Feasibility and Operational Lessons from Active Tuberculosis Disease Screening Among Ukrainian Refugees in Barcelona: A Pilot Study

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Given Ukraine’s high tuberculosis (TB) incidence and multidrug-resistant TB burden, the SYS-TB project piloted community-based active TB disease screening to assess the feasibility of implementing the World Health Organization (WHO) recommendations for vulnerable populations in a low-incidence European setting. Methods: Two TB screening events were conducted between July and October 2022 in collaboration with the Public Health Agency of Barcelona and the Ukrainian association Djerelo . Ukrainian refugees aged ≥ 16 years were invited to participate. The screening included an information session on TB symptoms and healthcare access, followed by a symptom questionnaire and referral for chest X-ray (CXR) for those reporting TB-related symptoms. Attendance, participation, and operational barriers were recorded and analysed descriptively. Results: Seventy-six individuals attended the two events, and 35 (46%) completed TB symptom screening. Of these, 28 (80%) were female, with a median age of 45 years. Most participants had arrived in Barcelona within the previous six months. Ten (29%) individuals were referred for CXR, and none were diagnosed with active TB disease. Main challenges included communication barriers, logistical constraints, and mismatched participant expectations. Introducing pre-registration and streamlining information sessions improved efficiency and participant flow during the second event. Conclusion: Community-based TB screening among Ukrainian refugees in Barcelona was operationally feasible but yielded few cases. Collaboration with trusted community organisations, adequate preparation, and culturally tailored communication were essential for engagement. Lessons from this pilot can inform future targeted screening initiatives for displaced populations in low-incidence settings. Trial registration: ClinicalTrials.gov Identifier: NCT06706596, retrospectively registered on November 29, 2024 Tuberculosis Screening Ukrainian Refugees Pilot study Active tuberculosis disease Introduction In 2023, following the coronavirus disease 2019 (COVID-19) pandemic, tuberculosis (TB) once again became the leading cause of death from a single infectious agent, causing 10.8 million cases and 1.25 million deaths worldwide [ 1 ]. While TB incidence has steadily declined in high-income countries, it remains disproportionately concentrated among vulnerable and hard-to-reach groups, particularly migrants and refugees [ 2 – 4 ]. The World Health Organisation’s (WHO) End TB Strategy targets a 90% reduction in TB incidence and a 95% reduction in TB-related deaths by 2035 [ 2 ]. Achieving these goals requires systematic approaches for early detection, prevention, and treatment, particularly in populations at higher risk of exposure and disease progression. Among migrants, risk is shaped not only by the TB burden in their country of origin but also by socioeconomic and structural factors encountered along migration routes and in the host country [ 3 ]. Across the European Union (EU) and European Economic Area (EEA), one-third of all reported TB cases in 2022 occurred in foreign-born individuals [ 4 ]. In response, the European Centre for Disease Prevention and Control (ECDC) has issued recommendations prioritising two key strategies: (i) identification of active TB disease before or soon after arrival using chest radiographs, and (ii) detection and treatment of TB infection (TBI). However, the operational details of these strategies who to screen, how, and where are determined by national or regional health authorities [ 5 – 8 ]. In Spain, TB screening policies vary across autonomous regions. Catalonia, where health competencies are devolved, has implemented active TB disease screening focused primarily on people who use drugs, migrants arriving by sea, and individuals experiencing homelessness [ 9 , 10 ]. However, implementation remains heterogeneous, with gaps in coverage and follow-up. In Barcelona, approximately two-thirds of TB cases detected between 2013 and 2021 occurred among foreign-born individuals, mainly from Morocco, Pakistan, and Latin American countries [ 11 – 19 ]. Following the Russian invasion of Ukraine in 2022, over 18 000 Ukrainian refugees arrived in Barcelona [ 20 ]. Ukraine has one of the highest TB incidences in the WHO European Region (71 cases per 100 000 population)[ 21 ] and a substantial burden of multidrug-resistant TB (MDR-TB) [ 22 ]. This sudden influx was estimated to include approximately 8–10 undetected active TB cases [ 23 ]. In response, the Experimental Tuberculosis Unit (UTE) launched the SYS-TB project to pilot systematic active TB disease screening in the Barcelona metropolitan area. Given the presence of Ukrainian-speaking health professionals within the research team several of whom were themselves refugees the project collaborated with the Public Health Agency of Barcelona (ASPB) and the Djerelo Association of Ukrainians to conduct two pilot screening sessions. This study describes the feasibility, challenges, and operational lessons learned from these events and discusses their implications for implementing community-based TB screening among newly displaced populations in low-incidence settings. Methods Study design A cross-sectional pilot study was conducted between July and October 2022 as part of the SYS-TB project (NCT06706596, retrospectively registered on November 29, 2024). Eligible participants were Ukrainian refugees aged ≥ 16 years residing in the Barcelona metropolitan area. Ethical and regulatory aspects The study is conducted in accordance with the guidelines of the Declaration of Helsinki. The study protocol was reviewed and approved by the Germans Trias i Pujol University Hospital Research Ethics Committee (PI-22-067). Participation was voluntary, and verbal informed consent was obtained from all individuals prior to screening. Setting and partners The screening events were organised jointly by the UTE and the ASPB, with the support of the Djerelo Association of Ukrainians in Barcelona. Djerelo acted as a liaison between the Ukrainian community and the research team, facilitating communication and providing the venue for both events. Information about the initiative was disseminated through Djerelo ’s social media channels (WhatsApp, Facebook, Instagram) and via printed posters distributed throughout Ukrainian community centres and local meeting points. Screening framework We followed the WHO-recommended sequential positive serial screening algorithm [ 24 ], which involves screening individuals for any TB symptom (cough ≥ 2 weeks, subfebrile temperature or fever, night sweats, weight loss, or chills), followed by a chest X-ray (CXR) for those with symptoms. Based on this algorithm, we developed a study-specific questionnaire for this project. The tool included the WHO-recommended symptom questions, along with additional demographic and personal information we considered relevant to our setting. The questionnaire also included procedural fields visible only to ASPB data collectors. These sections were completed exclusively for individuals who were referred for CXR and subsequently followed up. An English version of the questionnaire can be found in Additional file 1: Table 1 , Checklist of Questionnaire Content. Each event began with a short information session explaining TB symptoms, transmission, and the healthcare referral pathway, delivered in Ukrainian or Russian. Participants were then invited to complete a brief screening questionnaire covering TB symptoms and basic demographic data. Interviews were conducted in person or, for those unable to attend, by telephone using the same standardised questionnaire. Participants reporting one or more TB-related symptoms were referred for chest X-ray at their assigned TB Clinical Unit within the Catalan Public Healthcare System (CatSalut). As an incentive to facilitate follow-up attendance, those referred received a public transport card valid for ten trips. Subsequently, ASPB staff contacted all symptomatic individuals to confirm whether CXR had been completed and ensure appropriate linkage to care if TB was diagnosed. (Additional File 1 - Fig. 1 - Step-by-step process of the TB screening event) Data collection and management Data were collected electronically using Microsoft Forms hosted on the ASPB’s secure Office 365 platform. Interviewers followed a standardised form to ensure completeness and uniformity of data capture. Access to the database was restricted to authorised members of the research team and ASPB personnel. Collected data included sociodemographic characteristics (sex, age, time since arrival in Spain), TB symptoms, referral status, and participation in follow-up. Observational field notes were taken to document logistical challenges, community engagement, and reasons for non-participation Statistical analysis Quantitative data were summarised descriptively using absolute numbers and percentages. Feasibility indicators included participation rate, referral rate, and completion of diagnostic follow-up. Qualitative notes from field observations were used to identify recurrent operational themes, barriers, and facilitators. Given the small sample size, no inferential statistical analysis was performed. Results Participant characteristics Across the two screening events (July 22 and October 21, 2022), 76 individuals showed up at the venue and 35 (46%) completed TB symptom screening. Among those screened, 28 (80%) were female and 7 (20%) were male. The median age was 45 years (range 17–78). Most participants had arrived in Barcelona within the previous six months. Ten individuals (29%) reported symptoms compatible with TB and were referred for CXR at their corresponding TB Clinical Units. All completed the referral process, and none were diagnosed with active TB disease. Operational findings The first screening drew 68 attendees, most arriving earlier than scheduled, leading to unexpected crowding. The 15-minute informational talk proved too long, and an air-conditioning failure caused discomfort and participant dropouts. Several attendees requested advice on unrelated health concerns, extending interview times. Despite these challenges, staff flexibility, adding a fourth interviewing team, and bilingual translators ensured completion of all screenings. The second screening, held three months later, incorporated pre-registration and shorter information sessions to streamline workflow. Only eight people attended, six completed interviews, and three were referred for CXR. The introduction of a QR-code option for remote telephone screening generated a limited response (four registrations, three completed interviews). Across both sessions, 41 participants (54%) chose not to be screened after attending the information session. Reasons included time constraints, perceived good health, or confusion about the process. Collaboration with Djerelo and Ukrainian-speaking volunteers was crucial for recruitment, translation, and participant reassurance. Informal qualitative feedback highlighted the importance of empathy, clear explanations of healthcare entitlements, and personal contact with trusted intermediaries. Table 1 presents feasibility indicators. Table 1 Feasibility indicators Indicator Value Comment Total attendees 76 Two community events Completed screening 35 (46%) Moderate participation Female participants 28 (80%) Majority of attendees Referred for CXR 10 (29%) All completed evaluation TB cases detected 0 Consistent with low expected prevalence Main barriers Communication, logistics, expectations Reported at both events Key facilitators Trusted community partnership, bilingual staff, incentives Strengthened engagement Discussion In terms of feasibility and operational insights, this pilot demonstrates that community-based active TB disease screening among refugees is feasible within a low-incidence European city when anchored in strong inter-institutional collaboration. The participation rate (46%) is comparable to similar community screenings among migrants in Europe [ 6 – 8 ]. The full completion of diagnostic referrals reflects effective coordination between public-health and clinical teams. Key logistical lessons include the need for realistic scheduling, smaller group sizes, and clear physical flow between stages. Pre-registration improved organisation, although additional outreach was needed to ensure attendance. Shorter, interactive information sessions delivered in the participants’ own language increased attention and trust. Small incentives, such as refreshments and transport cards, were provided after the interviews. While they helped sustain engagement, personal interaction remained the primary motivating factor. The presence of Ukrainian-speaking health professionals proved decisive, underscoring that trust and cultural proximity are prerequisites for participation. In terms of yield and target population considerations, no TB cases were detected, consistent with expectations for a low-incidence host country and a refugee group that largely arrived through organised evacuation rather than hazardous migration routes. According to Greenaway et al. [ 25 ], screening more than 5 000 Ukrainians by pre-arrival CXR would detect roughly 20 active TB cases, confirming that small-scale community screening is unlikely to yield diagnoses but can serve as a valuable operational test. This finding supports the notion that there is no universal model for TB screening among displaced populations. Tailored strategies should account for migration patterns, social conditions, and health-system integration in the host context. Our pilot proved that screening interventions increase linkage to healthcare and favour social integration. Beyond TB detection, the events created opportunities to orient newly arrived refugees within the Catalan healthcare system. Many participants used the encounters to ask about other health problems or administrative barriers. Screening activities can therefore function as contact points that connect vulnerable groups with general healthcare and social support, an outcome aligned with broader public-health and equity goals [ 26 ]. It is worth noting that in Catalonia, following Royal Decree-Law 7/2018, passed in July 2018, undocumented migrants are entitled to healthcare access without the risk of their information being shared with immigration authorities [ 27 , 28 ]. Therefore, in countries with similar policies, such assurances must be clearly communicated during awareness and advertisement campaigns for any type of screening program, regardless of the disease, to ensure that individuals attend without fear of legal consequences The target population also determines other important elements. Firstly, it is imperative to identify and engage pertinent community leaders and associations associated with the specific population and country consulates or embassies, if considered appropriate. Additionally, it is vital to involve community health workers who will act as intermediaries between the administration (Public Health teams) and the individuals being served [ 26 , 29 , 30 ]. Trust is essential for any activity in vulnerable populations, and understanding language, cultural norms, and beliefs is crucial. Community representatives, associations, and health workers should collaborate to find effective incentives for screening participation, improving adherence. Whenever feasible, these incentives should be distributed through trusted local channels to strengthen community ties. Screening activities provide a unique opportunity to engage participants with community associations, social networks, and healthcare systems. Leveraging these interventions to strengthen links between screened individuals and community organisations, as well as relevant healthcare centres, is important. Depending on the setting and coverage, community integration and health linkage help refugees and vulnerable populations access health and social support, aiding their well-being and societal integration. Although no TB cases were detected, this screening represented a key operational step. It facilitated future screenings among vulnerable groups facing social and economic challenges such as housing instability, precarious employment, and limited healthcare access, factors that heighten TB risk. Experience from the Ukrainian refugee screening, particularly in logistics, multilingual communication, and community engagement, informed subsequent initiatives targeting other high-risk subpopulations in the Barcelona area. The pilot provided a valuable feasibility framework that strengthened later interventions’ effectiveness and cultural relevance. This progression underscores that small-scale, context-specific pilots can play a catalytic role in building sustainable, inclusive TB control strategies that respond to local structural health determinants, as WHO recommends [ 24 ]. Strengths of our pilot study include the community-based design, collaboration with public-health authorities, and inclusion of bilingual staff who were themselves refugees, enhancing cultural competence. However, limitations are notable: the small sample size, absence of a control group, and lack of systematic follow-up prevent generalisation. The study relied on self-reported symptoms without radiographic screening for all participants, which may have missed subclinical cases. Finally, the short observation period precludes assessment of longer-term health outcomes. Importantly, no active TB cases were identified among participants in the three years following the interventions. Regarding policy implications, additional contact tracing during active TB case detection and TB screening are essential to ensure treatment and prevent spread. However, for highly mobile groups such as refugees, implementing these measures is often more difficult and may not always be practical or economical. This highlights the importance of developing adaptable, targeted approaches to effectively manage TB among vulnerable populations. Finally, organisers should gather input from stakeholders, including healthcare professionals, community representatives, government and policy experts, and communication specialists when planning screening activities. Despite meticulous design, effective communication with the target population is essential for success yield. Based on the experience gained through this pilot, we outline key aspects to consider when planning similar screening initiatives: (i) Planning and communication: engage community associations early to co-design recruitment materials and messages. (ii) Workflow optimisation: pre-register participants in small groups; shorten information sessions; ensure adequate ventilation and privacy. (iii) Cultural mediation: involve interpreters or health mediators from the same community to build trust. (iv) Health-system linkage: use screening encounters to connect refugees with primary-care services. (v) Monitoring and scale-up: collect standardised feasibility indicators (participation, referral, completion) to inform regional TB-control planning. These insights contribute to the WHO call for integrating systematic TB screening into broader refugee-health frameworks while adapting interventions to local realities Abbreviations ASPB Public Health Agency Of Barcelona CatSalut Catalan Public Healthcare System COVID -19: Coronavirus Disease 2019 CXR Chest X-Ray ECDC European Centre For Disease Prevention and Control MDR -TB: Multidrug-Resistant Tuberculosis QR-Code Quick Response Code TB Tuberculosis TBI Tuberculosis Infection UTE Experimental Tuberculosis Unit WHO World Health Organisation Declarations Ethics approval and Consent to participate: The study protocol was reviewed and approved by the Germans Trias i Pujol University Hospital Research Ethics Committee (PI-22-067). Participation was voluntary, and verbal informed consent was obtained from all individuals prior to screening. Consent for publication: not applicable Competing interests: The Authors declare no conflict of interest Funding: This project received funding from the European Union’s Horizon 2020 research and innovation program under grant agreements No. 847762 (SMA-TB) and No. 823854 (INNOVA4TB). Andrii Dudnyk was funded through the MSCA4Ukraine project (ID: 1233336). Additionally, this work is based on contributions from COST Action ADVANCE-TB CA21164, supported by COST (European Cooperation in Science and Technology). This study also received support from the Catalan Government through 2021 SGR 00920. Author Contribution Conceptualisation and methodology were carried out by RP, JO, MLS, MAJ, PS, CR, JPM, and CV. Data curation was handled by NG and RP. The investigation was conducted by NG, ASA, RP, JO, LA, VB, AD, MF, DS, JPM, and CV conducted the investigation. RP, JO, JPM, and CV managed project administration. Resources were provided by NG, ASA, and CV. Supervision was performed by CV. The visualisation was created by NG. Writing of the original draft was done by NG, ASA, and CV, while all authors contributed to the review and editing of the manuscript. CV and JPM contributed equally to this work. Acknowledgement We would like to express our gratitude to the Djerelo Association, Kaori Fonseca, Marta Arch, Maria Vidal, and Nadia Buhiichyk for their support in organizing and implementing the action, as well as to all the individuals who participated in the screening activity. Availability of data and materials: The data collected within this study will not be available to others. References Global tuberculosis report 2024. Geneva, World Health Organization. : 2024. Licence: CC BY-NC-SA 3.0 IGO. Available at: https://www.who.int/publications/i/item/9789240101531 World Health Organization (WHO). The end TB strategy. Geneva: WHO; 16 Aug 2015. Available at: https://www.who.int/publications/i/item/WHO-HTM-TB-2015.19 Lönnroth K, Mor Z, Erkens C, et al. 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Healthcare. 2020;8(2):115. https://doi.org/10.3390/healthcare8020115 . Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1BMC1711.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 28 Dec, 2025 Reviews received at journal 25 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviews received at journal 22 Dec, 2025 Reviewers agreed at journal 21 Dec, 2025 Reviews received at journal 18 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor assigned by journal 27 Nov, 2025 Editor invited by journal 18 Nov, 2025 Submission checks completed at journal 17 Nov, 2025 First submitted to journal 17 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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06:18:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":446151,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1BMC1711.docx","url":"https://assets-eu.researchsquare.com/files/rs-8077431/v1/74a6bc39e96e35657dff65d6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility and Operational Lessons from Active Tuberculosis Disease Screening Among Ukrainian Refugees in Barcelona: A Pilot Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2023, following the coronavirus disease 2019 (COVID-19) pandemic, tuberculosis (TB) once again became the leading cause of death from a single infectious agent, causing 10.8\u0026nbsp;million cases and 1.25\u0026nbsp;million deaths worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While TB incidence has steadily declined in high-income countries, it remains disproportionately concentrated among vulnerable and hard-to-reach groups, particularly migrants and refugees [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organisation\u0026rsquo;s (WHO) End TB Strategy targets a 90% reduction in TB incidence and a 95% reduction in TB-related deaths by 2035 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Achieving these goals requires systematic approaches for early detection, prevention, and treatment, particularly in populations at higher risk of exposure and disease progression. Among migrants, risk is shaped not only by the TB burden in their country of origin but also by socioeconomic and structural factors encountered along migration routes and in the host country [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcross the European Union (EU) and European Economic Area (EEA), one-third of all reported TB cases in 2022 occurred in foreign-born individuals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In response, the European Centre for Disease Prevention and Control (ECDC) has issued recommendations prioritising two key strategies: (i) identification of active TB disease before or soon after arrival using chest radiographs, and (ii) detection and treatment of TB infection (TBI). However, the operational details of these strategies who to screen, how, and where are determined by national or regional health authorities [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Spain, TB screening policies vary across autonomous regions. Catalonia, where health competencies are devolved, has implemented active TB disease screening focused primarily on people who use drugs, migrants arriving by sea, and individuals experiencing homelessness [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, implementation remains heterogeneous, with gaps in coverage and follow-up. In Barcelona, approximately two-thirds of TB cases detected between 2013 and 2021 occurred among foreign-born individuals, mainly from Morocco, Pakistan, and Latin American countries [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16 CR17 CR18\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing the Russian invasion of Ukraine in 2022, over 18 000 Ukrainian refugees arrived in Barcelona [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Ukraine has one of the highest TB incidences in the WHO European Region (71 cases per 100 000 population)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and a substantial burden of multidrug-resistant TB (MDR-TB) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This sudden influx was estimated to include approximately 8\u0026ndash;10 undetected active TB cases [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In response, the Experimental Tuberculosis Unit (UTE) launched the SYS-TB project to pilot systematic active TB disease screening in the Barcelona metropolitan area.\u003c/p\u003e \u003cp\u003eGiven the presence of Ukrainian-speaking health professionals within the research team several of whom were themselves refugees the project collaborated with the Public Health Agency of Barcelona (ASPB) and the \u003cem\u003eDjerelo\u003c/em\u003e Association of Ukrainians to conduct two pilot screening sessions. This study describes the feasibility, challenges, and operational lessons learned from these events and discusses their implications for implementing community-based TB screening among newly displaced populations in low-incidence settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA cross-sectional pilot study was conducted between July and October 2022 as part of the SYS-TB project (NCT06706596, retrospectively registered on November 29, 2024). Eligible participants were Ukrainian refugees aged\u0026thinsp;\u0026ge;\u0026thinsp;16 years residing in the Barcelona metropolitan area.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical and regulatory aspects\u003c/h3\u003e\n\u003cp\u003e The study is conducted in accordance with the guidelines of the Declaration of Helsinki. The study protocol was reviewed and approved by the Germans Trias i Pujol University Hospital Research Ethics Committee (PI-22-067). Participation was voluntary, and verbal informed consent was obtained from all individuals prior to screening.\u003c/p\u003e\n\u003ch3\u003eSetting and partners\u003c/h3\u003e\n\u003cp\u003eThe screening events were organised jointly by the UTE and the ASPB, with the support of the \u003cem\u003eDjerelo\u003c/em\u003e Association of Ukrainians in Barcelona. \u003cem\u003eDjerelo\u003c/em\u003e acted as a liaison between the Ukrainian community and the research team, facilitating communication and providing the venue for both events.\u003c/p\u003e \u003cp\u003eInformation about the initiative was disseminated through \u003cem\u003eDjerelo\u003c/em\u003e\u0026rsquo;s social media channels (WhatsApp, Facebook, Instagram) and via printed posters distributed throughout Ukrainian community centres and local meeting points.\u003c/p\u003e\n\u003ch3\u003eScreening framework\u003c/h3\u003e\n\u003cp\u003eWe followed the WHO-recommended sequential positive serial screening algorithm [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], which involves screening individuals for any TB symptom (cough\u0026thinsp;\u0026ge;\u0026thinsp;2 weeks, subfebrile temperature or fever, night sweats, weight loss, or chills), followed by a chest X-ray (CXR) for those with symptoms. Based on this algorithm, we developed a study-specific questionnaire for this project. The tool included the WHO-recommended symptom questions, along with additional demographic and personal information we considered relevant to our setting.\u003c/p\u003e \u003cp\u003eThe questionnaire also included procedural fields visible only to ASPB data collectors. These sections were completed exclusively for individuals who were referred for CXR and subsequently followed up. An English version of the questionnaire can be found in Additional file 1: Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Checklist of Questionnaire Content.\u003c/p\u003e \u003cp\u003eEach event began with a short information session explaining TB symptoms, transmission, and the healthcare referral pathway, delivered in Ukrainian or Russian. Participants were then invited to complete a brief screening questionnaire covering TB symptoms and basic demographic data. Interviews were conducted in person or, for those unable to attend, by telephone using the same standardised questionnaire.\u003c/p\u003e \u003cp\u003e Participants reporting one or more TB-related symptoms were referred for chest X-ray at their assigned TB Clinical Unit within the Catalan Public Healthcare System (CatSalut). As an incentive to facilitate follow-up attendance, those referred received a public transport card valid for ten trips. Subsequently, ASPB staff contacted all symptomatic individuals to confirm whether CXR had been completed and ensure appropriate linkage to care if TB was diagnosed. (Additional File 1 - Fig.\u0026nbsp;1 - Step-by-step process of the TB screening event)\u003c/p\u003e\n\u003ch3\u003eData collection and management\u003c/h3\u003e\n\u003cp\u003eData were collected electronically using Microsoft Forms hosted on the ASPB\u0026rsquo;s secure Office 365 platform. Interviewers followed a standardised form to ensure completeness and uniformity of data capture. Access to the database was restricted to authorised members of the research team and ASPB personnel.\u003c/p\u003e \u003cp\u003eCollected data included sociodemographic characteristics (sex, age, time since arrival in Spain), TB symptoms, referral status, and participation in follow-up. Observational field notes were taken to document logistical challenges, community engagement, and reasons for non-participation\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were summarised descriptively using absolute numbers and percentages. Feasibility indicators included participation rate, referral rate, and completion of diagnostic follow-up. Qualitative notes from field observations were used to identify recurrent operational themes, barriers, and facilitators. Given the small sample size, no inferential statistical analysis was performed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eAcross the two screening events (July 22 and October 21, 2022), 76 individuals showed up at the venue and 35 (46%) completed TB symptom screening. Among those screened, 28 (80%) were female and 7 (20%) were male. The median age was 45 years (range 17\u0026ndash;78). Most participants had arrived in Barcelona within the previous six months.\u003c/p\u003e \u003cp\u003eTen individuals (29%) reported symptoms compatible with TB and were referred for CXR at their corresponding TB Clinical Units. All completed the referral process, and none were diagnosed with active TB disease.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOperational findings\u003c/h2\u003e \u003cp\u003eThe first screening drew 68 attendees, most arriving earlier than scheduled, leading to unexpected crowding. The 15-minute informational talk proved too long, and an air-conditioning failure caused discomfort and participant dropouts. Several attendees requested advice on unrelated health concerns, extending interview times. Despite these challenges, staff flexibility, adding a fourth interviewing team, and bilingual translators ensured completion of all screenings.\u003c/p\u003e \u003cp\u003eThe second screening, held three months later, incorporated pre-registration and shorter information sessions to streamline workflow. Only eight people attended, six completed interviews, and three were referred for CXR. The introduction of a QR-code option for remote telephone screening generated a limited response (four registrations, three completed interviews).\u003c/p\u003e \u003cp\u003eAcross both sessions, 41 participants (54%) chose not to be screened after attending the information session. Reasons included time constraints, perceived good health, or confusion about the process.\u003c/p\u003e \u003cp\u003eCollaboration with \u003cem\u003eDjerelo\u003c/em\u003e and Ukrainian-speaking volunteers was crucial for recruitment, translation, and participant reassurance. Informal qualitative feedback highlighted the importance of empathy, clear explanations of healthcare entitlements, and personal contact with trusted intermediaries. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents feasibility indicators.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFeasibility indicators\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal attendees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTwo community events\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate participation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMajority of attendees\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReferred for CXR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll completed evaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTB cases detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsistent with low expected prevalence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication, logistics, expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReported at both events\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKey facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrusted community partnership, bilingual staff, incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthened engagement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn terms of feasibility and operational insights, this pilot demonstrates that community-based active TB disease screening among refugees is feasible within a low-incidence European city when anchored in strong inter-institutional collaboration. The participation rate (46%) is comparable to similar community screenings among migrants in Europe [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The full completion of diagnostic referrals reflects effective coordination between public-health and clinical teams. Key logistical lessons include the need for realistic scheduling, smaller group sizes, and clear physical flow between stages. Pre-registration improved organisation, although additional outreach was needed to ensure attendance. Shorter, interactive information sessions delivered in the participants\u0026rsquo; own language increased attention and trust. Small incentives, such as refreshments and transport cards, were provided after the interviews. While they helped sustain engagement, personal interaction remained the primary motivating factor. The presence of Ukrainian-speaking health professionals proved decisive, underscoring that trust and cultural proximity are prerequisites for participation.\u003c/p\u003e \u003cp\u003eIn terms of yield and target population considerations, no TB cases were detected, consistent with expectations for a low-incidence host country and a refugee group that largely arrived through organised evacuation rather than hazardous migration routes. According to Greenaway et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], screening more than 5 000 Ukrainians by pre-arrival CXR would detect roughly 20 active TB cases, confirming that small-scale community screening is unlikely to yield diagnoses but can serve as a valuable operational test. This finding supports the notion that there is no universal model for TB screening among displaced populations. Tailored strategies should account for migration patterns, social conditions, and health-system integration in the host context.\u003c/p\u003e \u003cp\u003eOur pilot proved that screening interventions increase linkage to healthcare and favour social integration. Beyond TB detection, the events created opportunities to orient newly arrived refugees within the Catalan healthcare system. Many participants used the encounters to ask about other health problems or administrative barriers. Screening activities can therefore function as contact points that connect vulnerable groups with general healthcare and social support, an outcome aligned with broader public-health and equity goals [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It is worth noting that in Catalonia, following Royal Decree-Law 7/2018, passed in July 2018, undocumented migrants are entitled to healthcare access without the risk of their information being shared with immigration authorities [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, in countries with similar policies, such assurances must be clearly communicated during awareness and advertisement campaigns for any type of screening program, regardless of the disease, to ensure that individuals attend without fear of legal consequences\u003c/p\u003e \u003cp\u003eThe target population also determines other important elements. Firstly, it is imperative to identify and engage pertinent community leaders and associations associated with the specific population and country consulates or embassies, if considered appropriate. Additionally, it is vital to involve community health workers who will act as intermediaries between the administration (Public Health teams) and the individuals being served [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Trust is essential for any activity in vulnerable populations, and understanding language, cultural norms, and beliefs is crucial. Community representatives, associations, and health workers should collaborate to find effective incentives for screening participation, improving adherence. Whenever feasible, these incentives should be distributed through trusted local channels to strengthen community ties. Screening activities provide a unique opportunity to engage participants with community associations, social networks, and healthcare systems. Leveraging these interventions to strengthen links between screened individuals and community organisations, as well as relevant healthcare centres, is important. Depending on the setting and coverage, community integration and health linkage help refugees and vulnerable populations access health and social support, aiding their well-being and societal integration.\u003c/p\u003e \u003cp\u003eAlthough no TB cases were detected, this screening represented a key operational step. It facilitated future screenings among vulnerable groups facing social and economic challenges such as housing instability, precarious employment, and limited healthcare access, factors that heighten TB risk. Experience from the Ukrainian refugee screening, particularly in logistics, multilingual communication, and community engagement, informed subsequent initiatives targeting other high-risk subpopulations in the Barcelona area. The pilot provided a valuable feasibility framework that strengthened later interventions\u0026rsquo; effectiveness and cultural relevance. This progression underscores that small-scale, context-specific pilots can play a catalytic role in building sustainable, inclusive TB control strategies that respond to local structural health determinants, as WHO recommends [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengths of our pilot study include the community-based design, collaboration with public-health authorities, and inclusion of bilingual staff who were themselves refugees, enhancing cultural competence. However, limitations are notable: the small sample size, absence of a control group, and lack of systematic follow-up prevent generalisation. The study relied on self-reported symptoms without radiographic screening for all participants, which may have missed subclinical cases. Finally, the short observation period precludes assessment of longer-term health outcomes. Importantly, no active TB cases were identified among participants in the three years following the interventions.\u003c/p\u003e \u003cp\u003eRegarding policy implications, additional contact tracing during active TB case detection and TB screening are essential to ensure treatment and prevent spread. However, for highly mobile groups such as refugees, implementing these measures is often more difficult and may not always be practical or economical. This highlights the importance of developing adaptable, targeted approaches to effectively manage TB among vulnerable populations.\u003c/p\u003e \u003cp\u003eFinally, organisers should gather input from stakeholders, including healthcare professionals, community representatives, government and policy experts, and communication specialists when planning screening activities. Despite meticulous design, effective communication with the target population is essential for success yield. Based on the experience gained through this pilot, we outline key aspects to consider when planning similar screening initiatives: (i) Planning and communication: engage community associations early to co-design recruitment materials and messages. (ii) Workflow optimisation: pre-register participants in small groups; shorten information sessions; ensure adequate ventilation and privacy. (iii) Cultural mediation: involve interpreters or health mediators from the same community to build trust. (iv) Health-system linkage: use screening encounters to connect refugees with primary-care services. (v) Monitoring and scale-up: collect standardised feasibility indicators (participation, referral, completion) to inform regional TB-control planning. These insights contribute to the WHO call for integrating systematic TB screening into broader refugee-health frameworks while adapting interventions to local realities\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e \u003cstrong\u003eASPB\u003c/strong\u003e \u003cp\u003ePublic Health Agency Of Barcelona\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCatSalut\u003c/strong\u003e \u003cp\u003eCatalan Public Healthcare System\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eCOVID\u003c/b\u003e-19: Coronavirus Disease 2019\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCXR\u003c/strong\u003e \u003cp\u003eChest X-Ray\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eECDC\u003c/strong\u003e \u003cp\u003eEuropean Centre For Disease Prevention and Control\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMDR\u003c/b\u003e-TB: Multidrug-Resistant Tuberculosis\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQR-Code\u003c/strong\u003e \u003cp\u003eQuick Response Code\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTB\u003c/strong\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTBI\u003c/strong\u003e \u003cp\u003eTuberculosis Infection\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eUTE\u003c/strong\u003e \u003cp\u003eExperimental Tuberculosis Unit\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWHO\u003c/strong\u003e \u003cp\u003eWorld Health Organisation\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and Consent to participate:\u003c/strong\u003e \u003cp\u003eThe study protocol was reviewed and approved by the Germans Trias i Pujol University Hospital Research Ethics Committee (PI-22-067). Participation was voluntary, and verbal informed consent was obtained from all individuals prior to screening.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003enot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe\u003c/b\u003e Authors declare no conflict of interest\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis project received funding from the European Union\u0026rsquo;s Horizon 2020 research and innovation program under grant agreements No. 847762 (SMA-TB) and No. 823854 (INNOVA4TB). Andrii Dudnyk was funded through the MSCA4Ukraine project (ID: 1233336). Additionally, this work is based on contributions from COST Action ADVANCE-TB CA21164, supported by COST (European Cooperation in Science and Technology). This study also received support from the Catalan Government through 2021 SGR 00920.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation and methodology were carried out by RP, JO, MLS, MAJ, PS, CR, JPM, and CV. Data curation was handled by NG and RP. The investigation was conducted by NG, ASA, RP, JO, LA, VB, AD, MF, DS, JPM, and CV conducted the investigation. RP, JO, JPM, and CV managed project administration. Resources were provided by NG, ASA, and CV. Supervision was performed by CV. The visualisation was created by NG. Writing of the original draft was done by NG, ASA, and CV, while all authors contributed to the review and editing of the manuscript. CV and JPM contributed equally to this work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to express our gratitude to the Djerelo Association, Kaori Fonseca, Marta Arch, Maria Vidal, and Nadia Buhiichyk for their support in organizing and implementing the action, as well as to all the individuals who participated in the screening activity.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eThe data collected within this study will not be available to others.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal tuberculosis report 2024. Geneva, World Health Organization. : 2024. Licence: CC BY-NC-SA 3.0 IGO. 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Module 2: screening - systematic screening for tuberculosis disease. Geneva: World Health Organization. 2021. Licence: CC BY-NC-SA 3.0 IGO. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240022614\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240022614\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenaway C, Pareek M, Chakra CNA et al. 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Bolet\u0026iacute;n Oficial del Estado. 2018;(183):77004\u0026ndash;77012. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.boe.es/eli/es/rdl/2018/07/27/7/con\u003c/span\u003e\u003cspan address=\"https://www.boe.es/eli/es/rdl/2018/07/27/7/con\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNot A, Ouaarab-Essadek H, Montoro M, et al. Hepatitis B and C Screening and Linkage to Care in Migrants From Endemic Countries in Barcelona Through a Community Action. Liver Int. 2025;45(6):e70126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/liv.70126\u003c/span\u003e\u003cspan address=\"10.1111/liv.70126\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiza E, Kalkman S, Coritsidis A, Koubardas S, et al. Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices. Healthcare. 2020;8(2):115. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/healthcare8020115\u003c/span\u003e\u003cspan address=\"10.3390/healthcare8020115\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, Screening, Ukrainian Refugees, Pilot study, Active tuberculosis disease","lastPublishedDoi":"10.21203/rs.3.rs-8077431/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8077431/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eFollowing the 2022 Russian invasion of Ukraine, more than 18 000 Ukrainian refugees arrived in Barcelona, Spain. Given Ukraine\u0026rsquo;s high tuberculosis (TB) incidence and multidrug-resistant TB burden, the SYS-TB project piloted community-based active TB disease screening to assess the feasibility of implementing the World Health Organization (WHO) recommendations for vulnerable populations in a low-incidence European setting.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eTwo TB screening events were conducted between July and October 2022 in collaboration with the Public Health Agency of Barcelona and the Ukrainian association \u003cem\u003eDjerelo\u003c/em\u003e. Ukrainian refugees aged\u0026thinsp;\u0026ge;\u0026thinsp;16 years were invited to participate. The screening included an information session on TB symptoms and healthcare access, followed by a symptom questionnaire and referral for chest X-ray (CXR) for those reporting TB-related symptoms. Attendance, participation, and operational barriers were recorded and analysed descriptively.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSeventy-six individuals attended the two events, and 35 (46%) completed TB symptom screening. Of these, 28 (80%) were female, with a median age of 45 years. Most participants had arrived in Barcelona within the previous six months. Ten (29%) individuals were referred for CXR, and none were diagnosed with active TB disease. Main challenges included communication barriers, logistical constraints, and mismatched participant expectations. Introducing pre-registration and streamlining information sessions improved efficiency and participant flow during the second event.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eCommunity-based TB screening among Ukrainian refugees in Barcelona was operationally feasible but yielded few cases. Collaboration with trusted community organisations, adequate preparation, and culturally tailored communication were essential for engagement. Lessons from this pilot can inform future targeted screening initiatives for displaced populations in low-incidence settings.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eClinicalTrials.gov Identifier: NCT06706596, retrospectively registered on November 29, 2024\u003c/p\u003e","manuscriptTitle":"Feasibility and Operational Lessons from Active Tuberculosis Disease Screening Among Ukrainian Refugees in Barcelona: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 06:18:50","doi":"10.21203/rs.3.rs-8077431/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"226610269236969222260174466586936773482","date":"2025-12-28T09:18:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T18:47:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230771189359525951784323412401828854548","date":"2025-12-23T13:38:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T15:17:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261004302296927348131059163088690497943","date":"2025-12-21T18:26:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-18T10:05:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319503002564699568398760963079810777217","date":"2025-12-15T10:35:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165307053628324574974307880958096127903","date":"2025-12-12T12:42:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T10:55:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-27T10:03:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T08:53:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-17T16:46:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-17T16:44:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5864993-364b-462a-b522-15a8f6cfa0a6","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T06:18:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 06:18:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8077431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8077431","identity":"rs-8077431","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}