TB elimination at stake unless Europe cares urgently for vulnerable, poor and marginalized populations and migrants

Joint press release by WHO/Europe and the European Centre for Disease Prevention and Control (ECDC)

Copenhagen and Stockholm, 17 March 2016

New data released by the European Centre for Disease Prevention and Control (ECDC) and WHO/Europe ahead of World TB Day show that an estimated 340 000 Europeans had tuberculosis (TB) in 2014, corresponding to a rate of 37 cases per 100 000 population.

With new TB cases decreasing by 4.3% on average between 2010 and 2014, the WHO European Region has met the Millennium Development Goal target of reversing the incidence of TB by 2015. However, high rates of multidrug-resistant (MDR) TB and TB in vulnerable populations, such as the homeless, drug and alcohol abusers and migrants from countries with high numbers of cases of  TB continue to challenge TB elimination.

"One quarter of all 480 000 patients sick with MDR-TB globally were in the European Region in 2014. This alarmingly high number is a major challenge for TB control," says Dr Zsuzsanna Jakab, WHO Regional Director for Europe. "The most vulnerable groups, including poor and marginalized populations and migrants and refugees, are at greater risk of MDR-TB. Because of their living conditions, TB is often diagnosed late, and it is harder for them to complete a treatment course. If we really want to eliminate TB from Europe, no one must be left behind. This is in line with the framework of Health 2020 and the global agenda of the Sustainable Development Goals." 

"Some social circumstances or lifestyles may make it more difficult for people to recognize the symptoms of TB, access health care services, follow treatment or attend regular health care appointments. We need to find tailored interventions for such vulnerable people, which can include outreach teams or directly observed treatment," says ECDC Acting Director Dr Andrea Ammon. "In the EU/EEA, the number of new TB cases is decreasing only slowly, by around 5% each year, and, if TB is not successfully tackled in vulnerable groups, it will not be eliminated as planned. This is why ECDC is issuing scientific advice today to support countries in reaching poor and marginalized populations that are particularly vulnerable to TB." 

No systematic association between migration and transmission of TB

The risk that migrants and refugees will be infected or develop TB depends on several factors, including the TB rates in the country of origin. New TB cases in some of the countries of origin are lower than the European Region average. In the Syrian Arab Republic, for example, the rate of new TB cases is 17 per 100 000 population, which is less than half the European Region average (37) and not much higher than the EU/EEA average (12). In addition, as TB is not easily transmitted and contacts are limited, there is a low risk that migrants will transmit the disease to resident populations. 

Universal health coverage should be ensured not only for the resident population but also for refugees and migrants, both documented and undocumented. The European Region is the only one in the world with a consensus document on the minimum package of cross-border TB control and care interventions. These include ensuring access to medical services, irrespective of a migrant's registration status, and a non-deportation policy until intensive TB treatment has been completed.

WHO recommends that TB screening be targeted to those at greatest risk. Among refugees and migrants, those at highest risk are people coming from countries with many new TB cases or who have been living or travelling in precarious situations and may have been exposed to TB infection. The recently published Systematic screening for active tuberculosis: an operational guide provides guidance on targeting and tailoring TB screening in order to detect active disease and provide immediate treatment, thus breaking any chain of transmission among refugees and their close contacts. TB screening must never be used as a reason to reject a refugee or a migrant.