Communicable Diseases

Tuberculosis

In 2014, Syria notified WHO of 3,576 cases of tuberculosis (TB) and an overall incidence rate of 17 cases per 100,000 population ³⁶. Incidence rates of TB are similar (or lower) in countries where Syrian refugees are being processed, with the exception of Iraq, which has a relatively high incidence rate (Table 2). Additionally, the number of multi-drug resistant (MDR) TB cases in each country is relatively low. As TB incidence in Iraq is >20 per 100,000 population, Interferon-Gamma Release Assay (IGRA) or tuberculin skin test (TST) is still required as part of the overseas medical examination for Syrian refugees being processed in Iraq.

Table 2. Tuberculosis burden in countries processing Syrian refugees

Source: WHO Tuberculosis Country Profiles ³⁷

In a small sample of adult Syrian refugees (n=44) presenting at GeoSentinel sites after migration, 5 cases of active TB (3 pulmonary, 2 extrapulmonary) and 4 cases of latent TB infection (LTBI) were identified ³⁸. Initial screening data from Texas and Illinois indicate that approximately 10% of newly arrived Syrian refugees have LTBI, as detected by IGRA/TST ³⁹. This is consistent with findings from GeoSentinel surveillance data. However, preliminary screening data from Canada indicate substantially lower rates of LTBI in newly arriving Syrian refugees. Of 26,166 Syrian refugees screened upon arrival between November 2015 and February 2016, only 2 (<1%) were found to have LTBI ⁴⁰.

Infectious Hepatitis

The prevalence of chronic infectious hepatitis (B and C) among Syrian refugees appears to be low. In a recent cross-sectional survey of Syrian refugees residing in Iraq (N=880), 3.86% (34/880) were found to be infected with hepatitis B virus ⁴¹. Screening performed in unaccompanied Syrian children (<18 years) revealed no cases of hepatitis B among 448 screened children ³⁸. Initial domestic screening of Syrian refugees in Texas arriving between January 2012 and July 2016 found 1.2% (3/259) of those screened had hepatitis B infection ³⁹. Until additional data become available that confirm these low rates, Syrian refugees should continue to be screened for chronic hepatitis B virus infection.

Estimated hepatitis C virus infection prevalence is quite low in the general Syrian population (0.4%), as well as in surrounding countries, including Iraq (0.2%), Jordan (0.3%), and Lebanon (0.2%) ⁴². Among high-risk groups in the same countries, hepatitis C prevalence was considerably higher, particularly in Syria, where prevalence was estimated to be 47.4% ⁴². Hepatitis C virus infection is a major health concern in Egypt, with prevalence estimated to be greater than 10% nationally ^{43, 44}. Among Syrian refugees, few hepatitis C screening data are available. In the aforementioned cohort of 880 Syrian refugees living in Iraq, and 480 unaccompanied children screened in Berlin, no cases of hepatitis C were detected ^{38, 42}. Until further data are available, those with risk factors, and those for whom routine screening in the U.S. is recommended (e.g., born during 1945-1965), should be screened in accordance with current U.S. recommendations.

HIV and Syphilis

HIV and syphilis appear to be uncommon in resettled Syrian refugees. Data collected from domestic medical screening of Syrian refugees in Texas arriving between January 2012 and July 2016 revealed low rates of HIV and syphilis infection. Of those screened, 0.8% (2/261) were found to be HIV-positive, and syphilis infection was found in 0.7% (1/140) ³⁹. Although reported infection rates are low, routine screening according to the Domestic Refugee Screening Guidelines for HIV Infection and Sexually Transmitted Diseases should be followed until further data become available.

References

36. World Health Organization. Tuberculosis Profile. [cited 2015 November 6]; Available from: https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=SY&LAN=EN&outtype=html.
37. World Health Organization. Tuberculosis country profiles. [cited 2016 August ]; Available from: http://www.who.int/tb/country/data/profiles/en/.
38. Mockenhaupt, F.P., et al., Profile of illness in Syrian refugees: A GeoSentinel analysis, 2013 to 2015. Euro Surveill, 2016. 21(10).
39. Texas, Domestic Screening Data. 2012-2015.
40. Hansen L, Maidment L, and Ahmad R, Early observations on the health of Syrian refugees in Canada. Can Comm Dis Rep, 2016. 42(Suppl 2): p. S8-10.
41. Hussein, N.R., et al., Prevalence of HBV, HCV and HIV Infections Among Syrian Refugees in Kurdistan Region, Iraq. Int J Infect. In Press(In Press): p. e39420.
42. Chemaitelly H, Chaabna K, and A.R. LJ., The epidemiology of hepatitis C virus in the fertile crescent: Systemic review and meta-analysis. PLoS ONE, 2015. 10(8).
43. Mohamoud, Y.A., et al., The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis. BMC Infect Dis, 2013. 13: p. 288.
44. Progress toward prevention and control of hepatitis C virus infection–Egypt, 2001-2012. MMWR Morb Mortal Wkly Rep, 2012. 61(29): p. 545-9.