Tuberculosis infection in under-2-year-old refugees : should we be screening? : a systematic review and meta-regression analysis

Aim: Refugees are at increased risk of tuberculosis infection due to time spent in crowded camps, decreased nutrition and originating from countries whose own tuberculosis control systems may have been disturbed. In Australia, tuberculosis is screened for in for all refugees aged 11–34 years old and in those aged 2–10 years arriving from high-incidence countries. Our aims were to determine if refugee children aged under 2 years of age should also be screened. Methods: A systematic literature review and meta-regression was carried out on studies in refugee children under 18 years old, involving screening for tuberculosis (active or latent tuberculosis infection (LTBI)). Studies were extracted from the last 10 years from a range of bibliographic databases using the search terms ‘tuberculosis’, ‘children’, ‘screening’ and ‘refugee’, which tested for tuberculosis using the tuberculin skin test (TST) or QuantiFERON-Gold (Interferon Gamma Release Assay (IGRA)). Results: Of the 15 included studies, prevalence of LTBI in < 2-year-olds was 5% using IGRA and 15% using TST (P < 0.05). Prevalence increased with age (odds ratio 1.12; 95% confidence interval: 1.06–1.17) cumulatively and decreased where IGRA was used for screening compared to TST (odds ratio 0.38; 95% confidence interval: 0.25–0.58). Prevalence of LTBI did not differ between general versus clinic refugee cohorts. Conclusions: Refugees are a particularly vulnerable group in their susceptibility to tuberculosis, and LTBI management is a critical part of tuberculosis disease control due to the lifetime risk of developing active tuberculosis. A prevalence of 5–15% for LTBI in the under 2 years age group would support them being included in screening programmes.