Overview
Tuberculosis (TB) is the result of the interaction between the TB bacilli and the body’s immune system. In the WHO European Region, 1 in 7 people are infected with TB, but are not ill with the disease – this is called TB infection (TBI). Up to 10% of people with TBI develop TB disease at some point in their lives. High exposure to the TB bacilli and/or lower immune defenses increase vulnerability and therefore the chances of developing the disease.
TBI management requires specific guidance and is particularly relevant to sustaining the TB elimination phase in countries with low and intermediate TB incidence. WHO is developing evidence-based guidance and providing tailored support to countries in the European Region to improve TBI management and prevent the development of future epidemics.
Socioeconomic determinants and health-related risk factors for TB
The TB epidemic is strongly influenced by social and economic development, health-related risk factors and access to health care. Socioeconomic factors such as poverty, inequality, food insecurity and inadequate living and working conditions increase the risk of TB infection, disease progression and challenges in managing treatment – including its medical, financial and social demands. As a result, TB is primarily concentrated in settings affected by poverty and other socioeconomic challenges, disproportionately impacting the most vulnerable populations. Key health-related risk factors, including undernutrition, HIV, smoking, diabetes and substance use disorders, heighten the risk of developing TB. When combined with TB, these health conditions may lead to poorer treatment success rates.
Addressing the socioeconomic and health-related determinants of TB requires a coordinated, multisectoral approach that strengthens collaboration across sectors and health programmes to deliver people-centred services.
Multisectoral action on social and economic determinants of health can significantly improve TB prevention and care through policies that:
- implement comprehensive poverty reduction strategies and expand social protection;
- reduce food insecurity;
- enhance living and working conditions;
- improve environments in prisons and other congregate settings, such as refugee camps, nursing homes, transitional housing and university campus housing;
- address the social, financial and health needs of migrants; and
- promote healthy diets and lifestyles, which include reducing smoking and the use of alcohol and illicit drugs.
By integrating these measures, we can accelerate efforts to end TB and improve health outcomes for vulnerable populations.
Vulnerable populations
Prisoners, migrants and socially marginalized people are particularly vulnerable due to the increased exposure associated with their living conditions. People living with HIV or suffering from other conditions that weaken the immune system, such as diabetes, are especially vulnerable because this greatly increases their risk of developing the disease. Children are also vulnerable because of their weaker immune systems.
TB and migration
While usually fit to travel, migrants may have a higher risk of becoming infected or developing TB depending on: the TB incidence in their country of origin; the conditions experienced during their travel (physical stress and contact with infectious cases in camps and prisons); and their living and working conditions in the host country, including access to health services and social protection. Active disease occurs in only a proportion of those infected, and in half of the cases – 5 years after immigration.
TB is rarely transmitted from migrants to the resident population due to its low infectiousness and the limited social mixing of the two populations.
In consideration of the higher risk of TB for migrants, it is important to carry out tailored TB screening aimed at early detection and treatment of TB infection and disease. TB must, however, never be used as a reason to limit access to uninterrupted treatment through deportation. The continuum of care must be ensured at all levels and through appropriate cross-border communication and follow-up.
Minimum package of cross-border TB control and care interventions
Universal health coverage should be ensured for refugees and migrants, both documented and undocumented. The WHO European Region established a consensus on the minimum package of cross-border TB control and care interventions. These include ensuring access to medical services irrespective of a migrant’s registration status and a non-deportation policy until intensive TB treatment has been completed.
As part of the implementation of the package, WHO supports cross-border management of TB cases by facilitating communications among clinicians from different countries (in terms of sharing information for clinical management, contact tracing and referral of patients).
TB in prisons
In the WHO European Region, TB remains a major infectious disease in the prison system, especially in eastern Europe. Prisons are considered reservoirs facilitating TB and multidrug-resistant TB transmission within their walls and to the community at large. Transmission occurs through prison staff, visitors and released inmates.
Prison system challenges in TB control
- Prisoners tend to come from high-risk groups of the population and are in general poor health, have little education and come from socioeconomically deprived sectors of the population, where TB infection and transmission are higher. They have often had limited access to health care and suffer from additional health problems such as alcoholism, tobacco smoke, drug addiction and HIV.
- Prisons have high exposure to TB because of factors that cause infection and progression of the disease. These include overcrowding; poor ventilation; frequent transfer of prisoners between prisons; poor infection control practices; poor nutrition; limited access to health care, with delays in diagnosis (due to insufficient laboratory capacity and diagnostic tools); and inadequate treatment (for example, interrupted supply of medicines).
As a result, notified TB cases in European prisons are, on average, 17 times higher than in the general population – ranging from 11 times higher in western Europe to 81 times higher in eastern Europe.
Improving TB control in prisons
Improvements can only be achieved with government commitment, interventions equivalent to those in the civilian system and in close collaboration with it, and partnerships with civil society organizations.