Volume 195 - Issue 9
Cross-border patients with tuberculosis
Authors: Paul N Reynolds, John D Turnidge, Thomas Gottlieb and Michael J Moore
Med J Aust 2011; 195 (9): 523-524. || doi: 10.5694/mja11.10945
Published online: 7 November 2011
Published online: 7 November 2011
Position statement from the Thoracic Society of Australia and New Zealand, Australian Society for Microbiology, Australasian Society for Infectious Diseases and Public Health Association of Australia
Many high-income countries with a low incidence of tuberculosis (TB) are confronting the complicated issue of the cross-border movement of people with TB from neighbouring low-income countries with a high burden of TB. Well documented examples where this is an issue include the United States–Mexico border and Scandinavian countries adjacent to Russia and the Baltic States.1,2 In Australia, we face similar dilemmas, not only with Papua New Guinea (PNG) nationals crossing into the Torres Strait Protected Zone, but also with fisherpersons illegally entering our territory, temporary residents on short-term work visas and students attending tertiary education institutions.
Cross-border communicable diseases present a complex mix of clinical, public health, humanitarian, ethical, political and financial issues for governments and health care providers. Fortunately, international organisations have provided guiding principles that should underpin a country’s response to cross-border TB cases. For example, the World Health Organization (WHO) has published ethical guidelines for care of patients with TB and control of the disease.3 This document states that:
. . . all governments have a fundamental obligation to provide universal access to high-quality TB diagnosis and treatment . . . universal access to TB care implies a duty to ensure the quality of that care . . . The international community must provide financial and technical assistance to countries that lack the resources to satisfy this obligation on their own.
These ethical guidelines are based on numerous values including equity, solidarity, and common good (as providing effective TB treatment prevents ongoing transmission of disease, and thereby benefits everyone). Similar recommendations are made by two complementary documents, The patient’s charter for tuberculosis care (PCTC) and International standards for tuberculosis care (ISTC).4,5 These principles are also embodied in the final draft of the Australian National TB Strategic Plan (2011–2016), which is expected to be published in early 2012.
In view of these international ethical guidelines, the Thoracic Society of Australia and New Zealand (TSANZ), the Australian Society for Microbiology (ASM), the Australasian Society for Infectious Diseases (ASID) and the Public Health Association of Australia (PHAA) believe that Australia’s response to any situation involving cross-border TB cases should be based on the following four principles.
All patients with TB who present to health care services within Australia’s borders should have free and equal access to TB care from diagnosis to completion of treatment, irrespective of their legal status or other demographic characteristics as outlined in the PCTC.4
Health professionals dealing with these complex issues must have enough support from the relevant Australian state and federal health agencies to enable them to implement best-practice care, and should be closely engaged in the process of consultation about service delivery.
Patients should only be transferred to their home country for ongoing care when the TB service in the responsible Australian state is satisfied that the patient’s ongoing care will be of a suitable standard that meets the ISTC.5
Australia should provide financial and technical support to neighbouring countries where TB is endemic, so that they can develop national TB programs meeting the ISTC standards to which Australia’s TB services can confidently return international patients, who are increasingly mobile. The development of these programs may demand an ongoing investment over many years.
The complexity and cost of treating multidrug-resistant tuberculosis (MDR-TB) or TB/HIV co-infection compound the dilemmas in providing cross-border TB care. WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than for treating a patient with drug-susceptible TB.6 Poor standards of care of patients with cross-border mobility place nations on both sides of the border at risk of dissemination of untreatable drug-resistant disease. Based on the same values of equity, solidarity and common good, the international ethical guidelines argue that the universal right to receive medical advice and treatment must extend to patients with MDR-TB and/or HIV infection.3,4 The TSANZ, ASM, ASID and PHAA therefore recommend that the above four principles should also apply to cross-border patients with MDR-TB or TB with HIV co-infection.
Initial substandard care of patients with drug-susceptible TB is the greatest contributing factor to the development of MDR-TB and extensively drug-resistant TB. MDR-TB in expatriates therefore suggests that the national tuberculosis program in their home country is failing. Hence, health care professionals and governments who propose repatriating patients with MDR-TB must be wary of the level of care that will be available when those patients arrive home. The Green Light Committee, an MDR-TB working group that advises WHO and evaluates applications from countries for access to second-line antituberculosis drugs, has developed a set of criteria for assessing nascent MDR-TB treatment programs in low-income countries.7 These criteria include the level of government commitment and funding, the availability of medical personnel trained and experienced in managing MDR-TB, access to supporting laboratory services that are externally quality controlled, the reliability of second-line drug supplies, and existing strategies to assure patient adherence to treatment regimens. Australian governments and state TB services should use the same criteria when determining whether cross-border patients with MDR-TB can be safely returned to their home country for ongoing care.
Although they are ethically justified, the above four principles for the care of cross-border patients with TB may appear financially onerous. Interestingly, modelling has found that increasing United States investment in TB programs in Mexico, Haiti and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants, and produce net cost savings for the US.8
The TSANZ, ASM, ASID and PHAA therefore strongly support the four principles described above for the care of cross-border patients with TB on ethical, clinical and public health grounds (including the protection of Australian citizens), and we believe this approach is economically justified. It is critical that all parties involved in providing care of cross-border patients with TB work together to ensure that the necessary outcomes are achieved.
Competing interests
No relevant disclosures.
References
- Centers for Disease Control and Prevention. Preventing and controlling tuberculosis along the US–Mexico border: work group report MMWR Morb Mortal Wkly Rep 2001; 50: 1-28. 0_i1140259
- Bernitz BK. Communicable disease policy development in response to changing European political frontiers in Finland, Norway and Sweden? Scand J Public Health 2008; 36: 875-878. 0_i1140261
- World Health Organization. Guidance on ethics of tuberculosis prevention, care and control. Geneva: WHO, 2010. http://whqlibdoc.who.int/publications/2010/9789241500531_eng.pdf (accessed Oct 2011).
- World Care Council. Patient’s charter for tuberculosis care. 2010 http://www.worldcarecouncil.org/content/patients-charter-tuberculosis-care (accessed 30 June 2011).
- Tuberculosis Coalition for Technical Assistance. International standards for tuberculosis care. The Hague: TCTA, 2006. 0_i1140268
- Brown H. WHO identifies drug-resistant tuberculosis “hotspots”. Former Russian states are worst affected, but lack of data from China hides true extent of disease. Lancet 2004; 363: 951. 0_i1140270
- Green Light Committee. Application instructions. Geneva: WHO, 2010. http://whqlibdoc.who.int/hq/2010/WHO_HTM_TB_2010.1_eng.pdf (accessed Oct 2011).
- Schwartzman K, Oxlade O, Barr RG, et al. Domestic returns from investment in the control of tuberculosis in other countries. N Engl J Med 2005; 353: 1008-1020. 0_i1140277
Provenance: Not commissioned; externally peer reviewed.