Infectious diseases in asylum seekers: actions for health professionals
Clinicians are provided with actions to complete when managing infectious diseases in the asylum seeker population.
There have been a number of infectious disease notifications associated with asylum seeker accommodation across the country over the past 2 years, including:
- diphtheria
- shigella
- group A Streptococcus
- MRSA (methicillin-resistant Staphylococcus aureus)
- varicella zoster virus
- coronavirus (COVID-19)
- flu
- scabies
- tuberculosis
Diphtheria is a rare, vaccine-preventable disease in the UK caused by toxigenic strains of Corynebacteria. Diphtheria can initially present with either cutaneous or respiratory symptoms, including sore throat and in severe cases a membrane that can lead to airway obstruction. However, this is not universally present.
Without prompt treatment with diphtheria anti-toxin (DAT) and antibiotics, case fatality in respiratory diphtheria cases approaches 10%.
Cases of infectious diseases in asylum seekers this year
As of 31 January 2023, 73 cases of diphtheria have been identified in asylum seekers with recent arrival in the UK, with the majority of these cases having been detected between October to December 2022. Cases are predominantly young males aged 14 to 25 years, with approximately half of cases being cutaneous.
A proportion of asylum seekers arriving in the UK are presenting with diffuse and varied skin lesions. Testing of asylum seekers presenting with skin lesions has identified a range of pathogens including Staphylococcus aureus, Group A Streptococcus and Corynebacterium diphtheriae.
Several individuals also presented with scabies, with co-infection frequently seen. Fuel burns have also been an issue.
Information for healthcare professionals
The UK Health Security Agency (UKHSA) is encouraging clinicians to ensure the following actions are completed when managing infectious diseases in the asylum seeker population.
Diphtheria
For individuals who have been through an initial reception centre, a mass offer of antibiotic prophylaxis and vaccination has been recommended by the national incident management team. There is supplementary guidance for cases and outbreaks of diphtheria in asylum seeker accommodation settings.
Where a clinician diagnoses suspected diphtheria in an asylum seeker (recent updates to case definitions are available), they are requested to inform their local health protection team (HPT) promptly by phone to ensure appropriate public health action.
Clinicians are reminded that cases of suspected or confirmed classical respiratory diphtheria, or cutaneous diphtheria with a large lesion, should be urgently assessed, with the support of an infectious diseases clinician for consideration of the need for DAT.
Make sure any swabs (including skin and throat swabs) sent are labelled appropriately, making it clear that the swab has been taken from an asylum seeker. Testing for diphtheria is not universally performed at all local laboratories. Correct labelling of samples, and discussion of severe cases, will ensure laboratories undertake appropriate testing and onwards referral to UKHSA reference laboratories where potential toxigenic Corynebacterium species have been isolated. Due to a small number of multi-drug resistant cutaneous diphtheriae isolates associated with this cohort, clinicians are asked to ensure clearance of the organism, from the site it was originally detected. Information regarding antibiotic resistance and appropriate treatment and clearance can be found in the supplementary guidance.
Antibiotic sensitivity testing
It is strongly recommended that local laboratories undertake antimicrobial testing on all C. diphtheriae isolates to include as a minimum sensitivity to penicillin and erythromycin (according to local methods and reported using the (pre-publication) EUCAST Clinical Breakpoint Tables v.13.0). If resistance to either penicillin (R> 1mg/L) or erythromycin (R> 0.06 mg/L) is detected, further antimicrobial susceptibilities are recommended to include amoxicillin, tetracycline, trimethoprim-sulfamethoxazole, and fluoroquinolones (ciprofloxacin). If the patient requires parenteral antibiotics, then vancomycin +/- linezolid should ideally be tested.
Macrolide resistance should be reported to the local HPT, and the isolate should be referred to the UKHSA reference laboratory (RVPBRU) for typing and antimicrobial susceptibility confirmation. An Incident Management Team should be convened for these cases to inform treatment/prophylaxis decisions for cases and contacts.
Skin lesions other than diphtheria
Skin lesions in asylum seekers may be infected or colonised with multiple bacteria; it is not uncommon to see Staphylococcus aureus (+/- MRSA / PVL) and group A Streptococcus co-infection in this group, with on occasion cutaneous diphtheria. Group A Streptococcus remains universally susceptible to penicillin; however, resistance to macrolides, clindamycin and tetracycline antibiotics has more than doubled between 2016 to 2021.
Effective management of skin lesions may require complex antibiotic regimes, prescribed following local microbiology or infectious diseases specialist advice and guided by susceptibility data. Due to migratory routes, and countries of origin, diagnostic differentials may also include rarer pathologies such as Leishmaniasis. Failure to respond to initial clinical management strategies should prompt consideration for onwards referral to local Infectious diseases or Dermatology teams.
UKHSA recently published guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings.
Further information about health needs for asylum seekers
Guidelines on the public health management of diphtheria in England are available on GOV.UK.
Broader advice for healthcare practitioners about the health needs of migrants is in the migrant health guide.
A vaccination catch-up guide is available for individuals with uncertain or incomplete immunisation status.
Last updated 1 February 2023 + show all updates
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Updated number of cases and added antibiotic sensitivity testing section.
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First published.