Tuberculosis treatment outcomes of non-citizen migrants: Israel compared to other high-income countries

Immigration policies and shifting migration patterns over the past five decades have brought larger numbers of permanent and temporary migrants from regions of the world with a high incidence of active TB to areas with a low incidence [1]. Nearly 50% of TB cases in low-incidence countries are among foreign-born residents and citizens [1]. Among the 33 countries defined as being in the pre-elimination phase by the WHO in 2015, the proportion of foreign-born TB cases notified in 2012 for selected countries were as followed: Israel – 90%; Australia – 87%; The Netherlands – 73%; and the USA – 63% [2]. The United Kingdom, while not in the pre-elimination phase, has 73% of tuberculosis incidence among foreign-born migrants. However, policies regarding TB management for migrants in these countries are not clearly stated, especially for migrants without official legal status [1].

Trends in foreign-born TB cases vary across countries. In Israel, studies focused on migrants who obtained Israeli citizenship, as non-citizen migrants were a marginal proportion of the population prior to mass migration from high-endemic countries beginning in 2006 [3‐6]. Australia’s proportion of TB in foreign-born people has risen steadily over the past 15 years, despite decreases in overall incidence [2, 7]. Since 2000, migrants to Australia have contributed to more than 80% of TB cases [2, 7]. In the Netherlands, TB incidence is closely linked to the inflow of migrants and asylum-seekers [8, 9]. TB cases reported in the UK were 15 times higher among foreign-born migrants than the UK-born population [10]. In 2016, foreign-born individuals accounted for 66.2% of the reported cases in the US [11]. In the same year, the US saw an increase in the number of TB cases, the second time in 23 years the rate did not decline.

In these countries, migration presents a significant challenge for TB surveillance and control, particularly due to the tentative or undocumented status of many migrants. Subsequently, data specific to undocumented migrants are often missing or underestimated. Policies in low TB incidence countries are often imprecise concerning care for undocumented migrants, and sometimes for refugees, asylum seekers, and otherwise classified migrants [11‐13]. In this study, we explore the current policies of five high-income countries regarding TB patients who are non-citizens of these countries.

Five high-income countries, 4 of which had a significant proportion of foreign-born cases as notified in 2012 were selected, and a search of multiple databases (The Cochrane Database of Systematic Reviews, MEDLINE and EMBASE) was conducted in order to identify relevant articles on TB control policy among non-citizen migrants and TB treatment outcome published between January 2000 to August 2017. We used keywords in various combinations: ‘tuberculosis OR TB’ AND ‘Non-citizen’ OR ‘undocumented migrants’ OR ‘migrants’ OR ‘refugees’ OR ‘asylum seekers’ OR ‘foreign-born’ AND ‘policy’. Articles for which at least an English abstract was available were included.

In addition, TB treatment outcome among migrants diagnosed in Israel for the years 2000–2014 were analysed retrospectively. Data were used from the Israeli National Registry of TB at the Department of Tuberculosis and AIDS, Ministry of Health (MoH). Data from the 4 other countries for similar years were extracted from the literature or were sought through contacting medical officers in charge of TB control and/or surveillance in these countries (Dr. Gerard de Vries for the Netherlands & Dr. Maeve Lalor for the UK), and/or through the national website (for Australia and US). Incidence rate and TB outcomes were also determined. The data obtained were analyzed using IBM SPSS version 20.

Three hundred and nineteen articles and abstracts written in English, French, Spanish, Italian and Portuguese were considered. After screenings of the titles and abstracts, 59 studies were reviewed and 18 articles were used to generate the results (see Table 1 & Fig. 1). Articles that were not focused on TB Policy were excluded.

A major finding in the literature was the insufficient TB data on non-citizen migrants and the difficulty of stating clearly the distinction between a non-citizen migrant and a foreign-born migrant, and different application of these definitions across countries. Most of the literature focused on data on the foreign-born ignoring the possibility that some foreign-born could be eligible for citizenship on arrival or after several years in the low incidence TB country. This could be partly explained by the logistic difficulties of distinguishing between documented and undocumented migrants, which are often coupled with legal national restrictions concerning identified notifications [24].

In Israel, most non-citizen migrant TB patients originate from the Horn of Africa. This was also similar to the findings of previous studies which detected a significant increase of TB in immigrants who migrate to high-income countries [36]. We observed differences (p < 0.05) in the HIV infection and TB in migrants in Israel with migrants from African regions being the highest. Similar findings were seen in a previous study in the UK [36].

From 2000 to 2015, incidence rates of TB among non-citizen migrants fell between 10.5–71.5% in the countries of study. Across all the countries under study, Israel reported the lowest TB incidence rate among migrants and the UK reported the highest at the end of 2015. This low incidence rate was achieved despite Israel having the third lowest incidence rate among migrants in 2000. It’s important to note that, in addition to meeting the pre-elimination target during the years of study in the total population, Israel neared this target in the non-citizen migrant sub-population. Direct comparisons between countries must be made with caution, as the characteristics and health determinants of persons screened vary by both by country of origin and destination.

The successful outcome of TB treatment among non-citizens migrants may be attributable to the policy in various countries. However, not all countries under the current study could provide data on non-citizen migrant treatment outcomes. Countries who could provide this data also had migrant-friendly TB policies, with the most success in the Netherlands, where social assistance is provided to TB patients during their treatment. Additional social welfare may explain why TB treatment outcome in the Netherlands is higher than other countries under study.

WHO has emphasized that TB diagnosis and treatment must be free of charge for all migrants [2, 17]. This has guided some low-incidence countries to have low-cost or free TB treatment. However, problems for migrants to access treatment persist. Some low-incidence countries do not provide free TB care at a national level, as is the case in the US [2, 11]. In the UK, undocumented migrants may be excluded from national health services or insurance schemes, which limits overall service access. Moreover, while access to TB is universally accessible on paper in the UK, other important barriers can restrict access and adherence, including language, stigma, and discrimination [2]. In The Netherlands, where health insurance is available for non-citizen migrants, co-payments can constitute financial barriers for some.

Migrants in the US do not have completely free access to TB care and are provided treatment at a cost to the individual either as co-payment where health insurance is made available or out of pocket spending [12, 33, 37, 38]. This may discourage migrants who do not have a source of income to start treatment when diagnosed with active TB, especially migrants who are not legal residents in the country [2, 33].

In addition to policy and other barriers in the countries in the present study, the WHO notes further barriers for migrants in accessing TB care, including fear of being reported to migration officials and/or deported during treatment [24].

Interestingly, Israel created this policy over a decade before the WHO recommendation. This may greatly contribute to the success of TB control in this country [4, 22, 27]. The percentage of successful treatment outcome in Israel was high, particularly for a population considered difficult to reach [4]. The early implementation of a care-for-all strategy for TB may have contributed to the high rate of successful treatment among non-citizen migrants.

Lack of data on the outcome of TB treatment among non-citizens in the selected countries is a drawback to describing the relationship of each countries policy with respect to the treatment outcome. The US was the only country under this study that does not have a national policy for universal TB care, though many individual states within the US do extend no or low cost TB care. This study supports that TB policies that extend care to non-citizen migrants, including the undocumented, is essential for TB elimination. Moreover, this study highlighted the difficulties of researching TB among non-citizen migrants, as countries operate on their own definitions of migration and citizen type. There is a global need to standardize the definitions of migrants for research purposes. Israel’s trailblazing policy to provide TB care regardless of citizenship status extended care to a large percentage of the TB case load. Following the Netherlands’ model, TB treatment success among this population in Israel may benefit from additional social assistance during treatment to increase compliance and ability to complete treatment, including housing and cost of living.