HEN report describes effective services to prevent, diagnose and treat TB among refugees and migrants

A new Health Evidence Network (HEN) report examines evidence of effective and efficient service packages for the prevention, diagnosis and treatment of tuberculosis (TB) among refugees and migrants in the WHO European Region. This latest HEN report (#56), commissioned to inform related policies and strategies in the Region, was jointly developed by the Division of Information, Evidence, Research and Innovation, the Division of Policy and Governance for Health and Well-being and the Division of Communicable Diseases, Health Security and Environment.

While there is no systematic and causative link between being a migrant or refugee and having TB, a myriad of complex and interconnected factors that refugees and migrants can be exposed to during the migratory process increase their risk of acquiring TB.

The Region has faced high rates of external and internal migration in recent years, and WHO/Europe has responded by assisting Member States to develop migrant-friendly health-care systems. Increasing rates of migration are causing concerns that this is contributing to the burden of TB, multidrug-resistant TB (MDR-TB) and TB/HIV coinfection in some countries.

The Region is leading the way in promoting the health of refugees and migrants. The Strategy and action plan for refugee and migrant health in the WHO European Region, adopted by all European Member States, identifies 9 strategic areas for action. One of these areas specifically targets communicable diseases such as TB.

Significant efforts are underway to end TB. The Region adapted the global End TB Strategy to generate a roadmap to implement the Tuberculosis action plan for the WHO European Region 2016–2020. It aims for wide-reaching policies that aid migrant care, such as the implementation of cross-border mechanisms to ensure a continuum of care for internal and external migrants, as well as for stateless individuals.

Successful implementation of these strategies requires improved coordination of TB services in the Region, and a boost to the implementation of a minimum package for cross-border TB prevention and care.

The HEN report identifies significant regional variations in migration levels and TB burden among refugees and migrants, as well as variations in approaches to TB prevention and care. To exacerbate the issue, the quality of evidence is often low. Evidence suggests that the likelihood of TB transmission from refugees and migrants to host populations is low, and that, in countries with a low incidence of TB, the disease predominantly circulates within refugee and migrant communities.

Policy considerations

The report explains that, while it is unlikely that a single strategy or package will be effective for all situations, some common approaches could guide policy-making and service development. It also emphasizes that as TB is a global issue, solutions in the European context should be considered in conjunction with global efforts to end the disease.

TB elimination targets for the Region will not be met without addressing inequalities in access to screening and treatment for migrants. While effective decision-making in the field of TB and migrant health is complex and further data around key issues are required, the report puts forth the following policy considerations.

  • Incorporate adequate screening and treatment for latent TB infection and MDR-TB into refugee and migrant screening programmes (for example, at the first point of contact for newly arrived migrants with health services in the host country) in an accessible and culturally sensitive manner as part of a basic free package of care.
  • Improve cross-border collaboration for TB screening and care along the entire migration trajectory, with a focus on implementing a minimum package of TB screening and care.
  • Develop a more holistic approach to migrant health across the Region, recognizing the rights of migrants to health, and work towards removing legal, social and cultural barriers to health services to facilitate better TB prevention and care among migrants.
  • Develop health education/health literacy around prevention, treatment and care of TB to increase knowledge, awareness and, subsequently, patient involvement.
  • Align TB policies with initiatives within the social programme, as poverty and destitution are well known risk factors for TB transmission and reactivation.
  • Strengthen approaches to data collection to provide an intercountry evidence base on TB among refugees and migrants for monitoring and evaluation within national health systems.
  • Encourage research to understand patterns of TB and to define innovative implementation approaches, in particular cost–effectiveness and how to improve screening and treatment completion.

Relevance to evidence-informed policy-making

Evidence-informed policy-making is a core function of WHO/Europe. WHO/Europe works to ensure that the best available evidence is used to formulate national and regional policies and practices. To this end, the HEN Secretariat, located in the Knowledge Management, Evidence and Research for Policy-making unit in the Division of Information, Evidence, Research and Innovation, closely collaborated with the joint tuberculosis, HIV and viral hepatitis programme and the migration and health programme to produce a reliable evidence base to inform the effective implementation of TB strategies among migrants. The new report is the eighth in the HEN series on the theme of migration.