No Public Health without Refugee and Migrant Health: An overview of access to healthcare for Refugees, Migrants, and Asylum-seekers in Italy

ABSTRACT

1. Introduction
Migration is a global phenomenon driven by conflict, economic instability, climate change, and political persecution. As of June 2024, an estimated 43.7 million refugees worldwide have been forcibly displaced (4), with 24.9 million residing in Europe (5). In Italy alone, approximately 66,000 refugees arrived by sea between January and December 2024 (6). Italy serves as a key entry, transit, and destination country for migrants and refugees, mainly from Africa and Asia, due to its geographical location (3).
These individuals often face severe hardships before, during, and after their migration journey, including inadequate healthcare, exposure to infectious diseases, and poor living conditions, all of which contribute to a disproportionate disease burden (7). Despite international commitments to universal health coverage (8), many refugees and migrants in Europe continue to experience barriers to healthcare access. Challenges include language and cultural differences, limited health literacy, stigma, discrimination, and structural inefficiencies within healthcare systems (9). These factors can negatively impact individual and public health, leading to delayed diagnoses, untreated conditions, and the spreading of communicable diseases (10).
GPs are critical in addressing these challenges, as they are often the first point of medical contact for refugees and migrants. However, evidence suggests that many healthcare professionals lack adequate training in migrant health, leading to gaps in disease detection and management. This misallocation of resources results in inefficiencies, unnecessary healthcare costs, and missed early disease detection and treatment opportunities (11).
Equipping healthcare providers with the knowledge and skills to address the unique health needs of refugees and migrants is crucial (12).
This paper highlights the need to improve healthcare professionals’ understanding of migrant epidemiology to enhance healthcare outcomes for displaced populations and contribute to broader public health security by reducing disease transmission.
2. Directives and legislation on migration health
Refugees and migrants face a higher burden of infections than the general population, yet regulatory processes are lacking (10). In Italy, screening for infections and other health conditions is not mandatory but should be actively conducted for specific diseases (13). Active case-finding is recommended for TB, malaria, STIs, intestinal parasites, diabetes, and anaemia. Asymptomatic individuals from endemic areas or with risk factors should be offered to test for latent TB, HIV, HBV, HCV, STIs, parasitosis, and diabetes. Mass screening is advised for anaemia and hypertension, while pregnancy tests should be considered. Inclusion in cervical cancer screening and vaccination programs is also recommended (13).
Identifying migrants’ disease burden is crucial for individual and public health (14). This paper reviews international and national approaches to health screening, advocating for a more structured and inclusive strategy in Italy.
The WHO Global Action Plan on Promoting the Health of Refugees and Migrants (2024) emphasises strengthening healthcare services to provide essential care, including vaccination, disease screening, prevention, treatment, and mental health support, aligned with national priorities and resources. It also highlights the need to enhance health monitoring and information systems (15).
The EU (2024) regulation “The New Pact on Migration and Asylum” (16), a comprehensive migration management approach, includes a preliminary health and vulnerability check to screen migrants at the border (16). However, there are no established rules on medical checks, highlighting the need for regulations linking border control with asylum procedures (16).
The EU Charter of Fundamental Rights recognises everyone’s right to access preventive health care and benefit from medical treatment (8). Governments should ensure that migrants have access to appropriate health services supported by data systems to monitor their use and address inequities. Health services should adopt a culturally competent, organisation-wide approach, and health workers should actively overcome language, social, and cultural barriers (17).
3. Italian National Health System (SSN)
The Italian National Healthcare System is globally recognised for providing universal healthcare to all residents, regardless of personal or social factors. Moreover, Italy has pioneered migrants’ health policies, being one of the first in Europe to legislate migrants’ entitlement to healthcare, demonstrating its commitment to universal health rights (18).
The existing guidelines on the reception and health condition assessment of migrants, as well as subsequent care actions based on available scientific evidence, are not widely implemented (19). This includes documents and guidelines such as INMP-ISS-SIMM: “Border Controls. The Frontier of Checks” (last update 2023) and “Tuberculosis Control Among Immigrants in Italy” (last update 2024) (20).
3.1. General Practitioners
Asylum seekers and refugees in Italy must register with the public healthcare system and are entitled to a family doctor or paediatrician care for children under 14, along with access to other essential medical services (21). However, when caring for migrant populations, healthcare professionals face various challenges: language and cultural barriers, a lack of specific training, and organisational and care management systems that are not always adequate (22).
GPs receive training in primary care, preventive medicine, and chronic disease management, but their education lacks sufficient focus on global health and migrant healthcare. Data suggests that university and postgraduate programs do not adequately address these topics. This gap has been highlighted in various studies and reports.
An Italian study on the competencies and training needs of healthcare providers serving migrant populations highlighted the need to identify educational priorities and enhance healthcare workers’ capabilities to address the unique health challenges faced by refugees and migrants to implement global competency standards (3).
Furthermore, the European Association for the Study of the Liver emphasises the need for training and education, noting that healthcare professionals should be informed about their obligations to treat migrants and asylum seekers in a culturally sensitive manner (11).
Additionally, the World Health Organization (WHO) launched an e-learning course titled “Global Competency Standards for the Provision of Health Services to Refugees and Migrants” to improve health workers’ skills in delivering culturally sensitive and effective healthcare to refugee and migrant populations (23). Also, Instituto de Salud Global offered courses on migrant health, equipping healthcare providers to evaluate migrant patients by considering factors like migration routes and cultural diversity (24). These initiatives highlight the recognised need for specialised training in this area.
4. The disease burden among refugees and migrants
Migrants face a higher risk of exposure to pathogens due to endemic conditions in their home countries, poor living conditions during the journey, and inadequate housing in the destination countries (25).
4.1. Healthcare interventions in migrants upon arrival
In Italy, guidelines for triaging the urgent healthcare needs of migrants upon arrival were developed collaboratively by the National Institute for Health Migration and Poverty (INMP), the National Institute of Health (ISS), and the Italian Society of Migration Medicine (SIMM). These guidelines, last updated in 2023, provide recommendations for health assessments of migrants and asylum seekers upon arrival and during their stay in reception centres (26).
However, these guidelines are advisory and non-mandatory; adherence is not legally required. Additionally, while asylum seekers and beneficiaries of international protection are required to register with the National Health Service (SSN) and are entitled to equal treatment (27), there is no specific mandate enforcing the use of these triage guidelines.
The primary infectious and communicable diseases such as TB, malaria, hepatitis B and C, HIV, parasitosis, sexually transmitted infections (STI), and some chronic-degenerative conditions, such as diabetes, anaemia, hypertension, and cervical cancer, have been considered, as early diagnosis is associated with a reduction in adverse health outcomes and costs for the National Health Service (20). A general medical examination for migrants should include a detailed clinical, family, and social history, focusing on identifying the above-mentioned conditions for timely treatment. It should also assess nutritional status, cardiorespiratory health, vision, hearing, skin conditions, and signs of trauma or torture (26).
Tuberculosis
TB is highly prevalent in tropical regions not because it is a tropical disease but due to the higher incidence of poverty, overcrowding, and malnutrition, which make it an opportunistic disease in these areas (28).
Early identification of active TB in migrants should begin at the initial health assessment and continue throughout the reception process. Those with a persistent cough for over two weeks should undergo a chest X-ray or a rapid molecular test if X-ray access is limited. Routine screening for asymptomatic individuals using TST, IGRA, or radiographic methods is not recommended. Confirmed TB cases must receive free, timely treatment with ensured continuity of care, even during transfers (26).
For latent TB diagnosis, LTBI screening using a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA) should be conducted soon after arrival for all migrant populations from high-TB-incidence countries, with linkage to care and treatment where indicated (29).
Malaria
Early identification of malaria in migrants should start during the rescue phase for those with a history of living or travelling in malaria-endemic areas, with health professionals trained to recognise symptoms. In symptomatic individuals, rapid diagnostic tests or hepatoscopy (30) should be used promptly. Malaria should also be considered in those with splenomegaly or thrombocytopenia, even without symptoms. Individuals diagnosed with malaria, particularly severe cases, should be urgently referred to a specialist (26).
HIV/AIDS
Migrants should receive culturally sensitive counselling on HIV/AIDS, including precise information and access to treatment. HIV testing is recommended for individuals from high-prevalence countries, those aged 16 or older, pregnant or breastfeeding women, and those with risk factors such as prior blood transfusions, drug use, multiple sexual partners, or co-infections. HIV testing is also advised for minors under 16 if risk factors or co-infections like STI or TB are present (26).
HBV-HCV
Migrants from countries with a high prevalence of HBV (HBsAg >2%) and those with risk factors such as HIV, prior blood transfusions, drug use, multiple sexual partners, or close family members with HBV, should be screened for HBV, including testing for HBsAg, HBcAb, and HBsAb. If HBsAg is positive, referral to a specialist is necessary (29). Hepatitis B vaccination should be offered to all migrant children and adolescents from intermediate (≥2%) or high (≥5%) HBsAg prevalence countries who do not have evidence of vaccination or immunity (29).
For HCV, migrants from high-prevalence countries (>3%) or those with risk factors should be screened, with further evaluation using HCV-RNA and referral to a specialist if positive (26).
Sexually transmitted infections
During medical examinations, recently arrived migrants should be screened for STI symptoms and referred to specialists if needed. Asymptomatic individuals with risk factors, such as multiple sexual partners or recent STI, should be tested for Chlamydia and Gonorrhea. Syphilis serologic testing is recommended for individuals from high-HIV prevalence countries, for those with risk factors, and for minors with individual risk factors or other STIs. Sexual health counselling should also be provided during examinations (26).
Parasitosis
Migrants should be assessed for parasitosis symptoms, such as diarrhoea, abdominal pain, and itching, and if present, a stool test should be performed to detect intestinal parasites. Serologic testing for Strongyloidiasis (31) and Schistosomiasis (32) should be conducted for those who have lived or travelled in endemic areas, even for asymptomatic individuals. Positive results should prompt treatment, especially if the individual hasn’t been treated recently. Eosinophilia can be an indirect indicator of helminthiasis (26).
Diabetes, anaemia, hypertension, women’s health
Diabetes screening should start early, with blood glucose checks for symptomatic individuals and screening for at-risk asymptomatic migrants aged 35+. Migrants should also receive culturally tailored prevention information (26).
Anaemia screening should include assessing symptoms and offering a complete blood count test during the initial medical exam. Blood pressure measurement is recommended to screen for hypertension. Pregnant women should be tested early and receive appropriate care. Cervical cancer screening should be provided to women aged 25-64, ensuring culturally sensitive care (26).
Vaccinations
Migrant children and adolescents without immunisation records should be vaccinated against measles/mumps/rubella (MMR) and other diseases like diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type b (DTaP-IPV-Hib) (29). Vaccination for adult migrants without immunisation records should be offered according to the Italian vaccine schedule (33).
5. Screening recommendations
Signs and symptoms
The clinical examination for migrants should prioritise detecting signs and symptoms of key conditions, including persistent cough for TB, fever and splenomegaly for malaria, and skin inspection for ectoparasites (34), and symptoms like discharge, dysuria, ulcers, or lymphadenopathy for STI. Additionally, signs of parasitosis, such as diarrhoea, abdominal pain, and itching, along with symptoms of diabetes, anaemia, and hypertension, should be assessed (26).
Free of-charge screening, treatment, and vaccination
Screening and vaccination programs must be voluntary, confidential, non-stigmatising, and free of charge while addressing migrants’ unique needs to minimise loss to follow-up and treatment. Moreover, regular monitoring and evaluation are essential to assess the effectiveness and make necessary adjustments (29).
6. OVERALL CONCLUSIONS AND RECOMMENDATIONS
The health of refugees and migrants is a crucial component of public health, requiring a structured and inclusive approach to screening, treatment, and vaccination. Despite Italy’s commitment to universal healthcare, gaps remain in the implementation of evidence-based guidelines, particularly among GPs, who are often the first point of contact for migrants. Standardised screening protocols, improved healthcare access, and culturally competent services are essential to addressing the unique health challenges faced by these populations.
Front-line healthcare professionals, including GPs, need sufficient knowledge of the epidemiology of infectious diseases, especially those prevalent in countries where migrants originate (29). Gaps in knowledge and training often lead to ineffective or inappropriate medical practices. Strengthening healthcare workers’ understanding of the epidemiology of infectious diseases, improving access to standardised screening protocols, and fostering culturally competent care are essential. Ensuring that healthcare professionals are adequately trained and equipped to provide appropriate, timely, and non-stigmatising care is key to improving health outcomes for migrant populations and integrating their healthcare needs into national public health strategies. Training programs should address migrants’ disease burden through courses, continuing education, and public health collaborations supported by guidelines, policies, and funding for effective implementation (3).
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