[Failure to offer parasitology screening to vulnerable migrants in France: Epidemiology and consequences].

Abstract

The "Consultations de Diagnostic et d'Orientation" (CDO), created in 1998 by the Paris Health Department, are medical consultations for vulnerable populations, which are held in municipal clinics, free of charge. More than two-thirds of CDO patients come from Africa. Our study was designed to assess and analyze whether these clinics offered consulting migrants screening for intestinal parasitic and Schistosoma haematobium infections.Material and methodsThis retrospective study included all immigrants attending CDO for the first time at four Parisian municipal free clinics during 2003. Univariate and multivariate analysis adjusted for age, sex, and geographic origin were conducted. An interview with one of the CDO physicians provided qualitative data to round out the quantitative data from the record analysis.ResultsThe study included 503 migrants eligible for screening for intestinal parasitic infections because they come from regions where these infections are endemic; among them 481 were also eligible for urine screening for Schistosoma haematobium (SH). The sociodemographic characteristics for the entire sample (not significantly different from the 481-person subgroup) were: sex ratio (M/W): 4:1; more than 50% were 35 years old or younger; and more than 50% had no health insurance coverage. Overall, around 80% came from sub-Saharan Africa, around 16% from North Africa or the Middle East, and 4.5% from Asia or South America. Screening for intestinal or urinary parasitic infections was not offered to 3 out of 5 migrants from endemic areas. Screening for intestinal parasites was offered less often to migrants from regions other than sub-Saharan Africa, to those older than 35 years of age, and to those without abdominal symptoms. Schistosoma haematobium urine screening was proposed less often to those from North Africa or the Middle East, to those older than 35 years of age, and to those without either abdominal or genitourinary symptoms. Microscopic examination of urine for Schistosoma haematobium was performed for 171 patients; 22 positive results were reported, with viable SH eggs (13%). Microscopic examination of stool for ova and parasites was performed for 161 patients; 32 had positive results (20%). These included 14 cases of Entamoeba histolytica/dispar (our laboratory cannot distinguish the 2 strains).DiscussionThe failure to offer screening affects sub-Saharan Africans less than other migrants, perhaps because of a particular visibility due to their mass (they are the most prominent subgroup of migrants) or their higher frequency of abdominal/genitourinary symptoms. Nevertheless, more than 50% of them were not asked to undergo parasite screening, although they are the group with the highest rate of intestinal/urinary parasitosis. The most common and dangerous parasite found was Schistosoma haematobium; we do not know the pathogenicity of the Entamoeba found. Reasons for the frequent failure to suggest these screenings may include that physicians consider parasitosis as diseases of secondary importance, or have forgotten its symptoms, epidemiology, cycles, means of diagnosis, or treatment. Patients accepted the screening well when it was offered. Reasons during the course of consultation might have included insufficient time for pre-test counselling, some difficulties in communicating with the patient in French, or an overriding request or complaint from the patient. We propose the following strategy for parasite screening in CDO: standard "stool ova and parasite exams" proposed to any migrant in France for less than 5 years except sub-Saharan Africans, who should receive presumptive anti-parasite treatment instead; microscopic examination of urine for Schistosoma haematobium for sub-Saharan Africans from endemic regions. This detection can avoid - if treatment is early enough - severe uronephrological complications, which are rare but costly from a health care perspective (bladder tumor, renal failure). Physicians in non-tropical settings must remember to consider parasite infections when they see patients from endemic regions.