Infectious Diseases

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/infd20

Tuberculosis screening among newly arrived

asylum seekers in Denmark

Kristina Langholz Kristensen, Marie Norredam, Sidse Graff Jensen, Niels

Seersholm, Marie Louise Jørgensen, Banoo Bakir Exsteen, Franziska
Grundtvig Huber, Ebbe Munk-Andersen, Troels Lillebaek & Pernille Ravn

To cite this article: Kristina Langholz Kristensen, Marie Norredam, Sidse Graff Jensen, Niels
Seersholm, Marie Louise Jørgensen, Banoo Bakir Exsteen, Franziska Grundtvig Huber,
Ebbe Munk-Andersen, Troels Lillebaek & Pernille Ravn (2022) Tuberculosis screening
among newly arrived asylum seekers in Denmark, Infectious Diseases, 54:11, 819-827, DOI:
10.1080/23744235.2022.2106380

To link to this article: https://doi.org/10.1080/23744235.2022.2106380

Published online: 23 Aug 2022.

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INFECTIOUS DISEASES, https://doi.org/10.1080/23744235.2022.2106380
2022; VOL. 54,
NO. 11, 819–827

ORIGINAL ARTICLE

Tuberculosis screening among newly arrived asylum seekers in Denmark

Kristina Langholz Kristensena,b, Marie Norredamc,d, Sidse Graff Jensene, Niels Seersholme,
Marie Louise Jørgensenb, Banoo Bakir Exsteend,f, Franziska Grundtvig Huberf, Ebbe Munk-Anderseng,
Troels Lillebaeka,h
and Pernille Ravnf

a
International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark; bDepartment of
Pulmonary- and Infectious Diseases, Nordsjaellands Hospital, Hilleroed, Denmark; cResearch Centre for Migration, Ethnicity and
Health, University of Copenhagen, Copenhagen, Denmark; dSection of Immigrant Medicine, Department of Infectious Diseases,
University Hospital Hvidovre, Hvidovre, Denmark; eDepartment of Internal Medicine, Section of Respiratory Diseases, Herlev and
Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; fDepartment of Internal Medicine, Infectious Disease Section,
Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; gDanish Red Cross, Copenhagen, Denmark; hGlobal
Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark

ABSTRACT
Background: Tuberculosis (TB) screening programmes among asylum seekers tend to focus on chest radiography (CXR) for
early diagnosis, whereas knowledge on sputum examination is limited. We evaluated active TB screening using CXR and
sputum culture among asylum seekers arriving in Denmark. In addition, we assessed the coverage of a voluntary
health assessment.
Methods: Between 1 February 2017 and 31 March 2019, all newly arrived asylum seekers in Denmark  18 years from TB
high-incidence countries or risk groups, who attended a voluntary general health assessment, were offered active TB
screening with CXR and spot sputum examination. Sputum samples were examined by culture and smear microscopy.
Results: Coverage of the general health assessment was 65.1%. Among 1,154 referred for active TB screening, 923 (80.0%)
attended. Of these, 854 were screened by CXR and one case of active TB was identified equivalent to a yield of 0.12%.
Sputum samples were collected from 758 and one M. tuberculosis culture-positive TB case (also identified by CXR) was
identified, equivalent to a yield of 0.13%. No cases were found by sputum culture screening only. In addition, screening
found three cases of malignant disease.
Conclusion: We suggest that TB screening should focus on asylum seekers from TB high-incidence countries. Furthermore,
early health assessments should be of high priority to ensure migrant health.

KEYWORDS ARTICLE HISTORY CONTACT

Asylum seekers Received 20 December 2021 Kristina Langholz Kristensen
tuberculosis Revised 26 April 2022 krlk@ssi.dk
screening Accepted 21 July 2022 International Reference Laboratory of
sputum culture Mycobacteriology, Statens Serum Institut,
coverage Artillerivej 5, Copenhagen, 2300, Denmark

Shared last author, contributed equally.

ß 2022 Society for Scandinavian Journal of Infectious Diseases
820 K. LANGHOLZ KRISTENSEN ET AL.
Introduction
In tuberculosis (TB) low-incidence countries, the majority
of TB cases caused by Mycobacterium tuberculosis (Mtb)
occur among migrants from TB high-incidence areas
[1,2]. In Denmark, a TB low-incidence country with an
annual incidence of 5/100,000 population, more than
60% of TB cases are found among migrants [3].
Therefore, TB prevention, early diagnosis and treatment
among migrants are key public health priorities [4].
Among migrants, asylum seekers are considered to
have a high TB risk due to challenging conditions before
and during migration favouring TB transmission and
reactivation of latent infection [5,6]. Asylum seekers may
come from, or pass through, areas affected by a high TB
burden, war and underfunded health systems; and they
may have faced precarious migration conditions such as
overcrowding and lack of health care [1,7–9].
Early TB diagnosis is the cornerstone in effective pre-
vention strategies. It reduces TB transmission and
reduces the risk of severe disease [10,11]. In order to
facilitate early diagnosis, the World Health Organization
(WHO) recommends TB screening through active case
finding in vulnerable groups in TB low-incidence coun-
tries [12]. Across Europe, screening practices for active
TB among asylum seekers differ in screening tests, tim-
ing, definition of risk groups, and level of coercion
[13,14]. Most programmes use chest radiography (CXR)
on arrival, and some programmes include all asylum
seekers, whereas others target only those from TB high-
incidence countries.
Active case finding with screening by sputum culture
may also be used to identify TB cases at an earlier and
less infectious stage [15,16]. However, we are only aware
of one study screening asylum seekers for TB by sputum
culture in which 1.9% had culture-positive TB [17].
In the present study, we evaluate the yield of an
active TB screening programme including CXR and spot
sputum culture among newly arrived asylum seekers in
Denmark. In addition, we assess the coverage of a vol-
untary health assessment.
Methods
Study population
The study covered newly arrived asylum seekers 
18 years arriving at the national reception centre in
Denmark between 1 February 2017 and 31 March 2019.
Setting and routine screening procedures
In Denmark, all asylum seekers apply for asylum at the
national reception centre. The Danish Red Cross accom-
modates asylum seekers during the initial phase and are
responsible for the initial medical reception and all med-
ical needs during this phase. A voluntary general health
assessment is offered to all asylum seekers within
10 days of arrival comprising an interview-based evalu-
ation for diseases requiring medical assessment, includ-
ing TB. Since 1 February 2017 and onwards, systematic
TB screening with CXR has been offered to asylum
seekers  16 years at risk of TB defined as: (i) from a TB
high-incidence country (incidence  100/100,000 popu-
lation), or (ii) from a country with risk of MDR-TB [18] or
(iii) a TB high-risk group (former imprisonment, refugee
camp, war zone or human immunodeficiency virus), or
(iv) who presents with clinical TB signs. Individuals with
signs of active TB are referred to the nearest hospital for
further evaluation.
Additional study procedures
Asylum seekers, who were above 18 years and who were
at risk of TB according to the TB routine screening crite-
ria, were included in this study and offered TB screening
by both CXR and sputum culture. Asylum seekers eli-
gible for TB screening were informed regarding TB,
treatment, study information and confidentiality by reg-
istered nurses from the Danish Red Cross, together with
a translator, during the health assessment. All partici-
pants were offered 24 h of consideration before giving
consent. Because sputum screening was not part of the
routine screening, an informed written consent was
obtained before collecting sputum samples.
Sample handling and analysis
CXR was carried out at the Department of Radiology,
Nordsjaellands Hospital, Denmark, and evaluated by spe-
cialized radiologists. Spot sputum samples were col-
lected on site by medical professionals, who instructed
and supervised participants in producing sputum from
the lower respiratory tract. Sputum samples were ana-
lysed at the International Reference Laboratory of
Mycobacteriology (IRLM) at Statens Serum Institut (SSI),
Denmark. Sputum samples were examined for acid-fast
bacilli using auramine-rhodamine staining and fluores-
cence microscopy. Cultures were performed in both
liquid medium (BACTEC MGIT) and on solid medium

(Lowenstein-Jensen) with a final result after up
to 56 days.
TB cases
Active TB was defined as: (1) culture-positive, or (2)
smear-positive and CXR and/or symptoms suggestive of
TB, or (3) clinical TB diagnosis prompting TB-treatment
[19]. Previous TB was defined as CXR suggestive of for-
mer TB where active TB could be ruled out with culture-
and smear-negative sputum and no TB symptoms. For
the purpose of this study, asylum seekers were consid-
ered as having completed diagnostic evaluation when
the investigations prescribed by the attending physician
were performed.
Data generation
Baseline data on age, sex, country of origin, health
assessment attendance, CXR, further investigations, final
diagnosis, treatment initiation, loss to follow-up, and
reason for screening were obtained from Danish Red
Cross’ medical records. Microbiological data were
obtained from IRLM, SSI.
Statistical analysis
Descriptive statistics were reported as proportions and
numbers. The coverage of the health assessment was
calculated as the number of persons attending divided
by the total number of persons invited. The yield of CXR
screening was calculated as the number of TB cases
found divided by the total number CXR screened. The
yield of sputum culture screening was calculated as the
number of culture-positive cases found divided by the
total number of sputums collected. A p  0.05 was con-
sidered statistically significant. All statistical analyses
were performed using STATA statistical software 14.2
(Stata Corp., College Station, TX, USA).
Ethical approval
Data on health assessment and CXR screening was eval-
uated in collaboration with local asylum-operators and
health care providers within Danish Red Cross after
approval by the Danish Patient Safety Authority (journal
number 3-3013-3056/1). Sputum screening was
approved by the Danish National Committee on Health
Research Ethics (journal number H-15021682).
INFECTIOUS DISEASES 821
Results
A total of 3,446 asylum seekers were offered a voluntary
health assessment (Table 1). Most asylum seekers
(55.0%) were from countries with a TB incidence  49/
100,000 population. The most common country of origin
among all newly arrived was Syria (19.3%).
In total, 2,244 of 3,446 asylum seekers attended the
health assessment, corresponding to a coverage of
65.1% (Figure 1). Among the health assessment attend-
ees, 1,154 (51.4%) were at risk of TB according to the
screening criteria and referred for TB screening. Among
referred, 923 (80.0%) attended screening. Among
screened, 689 (74.6%) were screened by both CXR and
sputum culture, 165 (17.9%) by CXR only, and 69 (7.5%)
by sputum culture only. In total, 854 (92.5%) were
screened with CXR and 758 (82.1%) by sputum culture.
Among the 923 asylum seekers screened for TB, the
median age was 32 years (interquartile range 26–39) and
611 (66.2%) were males (Table 2). The most common
region of origin was Eastern Europe and Central Asia
(44.2%) and 165 (17.9%) came from Georgia. The main
reason for screening was originating from a country
with risk of MDR-TB (54.2%), followed by originating
from a country with a high TB incidence (38.0%).
Among the 2,244 asylum seekers who attended the
health assessment, two TB cases were identified (Figure
1). The first case (case #1) was identified at the initial
health assessment where the asylum seekers presented
with symptoms suggestive of TB. Thus, the asylum
seeker was not identified as part of the active TB screen-
ing study. This was an African-born asylum seeker with
weight loss, night sweats and enlarged lymph nodes.
The CXR was normal and sputum smear and -cultures
were negative. A lymph node biopsy showed caseous
necrosis, which was interpreted as tuberculous lymph-
adenitis. The second TB case (case #2) was identified
with both CXR- and sputum culture screening. This was
an African-born asylum seeker with a CXR suggestive of
TB. The asylum seeker was asymptomatic, sputum
smear-negative but culture-positive and diagnosed with
pulmonary TB. In both cases, standard treatment was
initiated. However, case #2 was lost to follow-up after 2
months of treatment.
Both CXR and sputum screening identified one TB
case (case #2). This was equivalent to a CXR screening
yield of 1/854 screened (0.12%), and equivalent to a
yield of sputum culture screening of 1/758 screened or
(0.13%). No cases were found by sputum culture screen-
ing only.
822 K. LANGHOLZ KRISTENSEN ET AL.

Table 1. Characteristics of all asylum seekers arriving and their attendance in the voluntary health assess-
ment (n ¼ 3,446).
Total Attending Not attending
Total, n 3,446 2,244 1,202
Sex,a % (n)
Male 66.4 (2,288) 59.6 (1,338) 79.0 (950)
Female 33.6 (1,158) 40.4 (906) 21.0 (252)
Ageb 30 (24–37) 31 (25–40) 27 (21–33)
Region of origin,a,c % (n)
Eastern Europe and Central Asia 31.1 (1,071) 31.9 (716) 29.5 (355)
Middle East and North Africa 49.0 (1,689) 46.8 (1,051) 53.1 (638)
South- and Central America 2.1 (72) 2.1 (46) 2.2 (26)
South-East Asia 4.4 (152) 4.8 (108) 3.7 (44)
Sub-Saharan Africa 12.7 (437) 13.5 (304) 10.1 (133)
Western Europe and the United States 0.7 (25) 0.9 (19) 0.5 (6)
Country of origin,a,d % (n)
Afghanistan 4.1 (143) 4.3 (97) 3.8 (46)
Albania 3.3 (113) 3.4 (77) 3.0 (36)
Eritrea 2.7 (93) 3.1 (69) 2.0 (24)
Georgia 10.8 (371) 10.1 (227) 12.0 (144)
Iran 8.6 (297) 9.3 (209) 7.3 (88)
Iraq 5.7 (196) 5.3 (120) 6.3 (76)
Morocco 5.3 (182) 2.5 (56) 10.5 (126)
Nigeria 3.9 (133) 2.6 (58) 6.2 (75)
Statelessness 4.3 (149) 4.4 (98) 4.2 (51)
Syria 19.3 (664) 22.2 (499) 13.7 (165)
Ukraine 2.0 (70) 2.6 (59) 0.9 (11)
TB incidencee in country of origina/100,000, % (n)
0–49 55.0 (1,894) 57.4 (1,288) 50.4 (606)
50–99 23.2 (799) 22.8 (511) 34.5 (288)
100–199 13.4 (461) 10.7 (239) 7.9 (222)
200 8.5 (292) 9.2 (206) 7.2 (86)
a
Data are presented as % (n) unless otherwise stated.
b
Median (interquartile range).
c
Modified from regions used by the World Bank Group (https://data.worldbank.org/country).
d
Ten most common countries of origin among all newly arrived.
e
World Health Organization estimated incidence.

Figure 1. Flow chart of health assessment attendance and active tuberculosis screening.

Two (0.26%) sputum samples were smear-positive,
but culture-negative. Both asylum seekers were asymp-
tomatic with normal CXR, and the samples were consid-
ered false-positive. Another two (0.26%) sputum samples
were culture positive for non-tuberculous mycobacteria
(M. abscessus and M. fortuitum). Both asylum seekers
were asymptomatic and had normal radiologic findings
i.e. no indication for treatment [20].
CXR was abnormal in 47 (5.5%) asylum seekers
(Figure 2). Of these, one was the active TB case #2, 15
(31.9%) were considered to have had previous TB and
three (6.4%) were diagnosed with a malignant disease
 INFECTIOUS DISEASES 823

Table 2. Baseline characteristics of asylum seekers attending tuberculosis screening (n ¼ 923).

Total attending CXR and sputum CXR only Sputum only
Total, n 923 689 165 69
Sex,a % (n)
Male 66.2 (611) 66.6 (459) 66.7 (110) 60.9 (42)
Female 33.8 (312) 22.4 (230) 33.3 (55) 39.1 (27)
Ageb 32.0 (26–39) 32 (26–39) 30 (24––8) 32 (26–42)
Region of origin,a,c % (n)
Eastern Europe and Central Asia 44.2 (408) 46.01 (317) 38.8 (64) 39.1 (27)
Middle East and North Africa 20.5 (189) 18.0 (124) 19.4 (32) 47.8 (33)
South- and Central America 0.2 (2) 0.2 (1) 0.6 (1) 0 (0)
South-East Asia 7.0 (65) 7.3 (50) 7.3 (12) 4.4 (3)
Sub-Saharan Africa 27.8 (257) 28.3 (195) 33.9 (56) 8.7 (6)
Western Europe and the United States 0.2 (2) 0.3 (2) 0 (0) 0 (0)
Country of origin,a,d % (n)
Afghanistan 7.7 (71) 7.6 (52) 7.3 (12) 10.1 (7)
Belarus 4.8 (44) 5.7 (39) 1.8 (3) 2.9 (2)
Eritrea 6.2 (57) 7.6 (52) 3.0 (5) 0 (0)
Georgia 17.9 (165) 18.0 (124) 17.6 (29) 17.4 (12)
Iraq 9.8 (90) 8.9 (61) 6.7 (11) 26.1 (18)
Morocco 3.8 (35) 2.5 (17) 6.1 (10) 11.6 (8)
Nigeria 5.1 (47) 4.5 (31) 7.9 (13) 4.4 (3)
Russia 4.3 (40) 4.8 (33) 3.6 (6) 1.5 (1)
Somalia 2.3 (21) 2.6 (18) 1.8 (3) 0 (0)
Ukraine 5.2 (48) 5.1 (35) 5.5 (9) 5.8 (4)
TB incidencee in country of origina/100,000, % (n)
0–49 24.1 (222) 24.2 (167) 16.4 (27) 40.6 (28)
50–99 37.9 (350) 39.8 (274) 35.2 (58) 26.1 (18)
100–199 19.8 (183) 17.9 (123) 26.1 (43) 24.6 (17)
200 18.2 (168) 18.1 (125) 22.4 (37) 8.7 (6)
Reason for screening,a % (n)
High-incidence 100/100,000 38.0 (351) 36.0 (248) 48.5 (80) 33.3 (23)
MDR-TB riskf 54.2 (500) 55.7 (384) 44.9 (74) 60.8 (43)
High-risk group 7.8 (72) 8.3 (57) 6.7 (11) 5.8 (4)
a
Data are presented as % (n) unless otherwise stated.
b
Median (interquartile range).
c
Modified from regions used by the World Bank Group (https://data.worldbank.org/country).
d
Ten most common countries of origin among TB-screened population.
e
World Health Organization estimated incidence.
f
MDR-TB incidence > 1/100,000 population and TB incidence < 100/100,000 population.

Figure 2. Results of tuberculosis screening with chest radiography (n ¼ 854).

(c. pulmonalis, metastatic c. mamma, and lymphoma).

The rest had miscellaneous abnormal CXR findings. The
asylum seekers with malignant diseases were referred to
specialized centres for further investigation and treat-
ment. Seven (14.9%) asylum seekers with CXR abnormal-
ities were lost to follow-up.
Discussion
This study evaluated screening for active TB among asy-
lum seekers at arrival in Denmark based on CXR and
spot sputum culture screening. Our study confirms pre-
vious findings, that voluntary TB screening among asy-
lum seekers is feasible. The coverage of the health
824 K. LANGHOLZ KRISTENSEN ET AL.
assessment was 65.1% and TB screening attendance
after the initial health assessment was as high as 80.0%.
Yield of sputum and CXR screening was around 0.1%. In
addition, TB screening resulted in the diagnosis of three
cases of malignant disease. Sputum culture screening
did not identify additional TB cases.
The yield of CXR screening was 0.12%. CXR-based
screening has been used for identifying TB among asy-
lum seekers in many studies and our findings are similar
to studies from neighbouring countries reporting screen-
ing yields between 0.1% and 0.5% [21–25]; however, our
study suggests that TB screening should focus on those
at high risk of TB to improve the yield of screening.
Screening among newly arrived asylum seekers in
Germany [21] and the Netherlands [24] reported slightly
lower yields. In Germany and the Netherlands, all asylum
seekers were screened regardless of incidence in the
country of origin. In Germany, most asylum seekers
screened were from Syria (42.0%), an intermediate-inci-
dence country, whereas in our study, Syrian asylum
seekers comprised < 1% of screened. Only few asylum
seekers in the German study were from TB high-inci-
dence countries, but these comprised nearly half of the
TB cases detected.
One of the most important TB risk factors is incidence
in the country of origin [26], which also affects the yield
of screening [5,27–29]. In a study from Germany, the
overall yield was 82 per 100,000 screened, but country-
specific yields ranged from 10 to 683 per 100,000
screened in Iraqi and Somali asylum seekers, respectively
[29]. This indicates that incidence in country of origin
among the screened population of asylum seekers may
account for differences in yield, and that it may be more
efficient to target TB screening towards asylum seekers
from TB high-incidence countries [30]. In our study,
62.0% were screened due to TB risk factors other than
originating from a high-incidence country. More than
half were screened based on MDR-TB risk. In Denmark,
the risk of MDR-TB is very low, but because many asy-
lum seekers arrive from Eastern European countries with
higher risk of MDR-TB, this is a screenings criterion.
However, several of these countries have TB incidences
< 50/100,000 population, which would be expected to
lower the overall yield in screening.
Other factors affecting the differences in yield could
be differences in migration routes and the conditions
faced during migration such as overcrowding, imprison-
ment and lack of health care [1,7,8]. In a CXR-based
screening from Italy, the yield among asylum seekers
mainly from Western Africa (81.0%) screened at arrival
was higher (535/100,000 screened) than the incidence in
their countries of origin [31]. Mostly, they reached the
Italian coast over the Mediterranean Sea after waiting
for transfer in Libya under precarious living conditions,
all increasing the TB risk. In the present study, the pro-
portion of asylum seekers arriving in Denmark from sub-
Saharan Africa was considerably lower compared to ear-
lier years, whereas a large proportion of migrants was
from Georgia. Most often, they travelled to Denmark by
plane and did not experience the same migration
related risk factors but were screened based on the high
MDR-TB risk in Georgia. However, the proportion of asy-
lum seekers arriving in Denmark from Georgia was not
representative compared to earlier years. In 2018, the
number of asylum seekers from Georgia who applied for
asylum in Denmark was about four to five times higher
than normal and the large majority was not recognized
for refugee status [32].
Sputum culture screening identified one case of cul-
ture-positive TB. In another Danish study, where home-
less and socially marginalized individuals were screened
for TB with sputum culture regardless of symptoms,
3.3% had culture-positive TB [15]. Twenty-two percen-
tages of these did not have a CXR suggestive of TB and
most were smear-negative, suggesting they were identi-
fied in an early and less infectious stage. To our know-
ledge, only one study using sputum screening among
asylum seekers in low-incidence countries has been pub-
lished [17]. This study screened newly arrived asylum
seekers in Italy using a symptom-based approach. All
were screened for TB symptoms and mainly symptom-
atic individuals were screened by sputum analysis with
Gene Xpert MTB/RIF, smear microscopy and culture [17].
Among 591 individuals, they found 3.0% had TB based
on at least one microbiologic laboratory test of which
1.9% were culture-positive. Potential reasons for the
high yield in this study may be that asylum seekers
were selected based on TB symptoms and that the
majority came from TB high burden Sub-Saharan Africa.
Finding TB cases as early as possible is important to
reduce transmission, especially in high-risk populations
such as asylum seekers and socially marginalized individ-
uals. In the Italian study [17], the Gene Xpert-based
screening facilitated rapid TB diagnosis; however, two
cases were culture-positive only and would have been
missed if using Gene X-pert only. The study did not
report data on smear or CXR. In a population including
more individuals from TB high-incidence countries, spu-
tum culture screening may prove effective for early diag-
nosis, or could potentially be offered to symptomatic

individuals. However, this cannot be answered from
our study.
In voluntary screening programmes, an important
aspect is coverage [33]. The coverage of the health
assessment in Denmark (65.1%) was slightly higher than
seen in a similar Swedish programme (50%) [34]. As a
result of implementing a new systematic TB screening in
Denmark during our study, there was an increased focus
on health assessment attendance including health staff
education and encouragement to attend. Likely, this had
a positive effect on coverage. Still, one-third of asylum
seekers did not participate in the voluntary health
assessment. One reason may be that the time shortly
after arrival is stressful for asylum seekers e.g. settling in,
meetings with authorities, uncertainties etc., and the vol-
untary health assessment may not be a priority. Another
reason is logistics: In periods of pressure on the asylum
system fewer asylum seekers are offered screening at
the reception centre because they are rapidly housed
elsewhere with less rigorous offers of assessment. Also,
TB is often associated with stigma, which could keep
migrants from attending both the health assessment
and the TB screening due to mistrust, concerns that a
TB diagnose will affect the asylum application or a fear
of discrimination and deportation [33,35]. Thus,
emphasis on patient-rights, confidentiality, and informa-
tion on health benefits as well as encouragement to
attend needs to be prioritized. Interestingly, we saw
large differences in attendance rates between national-
ities. Asylum seekers from Morocco and Nigeria had
non-attendance rates between 60% and 70%, whereas
the non-attendance for most other nationalities was
around 30%. Morocco and Nigeria are considered TB
high-incidence countries [36], which could mean TB
cases in this group were potentially missed during the
study period. Unfortunately, we do not know the rea-
sons for not attending, but this is an important factor
for improving the health care reception of asylum
seekers and should be further explored in future studies,
including perception of stigma among high-risk TB
groups. Additionally, easy access to screening should be
facilitated to improve screening adherence. In our study,
CXR screening was not offered on-site, which probably
created a structural barrier [33].
In this study, only asylum seekers referred for TB
screening were informed about symptoms of TB disease,
treatment free of charge, etc. Migrant status as an asy-
lum seeker or a refugee pose a risk factor for TB [26]. As
many TB cases develop years after arrival [6], raising
awareness regarding TB, symptoms, and treatment
INFECTIOUS DISEASES 825
availability should be prioritized and provided to all asy-
lum seekers as part of an early health assessment.
In our study, CXR abnormalities were observed in
5.5% of CXRs and three individuals had a malignant dis-
ease. Due to the screening, the malignant diseases were
likely detected at an earlier stage potentially resulting in
a better prognosis. A general concern is that migrants
have more challenges accessing health care facilities
than host populations, which can cause health inequal-
ities [37,38]. Our study underlines the importance of
facilitating an early contact to the health care system for
newly arrived refugees to reduce barriers. Providing a
general health assessment, including a CXR for TB high-
risk groups, might be an opportunity to identify unmet
health needs and optimize health among newly arrived
refugees [39,40].
Limitations
The study has some limitations. Only one sputum sam-
ple was collected, which may have decreased sensitivity
[41]. Data on TB cases among asylum seekers arriving in
Denmark before February 2017 were not available.
Therefore, we could not assess whether implementation
of systematic screening increased TB detection or
reduced diagnostic delay. Although asylum seekers were
assessed clinically, symptoms were not systematically
recorded, thus we could not assess a symptom-based
approach. Thirty-five percent of asylum seekers did not
attend the health assessment and thus were not
assessed for TB risk or clinically evaluated which could
possibly underestimate morbidity among the
study population.
Conclusion
Voluntary TB screening among asylum seekers is feasible
based on the high health assessment coverage we
achieved. However, the low yield of CXR and sputum
screening in our study suggest focussing TB screening
on asylum seekers from TB high-incidence countries.
Additionally, early health assessments should be of high
priority to ensure migrant health.
Disclosure statement
No potential conflict of interest was reported by the author(s).
826 K. LANGHOLZ KRISTENSEN ET AL.
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