Increase of immigrants in emerging countries : free public healthcare and vaccination as preventive measures in Brazil

In 2018, 65.6 million individuals around the world were forcibly displaced , according to the United Nations High Commissioner for Refugees (UNHCR), who were divided in 22.5 million refugees, 10 million stateless people and 189,300 resettled refugees. The majority of refugees (55%) were from three countries: South Sudan, Afghanistan and Syria 1. The reinforcement of cross-border policies in developed countries 2,3 lead refugees to seek emerging and even poor nations 4 as a new option due to the weak border surveillance and flexible entrance polices for foreigners which allow them to remain in these countries while awaiting the legalization of their stay. Brazil is one of these destinations for immigrants and refugees. The estimated population of immigrants in Brazil is 669,187, with a 160% increase from 2010 to 2016 (Table 1) 5. The number of asylum claims in the country increased to 33,865, but only 473 were approved in 2017, a low rate in 5 years (Table 2). The main emissive countries (Table 3) of refugees to Brazil are Bolivia (15,753 in 2010), Haiti (34,770 in 2014) and Venezuela (17,865 in 2017).


Introduction
In 2018, 65.6 million individuals around the world were forcibly displaced , according to the United Nations High Commissioner for Refugees (UNHCR), who were divided in 22.5 million refugees, 10 million stateless people and 189,300 resettled refugees.The majority of refugees (55%) were from three countries: South Sudan, Afghanistan and Syria 1 .
The reinforcement of cross-border policies in developed countries 2,3 lead refugees to seek emerging and even poor nations 4 as a new option due to the weak border surveillance and flexible entrance polices for foreigners which allow them to remain in these countries while awaiting the legalization of their stay.
Brazil is one of these destinations for immigrants and refugees.The estimated population of immigrants in Brazil is 669,187, with a 160% increase from 2010 to 2016 (Table 1) 5 .
The number of asylum claims in the country increased to 33,865, but only 473 were approved in 2017, a low rate in 5 years (Table 2).The main emissive countries (Table 3) of refugees to Brazil are Bolivia (15,753 in 2010), Haiti (34,770 in 2014) and Venezuela (17,865 in 2017).

Health public policies for immigrants in Brazil
Legal immigrants in Brazil receive the same healthcare as free medical assistance including preventive measures such as vaccination, pre-natal care and other protective clinical services offered by the Brazilian Unified National Health System (SUS) 6 , the free care system established by the Brazilian Government.
In addition, illegal immigrants in Brazil are not totally out of this healthcare system 7 , receiving treatment for some illnesses, such as tuberculosis, and even other clinical and surgery procedures such as obstetric care.
Birth in Brazil is a cessionary condition that provides Brazilian citizenship to foreigner parents, explaining the increase in childbirths in Brazilian hospitals in the country's borders 8,9 .

The current immigration flow to Brazil Bolivians
The major group of immigrants (legal and illegal) from poor countries in Brazil are the Bolivians (~90,000 in the state of São Paulo) 10 , who arrive by land crossing the borders in the state of Mato Grosso (city of Corumbá).Chagas disease 11 and tuberculosis 7 are reported to be the main chronic infectious diseases of Bolivian immigrants.
Tuberculosis in Bolivian immigrants might be explained by their precarious life conditions, with some of them being also subjected to slavery work.Many of them have fled to Brazil, with the state of São Paulo featuring the greatest incidence of Bolivian immigrants 12 .Some studies have described that Haitian immigrants were in good health conditions upon their arrival in Brazil (in the Amazonas State) 13,14 , leading us to the "healthy migrants" theory, because even after an exhausting journey (including the adverse conditions of their country), they were in good health conditions upon arriving at the receiving country, sometimes free of chronic diseases such as diabetes, hypertension and others.

Haitians
However, we may consider two groups of immigrants that come to Brazil.The first is composed by people with a considerable social condition, with good access to better education or financial support to escape or to seek new perspectives, which corroborates the previous concept.
They are responsible for stimulating the flow of people from one country to another, becoming the alert signal for the improvement of national surveillance systems to prepare the country's protective measures and infrastructure to receive the second group of immigrants, usually composed of people who used to be in worse socioeconomical conditions in their homeland, and who are thus more susceptible to local endemic diseases 15 .
For example, after four years of intensive migration from Haiti, there is an impressive peak in the flow of displacements in 2014 (n = 34,770 Haitians), and the concomitant introduction of the Asian genotype of the Chikungunya virus (the circulating strain in the Caribbean region since 2013) in Brazil by illegal Haitian or Dominican immigrants in the extreme North region of the country 16 .
Another study detected a silent infectious disease (lymphatic filariasis) in ten Haitian immigrants in Chapecó (state of Santa Catarina) 17 .The constant healthcare assistance for immigrants becomes an important preventive measure to reduce the reintroduction of lymphatic filariasis or other controlled and silent infectious diseases.

Venezuelans
Venezuelan refugees are the current and unexpected concern for Brazilian health authorities.In January 2018 only, the country received around 800 individuals/day in the city of Pacaraima (state of Roraima), who were displaced to Boa Vista (capital of the state).So far, Brazil is believed to have received ~40,000 illegal Venezuelan immigrants (Table 4).
The Department of Health of the state of Roraima confirmed, on 20 February 2018, that seven suspected cases of measles are under investigation.An 1-year-old Venezuelan child, with no vaccination history, had measles infection confirmed by the Oswaldo Cruz Foundation (Fiocruz) and local authorities 18 .Of the seven cases (five boys and two girls, in the age group between 7 months and 10 years old), six are Venezuelan and one is Brazilian, residents in Boa Vista and with no history of vaccination.Measles was considered an infectious disease controlled in Brazil since 2015.Venezuela's political and economic crisis is believed to be the main reason for immigration to Brazil.Source: Brazilian Ministry of Justice 23 .
In January 2018 only, 150 Venezuelan pregnant women received childbirth care in Pacaraima.The number of childbirths (452 births in 2015; 810 births in 2016; 1,681 births in 2017) and the neonatal care at this border city increased in the last three years due to the migration flow from Venezuela 19 .
Venezuelan refugees first seek medical care in Brazil, and then citizenship by naturalization as a consequence of the current immigration rules that grant parents this special concession.

The difficult task to receive immigrants: recommendations and possibilities
A massive plan which includes the refugees' registration, supply of adequate lodging and food services, hygiene program and mass vaccination for preventable infectious diseases are urgent to reduce the risks of outbreaks of controlled infectious diseases in the country.
We may infer this vulnerable condition of immigrants due to the measles outbreaks in the borders, previously cited, and the persistence of tetanus 20 , a controlled disease in some emerging countries such as Brazil, but still with high mortality rates of newborns in the main emissive countries such as poor regions of Africa and Asia 21 .
This low vaccination coverage and childbirths overloaded the local health systems in the border cities, which declared state of emergency and receive urgent assistance by the Federal Government 22 .
Current efforts are focused on public health policies, with direct investment in local public health clinics and vaccination for preventable infectious diseases (MMRV, influenza and others) to not compromise this group and the local population.
The emerging economies, such as Brazil, become an important destination for immigrants and refugees, receiving people from more distant countries and with poor origins (Table 4).

Conclusion
The current surveillance of migratory flows in emerging countries tends to become more complex, including not only the study of endemic infectious diseases from the emissive countries, but also the analysis and provision, if necessary, of healthcare assistance to this population near the borders, to avoid the reintroduction of some infectious diseases which are controlled in the host countries.
The continuous health support for these vulnerable communities should be established as a public health policy by all humanitarian nations, becoming a preventive measure for the containment of potential infectious diseases with difficult diagnosis or silent transmission and, as previously mentioned, a global strategy that protect immigrants, refugees and the host population.
Cad. Saúde Pública 2019; 35(2):e00228118 Cad. Saúde Pública 2019; 35(2):e00228118 Contributors D. M. Fujita contributed to the study design, writing and revision.F. S. Salvador and G. P. S. Damião contributed to the literature review and data collection.G. M. Figueiredo contributed to the data collection and study design.L. H. S. Nali contributed to the study design and revision.

Table 2
Immigrants and refugees in Brazil: asylum.

Table 1
Immigrants and refugees in Brazil: legally entry.
Haitian refugees come to Brazil by land, crossing the borders in the North (states of Acre, Rondônia and Amazonas) and Central regions.According to the 2014 Annual Report on Social Information (RAIS; http://obmigra.mte.gov.br/index.php/component/k2/itemlist/category/42,accessed on 11/ Apr/2018), Haitians established themselves in the formal labor market in the South region (59.2%mainly in the state of Santa Catarina), Southeast region (28.2% -mainly in São Paulo) and in other regions (12.6%).

Table 3
Immigrants and refugees in Brazil: main emissive countries.

Table 4
Immigrants and refugees in Brazil: asylum claims by country, 2016/2017.