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Why migrants must not be left behind in the fight against TB

The WHO TB statistics for India 2016 give an estimated incidence figure of 2.79 million cases.

The Economic Survey of India 2017 estimates that the magnitude ofannual inter-state migration was approximately 9 million. However,while Census 2011pegs the total number of internal migrants in the country (accounting for inter- and intra-state movement) at a staggering 139 million. Uttar Pradesh, Bihar, Madhya Pradesh, Punjab, J&Kare key source states; the destination states being Delhi, Maharashtra, Tamil Nadu, Gujarat, Andhra Pradesh and Kerala.It has been found that in some regions, three out of four households include a migrant.[1]

India has the highest burden of TB. The WHO TB statistics for India 2016 give an estimated incidence figure of 2.79 million cases. Multidrug resistant TB (MDR) is a cause of increased morbidity and mortality.TB affects poor and vulnerable populations; including migrants who are also vulnerable due to overcrowded living conditions, delayed diagnosis, poor levels of awareness and healthcare seeking behaviours andlack of treatment adherence. MDR-TB management among migrants is also challenging due to limited access to drugs and lack of isolation facilities and quality laboratories. Migrants also cannot access health and family care programmes due to their temporary residential status. A study under the Revised National TB control programme (RNTCP) in Tamil Nadu highlighted migration as one of the reasons for discontinuation of treatment[2].

In addition, forced displacement of persons after conflict or a natural disaster is often associated with an increased risk of TB due to factors such as malnutrition, overcrowding in camps or shelters and disruption of health services.Emergency response is usually limited to acute diseases such as cholera and measles outbreaks, leaving chronic conditions like TB unattended until much later when existing national health systems begin to recover and cope with increased health care demands following a crisis situation.

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On 19 May 2014, the 67th World Health Assembly (WHA) adopted the new global TB strategy with targets and benchmarks until 2035which aim to end the global TB epidemic.. The strategy builds on a "know your epidemic" approach and focuses particularly on serving those not reached the most vulnerable and marginalized populations. In line with the principles and three pillars of the new strategy, and resolution, TB and migration can be addressed through:

[1] Ravi Srivastava. An over view of migration in India, it's impacts and key issues. Jawaharlal Nehru University, New Delhi, India

[2]Sudha Ganapathy, Chandrasekaran V, Britto JJ, Jemima SF, Cahrles N, Santha T, Sudarsanam NM, Prabhakar R. A study of patients 'lost' from treatment under the district tuberculosis programme in south India.

Migrant-inclusive National TB Plan:

- Advocating the burden of TB among migrants and their needs in epidemiological assessments and national programme reviews.

- Including migrants in country processes for development of national TB strategic plans and resource mobilization.

- Strengthening country monitoring systems to include disaggregated data on migrants, where relevant.

Migrant-sensitive CARE and Prevention:

- Sensitizing health personnel and building a cultural competency reflective of migrants' TB needs.

- Ensuring that TB diagnostics, treatment and care services are adapted to the needs of migrants, including MDR-TB, TB/HIV management and access to new TB technologies.

- Establishing cross-border referral systems with contact tracing and information sharing to ensure continuity of care for migrants and harmonize treatment protocols across borders along migration corridors.

- Empowering migrant communities through social mobilization and health communications.

- Adopting policies and/or regulations which improve migrants' access to services, financial and social protection, regardless of status

India has shown high political commitment in ending TB by 2025 with Prime Minister reiterating this commitment to end TB by 2025at the Delhi END TB SUMMIT.The momentum gained shouldnot be lost and shouldmove forward into a larger and longer marathon involving all key stakeholders.There is a need to build reliable country statistical systems to include disaggregated data on migrant types, and migration-related variables (in routine health data monitoring and TB prevalence surveys). The RNTCP needs to make better use of administrative data such as census, labour surveys, immigration records and education data to identify migrant groups and ensure disaggregation of TB-related information. There is need to have interfaces between health and other migration data management mechanisms. We need to study the economic impact of not addressing TB among migrants, cost-effectiveness of active TB screening programmes and TB funding practices for hard-to-reach migrants to inform future migration health policies. Migrants' should have access to innovative TB technologies and services and should be empowered through social mobilization and health communications.

Recently, as per a Government notification issued on 21 March 2018, failure by clinical establishments to notify TB patient to the nodal officer and local public health staff would be a punishable offence with a jail term of six months to two years. Most migrant workers in India are employed in the unorganised sector, with or without permanent addresses, so it needs to be seen how the issue will be addressed in the times to come. Will stringent penalties improve their access to TB care or leave them unattended in the end game TB strategy?

[1] Ravi Srivastava. An over view of migration in India, it's impacts and key issues. Jawaharlal Nehru University, New Delhi, India

[1]Sudha Ganapathy, Chandrasekaran V, Britto JJ, Jemima SF, Cahrles N, Santha T, Sudarsanam NM, Prabhakar R. A study of patients 'lost' from treatment under the district tuberculosis programme in south India.

By Dr Rita Prasad, CARE India

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