Tuberculosis among migrants in Bishkek, the capital of the Kyrgyz Republic
O. Goncharova O. Denisiuk R. Zachariah K. Davtyan D. Nabirova C. Acosta A. Kadyrov
Setting: Twenty-two first-line, two second-line and one tertiary health facility in Bishkek, the capital of Kyrgyzstan.Objectives: Among migrants, a marginalised population at risk for acquiring and transmitting tuberculosis (TB), we determined the proportion ...
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PubMed Central (PMC)
Migrants are a vulnerable and often marginalised population at risk of acquiring and transmitting tuberculosis (TB). Migration, whether internal or cross-border, poses a major challenge to TB control in both high- and low-resource countries.1,2 This is because migrants encounter challenges in accessing care, and much TB in migrants may remain undiagnosed.3–5 Furthermore, those initiating anti-tuberculosis treatment may be unable to complete treatment for various reasons, including change in residence, limited access to longer-term housing, poor socio-economic status and variable access to health care services.4–6 These factors contribute to loss to follow-up (LTFU) and death, compromising TB treatment success in migrants. Improving the level of successful TB treatment in this group is an important element in controlling the global TB epidemic. This is of particular concern in the World Health Organization (WHO) European Region, where both multidrug-resistant (MDR) TB and migration are on the rise.7 Finding ways to improve access for hard-to-reach and vulnerable populations, including migrants, is an operational research priority.8,9

Kyrgyzstan is one of the 27 countries with the highest TB and MDR-TB burdens in the world.7 It has a large, seasonal and vulnerable migrant population that migrates internally and from neighbouring countries to the capital city of Bishkek. The vulnerability of migrants is accentuated by unfavourable employment conditions, illegal status and barriers to health care access.2 This may contribute to treatment-seeking delays, increased disease severity and transmission of MDR-TB.10 Preventing TB, by stopping the progression from infection to active disease and treating active cases effectively, is also very important for the performance of TB epidemic control.

A PubMed search on TB in migrants revealed no publications on TB programme performance among migrants in Kyrgyzstan or the neighbouring regions. Such information provides a yardstick to guide future TB treatment strategies. Improving TB treatment in migrants is also vital to achieving the global targets for TB control and eventual elimination by the year 2030.9

We therefore aimed to report on the proportion of migrants with TB and how well they fared on treatment. Specific objectives were to report on the overall numbers and proportion of migrants registered with TB in all types of health facilities in the capital city of Bishkek. For migrants who were registered at first-line health facilities (family medicine centres), we then reported on 1) their demographic and clinical profile, including the presence of drug resistance; 2) TB treatment outcomes; and 3) the characteristics and factors associated with unsuccessful treatment outcomes.

DISCUSSION

This first study on TB treatment outcomes among migrants in Kyrgyzstan shows that almost half of all registered TB patients in Bishkek city were migrants. Approximately one third (27%) of the migrants had crossed international borders, and MDR-TB was prevalent in almost one in ten individuals. Treatment success was 74% in new cases and 44% in retreatment cases, far below the desired WHO target of 85%. Unsuccessful treatment outcomes were mostly related to treatment failure and LTFU.

This study stems from a region where both internal and cross-border migration is common. It is likely to be of practical relevance to the WHO's consolidated action plan for improving TB prevention and care in hard-to-reach populations, including migrants.8

This study has several policy and practice implications that merit discussion. First, the fact that almost half of all registered TB patients in the study were migrants emphasises the need for the NTP to fully embrace this group as an integral part of TB control. Importantly, improving TB control at national level would depend on how well TB control is addressed in migrants. The fact that half of all migrant TB patients in our study were smear-positive and therefore infectious, including drug-resistant cases, makes this all the more relevant.

A first step to embrace TB care for migrants in Kyrgyzstan is for the NTP to formulate national guidelines that can be used by all levels of the health system.

Second, the treatment success rates of 74% for new TB and 44% for retreatment TB cases compare well with reports from other urban settings.15,16 However, as migrants are a high-risk group for both acquiring and transmitting TB, we should be striving for much higher rates of treatment success—better, in fact, than those in the general population.

Third, we observed a relatively high failure rate of 8% in new TB and 25% in retreatment TB cases. One of the main reasons for this is that all diagnosed patients were first placed on standardised treatment regimens while awaiting DST results. When drug resistance was detected, they were then declared as failures and consequently moved to the MDR-TB regimen. The way forward is to offer Xpert as a first-line diagnostic test for all migrants with presumed TB. Those with rifampicin-resistant TB should be placed directly on an MDR-TB regimen while awaiting their DST results. Although this is now the national protocol, we suspect practical problems of access. This merits specific research. Meanwhile, greater decentralisation of existing Xpert machines and prioritisation of migrants may need to be considered.

Fourth, we have identified a number of risk factors associated with unfavourable treatment outcomes, including male sex, single status, age > 25 years, retreatment TB cases and PTB. These groups could benefit from focused attention at programme level. Being male, single and aged >25 years may be linked to unfavourable health-seeking behaviour or lower levels of adherence, issues that are linked to migratory status. These two groups might be constantly searching for employment and economic opportunities. Specific qualitative research in this area is merited. The retreatment category of TB and patients with PTB were also identified as risk factors for unsuccessful outcomes. These two groups may have more severe clinical status at presentation. In particular, adherence to treatment in retreatment TB cases is more difficult, as the drug regimen involves injections, which requires patients to be close to health facilities. This may be practically difficult with migrant populations.

Finally, LTFU in both new and retreatment TB cases was high and may be explained by patients having to leave one geographic area for another in search of employment.

Possible ways to address this issue could include the following: 1) informing patients that if they wish to change their geographic area they can do so, and that they would be given a formal referral letter to another health facility to maintain TB treatment. A buffer stock of drugs could be offered as a safety net, and feedback on treatment outcomes should also be communicated to the referring facility. 2) Kyrgyzstan is planning to introduce an online electronic TB register system. The use of formal referral letters between health facilities, coupled with the introduction of a unique referral identity code, should facilitate information transfer and tracing at national level. This should be combined with increased efforts for patient awareness and empowerment for continued TB care. 3) The issue of ensuring continued care for cross-border TB migrants is more complex and needs greater regional and inter-country collaboration. We call on the WHO, national governments and other stake holders to urgently continue initiatives that can foster such collaboration.17

The strengths of the study include the following: 1) as all health care facilities involved with TB in Bishkek were included, the findings are thus likely to reflect the operational reality in the urban setting; 2) the focus on first-line health care facilities, which are the first point of contact with the health system, provides a good yardstick of the basic quality of TB care being offered to migrants; and 3) the study adhered to the Strengthening The Reporting of OBservational studies in Epidemiology (STROBE) guidelines on the reporting of operational research.14

A limitation of the study is that we used the definition of ‘migrant’ as recommended in Kyrgyzstan, which may not necessarily be the same for other countries in the region. Reaching agreement on a standardised definition of a TB migrant for all countries in Central Asia would seem a logical step and a priority to allow geographic comparisons in the region. Another limitation is that we did not include second-line and tertiary health facilities in our assessment of treatment outcomes. Our findings may thus reflect a ‘best case’ scenario. Third, our database did not contain specific information on whether patients with drug resistance were offered Xpert testing. This should be included in the database, as it would permit a good measure of the access to this rapid test. Finally, we were unable to compare the risk factors associated with poor outcomes in the region due to a paucity of published literature.

In conclusion, we have highlighted several possible ways of improving the quality of TB care for migrants. In a part of the world where drug-resistant TB is a major public health problem, making significant strides towards improving TB control for migrants is vital.