785LEADING ARTICLES
Tuberculosis and Immigration
THE LANCETLONDON 8 OCTOBER 1966
FOR many years, successive British Governments havebeen urged to
take action to prevent or reduce theimport of tuberculosis into
Britain by immigrants,particularly by those who come from areas of
the worldwhere the disease is common. The Ministry of Healthhas
always held that a compulsory medical examinationwith chest X-ray,
conducted in the immigrants countryof origin, or compulsory X-ray
examination of the cheston arrival in this country, is
impracticable. In 1965,the chief medical officer of the Ministry
wrote to allgeneral practitioners in the Health Service asking
themto look out for immigrants among their patients and toconsider
the need to have a chest X-ray.l The Ministryalso encouraged
immigrants to register promptly with ageneral practitioner in the
area where they settled, andwhere possible the Ministry notified
medical officers ofhealth when long-stay immigrants came to their
districts.In the same year, X-ray apparatus was installed atLondon
Airport for an on-the-spot examination whenthe medical inspectors
suspected tuberculosis. Whetherthese activities yield useful
results is doubtful. In anyevent there are no powers to examine
medically the largenumbers of dependants who continue to arrive
each yearto join immigrant relatives already here.The view that
tuberculosis is commoner among
immigrants than among the British-born population isbased on the
findings of SPRINGETT 2 in Birmingham,STEVENSON 3 and EDGAR in
Bradford, and ASPIN 5 inWolverhampton. After large numbers of
immigrantsbegan to arrive from 1955 onwards, these cities
hadrapidly rising numbers of tuberculosis notificationsamong the
immigrants but fewer notifications amongresidents born in Britain.
But these reports came fromthe North and the Midlands, where the
great majority ofimmigrants eventually settle, and they were not
repre-sentative of the whole country. A survey was obviouslyneeded
to discover what proportion of tuberculosisnotifications in Britain
as a whole was due to tuberculosisin immigrants, and whether
tuberculosis in immigrantswas widespread or confined to a small
number of urbancentres. Such a survey 6 has now been carried out by
theresearch committee of the British Tuberculosis Associa-tion.
Chest physicians were asked about all newnotifications of
tuberculosis in England and Walesbetween Feb. 1 and April 30, 1965
(the survey was
1. See Lancet, 1965, i, 150.2. Springett, V. H. ibid. 1964, i,
1091.3. Stevenson, D. K. Br. med. J. 1962, i, 1382.4. Edgar, W.
ibid. 1964, ii, 1565.5. Aspin, J. ibid. 1962, i, 1386.6. Tubercle,
Lond. 1966, 47, 145.
confined to England and Wales because few immigrantssettle in
Scotland and Northern Ireland). The objectiveof the survey could be
attained only if 90% of chestclinics in England and Wales took
part: in fact, 488 chestclinics agreed to do so-99% of the total.
Each chestphysician was asked to tell the coordinator of the
surveyof the birthplace of each patient newly notified, and
forthose born in countries other than Great Britain thedate of
entry to England and Wales was recorded.Persons born in countries
other than Great Britain andIreland contributed a disproportionate
share of thenotifications. Among 3806 cases of tuberculosis,
16-5%were in immigrants (that is, persons born in countriesother
than Great Britain and Ireland), who formed onlyabout 4% of the
population of England and Wales.Furthermore, 9-6% of the
notifications were amongthose born in India and Pakistan, who
formed onlyabout 1% of the population in 1965. Further
analysisshowed that persons born in India and now living inEngland
and Wales had a notification-rate twelve timesgreater than the rate
for those born in Britain; and thenotification-rate for those born
in Pakistan was twenty-six times greater than that for the
British-born popula-tion of England and Wales. The rates of
notification forthose born in Ireland, the rest of Europe, the
BritishCaribbean area, and Africa were only slightly higher thanfor
those born in Great Britain.
An interesting, but not unexpected, finding was that ahigher
proportion of non-respiratory forms of the diseasewas discovered
among immigrants from India (33%)and Pakistan (26%) than in those
born in Britain(11%). But this excess among Indians and
Pakistaniswas insufficient to account for the difference in
notifica-tion-rates of tuberculosis as a whole, because the
ratesfor respiratory tuberculosis were still considerably higherfor
those born in India and Pakistan than for thoseborn in Britain.
Unfortunately very little informa-tion is available about the total
numbers of personsmoving in and out of England and Wales, although
thishas to some extent been corrected since the Common-wealth
Immigrants Act of 1962. The survey showedclearly that many
notifications applied to those whohad not recently entered England
and Wales. But itwas not possible to know whether immigrants
arrivedwith active disease, or with quiescent disease whichbroke
down a few years later, or whether they camewithout disease and
acquired it in England and Wales.A national survey of primary drug
resistance in pul-monary tuberculosis in Great Britain, carried out
by theMedical Research Council in 1963,7 provides some
usefulinformation. Primary drug resistance was commoneramong
immigrants than among patients born in Britainor Ireland. Again,
drug resistance was seen moreoften among recently arrived
immigrants than amongthose who had been living in Britain for five
years ormore, or who had lived here since birth. But the num-ber of
immigrants in this group was not large and furtherstudy is
required.7. Miller, A. B., Tall, R., Wallace, F., Lefford, M. J.,
Mitchison, D. A.
ibid. p. 92.
786
Tuberculosis among immigrants amounts to a medicalproblem only
in certain cities and towns in the Northand the Midlands and the
London area: 27% of theimmigrants notified in the survey were
living in thecounty boroughs of Halifax, Bradford, West
Bromwich,Bolton, Wolverhampton, Smethwick, and Birmingham.In these
towns immigrants formed at least a third of allthe total
notifications. Of the administrative counties ofEngland, only
Bedfordshire, Middlesex, and Bucking-hamshire had a significant
number of notifications, andin these counties a quarter of the
notifications concernedpersons born outside Great Britain and
Ireland. To putthe matter into perspective it should be noted that
mostof the county boroughs and counties of England andWales rarely
encounter tuberculosis in this way becausetheir immigrant
population is very small.
In the light of this survey, what action is called for ?In 1965
the British Medical Association set up a workingPABfty of a senior
airport or seaport medical officer, achest physician, a
radiologist, and a medical officer ofhealth to investigate the
health problems of immigrantsto Great Britain. Their report 8
recommended routinechest radiography before admission to this
country forall immigrants over the age of 12 years. Much thoughtwas
given to where the medical examination should beconducted and who
should do it. Examination in thecountry of origin had several
advantages, particularly tothe immigrants themselves, and the
report favoured theuse of Government medical officers from this
country,aided where necessary by local doctors approved by
theUnited Kingdom Government. Other countries haveschemes with
built-in safeguards to prevent falsificationof papers. Examination
at the ports of entry has severaldisadvantages. It is often
impossible to have advanceknowledge of the numbers of immigrants
intending toarrive at a particular time. Once immigrants have
dis-persed from the ports of entry it is very hard to tracethem to
arrange further medical examinations. More-over, examination on
entry may mean considerablehardship to the immigrants because those
who get anunfavourable medical report may be sent back.SPRINGETT 9
says that " the very high tuberculosisnotification rates recorded
for Asian-born groups in thiscountry are due mainly to their
bringing with them thehigh rates they would experience in their own
country."Many physicians would share his view that if uncon-trolled
immigration from areas of high prevalence con-tinues, tuberculosis
is likely to be present in Britain fora very long time. If the
Ministry of Health does notaccept the B.M.A. report and examine all
immigrants,then it would be wise to examine all immigrants
fromAsia, particularly those from India and Pakistan.Finally, if no
action at all is taken, the Ministry of Healthshould at least show
to the country that no appreciableamount of tuberculosis is being
imported. How else canthis be done than by some form of compulsory
medicalexamination ?8. Medical Examination of Immigrants. British
Medical Association, 1965.
See Lancet, 1965, ii, 1229.9. Springett, V. H. in Immigration:
Medical and Social Aspects. Ciba
Foundation Report. London, 1966.
Cliac DiseaseSINCE the toxic effect of gluten in the small
bowel
was recognised, the causes and results of creliac diseasehave
been under continual scrutiny. BOOTH and hiscolleagues 1 have now
studied the intestinal epitheliumhistochemically before and after
the patients were givena gluten-free diet. In untreated patients
their findingslargely agreed with those of earlier workers 2
whodescribed three zones : a basal crypt region of small
ger-minative cells lacking phosphatases, and with low ester-ase and
succinic-dehydrogenase activities; an uppercrypt region which
corresponded histochemically to thenormal villous region in its
high phosphatase, esterase,and succinic-dehydrogenase content; and
a surfaceregion of pseudostratified cells deficient in
succinic-dehydrogenase, esterase, acid-phosphatase, and
adeno-sine-triphosphatase. BOOTH et al. have drawn attentionto some
features which suggest to them that the ratesof production of some
enzymes-notably alkaline-phosphatase, non-specific
acid-phosphatase, and thia-mine-pyrophosphatase-may be raised. The
signi-ficance of these changes is uncertain, but the suggestionis
that they may reflect an attempt, by increased pro-duction of crypt
cells, to compensate for loss of surfacecells. Finally, BOOTH et
al. deduce from other resultsthat dispersion of lysosomal
hydrolytic activity mayaccount for some of the histological
abnormality insurface cells.PITTMAN and POLLITT 4 followed up
earlier sugges-
tions 5-7 that the cells in the small intestine of patientswith
coeliac disease might, through lack of peptidase, beunable to
degrade peptides derived from wheat protein,They prepared
peptic-tryptic digests of gliadin, thealcohol-soluble fraction of
wheat gluten; and the resultsof further digestion by homogenates of
mucosal cellsof guineapig and by normal human and untreated
creliacmucosa were compared by means of multidimensionaldigestion
maps using combinations of chromatographyand high-voltage
electrophoresis. They found that, incontrast to normal mucosae,
homogenates from cceliacpatients failed to liberate proline from
gliadin peptides-an interesting result because previous work had
sug-gested that the toxic gliadin peptides contain thisaminoacid.
This work does not, however, distinguishprimary from secondary
peptidase deficiency, andthe findings may be similar to those in
secondarydisaccharidase deficiency. 8 ,
Since the first account of intestinal reticulosis as
acomplication of idiopathic steatorrhoea,9 further sugges-tive
cases have been recorded 10 11; and LEE,12 trying to1. Riecken, E.
O., Stewart, J. S., Booth, C. C., Pearse, A. G. E. Gut,
1966, 7, 317.2. Padykula, H. A., Stauss, E. W., Ladman, A. J.,
Gardner, F. H. Gastro-
enterology, 1961, 40, 735.3. Padykula, H. A. Fedn Proc. Fedn Am.
Socs exp. Biol. 1962, 21, 873.4. Pittman, F. E., Pollitt, R. J.
Gut, 1966, 7, 368.5. Frazer, A. C. J. Pediat. 1960, 57, 262.6.
Rubin, C. E. Gastroenterology, 1960, 39, 260.7. Laster, L.,
Ingelfinger, F. J. New Engl. J. Med. 1961, 264, 1246.8. See Lancet,
Oct. 1, 1966, p. 736.9. Gough, K. R., Read, A. E., Naish, J. M.
Gut, 1962, 3, 232.
10. Spracklen, F. Proc. R. Soc. Med. 1963, 56, 167.11. McCarthy,
C. F., Austad, W. I., Evans, K. T., Comes, J. S., Read, A. E.
Gut, 1966, 7, 104.12. Lee, F. D. ibid. p. 361.
