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


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          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.

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          Building a tuberculosis-free world: The Lancet Commission on tuberculosis

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            Syndemic vulnerability and the right to health.

            Investigators working both in syndemics, a field of applied health research with roots in medical anthropology, and in the field of health and human rights recognise that upstream social, political, and structural determinants contribute more to health inequities than do biological factors or personal choices. Syndemics investigates synergistic, often deleterious interactions among comorbid health conditions, especially under circumstances of structural and political adversity. Health and human rights research draws on international law to argue that all people deserve access not only to health care, but also to the underlying determinants of good health. Taking the urgent matter of migrant health as an empirical focus, we juxtapose the fields of syndemics and health and human rights, identify their complementarities, and advocate for a combined approach. By melding insights from these fields, the combined syndemics/health and human rights approach advanced here can provide clinicians and other key stakeholders with concrete insights, tools, and strategies to tackle the health inequities that affect migrants and other vulnerable groups by: (1) mapping the effect of social, political, and structural determinants on health; (2) identifying opportunities for upstream intervention; and (3) working collaboratively to tackle the structures, institutions, and processes that cause and exacerbate health inequities. Undergirding this approach is an egalitarian interpretation of the right to health that differs from narrow legalistic and individual interpretations by insisting that all people are equal in worth and, as a result, equally deserving of protection from syndemic vulnerability.
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              Tuberculosis in migrants in low-incidence countries: epidemiology and intervention entry points.

              As tuberculosis (TB) rates continue to decline in native populations in most low TB incidence countries, the proportion of TB patients born outside their country of residence ('foreign-born') increases. Some low-incidence countries have experienced a substantial increase in TB rates related to recent increases in the number of asylum seekers and other migrants from TB-endemic countries. However, average TB rates among the foreign-born in low-incidence countries declined moderately in 2009-2015. TB in foreign-born individuals is commonly the result of reactivation of latent infection with Mycobacterium tuberculosis acquired outside the host country. Transmission is generally low in low-incidence countries, and transmission from migrants to the native population is often modest. Variations in levels and trends in TB notifications among the foreign-born are likely explained by differences and fluctuations in the number and profile of migrants, as well as by variations in TB control, health and social policies in the host countries. To optimise TB care and prevention in migrants from endemic to low-incidence countries, we propose a framework for identifying possible TB care and prevention interventions before, during and after migration. Universal access to high-quality care along the entire migration pathway is critical. Screening for active TB and latent tuberculous infection should be tailored to the TB epidemiology, adapted to the needs of specific migrant groups and linked to treatment. Ultimately, the long-term TB elimination goal can be reached only if global health and socio-economic inequalities are dramatically reduced. Low-incidence countries, most of which are among the wealthiest nations, need to contribute through international assistance.

                Author and article information

                Int J Infect Dis
                Int J Infect Dis
                International Journal of Infectious Diseases
                The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
                26 March 2021
                December 2021
                26 March 2021
                : 113
                : S22-S27
                [a ]Institute for Global Health, University College London, London WC1N 1EH, UK
                [b ]Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
                [c ]Institute for the History of Medicine, University Justus Liebig Giessen, 35392 Giessen, Germany
                [d ]Partners in Health, Lima, Peru, and Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
                [e ]Imperial College London, Department of Infectious Disease, St Mary's Hospital, London, UK
                [f ]Syria Public Health Network, Syria
                [g ]Assistance Coordination Unit (ACU), Early Warning Alert and Response Network (EWARN), Gaziantep, Turkey
                [h ]WHO TB Program, Gaziantep, Turkey
                [i ]Advance Access & Delivery, Durban, South Africa
                [j ]Department of Infection, Division of Infection and Immunity, University College London NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
                Author notes
                [* ]Corresponding author.
                © 2021 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                : 2 February 2021
                : 12 March 2021
                : 16 March 2021

                Infectious disease & Microbiology
                tuberculosis,covid-19,migrant,refugee,health services
                Infectious disease & Microbiology
                tuberculosis, covid-19, migrant, refugee, health services


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