Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe

Tuberculosis incidence in foreign-born people residing in European countries in 2020

BackgroundEuropean-specific policies for tuberculosis (TB) elimination require identification of key populations that benefit from TB screening.AimWe aimed to identify groups of foreign-born individuals residing in European countries that benefit most from targeted TB prevention screening.MethodsThe Tuberculosis Network European Trials group collected, by cross-sectional survey, numbers of foreign-born TB patients residing in European Union (EU) countries, Iceland, Norway, Switzerland and the United Kingdom (UK) in 2020 from the 10 highest ranked countries of origin in terms of TB cases in each country of residence. Tuberculosis incidence rates (IRs) in countries of residence were compared with countries of origin.ResultsData on 9,116 foreign-born TB patients in 30 countries of residence were collected. Main countries of origin were Eritrea, India, Pakistan, Morocco, Romania and Somalia. Tuberculosis IRs were highest in patients of Eritrean and Somali origin in Greece and Malta (both > 1,000/100,000) and lowest among Ukrainian patients in Poland (3.6/100,000). They were mainly lower in countries of residence than countries of origin. However, IRs among Eritreans and Somalis in Greece and Malta were five times higher than in Eritrea and Somalia. Similarly, IRs among Eritreans in Germany, the Netherlands and the UK were four times higher than in Eritrea.ConclusionsCountry of origin TB IR is an insufficient indicator when targeting foreign-born populations for active case finding or TB prevention policies in the countries covered here. Elimination strategies should be informed by regularly collected country-specific data to address rapidly changing epidemiology and associated risks.

Drivers determining tuberculosis disease screening yield in four European screening programmes: a comparative analysis

BACKGROUND

The World Health Organization End TB Strategy emphasises screening for early diagnosis of tuberculosis (TB) in high-risk groups, including migrants. We analysed key drivers of TB yield differences in four large migrant TB screening programmes to inform TB control planning and feasibility of a European approach.

METHODS

We pooled individual TB screening episode data from Italy, the Netherlands, Sweden and the UK, and analysed predictors and interactions for TB case yield using multivariable logistic regression models.

RESULTS

Between 2005 and 2018 in 2 302 260 screening episodes among 2 107 016 migrants to four countries, the programmes identified 1658 TB cases (yield 72.0 (95% CI 68.6-75.6) per 100 000). In logistic regression analysis, we found associations between TB screening yield and age (≥55 years: OR 2.91 (95% CI 2.24-3.78)), being an asylum seeker (OR 3.19 (95% CI 1.03-9.83)) or on a settlement visa (OR 1.78 (95% CI 1.57-2.01)), close TB contact (OR 12.25 (95% CI 11.73-12.79)) and higher TB incidence in the country of origin. We demonstrated interactions between migrant typology and age, as well as country of origin. For asylum seekers, the elevated TB risk remained similar above country of origin incidence thresholds of 100 per 100 000.

CONCLUSIONS

Key determinants of TB yield included close contact, increasing age, incidence in country of origin and specific migrant groups, including asylum seekers and refugees. For most migrants such as UK students and workers, TB yield significantly increased with levels of incidence in the country of origin. The high, country of origin-independent TB risk in asylum seekers above a 100 per 100 000 threshold could reflect higher transmission and re-activation risk of migration routes, with implications for selecting populations for TB screening.

Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal

Tuberculosis (TB) is an infectious disease associated with poverty. In the European Union TB tends to concentrate in urban settings. In Lisbon, previous studies revealed, the presence of migrant populations from a high endemic country, is one of the risk factors contributing to TB. To better understand TB in foreign-born individuals in the Lisbon Metropolitan Area, a mixed-method case study was undertaken on a TB treatment centre in a high-risk part of urban Portugal. Quantitatively, annual TB cases were analysed from 2008 to 2018, dividing foreign-origin cases into recent migrants and long-term migrants. Qualitatively, we explored recent migrants’ reasons, experiences and perceptions associated with the disease. Our results showed that foreign-born individuals accounted for 45.7% of cases, mainly originated from Angola, Guinea-Bissau, and Cabo Verde. TB in recent migrants increased over the years for Angola and Guinea-Bissau, while for Cabo Verde TB cases were due to migrants residing in Portugal for more than 2 years. Recent migrants’ reasons to travel to Portugal were to study, to live and work, tourism, and seeking better healthcare. Visiting family and friends, historical links and common language were key drivers for the choice of country. Recent migrants and long-term migrants may present distinct background profiles associated with diagnosed TB.

Ethical challenges in the treatment of non-refugee migrants with tuberculosis in Canada

While attention to the ethical issues that migrants face in accessing tuberculosis care has increased in the last few years, most of the attention has focused on challenges that refugees face when emigrating. Less attention has been given to ethical challenges that arise in the context of providing tuberculosis treatment and care to non-refugee migrants in high-income countries (HIC), particularly those that do not face immediate danger or violence. In this paper, we analyze some of the ethical challenges associated with treating migrants with tuberculosis in the Canadian context. In particular, we will discuss (i) inter- and intra-jurisdictional issues that challenge quotidian public health governance structures, and (ii) the ethical imperative for the Canadian government and its provinces to clearly differentiate access to healthcare from a person's immigration status to help overcome power imbalances that may exist between public health workers and their clients. The arguments presented herein could potentially apply to other HIC with some form of universal health coverage.

Elucidation of potential challenges and prospects for regional tuberculosis interventions in East and Horn of Africa: a cross-sectional program assessment

Introduction

cross-border mobility of persons with Tuberculosis (TB) is a global public health concern. We aimed at documenting health systems´ potential bottlenecks and opportunities in pulmonary TB continuum of care in cross-border expanses of East and Horn of Africa.

Methods

a cross-sectional program assessment with descriptive analysis of TB services, health staff capacities, diagnostic capacities, data management and reporting, and treatment outcomes. Data were extracted from health facility TB registers and semi-structured key informant interviews conducted in selected 26 cross-border sites within the 7 member states of the Intergovernmental Authority on Development (IGAD) region.

Results

the overall cross-border TB cure rate in the year preceding the study (37%) was way beneath the global target with considerable variations amongst the study countries. The restricted support to the cross-border health facilities was mediated and even exacerbated by expansive distances from the respective capital cities. Restricted geographical access to the facilities by cross-border populations was a longstanding challenge. Substantial staffing gaps, TB service delivery capacity needs and inadequate diagnostics were noticeable. The TB control guidelines were not harmonized between the countries and the inter-country referral systems were either absent or inappreciable, contributing to ineffective cross-border referrals and transfers. The frail linkages between stakeholders were contemptible, but increasing governments´ commitments in tackling infectious diseases were encouraging.

Conclusion

cross-border TB interventions should drive regional TB policies, strategies and programs that sustain countries´ coordination, harmonization of management guidelines, advocacy for increased human resources support, enhanced capacity building of cross-border TB staff, adequate diagnostics equipping of the cross-border health facilities and seamless transfer and referral of patients traversing boundaries.

Tuberculosis in Adolescents and Young Adults: Emerging Data on TB Transmission and Prevention among Vulnerable Young People

Adolescents and young adults (AYA, ages 10-24 years) comprise a uniquely important but understudied population in global efforts to end tuberculosis (TB), the leading infectious cause of death by a single agent worldwide prior to the COVID-19 pandemic. While TB prevention and care strategies often overlook AYA by grouping them with either children or adults, AYA have particular physiologic, developmental, and social characteristics that require dedicated approaches. This review describes current evidence on the prevention and control of TB among AYA, including approaches to TB screening, dynamics of TB transmission among AYA, and management challenges within the context of unique developmental needs. Challenges are considered for vulnerable groups of AYA such as migrants and refugees; AYA experiencing homelessness, incarceration, or substance use; and AYA living with HIV. We outline areas for needed research and implementation strategies to address TB among AYA globally.

Who should be tested in a pandemic? Ethical considerations

BACKGROUND

In the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing.

MAIN TEXT

The distribution of scarce resources for testing: We emphasize the use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society's interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory.

CONCLUSION

In summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing.

The need for protecting and enhancing TB health policies and services for forcibly displaced and migrant populations during the ongoing COVID-19 pandemic

Disruption of health services due to the COVID-19 pandemic threatens to derail progress being made in tuberculosis control efforts. Forcibly displaced people and migrant populations face particular vulnerabilities as a result of the COVID-19 pandemic, which leaves them at further risk of developing TB. They inhabit environments where measures such as “physical distancing” are impossible to realize and where facilities like camps and informal temporary settlements can easily become sites of rapid disease transmission. In this viewpoint we utilize three case studies—from Peru, South Africa, and Syria—to illustrate the lived experience of forced migration and mobile populations, and the impact of COVID-19 on TB among these populations. We discuss the dual pandemics of TB and COVID-19 in the context of migration through a syndemic lens, to systematically address the upstream social, economic, structural and political factors that - in often deleterious dynamics - foster increased vulnerabilities and risk. Addressing TB, COVID-19 and migration from a syndemic perspective, not only draws systematic attention to comorbidity and the relevance of social and structural context, but also helps to find solutions: the true reality of syndemic interactions can only be fully understood by considering a particular population and bio- social context, and ensuring that they receive the comprehensive care that they need. It also provides avenues for strengthening and expanding the existing infrastructure for TB care to tackle both COVID-19 and TB in migrants and refugees in an integrated and synergistic manner.

Bridging the gap between policy and practice: a qualitative analysis of providers' field experiences tinkering with directly observed therapy in patients with drug-resistant tuberculosis in Addis Ababa, Ethiopia

OBJECTIVES

Drug-resistant tuberculosis (DR-TB) is one of the major public health threats in low-income countries such as Ethiopia. It is intertwined with larger socioeconomic and political factors that complicate its management and control. Whether directly observed therapy (DOT) is serving its purpose-better patient adherence and treatment outcome-still remains a debatable issue. To contribute to this discussion, this study explored health workers' field experiences tinkering with DOT in patients with DR-TB in Addis Ababa, Ethiopia.

DESIGN

A qualitative study using in-depth interviews and focus group discussion.

SETTING

Ten public healthcare facilities: eight health centres at Addis Ababa Health Bureau level and two TB-specialised hospitals at the Federal Health Bureau level in Ethiopia.

PARTICIPANTS

18 healthcare providers working with DR-TB patients.

RESULTS

Three findings emerged from the analysis. First, the purpose of DOT is to ensure that patients go to healthcare facilities and swallow pills under the observation of a healthcare provider. Thus, its rigid application could lead to the emergence of more DR-TB. Second, DOT should be tinkered with and its practice improved by incorporating more counselling and health education, with more flexibility towards, and attentiveness of, patient context. Third, there exists a family-like patient-provider relationship, and providers do understand their patients and empathise with them to provide better healthcare services.

CONCLUSION

If rigidly implemented, DOT could lead to more DR-TB-a problem DOT was invented to resolve. Front-line healthcare providers are sensitive to the tragic experiences of DR-TB patients and empathise with them. Thus, they do not strictly implement DOT and are willing to take any blame resulting from tinkering with it. It is high time to shape the practice of DOT for DR-TB patients, with meaningful contributions from front-line healthcare providers.

Electronic pillbox-enabled self-administered therapy versus standard directly observed therapy for tuberculosis medication adherence and treatment outcomes in Ethiopia (SELFTB): protocol for a multicenter randomized controlled trial

BACKGROUND

To address the multifaceted challenges associated with tuberculosis (TB) in-person directly observed therapy (DOT), the World Health Organization recently recommended that countries maximize the use of digital adherence technologies. Sub-Saharan Africa needs to investigate the effectiveness of such technologies in local contexts and proactively contribute to global decisions around patient-centered TB care. This study aims to evaluate the effectiveness of pillbox-enabled self-administered therapy (SAT) compared to standard DOT on adherence to TB medication and treatment outcomes in Ethiopia. It also aims to assess the usability, acceptability, and cost-effectiveness of the intervention from the patient and provider perspectives.

METHODS

This is a multicenter, randomized, controlled, open-label, superiority, effectiveness-implementation hybrid, mixed-methods, two-arm trial. The study is designed to enroll 144 outpatients with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who are eligible to start the standard 6-month first-line anti-TB regimen. Participants in the intervention arm (n = 72) will receive 15 days of HRZE-isoniazid, rifampicin, pyrazinamide, and ethambutol-fixed-dose combination therapy in the evriMED500 medication event reminder monitor device for self-administration. When returned, providers will count any remaining tablets in the device, download the pill-taking data, and refill based on preset criteria. Participants can consult the provider in cases of illness or adverse events outside of scheduled visits. Providers will handle participants in the control arm (n = 72) according to the standard in-person DOT. Both arms will be followed up throughout the 2-month intensive phase. The primary outcomes will be medication adherence and sputum conversion. Adherence to medication will be calculated as the proportion of patients who missed doses in the intervention (pill count) versus DOT (direct observation) arms, confirmed further by IsoScreen urine isoniazid test and a self-report of adherence on eight-item Morisky Medication Adherence Scale. Sputum conversion is defined as the proportion of patients with smear conversion following the intensive phase in intervention versus DOT arms, confirmed further by pre-post intensive phase BACTEC MGIT TB liquid culture. Pre-post treatment MGIT drug susceptibility testing will determine whether resistance to anti-TB drugs could have impacted culture conversion. Secondary outcomes will include other clinical outcomes (treatment not completed, death, or loss to follow-up), cost-effectiveness-individual and societal costs with quality-adjusted life years-and acceptability and usability of the intervention by patients and providers.

DISCUSSION

This study will be the first in Ethiopia, and of the first three in sub-Saharan Africa, to determine whether electronic pillbox-enabled SAT improves adherence to TB medication and treatment outcomes, all without affecting the inherent dignity and economic wellbeing of patients with TB.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04216420. Registered on 2 January 2020.

Tools to implement the World Health Organization End TB Strategy: Addressing common challenges in high and low endemic countries

AIM

The purpose of this viewpoint is to summarize the advantages and constraints of the tools and strategies available for reducing the annual incidence of tuberculosis (TB) by implementing the World Health Organization (WHO) End TB Strategy and the linked WHO TB Elimination Framework, with special reference to Oman.

METHODS

The case-study was built based on the presentations and discussions at an international workshop on TB elimination in low incidence countries organized by the Ministry of Health, Oman, which took place from September 5 to September 7, 2019, and supported by the WHO and European Society of Clinical Microbiology and Infectious Diseases (ESCMID).

RESULTS

Existing tools were reviewed, including the screening of migrants for latent TB infection (LTBI) with interferon-gamma release assays, clinical examination for active pulmonary TB (APTB) including chest X-rays, organization of laboratory services, and the existing centres for mandatory health examination of pre-arrival or arriving migrants, including examination for APTB. The need for public-private partnerships to handle the burden of screening arriving migrants for active TB was discussed at length and different models for financing were reviewed.

CONCLUSIONS

In a country with a high proportion of migrants from high endemic countries, screening for LTBI is of high priority. Molecular typing and the development of public-private partnerships are needed.

Defining a migrant-inclusive tuberculosis research agenda to end TB

BACKGROUND

Pillar 3 of the End TB Strategy calls for the promotion of research and innovation at the country level to facilitate improved implementation of existing and novel interventions to end tuberculosis (TB). In an era of increasing cross-border migration, there is a specific need to integrate migration-related issues into national TB research agendas. The objective of the present review is to provide a conceptual framework to guide countries in the development and operationalization of a migrant-inclusive TB research agenda.

METHODS

We conducted a literature review, complemented by expert opinion and the previous articles in this State of the Art series, to identify important themes central to migration-related TB. We categorized these themes into a framework for a migration-inclusive global TB research agenda across a comprehensive spectrum of research. We developed this conceptual framework taking into account: 1) the biomedical, social and structural determinants of TB; 2) the epidemiologic impact of the migration pathway; and 3) the feasibility of various types of research based on a country's capacity.

DISCUSSION

The conceptual framework presented here is based on the key principle that migrants are not inherently different from other populations in terms of susceptibility to known TB determinants, but that they often have exacerbated or additional risks related to their country of origin and the migration process, which must be accounted for in developing comprehensive TB prevention and care strategies. A migrant-inclusive research agenda should systematically consider this wider context to have the highest impact.

Migration, justice and health: Reimagining the earth as one country and humankind its citizens

Migration is a significant feature of the political discourse around the world. It is bewildering and polarizing policy makers, leaders and communities, grappling to address the questions raised. The growing body of empirical data on migrant health have profound ethical relevance for example around risk-benefit-analysis, justice and discrimination at the individual, micro, meso and macro levels. The policy decisions and actions to address the issues appear to be often guided by self-interest and increasing pressures to protect national interests, and the current structures and systems. This paper briefly outlines and reflects on the ethical dimensions of migration, diversity and health and implications for policy, and practice. We argue that there is a case for new paradigms of global solidarity, social justice, and health equity in an interconnected world. Health care for migrants should be built on values of equal human rights and of shared humanity and the health and wellbeing of migrants and citizens should be promoted and protected alike. Migrant health is of global concern and international strategies for global governance are required. Migration policies it is suggested should be based on the understanding of interconnectedness of our societies and founded on shared humanity, and health equity for all. There is a case to reimagine the earth as one country and humankind its citizens with its implications on policy and practice and the organized efforts of society.

Migration: a core public health ethics issue

OBJECTIVES

In this article, we outline the link between migration, public health and ethics.

STUDY DESIGN

Discussing relevant arguments about migration from the perspective of public health and public health ethics.

METHODS

Critical review of theories and frameworks, case-based analysis and systematic identification and discussion of challenges.

RESULTS

Migration is a core issue of public health ethics and must take a case-based approach: seeking to identify the specific ethical dimensions and vulnerabilities in each particular context. Public health as a practice, built upon the core value of justice, requires the protection and promotion of migrants' well-being (even if this produces tension with immigration services). Ethical analysis should take all phases of migration into account: before, during and after transit. We argue that migration policies, at least as they relate to migrants' well-being, should be founded upon a shared humanity, respect for human rights and on the idea that effective public health cannot and should not be confined within the borders and to the citizens of any host country.

CONCLUSIONS

We make the case for migration to be seen as a core issue of public health ethics.