A study just published in Clinical Microbiology and Infection documents that the rate of infection with MDR-TB is higher among migrants than in the general population, particularly in those born outside Europe and in those forced to leave their home country as asylum seekers and refugees.[i]
The data reviewed by Hargreaves et al. shows that 100% of the MDR-TB cases diagnosed in Austria, The Netherlands and Norway occurred in migrants to those countries. A high proportion of MDR-TB cases were also apparent in migrants to other European states – 90% in the UK, 89% in France, 87% in Italy and 94% in Germany.
Migrants are at higher risk of contracting MDR-TB both in their country of origin, because of the breakdown of their own healthcare system, and after arriving in Europe, because of destitution, homelessness, overcrowding in refugee camps or incarceration. A significant proportion of MDR-TB cases in migrants result from reactivation of latent infection.
Screening, diagnosis and treatment is available for all forms of TB, including active MDR-TB. However, this is rarely accessed by migrants due to restrictions set by healthcare systems or to fear on the part of the migrants that becoming known to the authorities might result in deportation back to the violence they have fled.
“Although there is evidence that transmission of TB from migrants to the general population is low – it predominantly occurs between migrants – there is a risk of transmission for both migrants and the native population,” notes Professor Jon S. Friedland of the International Health Unit, Infectious Diseases & Immunity, Imperial College London, UK, who is senior author of the study. “There is a human rights obligation to improve the diagnosis, treatment and prevention of MDR-TB in migrants.”
So what needs to be done?
After analysing the content of several studies on MDR-TB, the paper recommends a multi-faceted strategy to improve access to services, more consistent pan-European protocols for screening and treatment, and further research to document the level of MDR-TB infection in the European migrant population.
Detailed recommendations include:
· Changing healthcare policies so that there are fewer barriers to migrants with respect to TB screening, diagnosis and treatment. This would not be granting ‘favours’ to migrants; it would be a sound public health policy to reduce the risk of MDR-TB transmission to other migrants and the wider population.
· Providing better healthcare generally to migrant populations in individual host countries.
· Developing financial and social support mechanisms for migrants who are diagnosed with MDR-TB.
· Drawing up and adopting pan-European evidence-based guidelines for screening methods and how to implement them in the migrant populations.
· Research is also required to develop a reliable diagnostic test that can detect latent MDR-TB and to predict the risk of disease re-activation.
· We also need more evidence that can be used to develop guidelines on how to manage MDR-TB more effectively in migrant populations across Europe.
Friedland highlights that we have a serious “lack of data on effective screening strategies for MDR-TB or how routine practice should be adapted across diverse health systems in Europe to improve treatment outcomes in migrants at risk of low adherence to TB treatment or with MDR-TB.”
MDR-TB is widespread globally, with an estimated 480,000 cases in 2014.
Rates of MDR-TB is low in western Europe but higher in countries in Eastern Europe: the proportion of previously treated TB cases that are classed as multidrug-resistant is 69.0% in Belarus, 62.0% in Moldova and Estonia, 56.0% in Ukraine, 49.0% in Lithuania, 30% in Latvia and 23.0% in Bulgaria.
Across the EU and EEA Member States, reported surveillance data suggest that 73.4% of MDR-TB cases are in migrants from any origin outside the host country while 51.7% of MDR-TB cases occur in migrants originating from other parts of the EU.
In Germany, migrants comprise 94.0% of MDR-TB cases, but only 58.7% of TB cases. Similarly, in the UK migrants comprise 90.4% of MDR-TB cases, but only 69.1% of TB cases, and in France migrants account for 89.2% of MDR-TB infections, but only 55.6% of TB cases (see Table 1 for information on other EU countries).
ESCMID is a non-profit organization dedicated to improving the diagnosis, treatment and prevention of infectious diseases in Europe and beyond. The Society promotes and supports research, education and training and shares good medical practice in infection-related disciplines with a special focus on antimicrobial resistance to build capacity throughout the world. www.escmid.org
[i] Hargreaves S, et al., Multidrug-resistant tuberculosis and migration to Europe, Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.09.009