We must screen refugees to ensure no one is left behind: a case study of Malaysia
- 1School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
- 2Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia
- 3Gerontechnology Laboratory, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia
- 4School of Pharmacy, Taylor's University Lakeside Campus, Selangor, Malaysia
- Shaun Wen Huey Lee, School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 46150 Bandar Sunway, Malaysia. E-mail: shaun.lee{at}monash.edu
Abstract
Mandatory screening for tuberculosis should be considered for refugees upon their arrival in Malaysia https://bit.ly/3at5uMV
To the Editor:
The United Nation High Commission for Refugees (UNHCR) estimates that there are approximately 25.9 million refugees worldwide [1]. The adverse living conditions, poor nutrition, low health literacy as well as physical and mental stress encountered by refugees increases the risk of these underprivileged individuals acquiring communicable diseases such as hepatitis, parasitic disease, and respiratory infections including tuberculosis (TB) [2]. As such, rapid diagnosis and appropriate treatment among all refugees for active TB as a strategy to control TB should be a global priority to achieve the United Nations Sustainable Development Goals on ending the TB epidemic by 2030, which is aligned with the World Health Organization (WHO) End TB Strategy [3].
In Malaysia, there are approximately 178 990 refugees and asylum-seekers registered with UNHCR Malaysia mainly originating from Myanmar, Pakistan and Yemen [1]. Since Malaysia is not a signatory to the 1951 Refugee Convention, it only serves as a transition platform for refugees to have temporary shelter before transferring to another country for official resettlement. Thus, they are not entitled with any right for the access of basic health service, education and employment [2]. Active screening of refugees would only be conducted prior to their resettlement, but data suggest that more than one-fifth of the reported TB cases in Malaysia were from non-residents, many of which are refugees [4]. A recent study has shown 12.8% of refugee children in Malaysia were tested positive for latent tuberculosis infection (LTBI) [5]. The plight of the refugees, coupled with a lack of stringent enforcement on health screening among refugees before and upon arrival, increases the risk of acquiring TB infection, which progresses into TB disease.
As a consequence, the control of TB transmission in Malaysia will remain a challenge without additional and appropriate intervention for compulsory TB screening among refugees. The increase in number of reported TB cases and deaths due to TB corresponding to the influx of refugees is illustrated in figure 1. Malaysia is accommodating more than 100 000 Rohingya and Syrian refugees following their respective conflicts, with 101 010 registered Rohingyas, 2500 unregistered Rohingyas and up to 3000 Syrians seeking refuge in Malaysia [1, 6, 7]. To further complicate matters, most refugees have very poor health literacy, which worsens the problem [2]. Despite the legal and administrative predicaments on refugees in Malaysia, basic health screening, particularly on preventable infectious disease, should not be disregarded because TB could be transmitted to local communities who have routine interaction with the refugees.
The findings from a review by Dobler et al. [8] highlighted the importance of conducting pre-immigration TB and LTBI screening among high risk migrants including refugees and asylum seekers arriving from countries with high TB incidence, followed by treatment for those with confirmed diagnosis together with post-immigration follow-up on health surveillance. While screening all refugees may result in considerable strain on the limited healthcare resources available in Malaysia, high risk groups such as children, the elderly, and close contacts should be given priority [9]. In view of the considerable surge of TB incidence in Malaysia following the 2015 Rohingya refugee crisis (figure 1), this can be one of the plausible efforts to ensure early detection for TB, multidrug resistant-TB (MDR-TB) or LTBI, and ensure that patients are referred for immediate treatment. This procedure not only prevents further TB transmission from refugees, it also prevents the possibility of recalcitrant MDR-TB and TB reactivation from individuals with LTBI.
Nevertheless, this will require political commitments at the highest levels to achieve the milestones advocated by the WHO End TB Strategy. As universal health coverage and access to healthcare is a human right as enshrined in the United Nation Universal Declaration of Human Right Article 25, we should ensure that any health initiatives should encompass not only citizens of its country but also refugees [10].
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Footnotes
Conflict of interest: Y.J. Wong has nothing to disclose.
Conflict of interest: S.W.H. Lee has nothing to disclose.
- Received February 23, 2020.
- Accepted March 24, 2020.
- Copyright ©ERS 2020