Iran and the Challenge of Afghan Immigrants and Refugees With Tuberculosis

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. The World Health Organization estimates that about a quarter of the world's population has been infected with M tuberculosis. ¹ In 2021, globally about 10.6 million people—about 6 million men, 3.4 million women, and 1.2 million children—were living with TB and 1.6 million people died from the disease. The most important risk factors for TB are having a compromised immune system, such as living with HIV, diabetes, and undernutrition; having an alcohol use disorder; and smoking tobacco. ¹ Despite extensive efforts to contain TB, especially multidrug-resistant TB (MDR-TB), it remains one of the top health issues in many countries. ¹

Afghanistan has a high burden of TB, with an incidence rate of 189 per 100,000 population, 12,000 deaths, and an incidence of 4,800 multidrug-resistant/resistant to rifampicin TB (MDR/RR-TB) in 2021. ² Although treatment coverage has greatly increased from 19% in 2000 to 69% in 2021, the incidence rate has remained the same and new and relapse TB cases have increased since 2000. ² In a study by Sayedi et al, ³ findings showed that the yield of TB was almost 10 times higher than the national estimated incidence of TB for Afghanistan.

Compared with Afghanistan, Iran is in better condition, with a total TB incidence rate of 12 per 100,000 population, 880 deaths, and an incidence of 220 MDR/RR-TB in 2021. ⁴ Nevertheless, one of the most important challenges for Iran in containing TB is related to Afghan immigrants and refugees. The exact number of Afghans living in Iran is not known because a substantial number are unregistered and undocumented. Based on a statement from the United Nations High Commissioner for Refugees, until 2021 about 4.5 million registered and unregistered Afghans lived in Iran. ⁵ According to a report of the Islamic Republic News Agency, after the fall of Ashraf Ghani's government, the number of Afghans living in Iran reached more than 5 million people. ⁶ Studies have shown that the TB and MDR-TB rate in Afghan immigrants and refugees is higher than in the Iranian population. ⁷ It is worth noting that Afghan immigrants and refugees account for 1 in 5 TB cases in Iran. ⁸ A systematic review and meta-analysis study reviewed 40 studies on the most prevalent infectious diseases in Afghan immigrants in Iran from 1994 to 2011. ⁹ Of them, 22 studies addressed the number of Afghan immigrants with TB. The pooled proportion estimation of Afghan immigrants with TB on the basis of random effect was 29% (95% CI, 0.23 to 0.34).

As mentioned above, the high incidence of TB among Afghan immigrants and refugees is one of the main challenges for Iran's health system. Iran has tried to improve health conditions in this population, including the control of infectious diseases such as TB. ⁹ In this regard, Iran has implemented free-of-charge effective measures including Bacillus Calmette–Guérin vaccination, TB diagnosis, and TB treatment for both registered and unregistered Afghan immigrants and refugees.

Nevertheless, various economic, cultural, social, and health factors have posed challenges in containing infectious diseases, especially TB, among Afghan immigrants and refugees in Iran.^7,9,10 One of the major difficulties stems from the high mobility of the Afghan population between their country of origin and other destination countries, including Iran, Pakistan, Tajikistan, Turkey, and New Zealand. This mobility makes diagnosis, treatment (due to the long duration of treatment), and follow-up of TB patients more difficult and leads to clinical relapses and drug resistance. Another difficulty is the stigma and embarrassment that propels individuals to hide their disease and avoid going to health and treatment centers, increasing the severity and extent of the disease. Most Afghan refugees in Iran are not registered and do not have sufficient identity documents, which poses difficulties related to their diagnosis and treatment of TB, as well as difficulties in conducting epidemiological studies and monitoring and evaluation of TB control projects. In addition, despite repeated assurances by the Ministry of Health and Medical Education in regard to confidentiality and the absence of consequences for refugees who stay in Iran, unregistered people avoid going to health centers for vaccination, diagnosis, and treatment due to the fear of deportation. The high rate of MDR-TB, which is caused by various factors such as mobility and noncompletion of treatment, is yet another obstacle to controlling TB. Other factors affecting the ability to control TB in this population are lack of awareness, low levels of education, poor socioeconomic conditions, and a shortage of healthcare workers, facilities, and equipment in the country of origin. Strategies that would help manage these challenges include providing education to address cultural misconceptions and increase awareness of TB, strengthening surveillance systems, enforcing compliance with measures to limit mobility, conducting screening at points of entry, and ensuring management, census, and registration of immigrants and refugees.