The UK government has recently announced that migrants from at least 67 countries who intend to stay more than six months will need to have a TB test before applying for a visa. After years of progress in the global fight against TB, it has now clear that a major epidemic of the diseases again and the WHO predicts the situation will become worse in coming years unless steps are taken to improve better prevention and treatment of the disease.
TB is not a new challenge to Europe. TB was a major killer throughout the region and it has only been in the last 50 or so years that most (but not all) European countries have seen a major improvement in the prevalence of what is still a life-threatening disease. Rightly or wrongly, TB has also been typically seen as a disease imported by newcomers and most so-called “receiving” countries have instituted steps to assess migrants for their TB status. Some countries, such as the USA and Canada, have elected to screen people prior to their emigration or departure. Others have adopted on-arrival screening policies and practices.
Screening for any diseases is always costly and open to problems of sensitivity and specificity. Additionally, we believe that many of the screening policies and practices currently in place have not proved particularly effective. Pre-migration screening, for example, does not pick up cases of exposure to TB during the course of migration and on-arrival screening appears not to pick up a large proportion of all the people that go on to develop TB well after arrival. Screening for TB has also been associated with both real and perceived discrimination. Some countries in the Gulf, for example, refuse entry to people with TB and the USA, Canada and Australia require people who test positive for TB to complete a course of treatment before reapplying for a visa. The fear of being rejected entry as a result of TB has lead to considerable corruption around pre-migration screening and to various other ways of avoiding screening. The reality is that a significant proportion of all TB identified in migrants after entry is probably linked to the working and living conditions into which migrants in most parts of the world are directed. Migrants typically move into low-income neighborhoods, poor quality houses that are overcrowded and poorly ventilated. Many TB experts believe these are the prime conditions for transmission of TB. Low-income migrations also tend to eat poorly and invest less in health care, thus exacerbating the risk of TB. If TB in migrants is to be prevented and controlled, existing policies and practices on screening need to be reassessed and steps need to be taken to tailor screening to the realities of exposure and reactivation of latent TB. TB screening also needs to be presented much more forcefully as a nondiscriminatory practice and as one designed simply to identify those people who should be and are eligible for quality treatment.