Expert Panel: [ARCHIVED] Tuberculosis Among Migrants

When: Jan. 16, 2017 - Jan. 20, 2017 | Community: MDR-TB Treatment & Prevention  

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This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.

How can health systems be adapted to make them more effective at addressing TB in migrants? Should interventions be rights-based? Evidence-based?

Posted: 19 Jan, 2017   Recommendations: 3   Replies: 4

Good Morning from a gray Geneva! My name is Poonam, I work as migration health programme coordinator at the International Organization for Migration (IOM), and also co-Chair a Working Group on TB and migration at the International Union against TB and Lung Disease (UNION). And as a Panelist for this week's discussions on TB and migration, I will be here today to pose questions, participate in discussions with you and learn also from all.

With the end TB strategy, the Global Plan to end TB and TB related targets in the SDGs 2030 - the international community and national stakeholders have committed to reaching key populations - including migrants and mobile populations, with the appropriate TB prevention, treatment and care.

During the discussions today, we would like to raise issues around national health systems' response in this regard - how can national health systems adapt to ensure they are inclusive of migrants - including (but not limited to) both documented and undocumented migrants, refugees, asylum seekers, internally displaced persons, labour migrants, seasonal cross-border workers, etc.

How can countries develop migrant-inclusive national TB strategic plans, and ensure the underlying principles of the end TB strategy are well respected - for example, Protection and promotion of human rights, ethics and equity? Universal Health Coverage and the principle of 'leave no one behind' should indeed ensure health systems are capable of responding to the health needs of migrants as well as host communities. This requires innovative service delivery models, like mobile clinics; measures to address stigma and discrimination; culturally competent health care professionals and community engagement.

Adapting the end TB strategy to address TB in migrants would require capacity building of health systems - what are the key elements to consider? Are there experiences from your work in countries on what works and what does not? Health systems require the right level of human, financial and institutional capacity to respond to needs of migrants, and often serve hard-to-reach and most vulnerable groups.

A key element is of course building cross-border collaboration - some of you discussed the issues surrounding cross-border continuity of care yesterday. Are there critical gaps that emerged and could be addressed in health systems strengthening to address TB in migrants?

In building health service delivery models and policies that are evidence-based, a key challenge often is the lack of robust evidence on TB burden and risk factors among various migrant populations, especially in mid and high TB burden countries. So should national health systems wait for the right evidence before reaching out with TB services for marginalized or vulnerable migrant groups, such as those in undocumented status or urban refugees or forcefully displaced persons in a protracted conflict?

Some resources included here. More soon!



Lal Mani ADHIKARI Replied at 5:03 AM, 19 Jan 2017

Dear Dr. Poonam,
Greetings from Nepal,

As I involved in Tuberculosis control program in refugee and Internally displaced people (IDP) and have a sort of experience for TB screening, diagnosis and treatment management for them. Now, in absence of Migration health policy and act, what can be measures/approahes to be taken if we have to offer TB care services to the outbound migrants in Nepal to achieve 90-90-90 target among migrants which are key populations to be addressed. Also from the sustainability approach what sort of approaches would be beneficial? As I went through the attached reports (WHO and IOM migration factsheet) should you advise additional approaches other than mentioned strategies in context of Nepal.

Thank you very much in advance.

Kindest regards,
Lal Mani

Poonam Dhavan Panelist Replied at 8:09 AM, 19 Jan 2017

Hello Lal Mani. Thank you for writing, and for all the good work you must do in serving refugees and IDPs. Were you engaged in any health response operations, including TB for IDPs after the Nepal earthquake in 2015?

Indeed, in several countries lack of migration policy that addresses multiple sectors including health can be a key barrier in systematic measures to promote health of migrants. For outbound Nepalese migrants, these may include migrant workers, students, immigrants, right? Often for certain countries of destination, such as the United States of America, United Kingdom or Australia they undergo TB screening exams in Nepal before departure, correct? These screening programmes when inclusive of health education, contact tracing and links with treatment support can enable early detection and treatment in case of active TB and also allow for cross-border information sharing with the health systems of destination countries. Are you aware of any such programmes?

Often however, the outbound migration may be in more informal settings, example, migrants from Nepal to India. In this case, depending on their working and living conditions at destination, migrants may or may not seek healthcare for TB or other health conditions. In this case, to reach key populations, we require health systems and national TB programmes to have community outreach and migrant friendly health care centres that can create an enabling environment to offer TB care upon arrival.

The WHO IOM factsheet does provide a comprehensive set of actions, which can enable adaptation of the end TB strategy pillars in national and local contexts. Of course, sustainable implementation of some or all of these actions would require building capacity of health systems.

Amy Board Replied at 10:45 AM, 19 Jan 2017

Thank you, Dr. Dhavan, for raising some great questions for discussion. I work on a research project that assesses the diagnostic accuracy of screening tests for latent TB in newly arrived refugees and other vulnerable populations at a local health department in the U.S. At our clinic, I have observed some very effective and streamlined processes to ensure that refugees resettled in our area are thoroughly screened and evaluated for active and latent TB and offered treatment accordingly. Our clinic even provides outreach workers, some of whom are former refugees themselves, to deliver DOT treatment at the patient's residence if he or she does not have transportation or childcare to come to our office.

However, I think it is far more difficult to target other migrant populations in our area for TB prevention and control. I live in a border state, so there are high populations of immigrants, both documented and undocumented, that reside in my community. There is no comprehensive screening in place for these migrants, compared to the refugees that are resettled and systematically evaluated both before and after migration. In order to appropriately address the health needs of other immigrants in our community, it will take significant additional funding, resources, policy changes, and outreach efforts; however, these efforts can be bogged down by public perception, political restraints, and stigma surrounding the disease. This, I believe, speaks to some of those critical gaps in health care systems you referred to in your initial question. That being said, living in a low-risk country with a highly developed TB health care infrastructure means that a lot is being done to identify and prevent the spread of TB. Still, I think non-refugee migrant populations will continue to experience significant barriers to care without additional policy and programmatic efforts.

Poonam Dhavan Panelist Replied at 11:44 AM, 19 Jan 2017

Hello Amy! Thank you for writing and sharing your experience and excellent observations. It is great that your clinic is able to provide outreach workers, including from among refugees themselves to reach TB patients and ensure treatment completion.

You are right about the challenges and barriers faced by clinics like yours, and the health services at large in reaching other migrant populations without sufficient resources and policy support.

TB unfortunately continues to be associated with significant stigma especially for migrants such as those persons residing in your community in a border area. See below some resources on this topic.

Let us hope the evidence-based advocacy of public health practitioners like you can continue promote health of all migrants!

Attached resources:

This Expert Panel is Archived.

This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.