the cost estimation. RESULTS: A total of 546 patient visits accounted for 620 ICPC-2 coded reasons for encounter, diagnoses and process codes. The most common health problems were teeth/gum disease (10%), acute upper respiratory infection (5%) and oesophageal disease (3%). Visits seldom led to complementary investigations (2%), follow-up visits (5%) or referrals (11%). The total cost of treatment, excluding dental health costs, was 71 euros per visit. CONCLUSIONS: Migrants in an irregular situation present with a variety of health concerns, the majority of which can be treated in a basic primary healthcare facility at a relatively low cost. This encourages research to evaluate the health and cost effects of extending public healthcare for migrants in an irregular situation beyond emergency care.

Tuberculosis screening of asylum seekers in Finland, 2015-2016.

BACKGROUND: In Finland, asylum seekers from countries with high tuberculosis (TB) incidence (> 50/100,000 population/year) and those coming from a refugee camp or conflict area are eligible for TB screening. The aim of this study was to characterise the TB cases diagnosed during screening and estimate the yield of TB screening at the reception centres among asylum seekers, who arrived in Finland during 2015-2016. METHODS: Voluntary screening conducted at reception centres included an interview and a chest X-ray. Data on TB screening and health status of asylum seekers was obtained from the reception centres' national health register (HRS). To identify confirmed TB cases, the National Infectious Disease Register (NIDR) data of foreign-born cases during 2015-2016 were linked with HRS data. TB screening yield was defined as the percentage of TB cases identified among screened asylum seekers, stratified by country of origin. RESULTS: During 2015-2016, a total of 38,134 asylum applications were received (57% were from Iraq, 16% from Afghanistan and 6% from Somalia) and 25,048 chest x-rays were performed. A total of 96 TB cases were reported to the NIDR among asylum seekers in 2015-2016; 94 (98%) of them had been screened. Screening identified 48 (50%) cases: 83% were male, 56% aged 18-34 years, 42% from Somalia, 27% from Afghanistan and 13% from Iraq. Furthermore, 92% had pulmonary TB, 61% were culture-confirmed and 44% asymptomatic. TB screening yield was 0.19% (48/25048) (95%CI, 0.14-0.25%) and it varied between 0 and 0.83% stratified by country of origin. Number needed to screen was 522. CONCLUSIONS: TB screening yield was higher as compared with data reported from other European countries conducting active screening among asylum seekers. Half of the TB cases among asylum seekers were first suspected in screening; 44% were asymptomatic. TB yield varied widely between asylum seekers from different geographic areas.

Refugee crisis in Finland: Challenges to safeguarding the right to health for asylum seekers.

In 2015 Finland received an unprecedented number of asylum seekers, ten times more than in any previous year. This surge took place at a time the Finnish Government was busily undergoing a wide-range health and social care reform amid growing nationalist and populist sentiments. Our aim is to explore the governance of a parallel health system for asylum seekers with a right-to-health approach. We concentrated on three right to health features most related to the governance of asylum seeker health care, namely Formal recognition of the right to health, Standards and Coordination mechanisms. Through our qualitative review, we identified three major hurdles in the governance of the system for asylum seekers: 1) Ineffectual and reactive national level coordination and stewardship; 2) Inadequate legislative and supervisory frameworks leading to ineffective governance; 3) Discrepancies between constitutional rights to health, legal entitlements to services and guidance available. This first-time large-scale implementation of the policies exposed weaknesses in the legal framework and the parallel health system. We recommend the removal of the parallel system and the integration of asylum seekers' health services to the national public health care system.

Asylum seekers health and wellbeing (TERTTU) survey: study protocol for a prospective total population health examination survey on the health and service needs of newly arrived asylum seekers in Finland.

INTRODUCTION: Health, well-being and health service needs of asylum seekers have emerged as urgent topics following the arrival of 2.5 million asylum seekers to the European Union (EU) between 2015 and 2016. However, representative information on the health, well-being and service needs of asylum seekers is scarce. The Asylum Seekers Health and Wellbeing (TERTTU) Survey aims to: (1) gather population-based representative information; (2) identify key indicators for systematic monitoring; (3) produce the evidence base for development of systematic screening of asylum seekers' health, well-being and health service needs. METHODS AND ANALYSIS: TERTTU Survey is a population-based prospective study with a total population sample of newly arrived asylum seekers to Finland, including adults and children. Baseline data collection is carried out in reception centres in 2018 and consists of a face-to-face interview, self-administered questionnaire and a health examination following a standardised protocol. Altogether 1000 asylum seekers will be included into the study. Baseline data will be followed up with national electronic health record data encompassing the entire asylum process and later with national register data among persons who receive residency permits. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Coordinating Ethics Committee of the Helsinki and Uusimaa Hospital District. Participation is voluntary and based on written informed consent. Results will be widely disseminated on a national and international level to inform health and welfare policy as well as development of services for asylum seekers. Results of the study will constitute the evidence base for development and implementation of the initial health assessment for asylum seekers on a national level.

Public health response to large influx of asylum seekers: implementation and timing of infectious disease screening.

BACKGROUND: Infectious disease screening of migrants at increased risk is a feature of national infection prevention and control measures. Asylum seekers in Finland are offered screening of tuberculosis (TB), hepatitis B, human immunodeficiency virus infection (HIV) and syphilis based on individual risk assessment. We aimed to evaluate the public health response to a large influx of asylum seekers to Finland in 2015-2016 with respect to national guidelines on initial health services and infectious disease screening. METHODS: We used immigration and healthcare procurement data for all 38,134 asylum seekers to Finland during 2015-2016 to assess the implementation, timing and yields of infectious disease screening. RESULTS: The coverage of pulmonary TB screening was 71.6% [95% CI 71.1-72.0%] and that of hepatitis B, HIV or syphilis 60.6% [60.1-61.1%] among those eligible for screening. The estimated average delay from arrival to pulmonary TB screening was 74 days for adults and 43 days for children. Delay to hepatitis B, HIV and syphilis screening was 91 days for adults and 47 days for children. The seroprevalence of hepatitis B surface antigen positivity was 1.4% [95% CI 1.3-1.6%], HIV 0.3% [95% CI 0.1-0.4%] and Treponema pallidum specific antibodies 1.0% [95% CI 0.8-1.1%]. Data did not allow assessment of yields of pulmonary TB screening. CONCLUSIONS: Up to one third  of asylum seekers were not reached by screening and screenings were delayed from target timeframes. Children, as a vulnerable population, were screened earlier than adults. To ensure higher screening coverage, infectious disease risks should be reassessed and screening completed at contacts to healthcare during the post-asylum phase of integration. The large influx of asylum seekers to Finland in 2015-2016 tested the country's public health preparedness. After action reviews of the public health response to the large migrant influx such as screening implementation can be used for evidence-based improvement of public health preparedness and guidelines for initial health services and infectious disease screening.

Missed hepatitis b/c or syphilis diagnosis among Kurdish, Russian, and Somali origin migrants in Finland: linking a population-based survey to the national infectious disease register.

BACKGROUND: Migrants are considered a key population at risk for sexually transmitted and blood-borne diseases in Europe. Prevalence data to support the design of infectious diseases screening protocols are scarce. We aimed to estimate the prevalence of hepatitis B and C, human immunodefiency virus (HIV) infection and syphilis in specific migrant groups in Finland and to assess risk factors for missed diagnosis. METHODS: A random sample of 3000 Kurdish, Russian, or Somali origin migrants in Finland was invited to a migrant population-based health interview and examination survey during 2010-2012. Participants in the health examination were offered screening for hepatitis B and C, HIV and syphilis. Notification prevalence in the National Infectious Diseases Register (NIDR) was compared between participants and non-participants to assess non-participation. Missed diagnosis was defined as test-positive case in the survey without previous notification in NIDR. Inverse probability weighting was used to correct for non-participation. RESULTS: Altogether 1000 migrants were screened for infectious diseases. No difference in the notification prevalence among participants and non-participants was observed. Seroprevalence of hepatitis B surface antigen (HBsAg) was 2.3%, hepatitis C antibodies 1.7%, and Treponema pallidum antibodies 1.3%. No cases of HIV were identified. Of all test-positive cases, 61% (34/56) had no previous notification in NIDR. 48% of HBsAg, 62.5% of anti-HCV and 84.6% of anti-Trpa positive cases had been missed. Among the Somali population (n = 261), prevalence of missed hepatitis B diagnosis was 3.0%. Of the 324 Russian migrants, 3.0% had not been previously diagnosed with hepatitis C and 2.4% had a missed syphilis diagnosis. In multivariable regression model missed diagnosis was associated with migrant origin, living alone, poor self-perceived health, daily smoking, and previous diagnosis of another blood-borne infection. CONCLUSIONS: More than half of chronic hepatitis and syphilis diagnoses had been missed among migrants in Finland. Undiagnosed hepatitis B among Somali migrants implies post-migration transmission that could be prevented by enhanced screening and vaccinations. Rate of missed diagnoses among Russian migrants supports implementation of targeted hepatitis and syphilis screening upon arrival and also in later health care contacts. Coverage and up-take of current screening among migrants should be evaluated.

Important Gaps in HIV Knowledge, Attitudes and Practices Among Young Asylum Seekers in Comparison to the General Population.

Migrants are disproportionately affected by HIV in many European countries, including Finland. We aimed to compare the HIV-related knowledge, attitudes and practices (KAP) of young asylum seekers to those of the general young adult population. Two cross-sectional surveys were conducted among 20- to 25-year-old young adults: The TIE study among asylum seekers (n = 47) and the World AIDS Day 2014 study among the general population (n = 485). Important gaps in HIV KAP were identified especially among the young asylum seekers. For the general young adult population, previous HIV testing was associated with female gender, better HIV knowledge and increased sexual activity. Health education concerning HIV needs to be further enforced among young adults in Finland. Due to poorer HIV knowledge, young asylum seekers might be especially vulnerable to HIV. The asylum process is a window of opportunity for health education and HIV testing.

Achieving high acceptability of HIV testing in a population-based survey among immigrants in Finland.

AIMS: The aim of this study was to assess the acceptability of human immunodeficiency virus (HIV) testing among migrants in Finland and the factors contributing to non-acceptance. METHODS: The Finnish Migrant Health and Wellbeing Study 'Maamu' was the first national population-based Health Interview and Examination Survey (HIS/HES) among migrants in Finland. A total of 386 Kurdish, Russian and Somali immigrants in Helsinki participated in the study. RESULTS: Despite the participants' different sociodemographic backgrounds, a high rate of test acceptability (92%, 95% CI 90-95) was achieved. HIV test acceptance was associated with pretest counselling, ability to understand spoken Finnish or Swedish and employment status. No participants tested positive for HIV. CONCLUSIONS: The results imply that a universal HIV testing strategy is well accepted in a low-HIV prevalence immigrant population and can be included in a general health examination in immigrant population-based surveys.