Migration health and communicable disease Flashcards
(34 cards)
1
Q
What is the relationship between migration and health?
A
- Migrants are not less healthy than the host population
- Health can influence where you migrate
- There are biases on young men and women who migrate to an LMIC and they are known to be the fittest and healthiest in the host country. People think that people who migrate are fitter, younger and healthier than those that stay behind
Systematic review and meta-analysis of global patterns of mortality in international migrants (316 studies)
Overall mortality advantage ‘healthy migrant effect’
But increased mortality for infectious diseases
More vulnerable to infectious diseases than host populations like HIV and TB
2
Q
Give an example of a disease that affects migrants more than the host population
A
HIV:
- 19.2% of new HIV diagnoses in EUROPE in 2017 were migrants
- 10.5% of Europe’s population was foreign-born in 2017
- More HIV diagnoses in migrants occurred in western Europe,
Hep B
- Over half of Hepatitis B cases in Europe are imported (Either in migrants who have been infected previously, then they go to a host country. Estimate from 2011 data across 18 EU/EAA countries (Source: ECDC).
- Migrants are more likely to have a greater incidence of Hep B compared to the Danish born (Danish controls)
- Increased over time
HPV
- In southern Italy, the prevalence of HPV infection in foreign women is 51% vs 13-20% among Italian-born women (Tornesello et al, 2014)
3
Q
Who is a migrant?
A
‘ An umbrella tern, not defined under international law, reflecting the common lay understanding of a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons’ (IOM,2019)
You can think of internal migration (like china)
4
Q
Who is an ethnic minority?
A
BAME
5
Q
What are global migration trends?
A
‘ Migration is a defining issue of our generation. How the world addresses human mobility will determine public health and social cohesion for decades ahead
- 1 billion on the move globally
- Highest level of forced displacement on record: 68.5 million
- Unprecedented increase in global migration
Global migration trends
- 281 million international migrants in 2020, representing 3.6% of the worlds total population
- 89.4 million displaced persons globally in 2020
- 169 million migrant workers globally in 2020
- Children represented 14.6% of international migrants in 2020
- Women represented 48.0% of international migrants in 2020
6
Q
What are the types of migrants?
A
- Forced migrants Refugees and asylum seekers
- Economic/labour migrant
- Family-reunification migrant
- International students
- Retirement migrants
- Irregular/undocumented migrant
- Vast majority of migrants are migrant workers
7
Q
What is the term ‘intersectionality’?
A
- Individuals are not defined by their identity as a migrant, but also by a myriad of other identities that influence their experiences
8
Q
What are the recommendations to improve migrant health?
A
- Improved leadership and accountability at all levels: nation states, multilateral agencies, NGOs, and civil society
- Zero tolerance approach to racism and xenophobia
- Universal and equitable access to health services for migrants
- Better data on health of migrants to develop evidence based recommendations
- It is very difficult to collect data from migrant groups
9
Q
How is migration related to health?
A
- Led to an increase in xenophobia
- Migration is a determinant of health
- Migrants are a positive to the host population
- Universal health coverage is needed
10
Q
What is the ‘New york’ declaration for refugees and migrants?
A
‘ The new York declaration marks a political commitment of unprecedented force and resonance. It gills what has been a perennial gap on the international protection system-that of truly sharing responsibility for refugees’ UN High Commissioner for Refugees Filippo Grandi
- Contains a wide range of commitments by member states to strengthen and enhance mechanisms to protect people on the move
- Subsequent adoption of two global compacts in 2018
- Global compact on refugees
- Global compact for safe, orderly and regular migration
11
Q
What is the global compact for refugees?
A
- Four key objectives
- To ease the pressure on host countries
- To enhance refugee self-reliance
- To expand access to third-country solutions
- To support conditions in countries of origin for return in safety and dignity
12
Q
What is the Global compact for Safe, Orderly and regular migration?
A
- To support international cooperation on the governance of international migration
- To provide a comprehensive menu of options for states from which they can select policy options to address some of the most pressing issues around international migration
- So that they move legally and safely
- To give states the space and flexibility to pursue implementation based on their own migration realities and capacities
13
Q
What are the risks to health before migration?
A
- Local disease patterns e.g. endemic diseases
- Political and personal circumstances e.g. conflict
- Human rights violations -mental heath
- Weak health systems e.g. undervaccination
14
Q
What are the risks to health during migration ?
A
- Depends on mode and circumstances of travels
- E.G. Mexican migrants dying from health exposure in the desert crossing into the US
- E.g. migrants drowning attempting to reach Europe in flimsy boats
- E.g. spread of TB in overcrowded detention centres
- E.g. Burmese refugees fleeing through malaria-endemic areas
15
Q
What are the risks to health after migration?
A
- Do migrants show the disease patterns of their country of origin or of their host country?
- Depends on the time since migration, level of cultural integration, and disease
- What diseases have they been exposed to since migration
- Poverty/living conditions
- Mental health-loneliness/isolation
- Exclusion from health systems of host countries
- Language
- Not understanding the health system
16
Q
What is the hostile environment?
Give an example of where it is used
A
- Theresa May declared in an interview in 2012 that she wanted to create a ‘really hostile environment’ for irregular migrants in the UK
- This includes the NHS
- Makes it more difficult for people to settle in the UK
In the NHS
- Charging regulations- ‘immigration health surcharge’ for those seeking visas to enter the UK, up to 150% charge for some treatments
- Doctors required to check the eligibility of patients before providing treatments and charge patients upfront for non-urgent care
17
Q
How can healthcare be a barrier for migrants?
A
- Legal barriers to access
- Irregular migrants
- Lack of familiarity with local systems
- Lack of awareness of entitlements
- Language barriers
- Cultural barriers
18
Q
CASE STUDY TB IN THE UK
A
- Migrants in the UK have higher TB rates compared to the general population
- Migrants (born outside of the UK) accounted for 73% of TB notifications in 2020
- Rate of TB was 15x higher in migrants compared with the host population in the UK in 2020
- An incorrect assumption from the Daily express said that ‘we are still vulnerable to infection from other countries’ because ‘immigrants and visitors from less medically-advanced countries can carry the infection into Britain’.
19
Q
Case study: UK and migrants with TB
What is a differential pathogen exposure?
A
- It is true that rates of active TB diagnosed after arrival in the UK correlate with TB incidence in the country of origin- so in most cases migrants are exposed to TB in their home country before migrating to the UK
- Rates of TB are much greater in the migrant population, particularly black African, Pakistani and Indian have particularly high rates of TB
20
Q
How do migrants aquire TB?
A
- Migrants arrive in the UK with active TB disease
- This is very rare due to pre-entry screening (less than 1% of TB cases are to do with this)
- Migrants acquire latent M.tb infection before arrival, which re-activates post arrival
- Migrants acquire TB following arrival, through local transmission
21
Q
How can WGS (whole genome sequencing) be used to understand the epidemiology of M.tb transmisson?
A
- Sequence M.tb cultures from cases, assess clustering by genetic relatedness
- Evidence suggests that most migrants are not involved in local onward transmission
- Study in Oxfordshire, UK born patients were 4.8 x more likely to be part of a local transmission cluster
- This supports the idea that migrants are exposed to TB abroad and the TB reactivates upon entry to the UK
- This undermines the idea that migrants give health risks and bring diseases to the host populations
- Its hard to catch TB
22
Q
case study: UK, Migrants and TB
Is TB imported to the UK, or is it reactivated?
A
- Migrants very rarely arrive in the UK with active TB, and are rarely involved in local transmission (occasionally to other migrants, very rarely to local population)
- So the media assumption that migrants import TB to the UK is too simplistic
- The vast majority of Tb in the UK is reactivated latent infection- why does it reactivate?
23
Q
CASE STUDY: UK, migrants and TB
Why does Latent TB reactivate?
A
- In 5-10% of latently activated individuals, TB will reactivate and cause active disease
- Not entirely clear why
- Immune system is somehow compromised?
- HIV infection, diabetes, malnutrition, stress?
24
Q
Case study: UK, Migrants and TB
What might make migrants more vulnerable to reactivation of LTBI?
A
- Genetic susceptibility? Some evidence- controversial
- Vit D deficiency?
- Co-morbidities? Diabetes, HIV, chronic respiratory kidney disease
- Socio-economic status?
- TB is a disease of poverty
- Maybe people are living in an area of poor ventilation
- Occurs in most vulnerable communities
- Mixing in circles where there are a lot of druggies or alcohol addiction people
- Certain groups of migrants which make them more vulnerable to getting TB
- TB is a disease of poverty
- Experiences of migration? Including stress
25
Case study: UK, Migrants and TB
What is the poor outcomes of stigma regarding TB in migrants
* TB is highly stigmatised in some cultures-may **deter treatment-seeking**
* This causes health outcomes to be worse because if you catch and treat TB earlier then you are more likely to have a better treatment outcome AND more likely to not pass it onto other people. If you have TB for longer, then you are more likely to start coughing and spreading it around
E.g., in an ethnography of Somali-born migrants in the UK, TB was associated with expectations of shame, isolation and loss of self-worth; most believed that TB remained infectious after treatment; so, sufferers tended to isolate themselves or conceal their illness
26
Why may there be barriers to accessing healthcare in the UK for migrants?
* TB is treatment in the UK is free-for-all, regardless of migration status
* BUT migrants face barriers in accessing services, e.g., lack of awareness/understanding the health system, language barriers, fears of loss of privacy
27
CASE STUDY: COVID-19
Who are most affected by COVID-19 ?
Ethnic minorities have been disproportionately affected by the COVID-19 pandemic; it is unknown whether the same is true for migrant populations
Therefore, you must ask about what are the risk factors for COVID-19 and what are the adverse clinical outcomes in covid-19
Must consider the indirect health and social impacts
28
COVID CASE STUDY: What is the number of cases of migrants having covid?
* Most countries have very poor data collection of migrants, with the exception of NORDIC COUNTRIES (Norway, Sweden, Denmark)
* Migrants are at increased risk of SARS-CoV-2 infection and are disproportionately represented in cases
* E.g. In denmark, 26% of cases are in migrants (to Sep 2020), which is 3x their population share
* In Norwat, 42% of cases are in migrants (to April 2020), 2.5% their population share
* Also, the risk of SARS-Cov-2 infection among refugees and asylum seekers residing in reception camps in Greece was 2.5. to 3x higher than in the general population (to Nov 2020)
* Undocumented migrants, migrant health and care workers and migrants housed in camps & labour compounds are especially vulnerable
29
COVID CASE STUDY: What are the hospitalisation rates in 4 studies?
* There is some evidence that migrants are at greater risk of hospitalisation and ICU admission due to COVID-19
* E.g. in Sweden, 5x higher risk of ICU admission among those born in Africa and the Middle East vs Swedish-born (to Feb 2021
* _Deaths_
* Migrant groups experienced higher all-cause mortality during the pandemic, and potentially COVIS-19 specific mortality
* A study showed that there has been a **relative increase** in the total deaths in 2020 in the Uk compared to a normal year (2018)
* People from central & western Africa were more likely to die compared to the Previous years
30
CASE STUDY: What is the mortality in migrants in sweden compared to the swedish host population?
People born in Sweden was the baseline. Men on the left and women on the right
In Sweden, **migrants from NA and the middle east had 2-3x higher mortality from COVID-19** vs Swedish born ( to May 2020)
31
Why might migrants be disproportionately represented in COVID-19 deaths and cases?
* Exposure:
* High-risk occupations
* Front/line essential workers
* Low job security
* Overcrowded accommodation
* Camps and labour compounds
* Risk
* Restricted access to healthcare
* Immigration status and structural barriers
* Cultural and language barriers
* Inadequate info on COVID -29
* Caused by Cultural/language barriers
32
What are the indirect impacts of COVID-19 pandemic on migrans health?
* COVID-19 pandemic
* Socioeconomic impacts
* Job loss and economic hardship
* Exclusion and discrimination
* Indirect health impact
* Mental health
* Compromised access to health services
33
SUMMARY ABOUT COVID-19 and migrants
* Migrants in high income countries are overrepresented in SARS-CoV-2 infections and COVID-19 deaths
* Migrants face indirect health impacts and social impacts
* Migrants have jigher levels of many **vulnerabilities** and **risk factors** for COVID-19
* Migrants must be specificlly included and targeted in all aspects of the pandemic response
* Robust data collection
* Targeted public health messaging
* Acessible health systems
34
What is the lecture summary\>
The term migrant includes a diverse group of people moving for various reasons with different health needs
Generally, migrants are healthier than host populations, **'healthy migrant effect'**
However, migrants do face **unique threats** to health, these vary accourding to migrant and disease type, and at different stages of migration
In host countries migrants often face **barriers** to **healthcare access**
