Challenges in the equitable access to COVID-19 vaccines for migrant populations in Europe.

Migration and health are universally recognized as a global public health priority [1]. People who migrate, in particular holders of humanitarian protection, asylum seekers and undocumented migrants, may experience inadequate access to high quality and comprehensive health care services. The global COVID-19 pandemic has disproportionately affected vulnerable communities, with migrants across Europe finding themselves unprotected and overexposed to infection. Evidence shows that migrants in high-income countries are at increased risk of SARS-CoV-2 and are more represented among COVID-19 cases and deaths [2]. While reaching migrant population for routine vaccinations has been a challenge even before the pandemic [3], the implementation of an inclusive COVID-19 vaccination campaign to ensure an equitable distribution of COVID-19 vaccines should be a priority. The COVID-19 emergency has compounded existing challenges for migrants, asylum seekers and refugees by among others i) the overcrowded and unsafe housing, putting the people accommodated in informal settlements at increased risk of viral transmission ii) the occupational health risks, associated with greater close-contact exposure in substandard or informal job settings, potentially heightening their physical interactions and thus their probability of contagion; iii) limited awareness of prevention measures due to the absence of a consistent COVID-19 health information strategy for culturally and linguistically diverse communities [4]. Moreover, undocumented migrants - referred as a non national who enters or stays in a country without the appropriate documentation (International Organization for Migration) – are more likely to experience the greatest obstacles to access to care. This could be driven by less extensive coverage by mainstream health systems, social isolation, fear of deportation, inability to communicate and lack of knowledge about the healthcare system, as well as stringent bureaucratic requirements. International Organizations have conducted advocacy work with governments to raise awareness on States’ obligations to include migrants in official vaccination plans [5]. In December 2020, the European Centre for Disease Prevention and Control (ECDC) issued the report “COVID-19 vaccination and prioritisation strategies in the EU/EEA” [6], which includes migrants and refugees as potential target populations in vaccination campaigns. Nevertheless, broad inconsistencies in immunization directives adopted by European Union Member States (EU MSs) have been reported [7]. Indeed, some EU MSs explicitly mention migrants in their vaccination plans, with only a few including them as a priority group.

Germany's plan includes asylum seekers and staff of asylum seeker facilities as well as homeless shelters under their second priority group. Migrants are expected to receive their COVID-19 vaccine right after people aged over 80 and healthcare workers [8].

The Spanish national vaccination strategy reports migrants in two different groups of priority: “people who live or work in communities or closed settings” and “people belonging to vulnerable populations due to their socioeconomic situation”. The latter group includes migrants, people belonging to ethnic minorities, people with language barriers and people in an irregular administrative situation. Although the plan reports possible difficulties in the recruitment and prioritization of these populations due to their heterogeneity and barriers in accessing the health system, the vaccination process would be ensured and efforts would be made to increase the uptake of the vaccine by migrants [9].

In Portugal, COVID-19 vaccination is universal and thus intended for anyone present in the country [10]. It must be mentioned that Portuguese government granted temporary residence to migrants and asylum seekers who had pending applications for residence permits when the state of emergency was declared in March 2020, with the declared purpose to guarantee equal access to the same standard of care for citizens and non-citizens. The action was repeated in November 2020, during the second phase of emergency.

Recent evidence shows that non-Italian citizens received late diagnosis and were more likely to be hospitalized and admitted to ICU, with an increased risk of death in those coming from lower human development index countries [11]. However, the Italian COVID-19 Strategic Plan neither explicitly mentions nor includes migrants under any target group [12]. The Italian Drug Agency (AIFA) [13] states that every citizen can be vaccinated regardless of their administrative-judicial status. This is in line with the Italian Constitution which defines the “Right to Health'' as “a fundamental right of the individual and a collective interest, and [the Republic] guarantees free medical care to the indigent” pursuing the principle of Universal Coverage and access to care through its National Health Service [14,15]. Despite the right to be vaccinated, the current reservation system is only accessible through a social security number, making the access to vaccination for undocumented migrants challenging.

Migrants living in the UK will be eligible to receive COVID-19 vaccines regardless of their status - legally or undocumented, and without financial hardship. However, they have not been listed as a priority group [16]. Similarly, the Dutch vaccination plan, which specifically mentions that asylum seekers and undocumented people are also eligible for the COVID-19 vaccine, does not include them as a priority group [17].

The French Ministry of Health states that foreigners or homeless people will be able to be vaccinated even if they do not have a social security or identification number [18].

The Belgian Ministry of Health has disclosed that undocumented migrants would be included in the vaccination campaign. However, the strategic plan states that vaccinations are based on domicile address in the nation and the working situation, thus practical inclusion of illegal migrants would be challenging [19].

The Vaccination Programme in Poland establishes that every person legally staying in the nation, with temporary or permanent residence card, can get vaccinated, hence excluding irregular and undocumented groups [20].

The exclusion of migrants and specifically those who are undocumented from COVID-19 vaccination plans can lead to the failure in developing and implementing specific interventions to reach them. EU MSs should collectively ensure a consistent policy implementation, by identifying barriers and behavioural factors influencing vaccination uptake among migrants. These include, among others, the improvement of community outreach and engagement strategies for underserved subjects, and reliable immunization information and surveillance systems, which provide disaggregated data [21]. The Council of Europe urges that access to vaccination services should be adapted to the needs of persons in vulnerable situations who have difficulties in accessing services. In this regard, it suggests 11 target groups, including low-income migrant workers and persons without residence or with insecure legal status. The Committee on Bioethics of the Council of Europe has also called for EU MSs to develop strategies to ensure appropriate support for COVID-19 vaccination access for vulnerable populations while eliminating barriers to access [22]. As migrant health is a cross-cutting issue, positive health outcomes depend on a wider vision and on intersectoral policies linking the health sector with other public entities, particularly those dealing with migrants. This is even more pivotal during emergency events such as the COVID-19 pandemic. Such an approach is essential not only from an ethical perspective for the individual, but also pragmatically for the society as a whole, as “none of us will be safe until we are all safe”. Inclusive public health strategies are crucial to effectively contain outbreaks, as the risk of an epidemic resurgence is highly probable when specific groups of people or communities are excluded from national vaccination programs. Worldwide, as even further demonstrated by the COVID-19 pandemic, the need to acknowledge the right to health has never been more urgent. Addressing migration health is a necessary precondition to adequately reap the benefits of migration for migrants and both their countries of origin and destination. Structures, mechanisms and migrant-conscious policies should be put in place globally and locally, to ensure that migrants, notably those who are undocumented and in transit, are not left behind in the COVID-19 vaccine narratives, planning and implementation. As stated by the Global Agenda 2030, “no one will be left behind”; migrants irrespective of their legal status must be included in public health strategies, to embrace the universal right to health and the Universal Health Coverage target, while ensuring that they are not exposed to financial hardship or legal consequences. We endorse the principle that there can be no public health without migrant health [23].

Contributors

BA and BF conceptualised the viewpoint. BA, BF, CD and SU drafted the manuscript. MC, VM, FC and EM contributed to reviewing and finalising the manuscript. All authors approved the final version of the manuscript.

Declaration of interests

We have read and understood the Lancet Regional Health - Europe policy on declaration of interests and have no relevant interests to declare.