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The case of immigrant health and TB control is best-illustrated using Dadaab refugee camp in Kenya. It is the largest refugee camp located in the horn of Africa, a region that presents the largest population movement in the world. The continued vulnerability to importations and potential TB epidemic outbreaks due to cross border transmission is aggravated by political instability and weak or insufficient health systems.
According to the International Organization for Migration (IOM), a majority of refugees relocating from the region are from Somalia, many of them seeking treatment. These patients, especially those diagnosed with drug resistant TB (DR TB), cross the border to seek treatment at Ifo Hospital in Dadaab Camp because the Government of Kenya provides free treatment, laboratory services and social support as per the National Programmatic Management of Drug Resistant TB (PMDT) guidelines. Refugee patients comprise 18 – 20% of the DR TB patients on treatment at any given time in Kenya. However, there has been a decline of DR TB patients enrolled in care to only one patient in the first quarter of 2016 compared to 24 in 2015. This could be attributed to the establishment of a DR TB treatment centre in Mogadishu.

Challenges
The challenges facing TB management among immigrant populations are diverse and include:
• Quality of Care: The lack of specialised health services in special circumstances such as dialysis for patients with renal failure or ventilators for patients requiring support is a major challenge.
• Infrastructure: There is need for a well-equipped isolation ward with the necessary infrastructure to support the management of patients who require specialised inpatient care and management.
• Psychosocial Support: Due to the long duration of treatment for DR TB (20-24 months), these patients require counselling to alleviate states of depression as well as engagement in social activities such as entertainment. This makes their treatment days shorter and bearable
• High Staff Turnover: With insufficient human resource as a result of the high staff turnover, capacity and effort in the management of DR TB remains a challenge.
Surveillance System and Current Immigrant DR TB in Kenya
The surveillance system in Kenya identifies those at greater risk of developing DR TB compared to the general population. Refugees with signs and symptoms of TB are one such group. According to the algorithm, such patients are subjected to GeneXpert, Drug Susceptibility Testing (DST) and culture for diagnosis to determine their susceptibility. Monthly smears and culture follow up tests are conducted in the culture laboratory within refugee camps. The East Africa Public Health Laboratory Network (EAPHLN) and the World Bank project has set up laboratories and staff at the cross border points for DR TB surveillance. The renovation and construction of a new DR TB centre at Ifo is ongoing.

As part of surveillance, the National TB, Leprosy and Lung Disease Program (NTLD-Program) supplies GeneXpert consumables, servicing and capacity building at the refugee camp. To curb the potential of transmission and outbreaks, the NTLD-Program and Challenge TB/USAID through KNCV have established cross border initiatives and interventions to improve cooperation, coordination and collaboration between Kenya and Somalia to reinforce surveillance at all levels – local, national and International. Engagement and sensitization of counties along the border is ongoing.

In June of 2014, the Ministry of Health established a cross border TB control taskforce whose mandate is to coordinate activities and offer technical expertise in TB control at the refugee camp and in neighbouring Somalia.

Notably, IOM handed over the management of Dadaab Camp to Red Cross in December 2015. The camp now has four (4) qualified staffs (one clinician and three nurses) supported by six (6) auxiliary nurses-refugees. The Global Fund to Fight AIDS, Tuberculosis and Malaria also plans to engage more staff to support in the management and care of patients as well as the establishment of treatment facilities in Somalia.
World Vision International is another active player in TB control in Somalia, having established a DR TB treatment centre in Hargesia in August 2013 and in Mogadishu in December 2015. The Hargeisa and Mogadishu operations have a 45 and 30 bed capacity respectively and this may have led to a decline in the number of DR TB patients.

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