Europe is racing to vaccinate residents - but in some countries, undocumented immigrants have been left out

An estimated 4.8 million unauthorized immigrants lived in 32 European countries as of 2017, according to the Pew Research Center. Studies show they are more vulnerable to the coronavirus than European populations at large. But many countries have excluded them from vaccination drives in policy or in practice - and deep distrust among some immigrant populations toward authorities has caused complications for more inclusive campaigns.

Around 64 percent of adults have received at least one dose of a vaccine and roughly 44 percent are fully vaccinated across European countries surveyed by the European Centre for Disease Prevention and Control (ECDC). But the delta variant sweeping the continent has heightened urgency to vaccinate the rest.

Undocumented immigrants in the United States are eligible to get the vaccine, and the federal government has said it will not conduct immigration enforcement operations around vaccine sites.

In March, the E.U. published guidance calling for member states to include all immigrants in coronavirus vaccination programs, regardless of their legal status.

Still, vaccination policies and procedures vary widely across Europe, and an ECDC report last month found that low vaccination rates persist among some immigrant groups.

"The public health imperative (to vaccinate immigrants) is one that still has legs. But it's an invisibility issue in some countries," said Alyna Smith, an advocacy officer at the Platform for International Cooperation on Undocumented Migrants (PICUM).

The struggle to vaccinate this "invisible" population has underscored existing health care disparities. Public health experts say it may put a wrench in plans to return to normal life on a continent itching to shed coronavirus restrictions.

"It's important to address the issue of migrants because it's a priority group, it's a vulnerable group because of their risk factors, their living and working conditions," said Benedetta Armocida, a PhD candidate in global health at University of Geneva and a research assistant at the Institute for Maternal and Child Health-IRCCS Burlo Garofolo.

Even before the pandemic, undocumented immigrants faced steep barriers to health care in many European countries, according to Sally Hargreaves, a migrant health expert and lead author of the ECDC report.

In the past, countries including the United Kingdom have charged immigrants for health services that citizens receive free. Other countries have turned away those without documents. In some places, health authorities share information with immigration services.

Fears of deportation or hefty medical bills have deterred some undocumented immigrants from seeking treatment for chronic conditions that put them at increased risk of covid-19 complications, public health experts said. The same concerns are keeping some immigrants away from vaccination sites.

"What happens with any of these hostile policies is that it means that when you speak to lots and lots of migrants and the wider ethnic minority community, there's a real lack of trust in health systems," Hargreaves said.

A handful of countries have prioritized undocumented immigrants in their vaccination programs. The Netherlands' vaccination plan explicitly mentions that the group is eligible. Portugal created a registration platform for undocumented immigrants to book vaccine appointments, and more than 19,000 had signed up as of June, according to PICUM.

Everyone residing in Belgium is eligible to get the vaccine, and the Belgian government has specified that data collected during the vaccination process can only be used for health purposes. The government has deployed mobile vaccination teams and worked with local authorities and civil society groups to reach immigrant populations. In the capital, Brussels, public transportation to vaccination centers is free.

But in some countries where everyone is theoretically entitled to receive the vaccine, administrative hurdles remain. Coronavirus vaccines are free and available to undocumented immigrants in the U.K. Booking an appointment, though, often requires being registered with a general practitioner, and some GPs "routinely refuse" to register migrants who can't provide proof of address or ID, Anna Miller of Doctors of the World UK said.

Italian authorities, meanwhile, have sent mixed messages on whether unauthorized immigrants are eligible. Registration requirements mean they are often "de facto excluded," Human Rights Watch senior researcher Belkis Wille said in a webinar last month.

The German government clarified this spring that undocumented people could access the vaccine. But a law requiring public authorities to report them to immigration officials remains in effect. The result: Undocumented migrants avoid the medical system, nongovernmental organizations (NGOs) say.

Other countries are making little or no efforts to inoculate undocumented migrants. In Hungary, where Prime Minister Viktor Orban has long burnished his anti-immigrant reputation, it appears to be nearly impossible to register for a shot without proof of legal residence, according to PICUM.

Greece began vaccinating refugees living in camps in early June, after what critics called a sluggish start. But migrants without documents still cannot access the vaccine registration platform, according to Lefteris Papagiannakis, a former vice mayor of Athens and current head of advocacy, policy and research at SolidarityNow, an NGO that works with refugees and migrants in Greece.

Papagiannakis blamed anti-immigrant politics, and said that the country's stance may backfire as it seeks to revive its tourism industry.

"When you talk about tourism and you don't mention people who work as undocumented (people) in the kitchens, in the hotels, doing the laundry, guarding the elderly, then you have a hole in the protection of public health," he said.

Even in countries that have attempted to include undocumented immigrants, language barriers and misinformation may be contributing to vaccine hesitancy among migrant populations, the ECDC study found. And for those eager to get the shots, long work hours or difficulties traveling to vaccination sites can stand in the way, Hargreaves, the study author, said.

Some NGOs and municipalities have taken the lead in addressing these concerns. Doctors of the World UK has run information sessions across London and - with government support - is working to translate resources about the vaccine into roughly a dozen languages, Miller said. In Italy, health authorities in the region encompassing Rome ran an overnight vaccination drive earlier this month for "people on the margins of society," the New York Times reported.

Still, rights groups are calling for the E.U. to play a more active role in coordinating member states' efforts to reach marginalized groups. Human Rights Watch has also asked governments to drop documentation requirements for vaccine registration and to implement strict firewalls between health and immigration services.

The pandemic has exposed the danger of sidelining undocumented immigrants from health services, public health experts say - and the need for broader access in the future.

"Going forward, it's not acceptable in high income countries for tens of thousands of people to operate outside of health and vaccine systems," Hargreaves said. "The reality is, we're all in this together, aren't we?"