Review Open Access
Like 0


All asylum seekers in Germany undergo upon-entry screening for tuberculosis TB, but comprehensive evidence on the yield is lacking. We compared the national estimates with the international literature in a systematic review and meta-analysis of studies reporting the yield of TB, defined as the fraction of active TB cases detected among asylum seekers screened in Germany upon entry. We searched 11 national and international databases for empirical studies and the internet for grey literature published in English or German without restrictions on publication time. Among 1,253 screened articles, we identified six articles reporting the yield of active TB based on German data, ranging from 0.72 (95% confidence interval (CI): 0.45–1.10) to 6.41 (95% CI: 4.19–9.37) per 1,000 asylum seekers. The pooled estimate across all studies was 3.47 (95% CI: 1.78–5.73; I2 = 94.9%; p < 0.0001) per 1,000 asylum seekers. This estimate was in line with international evidence (I2 = 0%; p for heterogeneity 0.55). The meta-analysis of available international estimates resulted in a pooled yield of 3.04 (95% CI: 2.24–3.96) per 1,000. This study provides an estimate across several German federal states for the yield of TB screening in asylum seekers. Further research is needed to develop more targeted screening programmes.


Article metrics loading...

Loading full text...

Full text loading...



  1. World Health Organization (WHO). Global tuberculosis report 2015. Geneva: WHO; 2015. Available from: http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf
  2. Zimmerman C, Kiss L, Hossain M. Migration and health: a framework for 21st century policy-making. PLoS Med. 2011;8(5):e1001034.  https://doi.org/10.1371/journal.pmed.1001034  PMID: 21629681 
  3. Lönnroth K, Migliori GB, Abubakar I, D’Ambrosio L, de Vries G, Diel R, et al. Towards tuberculosis elimination: an action framework for low-incidence countries. Eur Respir J. 2015;45(4):928-52. PMID: 25792630 
  4. Dahle UR, Eldholm V, Winje BA, Mannsåker T, Heldal E. Impact of immigration on the molecular epidemiology of Mycobacterium tuberculosis in a low-incidence country. Am J Respir Crit Care Med. 2007;176(9):930-5.  https://doi.org/10.1164/rccm.200702-187OC  PMID: 17673698 
  5. Barniol J, Niemann S, Louis VR, Brodhun B, Dreweck C, Richter E, et al. Transmission dynamics of pulmonary tuberculosis between autochthonous and immigrant sub-populations. BMC Infect Dis. 2009;9(1):197.  https://doi.org/10.1186/1471-2334-9-197  PMID: 19961606 
  6. Sandgren A, Schepisi MS, Sotgiu G, Huitric E, Migliori GB, Manissero D, et al. Tuberculosis transmission between foreign- and native-born populations in the EU/EEA: a systematic review. Eur Respir J. 2014;43(4):1159-71.  https://doi.org/10.1183/09031936.00117213  PMID: 24114966 
  7. Eurostat. Asylum quarterly report. First time asylum applicants and first instance decisions on asylum applications: third quarter 2016. Vrussels: European Commission; 2016. Available from: http://ec.europa.eu/eurostat/statistics-explained/index.php/Asylum_quarterly_report
  8. Dara M, Gushulak BD, Posey DL, Zellweger JP, Migliori GB. The history and evolution of immigration medical screening for tuberculosis. Expert Rev Anti Infect Ther. 2013;11(2):137-46.  https://doi.org/10.1586/eri.12.168  PMID: 23409820 
  9. Klinkenberg E, Manissero D, Semenza JC, Verver S. Migrant tuberculosis screening in the EU/EEA: yield, coverage and limitations. Eur Respir J. 2009;34(5):1180-9.  https://doi.org/10.1183/09031936.00038009  PMID: 19880618 
  10. van der Werf MJ, Lönnroth K. Pre-entry, post-entry, or no tuberculosis screening? Lancet Infect Dis. 2014;14(12):1171-2.  https://doi.org/10.1016/S1473-3099(14)70998-3  PMID: 25455973 
  11. Norredam M, Mygind A, Krasnik A. Access to health care for asylum seekers in the European Union--a comparative study of country policies. Eur J Public Health. 2006;16(3):286-90.  https://doi.org/10.1093/eurpub/cki191  PMID: 16230318 
  12. Pareek M, Baussano I, Abubakar I, Dye C, Lalvani A. Evaluation of immigrant tuberculosis screening in industrialized countries. Emerg Infect Dis. 2012;18(9):1422-9.  https://doi.org/10.3201/eid1809.120128  PMID: 22931959 
  13. Robert Koch Institute (RKI). Bericht zur Epidemiologie der Tuberkulose in Deutschland für 2014. [Report on the epidemiology of tuberculosis in Germany in 2014]. Berlin: RKI; 2015. German. Available from: http://edoc.rki.de/series/rki-bericht-zur-epidemiologie-der-tuberkulose-in-deutschland/2015/PDF/2015.pdf
  14. Bozorgmehr K, Noest S, Thaiss MH, Razum O. Die gesundheitliche Versorgungssituation von Asylsuchenden. [The healthcare situation among asylum seekers]. Bundesgesundheitsblatt. 2016;59(5):545-55. German.  https://doi.org/10.1007/s00103-016-2329-4 
  15. Robert Koch Institute (RKI). Thorax-Röntgenuntersuchungen bei Asylsuchenden gemäß § 36 Absatz 4 IfSG - Stellungnahme des Robert Koch-Instituts. [Thoracic X-ray examinations in asylum seekers according to Section 36 (4) Infection Protection Act – opinion of the Robert Koch Institute]. Berlin: RKI; 2015. German. Available from: https://www.rki.de/DE/Content/InfAZ/T/Tuberkulose/Tuberkulose_Roentgen-Untersuchungen_Asylsuchende.html
  16. United Nations High Commissioner for Refugees (UNHCR). Asylum trends 2014: Levels and trends in industrialized countries. Geneva: UNHCR; 2015. Available from: http://www.unhcr.org/statistics/unhcrstats/551128679/asylum-levels-trends-industrialized-countries-2014.html
  17. Bundesamt für Migration und Flüchtlinge (BAMF). Aktuelle Zahlen zu Asyl. Ausgabe: Januar 2016. [Current asylum figures. January 2016 edition]. Berlin: BAMF; 2016. German. Available from: http://www.bamf.de/SharedDocs/Anlagen/DE/Downloads/Infothek/Statistik/Asyl/aktuelle-zahlen-zu-asyl-januar-2016.html?nn=7952222
  18. Gough D, Thomas J, Oliver S. Clarifying differences between review designs and methods. Syst Rev. 2012;1(1):28.  https://doi.org/10.1186/2046-4053-1-28  PMID: 22681772 
  19. Schneider C, Mohsenpour A, Joos S, Bozorgmehr K. Health status of and health-care provision to asylum seekers in Germany: protocol for a systematic review and evidence mapping of empirical studies. Syst Rev. 2014;3(1):139.  https://doi.org/10.1186/2046-4053-3-139  PMID: 25433520 
  20. Bozorgmehr K, Mohsenpour A, Saure D, Stock C, Loerbroks A, Joos S, et al. Systematische Übersicht und „Mapping“ empirischer Studien des Gesundheitszustands und der medizinischen Versorgung von Flüchtlingen und Asylsuchenden in Deutschland (1990–2014). [Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]. Bundesgesundheitsblatt. 2016;59(5):599-620. German. doi:  https://doi.org/10.1007/s00103-016-2336-5 .
  21. Centre for Evidence Based Medicine (CEBM). OCEBM levels of evidence. Oxford CEBM; 2016. Available from: http://www.cebm.net/ocebm-levels-of-evidence/
  22. Arshad S, Bavan L, Gajari K, Paget SNJ, Baussano I. Active screening at entry for tuberculosis among new immigrants: a systematic review and meta-analysis. Eur Respir J. 2010;35(6):1336-45.  https://doi.org/10.1183/09031936.00054709  PMID: 19840970 
  23. Diel R, Rüsch-Gerdes S, Niemann S. Molecular epidemiology of tuberculosis among immigrants in Hamburg, Germany. J Clin Microbiol. 2004;42(7):2952-60.  https://doi.org/10.1128/JCM.42.7.2952-2960.2004  PMID: 15243044 
  24. Dreweck C, Kerner E, Güllich K, Halder G. [The social dimension of tuberculosis in the City of Munich]. Gesundheitswesen. 2013;75(11):689-92. German. PMID: 24285156 
  25. Joggerst B, Käßmann J. Weniger Tuberkulosefälle als erwartet unter Asylbewerbern in BW von 2002 bis 2011. [Fewer tuberculosis cases than expected among asylum seekers in Baden-Wuerttemberg from 2002 to 2011]. Conference abstract. Gesundheitswesen. 2013;75(04):P22. German. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=22836936&dopt=Abstract https://doi.org/10.1055/s-0033-1337554  PMID: 22836936 
  26. Kesseler K, Maffei D, Meyer FJ, Konietzko N. [Tuberculosis in asylum seekers]. Gesundheitswesen. 1995;57(10):670-3. German. PMID: 8527885 
  27. Mohammadzadeh Z. [The Bremen primary examination program for refugees (II)]. Gesundheitswesen. 1995;57(8-9):462-6. German. PMID: 7496102 
  28. Michels H, Bartz C. Tuberkulose-Screening im Rahmen der infektionshygienischen Untersuchung Asylbegehrender in Rheinland-Pfalz, Trier. [Tuberculosis screening as part of the hygiene examination of asylum seekers in Rhineland-Palatinate, Trier]. Epidemiologisches Bulletin. 2015; 11/12. German. Available from: https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2015/Ausgaben/11_12_15.pdf?__blob=publicationFile
  29. Diel R, Lampenius N, Nienhaus A. Cost effectiveness of preventive treatment for tuberculosis in special high-risk populations. Pharmacoeconomics. 2015;33(8):783-809.  https://doi.org/10.1007/s40273-015-0267-x  PMID: 25774015 
  30. Dara M, Solovic I, Sotgiu G, D’Ambrosio L, Centis R, Goletti D, et al. Call for urgent actions to ensure access to early diagnosis and care of tuberculosis among refugees: Statement of the European Respiratory Society and the European Region of the International Union Against Tuberculosis and Lung Disease. Eur Respir J. 2016;47(5):1345-7.  https://doi.org/10.1183/13993003.00377-2016  PMID: 27009169 
  31. Mockenhaupt FP, Barbre KA, Jensenius M, Larsen CS, Barnett ED, Stauffer W, et al. Profile of illness in Syrian refugees: A GeoSentinel analysis, 2013 to 2015. Euro Surveill. 2016;21(10):30160.  https://doi.org/10.2807/1560-7917.ES.2016.21.10.30160  PMID: 26987893 
  32. Karo B, Hauer B, Hollo V, van der Werf MJ, Fiebig L, Haas W. Tuberculosis treatment outcome in the European Union and European Economic Area: an analysis of surveillance data from 2002-2011. Euro Surveill. 2015;20(49):30087. PMID: 26676247 
  33. Marx FM, Fiebig L, Hauer B, Brodhun B, Glaser-Paschke G, Magdorf K, et al. Higher rate of tuberculosis in second generation migrants compared to native residents in a metropolitan setting in Western Europe. PLoS One. 2015;10(6):e0119693.  https://doi.org/10.1371/journal.pone.0119693  PMID: 26061733 
  34. Brodhun B, Altmann D, Hauer B, Fiebig L, Haas W. [Current epidemiology of tuberculosis in Germany]. Pneumologie. 2015;69(5):263-70. German. PMID: 25970119 
  35. Kuehne A, Fiebig L, Jansen K, Koschollek C, Santos-Hövener C. [Migration and infectious disease surveillance in Germany: Analyses of tuberculosis, HIV and syphilis surveillance data]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2015;58(6):560-8. German.  https://doi.org/10.1007/s00103-015-2157-y  PMID: 25868420 
  36. Shapiro AE, Chakravorty R, Akande T, Lonnroth K, Golub JE. A systematic review of the number needed to screen to detect a case of active tuberculosis in different risk groups. Geneva: World Health Organization; 2013. Available from: http://www.who.int/tb/Review3NNS_case_active_TB_riskgroups.pdf
  37. Zenner D, Southern J, van Hest R, DeVries G, Stagg HR, Antoine D, et al. Active case finding for tuberculosis among high-risk groups in low-incidence countries. Int J Tuberc Lung Dis. 2013;17(5):573-82.  https://doi.org/10.5588/ijtld.12.0920  PMID: 23575321 
  38. Pareek M, Greenaway C, Noori T, Munoz J, Zenner D. The impact of migration on tuberculosis epidemiology and control in high-income countries: a review. BMC Med. 2016;14(1):48.  https://doi.org/10.1186/s12916-016-0595-5  PMID: 27004556 
  39. World Health Organization (WHO). Systematic screening for active tuberculosis: principles and recommendations. Geneva: World Health Organization; 2013. Available from: http://www.who.int/tb/tbscreening/en/
  40. de Vries G, van Rest J, Meijer W, Wolters B, van Hest R. Low yield of screening asylum seekers from countries with a tuberculosis incidence of <50 per 100 000 population. Eur Respir J. 2016;47(6):1870-2.  https://doi.org/10.1183/13993003.00099-2016  PMID: 26965289 
  41. Faustini A, Hall AJ, Perucci CA. Tuberculosis treatment outcomes in Europe: a systematic review. Eur Respir J. 2005;26(3):503-10.  https://doi.org/10.1183/09031936.05.00103504  PMID: 16135735 
  42. Loytved G, Steidle B, Benz E, Koszczynski W. [Tuberculosis control in lower Franconia 1995 - 2001. Case-finding and treatment outcome]. Pneumologie. 2002;56(6):349-56. German.  https://doi.org/10.1055/s-2002-32171  PMID: 12063615 
  43. Ritz N, Brinkmann F, Santiago Garcia B, Tebruegge M, Kampmann BPaediatric Tuberculosis Network European Trials group (ptbnet). Tuberculosis in young refugees. Lancet. 2015;386(10012):2475-6.  https://doi.org/10.1016/S0140-6736(15)01241-6  PMID: 26738710 
  44. Ritz N, Brinkmann F, Feiterna-Sperling C, Hauer B, Haas W. Tuberkulosescreening bei asylsuchenden Kindern und Jugendlichen ‹ 15 Jahren in Deutschland. [Tuberculosis screening in young asylum seekers <15 years in Germany]. Monatsschr Kinderheilkd. 2015;163(12):1287-92. German.  https://doi.org/10.1007/s00112-015-0007-5 
  45. Moher D, Liberati A, Tetzlaff J, Altman DGThe PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.  https://doi.org/10.1371/journal.pmed1000097 

Data & Media loading...

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error