The Union TB and Migration Statement and Upcoming Editorial

The Union TB and Migration Group recently published a statement concerning migrant health in the context of tuberculosis and the COVID-19 pandemic.

You can read the full statement below, or on the Union website.

World Union Against Tuberculosis and Lung Disease: Statement on Tuberculosis in Migrants during the COVID-19 Epidemic

Figure 1: International Migrants at Mid-year 2019, IOM

Figure 1: International Migrants at Mid-year 2019, IOM

Migration across the globe

Migration represents the movement of persons away from their place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons [1]. Migrants include, but are not limited, to refugees and asylum seekers, temporary and permanent workers, students and retired persons. In 2019, and before COVID-19 outbreak, the number of international migrants worldwide has reached 272 million [1] (an increase from 258 million in 2017) (Figure 1).

Within this umbrella term of migration, a special focus is on the most vulnerable migrants, and experts suggested two types of vulnerabilities which are relevant for the present statement [2]. The first is “situational vulnerability”, where migrants are travelling through unusual routes (smuggled, by boat, illegal border crossings, etc.), in the absence of a community to protect them, with a lack of material possessions or legal documents, and migrating away from poverty, war or natural disasters. This can lead to food insecurity and limited access to healthcare, risk of exposure to different health hazards and suboptimal housing conditions. The second is termed “individual vulnerability”, which includes migrants who are children, elderly, pregnant women or those with comorbidities, which make them more susceptible to other diseases. 

The map below (Figure 2) shows the number and geographical locations of refugees regionally. 

Figure 2 - Center for Global Development and the Tent Partnership for Refugees (truncated in source [3,4]. For the interactive version, visit https://www.cgdev.org/publication/are-refugees-located-near-urban-job-opportunities

Figure 2 - Center for Global Development and the Tent Partnership for Refugees (truncated in source [3,4]. For the interactive version, visit https://www.cgdev.org/publication/are-refugees-located-near-urban-job-opportunities

COVID-19 and Tuberculosis as “vulnerability enhancers”

Medical impact

Tuberculosis (TB) has been classified as a “medical emergency” since 1993. One in four people on the globe have latent TB infection (LTBI) and 4200 people die of TB daily [5]. The vast majority of the migrants originate from countries in which TB is endemic, and the rate of TB disease among migrants is greater than that of the native population in the host countries [6]. 

There are multiple threads connecting coronavirus-2 disease (COVID-19) to TB, especially in migrants. Both pathogens are transmitted via the respiratory route, and can cause respiratory symptoms. The data concerning the natural history of co-infection are still emerging, but evidence may point to worse TB-treatment outcomes in COVID affected patients [7].

Beyond the medical impact 

As a direct or indirect result of the COVID-19 global pandemic, some migrants have been stranded with increased vulnerability because of unemployment and loss of income, which may decrease their a-priori limited access to food, housing and healthcare services. In addition, the efforts for TB detection and treatment have been reduced, and resources have been diverted from TB needs to the containment of COVID-19. 

As migrants often do not have safety health and economic nets, they may be pushed to work even when ill or placed under isolation or quarantine to obtain their basic necessities. Furthermore, enforcing social distancing by national authorities can potentially increase the vulnerability of migrants by requirements of documents or by aggravating the attitudes of the authorities to the illegality of the migrants. To accentuate already present challenges in TB management among migrants, global chains of drug production and distribution are disrupted and precious human and physical resources are being diverted from other diseases, including TB, to the fight against COVID-19.

Medical personnel are being redirected to fight COVID-19 and hospitals are being turned into quarantine centers. Some medical equipment, such as the GeneXpert instruments used to diagnose TB are potentially being repurposed to analyse COVID-19 using new test kits. With global production depending on few sources and travel limitations, access to TB drugs is being disrupted. TB treatment disruption may not only enhance morbidity and mortality, but also promote the transmission of resistant bacteria.

In conclusion, as the fight against COVID-19 continues, migrants are at a potential risk of being underdiagnosed and undertreated for TB because of lack of access and limited resources. It is therefore the role of The Union to call for the continuum of TB care and address the attention of the medical community to the needs of vulnerable population, including migrants. 

The expertise of TB program staff can be used to fight COVID-19

Experts who work in TB programs have gained wide experience in treating vulnerable populations. They paved effective communication channels with the migrants, reduced knowledge gaps, built trust and established effective mechanisms which are essential for support and involvement of the migrants. The expertise and infrastructure which has been built for TB-care should also be used to respond to COVID-19 among the migrants. This provides an opportunity to integrate TB and COVID-19 efforts among the migrants rather than disperse health services and fight against both infections in a more beneficial and cost-effective way. 

 

Recommendations concerning tuberculosis in migrants during the COVID-19 pandemic

Do not neglect TB 

Mycobacterium tuberculosis is a hardy, highly opportunistic bacteria, which is easily transmittable in overcrowded and suboptimal living situations, too often endured by migrants. TB diagnosis and treatment are lengthy and characterized with high mortality rates.

  • Ensure that timely TB diagnosis is available and access to treatment is uninterrupted, especially among vulnerable groups, including migrants. 

  • Do not consume all the diagnostic tests only for SARS-CoV-2, and preserve testing for Mycobacterium tuberculosis. 

Do not neglect migrants

Identify migrants who are living in suboptimal conditions or have limited access to healthcare due to social distancing, lack of resources or fear of authorities. Migrants can be classified to have both "situational vulnerability" and "individual vulnerability". Situational, as migrants who cross borders may be incarcerated in detention centers with limited access to food, shelter and personal protection equipment. Individual, as migrants in these settings who are infected SARS-CoV-2 are at a potential higher risk for TB. 

  • Offer migrants access to medical treatment, adequate nutrition and secure housing, provide legal immunity against deportation to limit Mycobacterium tuberculosis and SARS-CoV-2 transmission and encourage rapid medical response to contain outbreaks.

  • Maintain routine childhood vaccination schedule. 

Do not neglect TB among migrants especially during COVID-19

Emerging evidence indicates that the presence of TB will complicate COVID-19 management and vice versa. Resources are being redirected to respond to COVID-19, while care for other diseases are neglected, including TB. 

  • Migrants should be tested for SARS-CoV-2 and for Mycobacterium tuberculosis in case of clinical suspicion, as migrants are at risk for both of the infections and symptoms may overlap.

  • As GeneXpert/other rapid molecular diagnostic platforms are approved for COVID-19 testing. Health facilities equipped with these technologies should explore the feasibility of initiating COVID-19 testing for migrants in the existing setup. However, resources for COVID-19 should be added without impacting on other diseases, especially TB. 

  • Make sure that treatment for TB is uninterrupted and patients who are isolated are contacted (via phone or internet) to ensure treatment completion and avoiding adverse clinical issues, including mental health. Force return or refoulement are not justified and detention due to the threat of COVID-19 is unnecessary, as the migrants are more susceptible to be infected with SARS-CoV-2 than the general population in the host countries. 

The Tuberculosis and Migration group recognizes that COVID-19 is an unprecedented pandemic in modern history, however no public health emergency can be fully recovered unless all the levels community, including the migrants, are free of the disease. Although resources are required to fight COVID-19, it is important to avoid deprioritising TB, and the migrants should be included in the ongoing protective measures, share reliable information and access medical services [8]. Countries should ensure that migrants are not scapegoated, stigmatized or targeted for specific or discriminatory measures [9].


References

1. International Organization for Migration. World Migration Report 2020. 2019. Available: https://publications.iom.int/system/files/pdf/wmr_2020.pdf

2. United Nations High Commissioner for Refugees. Refworld | “Migrants in vulnerable situations” UNHCR’s perspective. In: Refworld [Internet]. [cited 16 Apr 2020]. Available: https://www.refworld.org/docid/596787174.html

3. Map of the Day: Where Refugees Live | UN Dispatch. In: UN Dispatch [Internet]. 20 Jun 2018 [cited 16 Apr 2020]. Available: https://www.undispatch.com/map-of-the-day-where-refugees-live/

4. Huang C, Graham J. Are refugees located near urban job opportunities. CGD Report Washington DC: Center for Global Development. 2018. Available: https://www.cgdev.org/publication/are-refugees-located-near-urban-job-opportunities

5. WHO Organization, Others. Global tuberculosis report 2019. Geneva (Switzerland): World Health Organization; 2019. 2019.

6. Pareek M, Greenaway C, Noori T, Munoz J, Zenner D. The impact of migration on tuberculosis epidemiology and control in high-income countries: a review. BMC Med. 2016;14: 48.

7. Liu Y, Bi L, Chen Y, Wang Y, Fleming J, Yu Y, et al. Active or latent tuberculosis increases susceptibility to COVID-19 and disease severity. Infectious Diseases (except HIV/AIDS). medRxiv; 2020. doi:10.1101/2020.03.10.20033795

8. A statement of the migrants and ethnic health section of the European Public Health Association. In: Bhopal R. COVID-19: undocumented migrants are probably at greatest risk. BMJ. 2020;369:m1673.

9. Hargreaves S, Zenner D, Wickramage K, Deal A, Hayward SA. Targeting COVID-19 interventions towards migrants in humanitarian settings. Lancet Infect Dis 2020;20(6):645-646.


TB Migration Group Union