Public Health Policy Can Augment Threat Posed by Infectious Diseases: Public Health Watch

At a time when countries are closing borders to migrants and refugees—and tourists—as part of their efforts to contain the coronavirus disease 2019 (COVID-19) pandemic, the findings of a new study suggest that denying these same populations health care services can lead to delays in the diagnosis and treatment of tuberculosis (TB), not to mention other infectious diseases.

Indeed, the public health implications of this research, which was published on April 20^th by BMC Public Health, have arguably never been more obvious. The authors observed that, following the implementation of the UK's National Health Service (NHS) Visitor and Migrant Cost Recovery Programme (CRP), in 2014, the number of years migrants had been living in the UK prior to TB diagnosis increased from 10 years to 14.8 years.

In addition, the average number of days between symptom onset and starting treatment rose from 69 to 89 days following the enaction of the new policy.

“The earlier you identify an infectious disease in an individual the sooner you can institute infection control measures and begin treatment,” study coauthor Jessica Potter, PhD, Honorary Clinical Lecturer, Queen Mary University of London’s Centre for Primary Care and Public Health, told Contagion^®. “With infectious cases of TB, the sooner effective treatment is started, the sooner that person will stop being able to spread infection to other people.”

She added, “The same issues are very much relevant to all infectious diseases, including COVID-19. If you know you are infectious, you can take measures to prevent the transmission of that infection, and accessing testing requires an ability to access the health system for anyone at risk of the disease. That includes everyone.”

The British government established the NHS Visitor and Migrant CRP to recoup costs from “chargeable”—primarily non-UK born—patients who are not entitled to free NHS care. Potter and her colleagues analyzed data from the London TB Register on 2,237 TB cases diagnosed between 2011 and 2016 within the Barts Health NHS trust, which serves 3 East London neighborhoods and treats more than 500 patients with TB annually. This represents approximately 10% of all TB cases in England.

The authors attributed the delays in diagnosis and treatment to a number of factors. They noted that earlier research has suggested that migrants in the UK are often not aware that they are entitled to NHS care and that their concerns about being charged for treatment may cause to delay seeking health advice of any kind. Although they acknowledge that their analysis focuses on a relatively small geographic area, their findings may be applicable to other regions of the country that have similar migrant populations and have been subject to similar policies.

“Access to diagnosis and treatment is a central part of TB control strategies globally, (and) it is important to note infectious diseases in many countries are exempt from charging systems,” Potter noted. Still, “(e)xemptions to charging cannot overcome barriers to accessing care and will therefore not limit the spread of infectious disease.”

Not surprisingly, given where she lives and lectures, most of Potter’s recommendations for change focus on the UK. However, they can certainly be modified and applied to other nations across the globe, particularly in the midst of the ongoing pandemic. At their essence, the objective is to reduce the barriers to care for those most in need.

“I want the UK government to scrap charging for health care—this means suspending the NHS charging regulations and scrapping the immigration health surcharge,” she said. “In addition, it is vital people are not afraid to seek help when they are unwell and so there must be a firewall between the UK Home Office, which manages immigration, and the NHS. Data-sharing between these two bodies has been used to aid deportation of people living in the UK without the legal right to do so and there is clear evidence this deters people from seeking help when they are unwell. We must also address broader anti-immigration sentiment and structural racism, both of which shape how people access health care.”